Transcript Mock Code

Mock Code
By: Angelique Johnson, M.D.
Mock Code
Paramedics call with an 8 month old 10
minutes from your ER with a generalized
tonic seizure X 20 minutes and cyanosis
Mock Code

Question 1
What things should be done to prepare for
the arrival of the child in the ER?
call for help: RT, nursing, MDs
get supplies: monitors, airway supplies,
IV access supplies, drugs
Mock Code
Child arrives to the ER 10 minutes later via
paramedics with continued seizure activity
and oxygen via face mask with irregular
respirations. Child is placed on the gurney
and CR and pulse ox monitors placed.
HR 180 RR 8 and pulse ox not reading
Mock Code

Question 2
What things are you looking at in your initial
assessment of the child?
1) Airway/ Breathing: is there a patent airway
with chest rise, are the respirations effective
2) Circulation: color of the child, perfusion, CR,
pulses
Mock Code
Initial assessment by the ER physician is an
8 month old with active seizures, agonal
respirations and compromised perfusion.
Mock Code

Question 3
What to do next (order of reasonable
priority)?
1) Airway – this does not equal
intubating but means establishing
an airway to maintain effective
ventilation
Mock Code

Non invasive techniques for obtaining an
airway:
– Positioning
 Shoulder Roll
 Chin Lift
 Jaw Thrust
– Oral Airway
– Nasal Trumpet
Mock Code
An oral airway and nasogastric tube was placed in
the 8 mos old. The child has good chest rise with
bag valve mask ventilation at a rate of 28. VS :
RR-28, HR-190, 98%on 100% oxygen and unable
to obtain a blood pressure, CR 4-5 secs. Patient
continues to have seizures and no IV access
despite multiple attempts for several minutes.
Mock Code

During the attempts at getting an IV labs
were obtained. Question 4: In order of
priority what labs would be helpful?
–
–
–
–
–
Chemstrip
Lytes
Anticonvulsant levels
Blood gas
CBC, Blood Culture
Mock Code

Correction of Electrolyte Abnormalities
– Hypoglycemia: glucose <60 give 2 cc/kg of
D10 and check chemstrip q 15-20 minutes
– Hyponatremia: if Na <125 may be cause of
seizure therefore should correct by 5 or to 130


meqNa to give= wt in kg (0.6) (desire-actual)
Remember NS = 154 meq Na 3%NS = 513meq Na
– Hypocalcemia
Mock Code

Question 5: Why is vascular access a
priority in this child?
In this particular example, tachycardia,
inability to obtain a blood pressure, poor
capillary refill make vascular access a
priority.
Mock Code

Vascular Access

Peripheral access is often difficult in a patient
having seizures may try for one minute according to
PALS before alternate source of vascular access is
attempted. In practice, this isn’t always practical.
Many will try a rectal anticonvulsant if able to do
adequate BVM ventilation. Next option is an IO
line.
Mock Code

Placement of an Intra-osseous Line:
– Landmarks – needle insertion is 2 cm below and medial
–
–
–
–
to the tibial tuberosity
Tip of the needle is directed away from the growth plate
by aiming caudal
Needle is advanced using a firm screwing motion until
a pop or crack is felt or heard
Attempt to aspirate bone marrow back and carefully
infuse fluids
In a code be sure to anchor the line as it may be your
only access for awhile
Mock Code

Complications of IO line placement:
– Fracture at the site
– Compartment Syndrome
– Extravasation of fluid or medication
– Osteomyelitis
– Growth plate injury
– Local Cellulitis
Mock Code
The I/O line has been placed and the child
continues to convulse.
Question 6: What is the first line medications for
ongoing seizure activity?
Benzodiazepines:
1) Ativan is preferred because of short half life
and good anticonvulsant effect
2) Versed similar and a reasonable choice but has a
shorter half life
3) Valium is the least preferred because of its long
half life but short anticonvulsant effect
Mock Code

Doses of the Benzodiazepines:
– Ativan 0.1 mg/kg generally do not give more
than 2 at a time. May give every 3-5 minutes
– Valium rectal or IV 0.5mg/kg max dose is 5mg.
May give every 10 minutes
– Versed 0.1 mg/kg generally do not give more
than 2 mg at a time. May give every 3-5 mins
Mock Code

Side Effects of Benzodiazepines
– Respiratory
 Decreased rate
 Apnea
 Laryngospasm
– Cardiovascular
 Bradycardia
 Hypotension
 Cardiac Arrest
Mock Code
After successful placement of an Intraosseous
line, the patient received 0.8 mg of Ativan X2
five minutes apart. 5 minutes later the patient
stopped having seizure activity and became
apneic. BVM ventilation was restarted.
Question 7: Why is intubation of this patient
now indicated ?
Mock Code

Indications for intubation
– No respiratory effort
– Controlled setting:



Personnel: RT, nursing, skilled inubator
Equipment
Vascular access
– This patient has also received a sedating/ resp
depressing drug and is post ictal making it likely for
him to need prolonged ventilator support
Mock Code

What medications and supplies are needed to for
intubation?
– Supplies







Laryngoscope, blade (check that light works)
ETT ( have 2 sizes available uncuffed if <8yrs)
Suction Catheters
Stylet
BVM apparatus / Oral Airway
Monitors
Shoulder Roll
Mock Code

Medications
– Sedation (not needed in this example)
 Ativan or Versed 0.1mg/kg
– Paralytic
 Norcuron 0.1mg/kg
 Rocuronium 1-1.2 mg/kg
– Atropine
 This is to prevent the vagal bradycardia. Min dose
0.1mg to a max dose of 0.4mg dose is 0.02 mg/kg
Mock Code

Differences in children and adult airways:
– Large Occiput: Head flexes and obstructs the airway
– Anterior Larynx: Difficult to visualize the cord making
a straight blade better and use of cricoid pressure
– Cricoid Ring: the narrowest part of the airway therefore
does not require a cuffed tube
– Short Trachea: making intubation of the right mainstem
common
Mock Code

Steps of Intubation
– Place patient with head extended using a shoulder roll
–
–
–
–
and give 100% oxygen.
One person should be providing cricoid pressure during
the entire process once a paralytic has been given.
Open mouth with index finger inserting the blade in the
right side of the mouth and sweeping to the midline.
Place straight blade all the way in and withdraw slowly
until cords are visualized.
Insert tube from the right side watching it go thru the
cords.
Mock Code

How to check for correct ETT placement
– See the ETT go thru the cords
– Auscultation
– Condensation in the tube
– ETCO2
– CXR
Mock Code
The child is placed on a ventilator in a
monitored setting. You are called back to
the bedside about 10 minutes later for
seizure activity. After about 20 minutes and
3 doses of Ativan q 5-10 minutes the child
continues to convulse. Question 8: What is
the next pharmacotherapy that can be used?
Mock Code

Other Anticonvulsants:
– Dilantin would be the second line drug in most
instances


Dose 20 mg/kg load
Advantages
– Last for about 8-24 hours
– Not a respiratory depressant
Mock Code

Dilantin Cont’d

Disadvantages
– Onset of action about ½ hr
– Takes about ½ hr to infuse
– If rapid infusion can cause hypotension and bradycardia
• This is why in some places phosphenytoin is used
because it reduces these side effects
– In infants < 3 mos old it is often the 3rd line drug
Mock Code
– Third Line Drug is Phenobarbital
 Dose is 20 mg/kg
 Advantages
– Safely given in all ages
– May be given as a slow push
– Synergistic with benzos

Disadvantage
– Respiratory depressing
– Sedating
– Hypotension
Mock Code
If seizure activity continues the patient
should be transferred to an Pediatric ICU
with the capability of doing continuous
EEG monitoring. Often times these kids
require a continuous infusion of a benzo or
barbituate that induces a coma and is
gradually increased until EEG demonstrates
suppression of the seizure
Mock Code
The 8 month old was loaded on Dilantin
with good control of the seizures. Question
9: What history would be good to obtain
from parents at this time by you or to have
someone else obtaining during the acute
process?
Mock Code

Essential History to obtain
– HPI
 Fevers other illness symptoms
 Time of onset and what exactly patient was doing
 Trauma
 Caretaker
 Medications in the home
Mock Code
– Past Medical History
 Previous History of seizures
 Medications especially anticonvulants and dosage
changes
– Family History
 History of seizure disorders
 History of children dying
 Consanguinity
Mock Code
– Physical Exam
 Signs of NAT
 Signs of Inborn Errors of Metabolism
 Signs of Neurocutaneous disorders
– This is a separate lecture
Mock Code
History was unremarkable for trauma,
previous history of seizures, toxin ingestion,
infection. Family history was positive for
epilepsy on the maternal side.
Mock Code
Patient continued to have good control of
seizures and about 8 hrs later he was awake
with spontaneous respirations. CT was
unremarkable and EEG was remarkable for
epileptic discharges. Patient was maintained
on Dilantin and extubated the next day. 2 days
later he was discharged home with Dilantin and
follow up to Neurology.