372 - Rural Critical Care Management of Pediatric Status ... Syllabus/372... · RURAL CRITICAL CARE...
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Transcript of 372 - Rural Critical Care Management of Pediatric Status ... Syllabus/372... · RURAL CRITICAL CARE...
Society of Rural Physicians of Canada 26TH ANNUAL RURAL AND REMOTE MEDICINE COURSE
ST. JOHN'S NEWFOUNDLAND AND LABRADOR APRIL 12 - 14, 2018
• 372
Dr. Gordon Brock • LA PRAIRIE • QC
RURAL CRITICAL CARE - MANAGEMENT OF PEDIATRIC STATUS EPILEPTICUS
Role playing. A group will be selected to play the role of doctor, Nurse, second physician, etc.....they will 'Manage' the case of a 5-6 year old in status epilepticus at the front, in conjunction with a PowerPoint show and questions posed to the audience as to treatment options at that time, in a sequential way. 1. How to make the most of what you have and set priorities, using the 'SRPC Generic Approach to the Critically-ill rural Patient' 2. Familiarization with the route and technique of 'non-IV route' for the medications used in the treatment of pediatric status epilepticus 3. Stress Importance of personnel management and calling for help early 4. Making a proper differential of the 'causes' of status epilepticus and treatment priorities
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1
SIRCC: Module # 7
Pediatric Status Epilepticus
Summary
• It’s the Airway: May need to Manage it yourself if you are the most experienced person there?
• Think of non‐IV routes for drugs early on
• Treatable causes? (Febrile, Glucose, missed drug doses)
• Infection at back of your mind
• Get someone on the phone early
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Situation…….
• Saturday, 22:05 hr: Frantic Parents rush into your hospital holding what appears to be about a 5 year‐old child who appears to be having a generalized tonic‐clonic seizure……
Why do children scare us so much ?
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Why do children scare us so much ?
• Their lives seem to have greater value
• Everything is small – veins, trachea, etc
• They get rare (and bad) diseases we have less experience with….
• Less reliable history
• Too much numbers, too much math
• Vital signs don’t tell the whole story
• Specialized techniques, i.e. intraosseus infusion
• They (usually) come equipped with parents
General Principles in kids
• It is still the ABCs but airway and breathing are even more important than in adults
• Your instinct is as, if not more, important as things such as vital signs
• Kids “compensate” well, a “decompensated”child is a truly sick child.
• Bradycardia instead of tachycardia
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Remember the SRPC Approach
• Environment: Where do put the child?
• SRPC QuikLook + QuikHx: What is the “Best Diagnosis” and the Immediate Priorities (ABC) ?
• What Help do you have now ?
• What Tasks do you assign to each ?
• What Equipment do you need ?
• Who do you need to call (Internal + External) ?
Environment
• Where will you put this child?
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5
RCC QuikLook
• You see an otherwise healthy looking 5‐year old child having a tonic‐clonic convulsion. Her colour is good and she is breathing
Nurse hands you:
• V.S. = P 102/min, RR 32 BP not taken T 39.6
• O2 sat = 94%
SIRCC QuikHx !!!
• How long has the seizure been going on for?
• Has the child ever had seizures before? What worked?
• What medications are they on? Anticonvulsants ? Have you missed doses?
• Have the child had any recent illness or fever or injury?
• Are they generally well ?
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Start to Manage• A – Oral airway. Assign one person to the airway: Position Head/Open the Airway/ Suction/ Give 100% Oxygen + pulse oximeter
• B – Prepare for advanced airway intervention if necessary, Bag‐mask
• C – Gain IV access as quickly as possible
• Drugs of choice :
diazepam (0.2‐0.3 mg/kg IV)
lorazepam (0.1 mg/kg) IV)
• Other: Glucometer (or just give glucose)
• Repeat the benzo up to 4 total doses at 2‐3 minute intervals. Max= 5 mg diazepam if < 5 y.o. and 10 mg if > 5
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I can’t get an IV going
“I can’t get an IV going”
Rectal Diazepam IV 0.5 mg/kg.
Buccal Midazolam 0.2 mg/kg
IM Midazolam 0.1‐0.2 mg
Nasal Midazolam
(Note short duration of Midazolam means may need infusion of 0.05‐0.4 mg/kg/hr.)
#3 Intraosseous: Easy under 5, new IO drills available
Proper technique is vital
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Technique is important
• Technique is important in Alternate Routes…
For rectal diazepam:
Rectal Diazepam
• Turn child on his/her side facing you, bend his/her upper leg forward, and separate his/her buttocks
• Gently insert the syringe tip into the rectum, against the wall
• Slowly count to 3 while pushing in the plunger until it stops.
• Slowly count to 3 again, and then remove the syringe from the rectum.
• Hold the buttocks together so the gel doesn't leak from the rectum, and slowly count to 3 before letting go.
• Keep the child on his/her side.
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How to give buccal Midazolam
• Use 5 mg/ 1 ml solution
• Draw up 0.2 mg/kg in 1 ml syringe
• Can be given supine or on‐side.
• Support the head
• Put the syringe in the child’s mouth between the gums and the teeth.
• ? Trickle in half‐the‐dose on one side and half on the other side
Brigo et al. (2015): 1602 cases
• What counts is Time‐from‐Arrival‐in‐ER to Seizure‐cessation
• Not Time‐from‐Drug‐adminstration‐to‐Seizure cessation
• So……
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Most Important
• Give whatever you are comfortable with, but giving it quickly is more important than the drug or the exact route!
The Kiddy is still convulsing.
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Second‐line Medications
• Second line agent – Phenytoin 20mg/kg at a rate of 50 mg/min or slower to avoid arrhythmias
• Fosphenytoin (pro‐drug of phenytoin) in theory better, can be infused faster.
Third‐line Medications
–Phenobarbitol 10‐20 mg/kg. Airway management often necessary
–Propofol – 3‐5 mg/kg load then 1‐15 mg/kg/hr
–Midazolam infusion 0.05‐2.0 mg/kg/hr
–Valproic acid 15‐20 mg/kg IV prep but not available routinely in Canada
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.Good News, the Seizure has stopped !
Management of “Treatable” Causes
• Febrile – febrile seizures vs CNS infection/ sepsis? (Remember, Status can cause low grade fever) Unclear guidelines to do LP “routinely”
• If on anticonvulsants: Low blood drug levels
• Glucose if Hypoglycemic
• Drug or toxins, Na, K, BUN, LFTs, CK, calcium, magnesium, drug screen – rare, but “treatable”.
• Trauma or mass lesion suspected : CT
• ABG: Acidosismay be cause or be caused by Status
• TRANSFER ????
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Review of 602 cases (Kravijanac at al. 2015)
• “Idiopathic” and “Febrile” commonest causes
• Midazolam more effective than diazepam
• 5.1% mortality
Overall factoids
• “Status Epilepticus (SE)” defined as seizure activity lasting more than ???
• “Non‐convulsive SE” ‐ Multiple seizure activity on the EEG, without motor activity and NO intervening periods of consciousness
• 5‐10% of children with epilepsy will have at least one bout of SE. Mortality – 3‐9%
• May be first manifestation of epilepsy
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Management Tips 1
• Identify and treat Hypoglycemia – Glucometer or just give 5ml/kg D10W
• Fever – treat with acetaminophen, (suppository if indicated)
• Identify and treat rhabdomyolysis
• Antibiotics now if sepsis or meningitis
Management Tips 2: Labo
• Serum anticonvulsants level, if on them.
• Glucose (blood or pinprick)
• CBC, creatinine, Calcium, electrolytes
• ABG or venous gases
• Urine drug screen?
• LP: In Primary Care practice, may not be necessary if child is well‐looking after the seizure……Low incidence of meningitis
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Management 2
• TRANSFER:
Consider such things as Cause, Age of child, Your local situation, distance to “Pediatrics”, etc
Just because “the seizures stop” : Brain may still be seizing on EEG: (Just lettin’ you know)
Summary
• It’s the Airway: May need to Manage it yourself if you are the most experienced person there?
• Think of non‐IV routes for drugs early on
• Treatable causes? (Febrile, Glucose, missed drug doses)
• Infection at back of your mind
• Get someone on the phone early…..