You are working as a single coverage in a rural emergency department. An 8 month old male presents to the ED actively seizing. Finger stick is 20. You make sure that the airway is patent and provide supplemental oxygen. You place an IO while the nurse is getting IV access. What concentration of dextrose do you give? How much? How do you estimate the baby’s weight?
After giving the dextrose, the fingerstick is now normal but the baby continues to seize. You decide to give midazolam. How much?
After a dose of midazolam the baby stops seizing but is unresponsive. You check for a pulse. There is no pulse. You check the monitor: ventricular fibrillation. You decide to shock, but how much voltage are you going to use?
After chest compressions, how much epinephrine are you administering?
Despite a few rounds of CPR the baby is still in ventricular fibrillation. How much amiodarone can you give? What about lidocaine?
The baby now has a pulse and is becoming more responsive. You check the monitor and realize that the baby is bradycardic despite normal oxygenation. What’s the dose of atropine?
The heart rate comes up but the baby becomes unresponsive again. You decide to intubate. What meds are you going to use to RSI? What blade are you going to use? What size tube? How deep? What vent settings are you going to use? What medications are you going to use for sedation?
After intubation the baby’s vitals normalize. You transfer the baby to a tertiary care center and three days later the baby is extubated. He gets discharged and lives happily ever after. The family thanks you for saving the baby’s life.
Take Home #1
How to estimate weight:
Use Broselow tape. If you don’t have it...
< 1 year = (age in months + 9)/2
> 1 year = 3(age) + 7
Dextrose for hypoglycemia Rule of 50:
(Dextrose 5% - 10% - 50%) x (cc/kg) = 50
For example D5 x 10cc/kg = 50, D10 x 5cc/kg = 50 etc.
Midazolam for seizure:
0.1 mg/kg IV
0.2 mg/kg IM or intranasal
Defibrillation: first shock 2J/kg, second shock 4J/kg, subsequent >4J/kg
Epinephrine for cardiac arrest: 0.01 mg/kg (0.1 mL/kg of cardiac epi)
Epinephrine drip for hypotensive shock: 0.1 to 1 mcg/kg/min
Amiodarone for V-fib: 5 mg/kg
Lidocaine for V-fib: 1 mg/kg
Atropine: 0.02 mg/kg
Take Home #2
RSI:
Etomidate: 0.3 mg/kg
Ketamine: 1 - 2 mg/kg
Midazolam for RSI: 0.2 mg/kg
Rocuronium: 1 mg/kg
ETT size uncuffed: (Age/4) + 4
ETT size cuffed: (Age/4) + 3.5
Depth of ETT: 3 x ETT
Laryngoscope Blade:
Newborn = Miller 0
1 month to 2 years = Miller 1 or 1.5
2 to 6 years = Miller 2 or Mac 1
6 to 12 years = Miller 2 or Mac 2 or Mac 3
> 12 years = Mac 3
You can also check the PALS Pocket Reference card
Take Home #3
Ventilator settings
Mode: whatever you are comfortable with
Tidal Volume: 8 mL per kg
Peep: 5
Respiratory Rate: depends on the disease and age
Normal respiratory rate based on age
Infant = 30 to 53
Toddler = 22 to 37
Preschooler = 20 to 28
School aged child = 18 to 25
Adolescent = 12 to 20
You can also check the PALS Pocket Reference card
Sedation during mechanical ventilation:
Midazolam: 0.05 mg/kg/min and titrate up
Fentanyl: 1 mcg/kg/hr
Propofol: 20 mcg/kg/min and titrate up
Philip Siva Vittozzi Wong, MD is a current third year resident at Stony Brook Emergency Medicine.
References
http://www.lasvegasemr.com/foam-blog/peds-em-pearl-hypoglycemia
PALS Pocket Reference Card. 2016 American Heart Association Guidelines
Kneyber MCJ, de Luca D, Calderini E, et al. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med. 2017;43(12):1764–1780.
Luscombe MD, Owens BD, Burke D. Weight estimation in paediatrics: a comparison of the APLS formula and the formula 'Weight=3(age)+7'. Emerg Med J. 2011 Jul;28(7):590-3
Tinning K, Acworth J. Make your Best Guess: an updated method for paediatric weight estimation in emergencies. Emerg Med Australas. 2007 Dec;19(6):528-34.
Special thanks to Dr. Carl Kaplan for helping out
Edited by Bassam Zahid, MD