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.

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By: Angelique Johnson, M.D.

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Paramedics call with an 8 month old 10 minutes from your ER with a generalized tonic seizure X 20 minutes and cyanosis

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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

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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

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Question 2What 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

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Initial assessment by the ER physician is an 8 month old with active seizures, agonal respirations and compromised perfusion.

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Question 3What to do next (order of reasonable priority)?

1) Airway – this does not equal intubating but means establishing an airway to maintain effective

ventilation

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Non invasive techniques for obtaining an airway:– Positioning

Shoulder Roll Chin Lift Jaw Thrust

– Oral Airway – Nasal Trumpet

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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.

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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

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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

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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.

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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.

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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

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Complications of IO line placement:– Fracture at the site– Compartment Syndrome– Extravasation of fluid or medication– Osteomyelitis– Growth plate injury– Local Cellulitis

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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 effect2) Versed similar and a reasonable choice but has a shorter half life3) Valium is the least preferred because of its long half life but short anticonvulsant effect

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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

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Side Effects of Benzodiazepines– Respiratory

Decreased rate Apnea Laryngospasm

– Cardiovascular Bradycardia Hypotension Cardiac Arrest

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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 ?

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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

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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

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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

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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

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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.

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How to check for correct ETT placement– See the ETT go thru the cords– Auscultation– Condensation in the tube– ETCO2– CXR

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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?

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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

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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

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– 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

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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

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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?

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Essential History to obtain– HPI

Fevers other illness symptoms Time of onset and what exactly patient was doing Trauma Caretaker Medications in the home

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– Past Medical History Previous History of seizures Medications especially anticonvulants and dosage

changes

– Family History History of seizure disorders History of children dying Consanguinity

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– Physical Exam Signs of NAT Signs of Inborn Errors of Metabolism Signs of Neurocutaneous disorders

– This is a separate lecture

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History was unremarkable for trauma, previous history of seizures, toxin ingestion, infection. Family history was positive for epilepsy on the maternal side.

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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.