Podcast: sepsis

Cite this article as:
Emily Pascoe. Podcast: sepsis, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16828

This month’s Podcast of the Month is from the Intensive Care Network.

In a 40 minute podcast Shree Basu and Marino Festa (Children’s Hospital Westmead PICU) discuss paediatric sepsis management in the intensive care setting. They cover epidemiology, evidence, diagnosis and management. There’s some handy clinical tips for the non-intensivist too.

Is cap refill a useful sign of septic shock?

If you only squeeze in one podcast this month, make it this one.

Listen to the podcast.

Lumbar Puncture Needle Depth

Cite this article as:
Henry Goldstein. Lumbar Puncture Needle Depth, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14720

Recently, I prepared up to perform a lumbar puncture for the first time in a few months and a quiet voice at the back of my brain whispered ;

How deep would I need to go?
Which length needle would be the best?

I asked a handful of senior and junior colleagues, both at the time and in the writing of this post, and the response was almost universally “deep enough that the CSF comes out.” Certainly true, but not very pragmatic, and lacking the kind of detail I was hoping for…

Background


I know there’s much discussion about the tip shape of a lumbar puncture needle, and in honesty, I’ve yet not read sufficiently to have strong opinions. However, in the fifteen minutes before the procedure, I had a look at the literature around needle length, and swiftly realized there was much more to this than I’d thought. Procedure finished, I was back to the drawing board.

Essentially, the balance is that a needle that is too short won’t reach the sub-arachnoid space, and a needle too long confers additional technical difficulty and increases the risk of going through.

So first, some basic anatomy; the aim of the exercise for lumbar puncture and CSF examination is to be in the sub-arachnoid space. To reach this space, the needle must pass through (in order) skin, superficial fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater and the arachnoid. I’m no neurosurgeon, but I’m pretty sure that it’s impossible to feel each of these layers on the end of the needle.

Lumbar puncture layers

The anatomical target is either the L3/4 or L4/5 vertebral interspace, which respectively lie one vertebral body above & below the level of Tuffier’s line. Tuffier’s line is the imaginary line running between the superior iliac crests, and is used to demarcate the lower end of the spinal cord (which, in neonates, ends around L3 and moves superiorly with linear growth).

Finding a formula

One of the more widely used formulas is from a 1997 paper where Craig et al. derived an elegant formula that;

 LP needle depth (cm) = 0.03 x height of child (cm).

Easily memorable and from a sample of 107 children receiving an LP with macroscopically clear CSF, the authors’ intention was a formula requiring only one variable that could be obtained in a critically unwell child – height being easily obtained with a measuring tape or Broselow tape.



In my department, the most common single measure recorded is weight; Bilic’s 2003 study of 195 Croatian children (over 3m of age) found the best correlate for LP depth was weight, using the formula

LP depth (cm) = 1.3 + (0.07 x Body weight (kg) )

The above formulae use a single variable and hence are probably more useful and pragmatic in the setting of an unwell child. Several other articles have discussed the most accurate formula for LP depth; all of which are reliant on at least two measured parameters. The following formulae may be more beneficial for elective CSF examination.



Several formulae were derived for LP depth from a cohort of 279 paediatric oncology patients in Malaysia; the best fit for their dataset was

y = 10 (weight (kg)/height (cm)) + 1

For this cohort, the LP depth was measured by perhaps a less reliable method than other datasets described, as the investigators measured the distance from their finger on the needle when pressed to the back at withdrawal. Irrespective, this paper summarizes many of the preceding papers in the discussion section.



Abe and foundation DFTB contributor Loren Yamamoto took a slightly different approach in a 2005 study; they reviewed 175 abdominal CTs to identify spinal canal depth at the iliac crest, deriving the formula of

LP depth (cm) = 1+ 17( weight/height).

Crucially, they went on to compare standard needle sizes to these depths to identify if the needle was too short or too long.

Defining the needle depth in this way has several benefits – firstly, it’s relatively prescriptive and secondly, it draws to attention the risks associated with using a needle that is too short (multiple punctures, anatomically impossible to reach the CSF), which amount to avoidable harm. In this context, it’s pertinent to know your tools. That is, identify which spinal needles are available in your department, their lengths and the type of tip.

LP needles are available in the following lengths (mm), depending on the brand, introducer, tip type: 25, 35, 38, 50, 64, 70, 75, 90, 103, 120, 150. Find the stock in your department  and see what’s there.

What about ultrasound?


The use of ultrasound to identify the depth of the spinal cord has been trialed in a number of papers; the two mentioned here were both produced from Addenbrooke’s Hospital in Cambridge, UK.

Firstly, in a neonatal population (105 neonates), weighing between 500g and 4500g, USS was used to measure median spinal cord depth (MSCD). They subsequently derived a formula of

LP depth (median spinal cord depth in mm) =  2(Weight) + 7 mm (R^2 0.76).

Subsequently, this nomogram was validated (albeit by the same author group and unit) in this study.

A later study by the same group undertook USS on 225 children aged 3m to 17 years presenting for echocardiography. The majority of patients were over 5 years of age. MSCD was identified as above, and a number of prediction models developed. The formula put forward by the group as satisfying the inherent tradeoff between accuracy (R^2 =0.72) and utility is

MSCD (mm)=0.4 W (kg)+20

So, does this change my practice? I will admit that I don’t have any of the above formulas fixed in my head, as yet.  Spinal needles in my hospital don’t have depth markings (it would be interesting to know if these exist). Instead, the above information serves to help in selecting a needle, particularly in those patients somewhere between neonate and adult sized. On this basis, I suspect I’m most likely to utilize formulae with weight as the single variable. I also went and re-read Ben Lawton’s post on champagne taps before the next one.

In summary;

  • Formulae are not yet in regular practice to identify needle depth for lumbar puncture.
  • We advocate increased awareness of the depth of the target structure, particularly when it comes to needle selection.
  • A needle can be too short, but it can’t be too long – it just becomes harder to use.

Peripheral Vasoactive Drugs

Cite this article as:
Pascoe, E. Peripheral Vasoactive Drugs, Don't Forget the Bubbles, 2017. Available at:
https://dontforgetthebubbles.com/podcast-of-the-month-peripheral-vasoactive-drugs/

This month’s Podcast of the Month is from paediatricemergencies.com.

In a 30 minute podcast aimed at the non-intensivist, Chris Flannigan (Paeds ICU Royal Belfast Hospital) discusses ‘push dose pressors’ and peripheral adrenaline infusions. He presents a simple and quick approach to the crashing kid on the ward who doesn’t have central access and isn’t responding to fluid boluses.

Do you know how to avoid reflex bradycardia in this situation?

After you have listened to DFTB’s own podcast, if you only squeeze in one more podcast this month, make it this one.

Listen to this podcast.

PETS knowledge

Cite this article as:
Andrew Tagg. PETS knowledge, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11497

When I’m not working in the emergency department, playing with my children or doing DFTB ‘stuff’ I work for the state retrieval service. As the name Adult Retrieval Victoria implies I spend my time moving and coordinating the movement of critically ill or injured adults around the state. There is a dearth of retrieval textbooks out there and so I was excited to see the Oxford Handbook of Retrieval Medicine make it into print.

Asthma for ambos HEADER

Asthma for Ambos

Cite this article as:
Andrew Tagg. Asthma for Ambos, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9592

Tonight I had the privilege to talk to the team at the Werribee branch of Ambulance Victoria. I was given the brief to talk on something to do with paediatric respiratory problems so I thought I would focus on one of their most common presentations – asthma.

Asthma is a common condition and affects one in ten Australians. Approximately 17.2% of all kids in Victoria have been diagnosed with it. The incidence in Aboriginal or Torres Strait Islanders is higher at around 20%. Whilst a large number of these will never need to go to hospital, of those that do go, 43% per cent need admission. This is much higher than their adult counterparts. A large number can be safely managed at home with their pre-written asthma action plan (though only 41% of kids under 15 years of age have one) but some children are more at risk of critical or life-threatening asthma than others. Fortunately, the death rate in the under 15-year-old sub-population is around 0.2 per 100,00 people.

Risk factors for a more severe attack include:-

  • A previous severe asthma attack requiring an ICU admission
  • Two or more hospital stays because of asthma in the last year
  • Use of more than two reliever inhalers in the last month
  • Exposure to tobacco smoke
  • Previous allergic rhinitis, food allergies or hay-fever

There is a seasonal peak in ED visits in late summer and autumn for children, whereas more adults present in the winter. This may possibly be due to the increased incidence of viral upper respiratory tract infections among grown-ups at this time of year.

Some people are more likely to call an ambulance than others. They include those with :-

  • Poor knowledge about asthma
  • No asthma action plan
  • Poor self-management skills
  • Limited access to primary care

Paramedics are very experienced in managing it because asthma is such a common condition. I want to focus on some areas where what should happen and what does happen might diverge.

Myth – Oxygen saturations are useful in the management of asthma

An acute attack is characterised by bronchospasm, coupled with mucosal oedema and hypersecretion of mucus. This leads to aV/Q mismatch as there is hypoxic vasoconstriction and decreased blood flow to the under-ventilated lung in order to match pulmonary perfusion with alveolar ventilation.

In the hospital setting, oxygen saturations of less than 91% may predict the need for prolonged bronchodilator therapy.

Hypoxaemia and hypocarbia only occur in the presence of life-threatening asthma. If you take into account the haemoglobin-oxygen dissociation roller-coaster it is easy to see how many children may teeter on the precipice of collapse before critical desaturation occurs. Whilst low oxygen saturations mean that a patient is unwell it should be clinically obvious at this point.  On the flip side, normal oxygen sats do not mean the patient is fine.  There is a concern that oxygen administration may lead to a delay in recognising clinical deterioration. Low oxygen saturations may also represent a degree of mucus plugging that may be helped with repositioning.

Hyperoxia can lead to absorption atelectasis as well as intra-pulmonary shunting with a subsequent reduction in cardiac output. As the 78% nitrogen in the alveoli gets washed out with increasing amounts of supplemental oxygen, tt is resorbed. This leads to a reduction in alveolar volume and collapse.

Myth – Nebulizers are better than spacers

A recent Cochrane review comparing nebulizers with spacers found that there was no real difference in hospital admission rate with either mode of delivery. Lung function tests and oxygen saturations were also unaffected by the mode of medication delivery. What was different, however, was the adverse effect profile. If you used a nebulizer you were much more likely to see tremor and tachycardia.

Old British Thoracic Society guidelines suggested using up to 50 puffs of salbutamol via spacer but this is probably a bit excessive.  The current recommendation is that 400mcg of salbutamol via spacer is probably equivalent to 2.5mg via nebulizer.

So do you know how to use a spacer? I took the Werribee team through the procedure.  If you are not sure then take a look at this great instructional video from Asthma Australia:-

Whilst spacers are cheap, those of you with the MacGyver instinct may want to make your own.

These jerry rigged spacers have certainly been shown to be as effective as conventional devices in resource poor settings.

Myth – You can never give enough salbutamol

Inhaled B2 agonists relieve bronchospasm and improve oxygenation.  The minor side effects that we have all seen include tremor, anxiety, headache, dry mouth and palpitations. If given, without oxygen, they have also been shown to cause or worsen hypoxaemia. Pulmonary vasodilation leads to a worsening ventilation-perfusion mismatch.

Inhaled salbutamol may also cause metabolic acidosis even when the mechanical work of breathing has been improved with paralysis and ventilation this still occurs. In the non-paralysed patient, the body compensates for this acidosis by increasing the respiratory rate to blow off the CO2. Be mindful that the tachypnoea in your asthmatic patient may be due to excess beta-agonist and not their asthma.

So how does one recognise potential salbutamol toxicity in the pre-hospital setting? Consider it in all children who are wheezy, restless, tachycardic and have had large doses of beta-agonist.

Normal doses of inhaled salbutamol have been shown to cause hypokalaemia but the clinical significance of this is unknown. Hypokalemia, coupled with worsening respiratory and metabolic acidosis can have catastrophic cardiac effects.

Myth – Adrenaline is dangerous in asthma

One of the most most obvious reasons for using adrenaline in the setting of apparent severe or life threatening asthma is that the diagnosis may be in doubt.  Asthma and atopy often co-exist. Patients with known food allergies and asthma are much more likely to die due to anaphylaxis than those without asthma.  A child with severe anaphylaxis may initially have no more signs than a wheeze and worsening air hunger that is mistakenly treated as asthma. The diagnosis of anaphylaxis should be considered in all who fail to respond to initial therapy.

Nebulized adrenaline may be helpful in acute asthma via direct beta adrenoceptor mediated bronchodilatation. It is possible that there are also some alpha effects via reduction in localized oedema and reduction in microvascular leakage. Small studies have shown no difference between nebulized adrenaline and nebulized salbutamol in terms of increased peak expiratory flow. The may also be less of a drop off in PaO2 due to the V/Q mismatch seen with salbutamol use due to alpha action.  In younger children, bronchospasm may be less of an issue than mucosal oedema.
Remember all inhaled therapies are ineffective if they don’t go anywhere. If the child is so tight that they can barely inhale then salbutamol or nebulized adrenaline are likely to be of benefit and so alternative route should be sought.  IM adrenaline can be given quickly to the critically ill asthmatic whilst IV access is obtained.  At the time of writing a clinical trial into the potential benefit of IM adrenaline as an adjunct to inhaled B2 agonists is recruiting in the US

Myth – If the child is wheezing, they have asthma

Around 17% of infants experience wheeze with the first three years of life. Not all of these end up with a diagnosis of asthma. By the age of 4-5 the incidence of wheeze is around 21.7% which is almost double the incidence of asthma (11.5%) in this population. By the school years, the incidence of wheeze and asthma are near identical.
Wheeze is characterized by “a continuous whistling sound during breathing that suggests narrowing or obstruction in some part of the respiratory airways.” With that definition in mind, there are a number of clinical entities that may cause a wheeze. There is a grey area between those children with obvious asthma and obvious bronchiolitis. Whilst bronchodilators would be appropriate in asthma a large Cochrane review found them to be ineffective in bronchiolitis.  Most clinicians would give a one-off trial of salbutamol as long as it did not interfere with other management.  There is also no evidence of benefit for the use of systemic corticosteroids in pre-school wheeze.  Other potential diagnoses to consider include inhaled foreign bodies, pneumonia or pneumonitis, tracheomalacia or complications of congenital conditions.

So the presence of wheeze does not guarantee that the child has asthma. It is also worthwhile mentioning that the absence of a wheeze does not rule it out either. If there is severe bronchospasm and mucosal oedema not enough air entry will occur to cause a wheeze

Selected References

Asthma in Australia: with a focus chapter on chronic obstructive pulmonary disease. 2011 Full text

Oxygen saturations are useful in the management of asthma

Mehta SV, Parkin PC, Stephens D, Schuh S. Oxygen saturation as a predictor of prolonged, frequent bronchodilator therapy in children with acute asthma. The Journal of pediatrics. 2004 Nov 30;145(5):641-5.

Inwald D, Roland M, Kuitert L, McKenzie SA, Petros A. Oxygen treatment for acute severe asthma. British Medical Journal. 2001 Jul 14;323(7304):98.

Helmerhorst HJ, Schultz MJ, van der Voort PH, de Jonge E, van Westerloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Critical Care. 2015 Aug 17;19(1):1.

Nebulizers are better than spacers

Zar HJ, Brown G, Donson H. Are spacers made from sealed cold-drink bottles as effective as conventional spacers?. Western Journal of Medicine. 2000 Oct;173(4):253.

Castro-Rodriguez JA, Rodrigo GJ. β-Agonists through metered-dose inhaler with valved holding chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5 years of age: a systematic review with meta-analysis. The Journal of pediatrics. 2004 Aug 31;145(2):172-7.

You can never give enough salbutamol

Tomar RP, Vasudevan R. Metabolic acidosis due to inhaled salbutamol toxicity: A hazardous side effect complicating management of suspected cases of acute severe asthma. medical journal armed forces india. 2012 Jul 31;68(3):242-4.

Yousef E, McGeady SJ. Lactic acidosis and status asthmaticus: how common in pediatrics?. Annals of Allergy, Asthma & Immunology. 2002 Dec 31;89(6):585-8.

Udezue E, D’Souza L, Mahajan M. Hypokalemia after normal doses of nebulized albuterol (salbutamol). The American journal of emergency medicine. 1995 Mar 31;13(2):168-71.

Starkey ES, Mulla H, Sammons HM, Pandya HC. Intravenous salbutamol for childhood asthma: evidence-based medicine?. Archives of disease in childhood. 2014 Jun 17:archdischild-2013.

Adrenaline is dangerous in asthma

Coupe MO, Guly U, Brown E, Barnes PJ. Nebulised adrenaline in acute severe asthma: comparison with salbutamol. European journal of respiratory diseases. 1987 Oct;71(4):227-32.

If the child is wheezing they have asthma

Ducharme FM, Tse SM and Chauhan B. Asthma 2: Diagnosis, management, and prognosis of preschool wheeze. Lancet. 2014. 383:1593-604.

Okpapi A, Friend AJ, Turner SW. Acute asthma and other recurrent wheezing disorders in children. American family physician. 2013 Jul;88(2):130-1.

Goldstein H, Tagg A, Lawton B, Davis T. Easing the wheeze. Emergency Medicine Australasia. 2015 Oct 1;27(5):384-6.

Gadomski AM, and Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews. 2014;6:CD001266

DFTB in Dublin – the Workshops

Cite this article as:
Tagg, A. DFTB in Dublin – the Workshops, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/dftb-in-dublin-the-workshops/

Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles.  Although the editors regularly chat online this was the first time Henry and I have met in person.

In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.

SMACCMini

With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us) we were excited to see what they had to offer. With a variety of lightning 10 minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.

Resuscitation update

Natalie May was our leatherette clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines.  Whilst little has changed in resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most.  Whilst a precipitous delivery in the department may be a rare event, it does happen.  Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear.

PEM literature update

Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of.

Approaches to spotting the sick child

The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would echoed by many speakers throughout the morning.  She took us on a choose-your-own adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery.  If you want to know more about the dangers of these deadly discs then take a look at her video.

Spotting sepsis early

Adrian Plunkett talked eloquently on the the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take home points to lock onto:-

  • Be worried if there is a change of state – they are not the same as they were yesterday
  • Be worried if this illness is like no other illness they have ever had

By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, keep the child in for a period of further observation.

Sick neonates are simple

Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected.  When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb.  By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.

Mistakes and pitfalls in critical care

Phil Hyde, who gave an excellent talk about the use of real children during simulation at last years conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful.  We have all been in a resuscitation when there is a palpable sense of half-repressed panic.  Voices are raised and critical instructions missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating.  By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.

This can be a challenge so there are things we can do to mitigate the internal stress. Cliff  Reid talks of using the high fidelity simulator that is our brain to visualize these high stress scenarios, before they happen.  That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t.  Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear.  He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.

Paediatric ultrasound

The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasound on children.  In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history.  Waving the magic wand is easy and can be taught in just four minutes.  It is certainly a skill that I am going to take home to my place of practice.(Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)

What paediatric surgeons wished you knew

The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of personal bugbears.  After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of  proper physical examination prior to imaging he put us in his shoes.  Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.

Paediatric toxicology

As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would.  Eschewing the usual list of one pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids’s. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.

Paediatric trauma

As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it.  Mechanisms of trauma vary with age from the drunken horse riding antics of teenagers, to younger children who skateboard in front of cars.  Paediatric trauma can be very confronting and how we approach our parents and their families can have a great impact on their long-term outcomes.

The SMACCmini superheroes

Appropriately caffeinated we headed back to the hall for another round of talks.

Excellence in critical care

Adrian Plunkett started off the session on a positive note.  Whilst it is easy to criticise bad practice it is much harder to praise the good.  He urged us to learn from the things we do well.  By actively promoting best practice within your network a culture of positivity and a ‘can-do’ attitude arises.  If you visit the Learning from Excellence website you can learn from others peer-reported episodes of excellence in practice.    Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.

Communication: Kids and families

We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved.  When harsh words are spoken it is important to have the emotional intelligence not to snap back, not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem.  Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.

Communication: Adolescents

Most of us know how to talk to children but, via the power of video, Thom O’Neill, spoke passionately about an issue we should all know more about- dealing with LGBT adolescents and youths.

Most traditional textbooks of paediatrics have yet to cover the subject and Thom gave us a useful framework to hang a conversation on, starting with recognising the child or youths right to be called what they want and to identify themselves how they want.  We hope to get Thom to write more on this subject for Don’t Forget The Bubbles. 

Resource poor settings

Nat Thurtle returned to the limelight to talk about her time working in resource poor settings.  Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we al stopped and reflected on how lucky we truly are.

Complex kids

After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology dependent children and their complex needs.  Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect.  As is nearly always the case in paediatrics – the parents know best, so listen.

Surgical surprises

Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.

Neonatal procedure tips

Having previous told us that looking after sick neonates was easy-peasy, Trish Woods then went n to teach us how. By focusing on the ABC’s of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation early vascular access as a means of giving fluids and adrenaline can save a life.  

Intubation tips

This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants.  We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to ones repertoire we should increase our chance of first pass success.

  • Use the shoulder bump
  • Use the jaw thrust
  • Change your position and look high

Ventilation tips

Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and and an SpO2 >92%. Attention to the simple things such as sedation, paralysis and monitoring can make all the difference.

Phil Hyde on the basics of neonatal ventilation

Patient experience

The final session of the day brought home to all of us in the room why we do what we do.  We heard from Emer, a brave 11 year old girl, who had spent 5 days in ICU with tracheitis, of her experience, both in the emergency room and in the unit.  Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words’. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues.  We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak.

The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better. If you came along to the workshop and took away something that will change the way you treat children (or their parents) then please feel free to comment below.

pablo

 

Sedation for transport

Cite this article as:
Andrew Tagg. Sedation for transport, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8397

One of your colleagues, Andy, has been lucky enough to grab a ticket to a prestigious international conference to be held in Dublin. He is thinking about taking his children but wonders how to keep them happy on the long international flight. He wonders if you have any tricks up your sleeve for keeping children calm during transit.

PAC conference – Long on High Flow Oxygen Therapy

Cite this article as:
Tagg, A. PAC conference – Long on High Flow Oxygen Therapy, Don't Forget the Bubbles, 2015. Available at:
https://dontforgetthebubbles.com/pac-conference-long-on-high-flow-oxygen-therapy/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

Topical anaesthetic creams

Cite this article as:
Andrew Tagg. Topical anaesthetic creams, Don't Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7762

Six year old Angela comes into your department with a three day history of diarrhoea and vomiting. You determine that she needs cannulation both to assess her renal function and to begin treatment. You know that cannulating children can be a painful and traumatic experience and are keen to make it as stress-free as possible. The nurses ask you what you would like them to put on the child?