Paediatric pieces for Prehospital practitioners

Cite this article as:
Jason van der Velde. Paediatric pieces for Prehospital practitioners, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32110

I’m one of those that see little humans as little humans and big humans as big humans and don’t buy into the whole angst that children are different. Some humans require small bits of kits and some require rather large bits of kit….

Now before I get hissed at by a sizable proportion of readers, may I place my views into context? This may go some way into keeping you engaged, and, perhaps, convincing you that an alternative approach to equipment management might indeed be applicable to your practice. I’m a rural Prehospital Emergency Medicine and Critical Care Retrieval Physician. I grew up in the ambulance and rescue services in South Africa and have been engaged in looking after humans of all shapes and sizes since 1992. I currently work in stunningly beautiful West Cork, which despite being on the edge of Europe, can feel like being in the Australian Outback when you’re 3 hours away from a hospital with a post-arrest neonate or an 8-year-old with polytrauma. The Trauma Centre I’m attached to in Cork City is exceptionally busy, with a mixed adult and paediatric caseload. Approximately a third of my personal workload is paediatrics; oh and I have 5 children under the age of 14.

COVID has brutally shone a spotlight on the CRM issues we face every day in acute care specialities;  particularly with regards to equipment and consumables management. Overnight we decluttered many of our cubicles, creating isolation spaces. Rooms that are devoid of anything that might possibly become “contaminated”. Rooms are just “rooms” and no longer “clinical environments”.  We’ve had to adapt and conscientiously think about what consumables we bring to the bedside. Whatever we don’t use will need to be thrown out and whatever we don’t bring in will result in a potentially adverse delay, whilst a runner goes to fetch it from a distant storeroom. Folks, the latter is nothing new to the high visibility brigade… Welcome to Prehospital Care in the hospital! 

I’ve recently gone through a major upheaval, totally rethinking my equipment lists and layout whilst bringing a new 258 brake horsepower 4×4 into service. I manage circa 500 patients every year in the field. Kit logistics is everything, given the distant storeroom is a hospital up to 3 hours away and Gardai (the Irish word for police) don’t like to be used as runners. I must confess that I’m pretty old fashioned with what I use, and I don’t like change. It’s probably because I’m used to carrying what I need on my back and started my career in a system that at the time had very little. 

I’ve been motivated by the wealth of novel kit management ideas that have evolved from COVID preparation freely shared by colleagues on Social Media. In my own department, we’ve adopted various “Packs” to bring into  “COVID Rooms” to both reduce waste and to re-create our “clinical environment”, albeit one patient at a time.  

Pre-packaged kits ready to grab and go

I was asked to write a prehospital post on “adapting kit for children” and to highlight how I “improvise for children”. Sorry to disappoint, I certainly don’t “adapt kit” for children and I certainly don’t “improvise” either. What I do is innovate, putting hours and hours of iterative design and experience into safe equipment governance regardless of the size, shape or dilemma a human might find themselves in. 

How often have you reached for the simple in-hospital ward transfer bag, only to realise you probably should have been making use of that gym membership, let alone the health and safety implications of a ridiculously heavy bag stuffed to the gunnels? When you carry everything on your back as part of your daily routine, you get very used to minimising not only packaging but bulk. We’ve effectively been doing this in prehospital care for years without really thinking about it. Modulising equipment by clinical task reinforces a minimalistic approach and dramatically reduces both waste and weight. My new iteration of equipment bags takes this into account whilst also the addition of tackling the COVID infection control dilemma. 

Equipment ergonomics is nothing new to paediatric practice. For example, having everything to hand in a logical order is the hallmark of successful phlebotomy in a squirming toddler. The MOST important thing to start with is to ask yourself what you need a kit bag to achieve? I have evolved the primary platform on a comfortable army Bergen, which is equipped to ONLY provide life and limb threatening care to a human from preterm to centenarian a few hours hike through a mountain trail. To achieve this takes an immense amount of preplanning. For me, this latest iteration has built on a prehospital career of over 25 years, with 12 years of Irish practice to adapt, and there’s still so much more to do. The hallmark of quality prehospital care is not cutting corners and not improvising. I have the exact same standard of equipment, monitoring and drugs that you would expect available in a trauma unit. Innovation comes through layout and the principle of packaging everything into procedure based modules.

Experience has proven that it’s counterproductive to have a little bag full of syringes and needles. You’ll either have too many or not enough. Think about each and every life-saving procedure, for example, a chest drain then break it down into individual component parts. Do you have everything you need? With just one flap open on my bag, I have everything I need to pre-oxygenate an infant. There’s an Ayres T-piece, HME, angle piece, and one of each size 1 to 3 facemask, plus a single 10ml syringe for letting air into or out of the facemask seal. I consider airway adjuncts to be a separate module. 

In prehospital care, you do not have the luxury of knowing the size of the next patient. In the picture of my opened airway module, you will note I’ve everything required to manage a human airway. Spot the vacuum sealed hand suction if you can! You may notice a lack of toys. Airway cameras fail in the cold and wet. I’ve not yet met one that’s West Cork proof. 

Working repeatedly in  “COVID positive” homes really wakes you up to the realities of how poor our infection control practices were. In the new system, each module is vacuum-sealed in a clean room, before going into the main bag. If a module is opened, everything, regardless of if it’s used or not, is either discarded or re-sterilized as appropriate. The outside packaging of an unused module is easily decontaminated with a simple wipe or UV light. The bag itself is washable. 

Kit unused in a bag that’s been touched repeatedly by contaminated gloves should never have been a thing in the first place. Think about it! When you’re sucked into the moment of treating a sick child, the last thing you appreciate is infection control. Solutions need to be human proof. We can’t simply just do what we’ve always done. I call it the RNLI test. If your kit and all its contents reliably can survive a winter trip to an Irish offshore island, lying exposed in the hull of an open rescue boat, you’ve achieved infection control packaging! This means EVERYTHING, down to the stethoscope and SpO2 monitor requires vacuum sealing. 

Another advantage of having everything vacuum sealed is that when you prepare your kit, you’re not rushed, and everything can be meticulously checked with a colleague, using a challenge-response checklist. When you open your kit in chaos, you can be confident that everything you need is there, laid out exactly the same way on a nice clean piece of plastic – and not a dirty floor. Disposing excess packaging reduces clutter around the patient. Whilst there is a cost associated with setting up such a system, there are savings too. You don’t end up throwing as much away. By using a checklist , you also have the ability to record the expiry date of a piece of kit on the outside of the module.  You can either opt for having a store room with all the various modules vacuum sealed on a shelf to simply replace, or like me, you have a number of fully stocked bags always ready to go. I chose the latter, with three identical bergens allowing me the “luxury” of being able to offer one bag per polytrauma patient at a rural Road Traffic Collision.

Monitoring has always been a bulky problem. The solution has come about out of a novel community defibrillation project we initiated in West Cork. We wanted to equip every single off-duty member of the ambulance service with a patient monitor and defibrillator in the back of their private vehicle. With these professionals on a text alert system, we are able to go a long way to achieving a 10min response time in rural life or limb-threatening calls. Even the cheapest patient monitor, that conforms to the standards, costs €20k. By modularising everything into a sturdy waterproof case, ie purchasing SpO2, 12 lead ECG, defibrillator, BP cuff individually, we produced the same monitoring and defibrillation standard, in a far more rugged pack for a quarter of the price. 

Moving forward, my single kit bag now includes all the monitoring and drugs required for an RSI or cardiac arrest, including waveform capnography and ECG! These are not new technologies, but smaller, cheaper items such as EMMA Capnography and Bluetooth-to-iOS ECG devices. I no longer have the heavy monitor or hands so full of equipment that I can’t safely climb a flight of stairs, let alone reach a child trapped in a mindboggling place! It helps create that clinical environment in a non-clinical area. If further “next step” critical care retrieval paraphernalia is required, such as a ventilator, blood warmer or syringe driver,  this can be brought out from the car. 

But why on earth would all this be relevant to a paediatrician or paediatric nurse in an average hospital who may or may not ever have to retrieve or transport a sick child anywhere further than radiology? 

Around the corner, around the world” is a philosophy that defines risk in retrieval medicine. It’s not distance, but the very act of transferring a patient from one place to another that carries the risk. Most people are worried about a cardiac arrest en route. What will you do today if that cardiac arrest was caused by an infusion line, chest drain or endotracheal tube dislodging in transit in that unfamiliar, non-clinical space? The riskiest time is just transferring a patient across the bed to the trolley, radiology table or theatre table. After that, my least favourite place to be is an elevator or crowded corridor. Ask yourself the most basic and simple safety question… Is the equipment bag that accompanies me fit for purpose to provide critical care support to this little patient in an elevator? 

Neonatal intubation: Shabs Rajapaksa at DFTB18

Cite this article as:
Team DFTB. Neonatal intubation: Shabs Rajapaksa at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17490

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

Mechanical CPR in children

Cite this article as:
Andrew Tagg. Mechanical CPR in children, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11177

Sometimes a single tweet can stir up something deep inside me that I want to know the answer to.  This time it was Jim DuCanto, airway guru.

Since this is a blog about paediatrics I won’t go into my opinions about mechanical CPR (mCPR) in grown ups. I’ll leave it to Robbie Simpson to rant for me. I have very limited experience in its use which really leads to opinion based rather than evidence based medicine.

My limited experience

I have been at the airway end when it was used as a bridge to ECMO and the cath lab in a case of VF storm in a man younger than me. He walked out of the hospital neurologically intact (N=1). I have also seen many, many dead – if not for the rhythmic mechanical thumping on the chest – that I have had to pronounce when they get to hospital instead of them being left in their own home/residential facility.

Cardiorespiratory arrests in kids are rare with an incidence of around 1-20 per 100,000 person years. The majority are respiratory or due to progressive circulatory shock and occur when physiological compensation can no longer occur. Other than a few rare instances cardiopulmonary resuscitation is liable to be futile. One large study of paediatric arrests found that of those children transported to hospital by EMS survival to discharge was 7.8% (3.5% of infants, 10.4% of children and 12.6% of adolescents). According to the ROC Epistry – Cardiac Arrest the incidence of a shockable rhythm was 4-5% in infants and 15% in adolescents.

 

Jim posited that mCPR might buy staff breathing room to plan interventions, but the intervention that is most likely to be effective is airway control and ventilation.

Both devices in current use – the Autopulse and LUCAS-2 – specifically mention paediatric arrests as a contraindication to use. And it is easy to see why. With such variability in sizes it would be near impossible to build a machine that could work on every size of child. So is there an alternative?

Perhaps, rather than relying on technology to do our job better we should focus on incremental gains – doing the basics well.

 

Airway

Even in a large Melbourne quaternary paediatric centre endotracheal intubation is a rare event with only 71 reported events over a one year time period. The majority of these were due to trauma or status epilepticus rather than cardiac arrest. Even then, the first pass success rate was 78%. Other studies have shown an even lower incidence of first pass success when video review was used. They also are associated with prolonged pauses in CPR. You might think that using video laryngoscopy might improve things but that doesn’t seem to be the case in simulation based studies.

 

Breathing

Once the tube has gone through the cords we often breath a sigh of relief. If you are anything like me you may have been holding your breath for the attempt and there is a tendency to hyperventilate the patient. A review of simulated paediatric codes found that every single one of them ended up with the patient being bagged around a rate of 40 breaths per minutes rather than the recommended 8-20 breaths. If we want to up our game perhaps we could consider adding an impedance threshold device. These valves attach to the endotracheal tube and limit air entering the lung during the passive expansion phase. This creates a reduction in negative intrathoracic pressure thus improving venous return.

 

Circulation

There still seems to be a fear, amongst some healthcare providers, of inserting an intraosseous needle.  It can be confronting, crunching through the outer cortex of bone, but it can (and should) be completed in seconds.

 

High quality chest compressions

Most studies of paediatric CPR involve small numbers of patients and the heterogenous nature of the circumstances surrounding the arrests make it difficult to combine the data in a meta-analysis. The higher quality studies rely upon video review of the events rather than bystander or scribe feedback. A number of common themes emerge. Chest compressions are performed more slowly than recommended around 10% of the time and too fast around 44% of the time. Once simple low-tech way of improving this is the use of a metronome (or a metronome app if you are so inclined).

We are used to practicing CPR on adult mannequins and know how far to compress the chest. This is less obvious in children and we have a tendency to lean on the chest during the decompression phase. Force transduce/accelerometer technology can provide real time feedback

It’s hard to get real time feedback regarding the quality of compressions and so practitioners could take a leaf from the world of adult resuscitation and use end tidal CO2 as a surrogate marker for perfusion.

Low dose, high frequency training can help staff retain their skills. Rather than mandated tri-yearly refresher courses, brief booster training has been shown to be equally as effective in improving skill retention.

One other effect of technology has not been considered. It is that it removes us from our patients. It distances us at a time when our empathy needs to be at its greatest. When CPR fails (and it will) how will we feel if we had done everything, using a machine to pump on the chest? Would we feel better or worse than if we had laid on hands? Would it make our young patient more of a person, of a life lived, or less, in our eyes?

 

So how can we create a calmer resuscitation? Come to DFTB17 and listen to Tim Horeczko to find out.

References


Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA, Resuscitation Outcomes Consortium Investigators. Epidemiology and outcomes from out-of-hospital cardiac arrest in children. Circulation. 2009 Mar 24;119(11):1484-91

Leman P, Morley P. Review article: Updated resuscitation guidelines for 2016: A summary of the Australian and New Zealand Committee on Resuscitation recommendations. Emergency Medicine Australasia. 2016 Aug 1;28(4):379-82.

Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Pediatric Anesthesia. 2014 Dec 1;24(12):1204-11.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine. 2012 Sep 30;60(3):251-9.

Niebauer JM, White ML, Zinkan JL, Youngblood AQ, Tofil NM. Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies. Pediatrics. 2011 Nov 1;128(5):e1195-200

Schuerner P, Grande B, Piegeler T, Schlaepfer M, Saager L, Hutcherson MT, Spahn DR, Ruetzler K. Hands-off time for endotracheal intubation during CPR is not altered by the use of the C-MAC video-laryngoscope compared to conventional direct laryngoscopy. A randomized crossover manikin study. PloS one. 2016 May 19;11(5):e0155997.

Milander MM, Hiscok PS, Sanders AB, Kern KB, Berg RA, Ewy GA. Chest compression and ventilation rates during cardiopulmonary resuscitation: the effects of audible tone guidance. Academic Emergency Medicine. 1995 Aug 1;2(8):708-13.

Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics. 2011 Jul 1;128(1):e145-51.

Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detector during pediatric cardiopulmonary resuscitation. Pediatrics. 1995 Mar 1;95(3):395-9.

Can’t intubate, Can’t Oxygenate

Cite this article as:
Andrew Tagg. Can’t intubate, Can’t Oxygenate, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9814

Paediatric critical procedures are rare in the emergency department. Data from one Victorian network showed that 83% of emergency physicians had not performed one in a twelve month period. We also know from audit data that we seem to have a lower first pass success rate (around 78%) when it comes to paediatric intubation. We can put in a lot of strategies to increase the chance of first pass success but what happens if you get into a ‘Can’t Intubate, Can’t Oxygenate” (CICO) scenario?

Polly put the kettle on… and poured a cup of tea

Cite this article as:
Amie Beattie. Polly put the kettle on… and poured a cup of tea, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9038

Jack, a 2 year old boy, is rushed into the Emergency Department by his distraught mother, Polly. She had just poured a cup of tea and prior to adding milk, Jack reached up to the kitchen table, pulling the tea toward himself and sustaining a burn to his neck and chest. You recall an article that was presented at Journal Club recently – ‘Airway compromise in children with anterior neck burns: Beware the scalded child’, and you wonder what to do next….