Mock Code

1. Mock Code By: Angelique Johnson, M.D.

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

3. Mock Code • 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

4. Mock Code 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

5. Mock Code • Question 2 What things are you looking at in your initial assessment of the child? • Airway/ Breathing: is there a patent airway with chest rise, are the respirations effective • Circulation: color of the child, perfusion, CR, pulses

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

7. Mock Code • Question 3 What to do next (order of reasonable priority)? 1) Airway – this does not equal intubating but means establishing an airway to maintain effective ventilation

8. Mock Code • Non invasive techniques for obtaining an airway: • Positioning • Shoulder Roll • Chin Lift • Jaw Thrust • Oral Airway • Nasal Trumpet

9. Mock Code 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.

10. Mock Code • 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

11. Mock Code • 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

12. Mock Code • 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.

13. Mock Code • 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.

14. Mock Code • 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

15. Mock Code • Complications of IO line placement: • Fracture at the site • Compartment Syndrome • Extravasation of fluid or medication • Osteomyelitis • Growth plate injury • Local Cellulitis

16. Mock Code 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 effect 2) Versed similar and a reasonable choice but has a shorter half life 3) Valium is the least preferred because of its long half life but short anticonvulsant effect

17. Mock Code • 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

18. Mock Code • Side Effects of Benzodiazepines • Respiratory • Decreased rate • Apnea • Laryngospasm • Cardiovascular • Bradycardia • Hypotension • Cardiac Arrest

19. Mock Code 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 ?

20. Mock Code • 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

21. Mock Code • 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

22. Mock Code • 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

23. Mock Code • 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

24. Mock Code • 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.

25. Mock Code • How to check for correct ETT placement • See the ETT go thru the cords • Auscultation • Condensation in the tube • ETCO2 • CXR

26. Mock Code 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?

27. Mock Code • 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

28. Mock Code • 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

29. Mock Code • 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

30. Mock Code 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

31. Mock Code 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?

32. Mock Code • Essential History to obtain • HPI • Fevers other illness symptoms • Time of onset and what exactly patient was doing • Trauma • Caretaker • Medications in the home

33. Mock Code • Past Medical History • Previous History of seizures • Medications especially anticonvulants and dosage changes • Family History • History of seizure disorders • History of children dying • Consanguinity

34. Mock Code • Physical Exam • Signs of NAT • Signs of Inborn Errors of Metabolism • Signs of Neurocutaneous disorders • This is a separate lecture

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

36. Mock Code 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.