Category: Resuscitation

Categories
Resuscitation

ECPR

This episode of PEM Currents discusses ECPR (Extracorporeal Cardiopulmonary Resuscitation), an advanced procedure used in cases of cardiac arrest when traditional CPR fails. ECPR involves using ECMO (Extracorporeal Membrane Oxygenation) to take over heart and lung functions, offering a last-resort option that is becoming more common in large pediatric hospitals. While ECPR shows promise in improving survival rates, particularly in pediatric patients with conditions like congenital heart disease, it is resource-intensive and carries significant risks. Establishing an ECPR program requires robust infrastructure, multidisciplinary teamwork, and extensive training. The episode highlights the importance of understanding eCPR as a critical therapy for both in-hospital and out-of-hospital cardiac arrests.

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References

Gajkowski EF, Herrera G, Hatton L, et al. ELSO guidelines for adult and pediatric extracorporeal membrane oxygenation circuits. ASAIO J. 2022; 68:133–152. 

Stratton, M., & Edmunds, K. (2024). Extracorporeal Cardiopulmonary Resuscitation. Pediatric Emergency Care, 40(8), 618-622. 

ECC Committee, Subcommittees, and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(suppl):IV1–IV203. 

Yannopoulos D, Kalra R, Kosmopoulos M, et al. Rationale and methods of the advanced R2Eperfusion STrategies for refractory cardiac ARREST (ARREST) trial. Am Heart J. 2020;229:29–39. 

Bartos JA, Yannopoulos D. Starting an extracorporeal cardiopulmonary resuscitation program: success is in the details. Resuscitation. 2023; 187:109792.

Podcast: Play in new window | Download (Duration: 7:35 — 10.4MB)

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Categories
Resuscitation

Stress Dose Steroids

Your time is valuable and so is mine. That’s why I’m sharing brief, focused podcast episodes that will hone in on a single problem. This time, it’s stress dose steroids. Learn about how to give them and to not worry about tons of body surface area related math when you have a sick child in front of you.

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I am proud to offer CME and MOC Part II through Cincinnati Children’s for listening to my podcast. All you have to do is listen to these four brief episodes that were released in the last couple of months, and then complete the multiple choice questions at the following link. Note that registration is open to any provider seeking physician CME even if you are not a Cincinnati Children’s employee.

The link to the CME for these episodes are: https://cchmc.cloud-cme.com/course/courseoverview?P=0&EID=40150

The episodes included in this CME / MOC Part II program are:

Cannabis Hyperemesis Syndrome – 10/29/2021

Ovarian Torsion – 11/3/2021

Stress Dose Steroids – 11/9/2021

DVT 11/29/2021

That CME link again is – https://cchmc.cloud-cme.com/course/courseoverview?P=0&EID=40150

References

Huan D and Tat S. PEM Pearls: Hydrocortisone stress-dosing in adrenal insufficiency for children. Academic Life in Emergency Medicine. https://www.aliem.com/pem-pearls-hydrocortisone-stress-dosing-adrenal-insufficiency-children/ May 2, 2016

Miller BS, Spencer SP, Geffner ME, Gourgari E, Lahoti A, Kamboj MK, Stanley TL, Uli NK, Wicklow BA, Sarafoglou K1. Emergency management of adrenal insufficiency in children: advocating for treatment options in outpatient and field settings. J Investig Med. 2019 Feb 28. PMID: 30819831. 

Podcast: Play in new window | Download (Duration: 5:51 — 8.0MB)

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Categories
Resuscitation

Drowning

With the warm weather upon us here in the Northern Hemisphere it will soon be time for the pools to open. This episode is therefore incredibly timely, and focuses on the spectrum of submersion injuries and their management. Learn about drowning physiology, when to admit to the hospital, and how to assess the child who went under water unexpectedly but looks fine from this episode’s special co-host and producer, Joe Finney, MD a PGY-5 Pediatric Emergency Medicine and EMS fellow from Washington University in Saint Louis, MO. You can connect will Joe via email at Josephfinney@wustl.edu.

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References

A65. NICU, PICU AND CHRONIC VENTILATION. American Thoracic Society International Conference Meetings Abstracts American Thoracic Society International Conference Meetings Abstracts, www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A2198. 

Zuckerman GB, Gregory PM, Santos-Damiani SM. Predictors of Death and Neurologic Impairment in Pediatric Submersion Injuries: The Pediatric Risk of Mortality Score. Arch Pediatr Adolesc Med. 1998;152(2):134–140. doi:10.1001/archpedi.152.2.134

Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma. 2001 Oct;51(4):658-62. doi: 10.1097/00005373-200110000-00006. PMID: 11586155.

Gonzalez-Luis G, Pons M, Cambra FJ, Martin JM, Palomeque A. Use of the Pediatric Risk of Mortality Score as predictor of death and serious neurologic damage in children after submersion. Pediatr Emerg Care. 2001 Dec;17(6):405-9. doi: 10.1097/00006565-200112000-00002. PMID: 11753182.

Noel S. Zuckerbraun, Richard A. Saladino, Pediatric Drowning: Current Management Strategies for Immediate Care, Clinical Pediatric Emergency Medicine, Volume 6, Issue 1, 2005, Pages 49-56, ISSN 1522-8401, https://doi.org/10.1016/j.cpem.2004.12.001. (https://www.sciencedirect.com/science/article/pii/S1522840104000874)

Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2020 Oct 14:S0012-3692(20)34896-0. doi: 10.1016/j.chest.2020.10.007. Epub ahead of print. PMID: 33065105.

Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996 Sep;98(3 Pt 1):368-71. PMID: 8784358.

Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics. 1992 Dec;90(6):909-13. PMID: 1437433.

Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. 1997 Sep;112(3):660-5. doi: 10.1378/chest.112.3.660. PMID: 9315798.

Best RR, Harris BHL, Walsh JL, Manfield T. Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion. Pediatr Emerg Care. 2020 Mar;36(3):143-146. doi: 10.1097/PEC.0000000000001169. PMID: 28486266.

Davey M, Callinan S, Nertney L. Identifying Risk Factors Associated with Fatal Drowning Accidents in the Paediatric Population: A Review of International Evidence. Cureus. 2019 Nov 19;11(11):e6201. doi: 10.7759/cureus.6201. PMID: 31890403; PMCID: PMC6919957.

Habib DM, Tecklenburg FW, Webb SA, Anas NG, Perkin RM. Prediction of childhood drowning and near-drowning morbidity and mortality. Pediatr Emerg Care. 1996 Aug;12(4):255-8. doi: 10.1097/00006565-199608000-00005. PMID: 8858647.

Son KL, Hwang SK, Choi HJ. Clinical features and prognostic factors in drowning children: a regional experience. Korean J Pediatr. 2016 May;59(5):212-7. doi: 10.3345/kjp.2016.59.5.212. Epub 2016 May 31. PMID: 27279885; PMCID: PMC4897156.

“Almost 800 Kids Drown Each Year; More than Half Are Under Age 5.” Safe Kids Worldwide, 29 June 2016, safekids.org/press-release/almost-800-kids-drown-each-year-more-half-are-under-age-5.

“Drowning Prevention.” Services.aap.org, services.aap.org/en/news-room/campaigns-and-toolkits/drowning-prevention/.

“WISQARS (Web-Based Injury Statistics Query and Reporting System)|Injury Center|CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 July 2020, www.cdc.gov/injury/wisqars/. 

Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe PE, Quan L, Szpilman D, Wigginton JG, Modell JH. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style.”Circulation. 2003; 108:2565–2574. doi: 10.1161/01.CIR.0000099581.70012.68

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Categories
Resuscitation

Pulmonary Embolism

Yes, PEM Currents is a Pediatric Emergency Medicine podcast, but during the COVID-19 pandemic we may be tasked with seeing patients outside of our area of expertise. Plus, there’s a lot we can learn from big people that we can extrapolate to children. I have partnered with POPCoRN, the Pediatric Overflow Planning Contingency Response Network to deliver content that will benefit those of us who may have been asked to care for adults both in their native habitat, and in our pediatric facilities. David Shore, a 4th year Internal Medicine/Pediatrics Resident from Penn State delivers some timely content on PE diagnosis and management, including an instructive case of a young adult that is very applicable to the Pediatric Emergency Department in this brief, focused episode.

References

Aujesky et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011 Jul 2;378(9785):41-8. doi: 10.1016/S0140-6736(11)60824-6. Epub 2011 Jun 22.

Aujesky et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6. Epub 2005 Jul 14.

Kline et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55.

Stein et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest. 1991;100(3):598.

Wells et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001 Jul 17;135(2):98-107. PubMed PMID: 11453709.

Podcast: Play in new window | Download (Duration: 19:55 — 27.4MB)

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Categories
Resuscitation

Vasopressors

Vasopressor use in the Pediatric Emergency Department has been a moving target for my entire career. Back when I was a resident and fellow we used Dopamine. Then we went to epinephrine because it can be given through a peripheral IV because norepinephrine was too dangerous to run peripherally. But maybe that’s not entirely true. I talked about initial pressor choice and more in a recent recorded Zoom conference call with Critical Care Attending Matt Zackoff from Cincinnati Children’s. I hope you find his thoughts on vasopressor selection, pitfalls, and the emerging therapies as illuminating as I did.

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References

Sadoway et al. A systematic review of local complications from central and peripheral administration of vasopressors in the pediatric population. Canadian Journal of Emergency Medicine, 2019.

Surviving Sepsis Campaign: Initial Algorithm for Children

Weiss et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.Pediatr Crit Care Med. 2020;21(2):e52. 

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Resuscitation

Anaphylaxis: Admit or Discharge?

You will no doubt see a child with anaphylaxis in the Emergency Department. Recognition, management and disposition are all key questions that feel incredibly fluid at this juncture. I had the pleasure of interviewing Tim Dribin, an Emergency Medicine Attending from Cincinnati Children’s who recently published a paper in PLUS ONE focusing on admissions for children with anaphylaxis. Should we move the observation time from four to two hours? Who is most at risk for biphasic reaction? And how can we use data form kids that were admitted, and received no interventions, to inform practice in the ED?

Read the article from Dribin et al. right here! 

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References

Dribin TE, Michelson KA, Monuteaux MC, Stack AM, Farbman KS, et al. (2019) Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies. PLOS ONE 14(2): e0211949. 

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Resuscitation

Hyperkalemia

Hyperkalemia is more than just peaked T-waves on an EKG. Learn why an elevated serum potassium level can put patients in the danger zone and how to acutely manage patients in a goal directed manner.

Check out more great educational content on PEMBlog.com

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Podcast: Play in new window | Download (Duration: 13:11 — 12.3MB)

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Podcast Resuscitation

Rapid Sequence Intubation

This episode of PEM Currents, featuring Preston Dean – @prestonndean on Twitter, a senior Pediatric Resident at Cincinnati Children’s, is about all things Rapid Sequence Intubation. You’ll learn about equipment, techniques, drugs and more!

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Podcast Resuscitation Trauma

Management of Elevated ICP

Get ahead of your peers and listen to this episode of PEM Currents, the Pediatric Emergency Medicine podcast where you’ll learn all about the management of acutely elevated intracranial pressure. You’ll learn about common maneuvers such as optimizing the ABCs, Keeping the head elevated and midline as well as thermoregulation. I also discuss osmotic therapies and make the case for one agent versus another.

As always you can check out more great educational content at PEMBlog.com

Podcast: Play in new window | Download (Duration: 17:21 — 16.2MB)

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Podcast Respiratory Resuscitation

Interview with Ben Kerrey about Pediatric Rapid Sequence Intubation

Ben Kerrey is a rising star in Pediatric Emergency Medicine and is the point man for an ongoing initiative at Cincinnati Children’s centered around improving safety and limiting complications during rapid sequence intubation. I recently sat down with Ben to talk about the state of RSI in pediatric patients, the difference between a checklist and a a true cognitive aid, the role of residents during RSI and more.

You can check out several related articles right here – all provided by Dr. Kerrey.

A Modern and Practical Review of Rapid Sequence Intubation in Pediatric Emergencies

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

Response to the above article from Steve Green

The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View

Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department

Preoxygenation and Prevention of Desaturation During Emergency Airway Management

Podcast: Play in new window | Download (Duration: 25:08 — 23.4MB)

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