Grand Rounds Recap 9.13.23

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EKG QUICK Hits: electrolyte abnormalities - air care grand rounds - pediatric pain and procedural sedation

EKG Quick hits: electrolyte abnormalities WITH Dr. Baez

  • Potassium

    • Hyperkalemia

      • Peaked T-waves (there is tall and spiked T-waves, that you “wouldn’t want to sit on”)

      • PR interval increases

      • Widening of the QRS

      • Can lead to a sine wave

    • Hypokalemia

      • T wave widening/flattening

      • T wave inversion and U wave (upward deflection after the T wave)

  • Calcium

    • Hypercalcemia

      • Shortened QT interval

      • Osborn wave (positive deflection seen at the J point)

    • Hypocalcemia

      • Prolonged QT

  • Magnesium

    • Hypomagnesemia

      • Prolonged QT/PR

      • Ventricular ectopy

air care grand rounds WITH dr. tillotson

  • Inhaled therapies administration 

    • Air Care team can administer epoprostenol, as well as albuterol and duonebs

  • You may set up to administer inhaled bronchodilators on the ventilator prior to placing the patient on the vent

    • As well as adding them to the vent circuit later in the patient’s course

  • Velitri (epoprostenol) is a continuous inhaled medication targeting the prostaglandin pathway to treat pulmonary HTN and ARDS

    • It requires placement on the infusion pump as it is dosed in nanograms and improper dosing can cause hypotension

    • The infusion pump is then administered via the Aerogen system

  • Do not start unless able to transition to another pulmonary vasodilator on arrival to the receiving facility

  • Dosing is based on ideal body weight. Protocol is in the veletri/epoprostenol case (as well as on the Metro app)

  • Videos are forthcoming to TamingTheSRU to help review the veletri/epoprostenol set-up on Air Care

pediatric pain and procedural sedation WITH Dr. chang

  • Timely and effective multimodal pediatric pain control:

    • Improves procedure rates

    • Prevents need for repeat attempts

    • Improves patient flow in the ED

    • Improves patient/caregiver satisfaction

  • Categories of multi-modal pain control

    • Physical

      • Rocking, tucking, swaddling

      • Oral sucrose, cold/hot packs

    • Distractions

      • Music, bubbles, videos, conversations

      • Concept of “one voice” where only a single patient talks directly to a patient

    • Medications

      • Various classes of medications can be used (see the tables below)

  • Various depths of sedation

    • Minimal: normal responses to verbal stimuli

    • Moderate: purposeful responses to verbal/tactile stimuli

    • Deep: purposeful response to noxious stimuli

    • General: patient can’t be aroused and need assistance to maintain airway (typically performed in the OR)

  • Preparing for a sedation

    • Pre-sedation assessment of patient

      • ASA class assess patient’s co-morbidities and determines if patient is likely safe for sedation in the ED

        • Typically can sedate ASA I and II in the ED

      • PHM, prior anesthesia history, allergies, last food intake

      • Mallampati score

    • Preparation of equipment

      • Cardiac monitor, SpO2, capnography

      • Oxygen

      • Airway adjuncts

      • Suction, BVM

    • Preparation of medication

      • Various class of medications that are typically used in pediatric sedations

        • Analgesics: treat pain

        • Anxiolytics: reduce anxiety

        • Hypnotics: induce sleep-like state

        • Dissociate: interfere with consciousness

        • Choosing the right medication

      • Need to consider the best medication to use for the type of procedure being performed

        • Consider the route of administration, timing of onset, duration of medication effect, as well as the drawbacks of the specific medication