Thanks to everybody who commented and contributed to the discussion on our final “Flight!” If you missed out on the case, check it out here. Below you’ll find a curation of the comments to each question and a podcast with expert commentary from Jenn Lakeberg, APRN. This was the final “Flight” for this spring/summer. Look for the cases to return again in January 2016 as we begin Flight MD Orientation with the next class of future Air Care Flight Docs.
The Gist of the Case
You are on a scene flight responding to a 3 year old male with seizures. On your exam you note a 3 year old male, appropriately developed with a large hematoma over his occiput, asymmetric pupils, and currently having seizure activity. His respirations are currently being assisted with BVM ventilations.
P: 145, BP: 100/65, RR: 38, O2 Sat: 86% on BVM, Glucose: 114
On to the Questions!
Are there any immediate procedures that need to be performed? Are there any medications that need to be given immediately? What if the child is still unresponsive after benzodiazepines?
With ongoing seizure activity and the O2 saturations of 86% despite assisted respirations, the commenters focused on a couple of key procedures and actions that need to occur in the acute management of this patient. 1.) Stop the seizures - Dr. Thompson and Dr. Renne both stated that quickly establishing vascular access through an IO would allow quick administration of a benzodiazepine. While establishing intraosseous access is fast (should take <1 min), Dr. Gorder pointed out that IM administration of a benzodiazepine should be considered as IM administration has been shown to be equivalent to IV administration (see Silbergleit, et al, 2012). As she points out, if given an accurate weight and information about continued seizure action, you could pull up the med prior to landing on scene and administer the benzo of your choosing in seconds.
As pointed out by most, the treatment for status is going to be benzos, benzos, and more benzos. But what happens when the benzodiazepines just don’t work. There were several excellent suggestions brought up. Dr. Gorder recommended propofol as a second line agent that we carry on the helicopter. Propofol is an appropriate second or third line agent for status with loading doses of 1 mg/kg repeated every 3-5 min until response up to a max of 10 mg/kg (see Lee, et al 2011). Propofol is not without its downsides however. In the acute phases of administration, hypotension and loss of respiratory drive are well known complications. Prolonged use (>48 h) is also associated with propofol infusion syndrome which is characterized by the development of severe metabolic acidosis, cardiac dysrhythmia, and circulatory collapse. As suggested by Dr. Renne and Dr. Qasim, ketamine is yet another medication to consider for refractory status epilepticus. There is animal data and limited human data that ketamine is effective as an adjunctive agent in the treatment of refractory status epileptics (See Synowiec, et al 2013). It obviously also has an extremely favorable hemodynamic profile as compared to propofol.
If you decide to intubate this child, describe what medications you would use for rapid sequence intubation and sedation? Would you place the child on the ventilator and how would you determine tidal volume and rate?
In assessing this patients airway, all commenters felt as if the patient would require intubation. Flight Nurse Diana Deimling did a superb job laying out the steps need to properly prepare and pre-oxygenate the patient.
“With this Sp02, I would re-position the airway into a sniffing position + add a NPA & bag better w 100% 02. If not immed. Improvement - add PEEP. *Remember CS immobilization w ? trauma…. Add NC for Apneic Oxygenation, Suction, 4.0, 4.5 & 5.5 cuffed ETT’s + stylet (size 10fr), Pedi bougie, #2 laryngoscope blade,#2 iGel, Set up ETC02 + turn on, Trach Tape. Assure as close to 100% Sp02 for 3 mins prior to intub attempt”
Several commenters recommended pre-treatment with either fentanyl or lidocaine. EMLyceum did a nice job of summarizing the literature on this subject. In short, there is no excellent literature to say either way whether or not these medications are effective at blunting ICP elevations with direct laryngoscopy. That being said, both agents would be recommended by at least one of the major airway textbooks (Walls, Manual of Emergency Airway Management).
In terms of medications for induction and paralysis, most commenters were leery of rocuronium as the paralytic in this patient. The concern for masking ongoing seizure activity outweighed any potential benefit from rocuronium in the minds of most commenters. As for induction, a number of agents were suggested including etomidate, propofol, and ketamine. As mentioned above, ketamine and propofol have the potential to further treat or mitigate seizure activity. Etomidate is hemodynamically neutral and a perfectly appropriate choice as well. Thanks to Dr. Qasim for pointing to an excellent review of recent HEMS-based research on RSI from the folks over at The Bottom Line.
Would you be concerned for elevated ICP on this child’s exam? What medications, maneuvers, and strategies would you consider to mitigate this?
All of the commenters were concerned about elevated ICP (asymmetric pupils, decreased GCS). Hypertonic saline is one of the treatments for elevated ICP available for use on Air Care. Pediatric dosing is 8 ml/kg and it can be administered either IV or IO. But administration of hyperosmolar therapy is not the only treatment or management consideration for elevated ICP. Eucapnia, Normotension, Normoxia, and adequate analgesia and sedation are the goals of treatment for patient’s with elevated ICP. Further interventions that should be taken during transport include:
Elevation of head of bed (can use towel rolls to raise backboard if the child was boarded and collared)
Continuous EtCO2 with goal EtCO2 of 30-35 mmHg
Maintain patient on the ventilator (more consistent and better tolerated than bagging)
Treat pain and give sedative medications (Fentanyl, benzodiazepines, or propofol are all appropriate. Ketamine is also an option but would require approval from medical control)
The parents show up on scene as you are about to move the child to the stretcher and are insistent to fly with the child. Are you concerned for non-accidental trauma? Do you let them fly with you or how do you explain to them that you are denying them the ability to fly with their sick child?
The decision to transport or not to transport a parent for a pediatric flight can be complicated and, occasionally, heart wrenching. The first priority on any flight is the safety of the crew. Parents that are extremely distraught could very well be a danger to the crew once in the air. As pointed out by Diana Deimling, placing the parent in the jump seat immediately behind the pilot is generally the safest place, allows them to easily see their child, and still allows the medical crew treat the patient in flight. The decision to fly or not fly a parent should be a collaborative one between pilot, flight nurse, and flight MD/APN. The factors that go into that decision include:
Mentality and emotional state of parent
Weight of the parent and weight of the patient
Fuel load of the helicopter
As you can see several of these are known only by the pilot. Ultimately they have the final word on who can or cannot ride along on the helicopter. In general, however, whenever possible and safe we should try to have parents ride along to the hospital. If they are unable to fly along you can talk with EMS or police on scene and see if someone would be willing and able to give them a ride to the destination facility (in our case CCHMC).
Take a listen to the podcast below or listen on iTunes!
Robert Silbergleit, M.D., Valerie Durkalski, Ph.D., Daniel Lowenstein, M.D., Robin Conwit, M.D., Arthur Pancioli, M.D., Yuko Palesch, Ph.D., and William Barsan, M.D. for the NETT Investigators. N Engl J Med 2012; 366:591-600 February 16, 2012 DOI: 10.1056/NEJMoa1107494
James Lee, MD, Linda Huh, MD, Paul Korn, MD, FRCPC, Kevin Farrell, MBChB. Guideline for the management of convulsive status epilepticus in infants and children. BCMJ, Vol. 53, No. 6, July, August, 2011, page(s) 279-285 — Articles.
Kam, P. C. & Cardone, D. Propofol Infusion Syndrome. Anaesthesia. 2007. 62 (7) 690-701. PMID: 17567345
Synowiec, A., Singh, D. Yenugadhati, V., Valeriano, J., Schramke, C. & Kelly, K. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Res. 2013. 105 (1-2): 183-188. doi: 10.1016/j.eplepsyres.2013.01.007. PMID: 23369676
EM Lyceum. Rapid Sequence Intubation, Episode 1: “Answers”. 2011. http://emlyceum.com/2011/07/26/rapid-sequence-intubation-episode-1-answers/ Retrieved on 6/19/15.
The Bottom Line. Lyon: Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital anaestheia. May, 2015. http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=7431476198033151752 Retrieved June19, 2015.