Grand Rounds Recap 9.13.23

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

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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

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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

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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

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