Episode 35- An expert talks: PALS

Hello and welcome to episode 35 of ER RX in this expert talk series. We have Dr. Rebecca Gregg with us. Dr. Rebecca Gregg is a pediatric emergency room pharmacist at a large level 1P pediatric trauma center. Hi, Rebecca.

Hi.

Would you mind just introducing yourself to our audience?

Yes. Thanks for having me on. I'm really excited to be here. I graduated from the University of Arizona with my PharmD degree in 2009. This is actually a second career for me. I wanted to do something a little bit more meaningful with my life than what I was doing before. I started a pediatric hospital near where I live. It's the same one where my son had surgery when he was years old and where I gave birth to my two children. It's also an adult hospital. Two years after that, I started working as one of the very first emergency room pharmacists at the hospital where I'm at now. We were just starting our program there. There were two of us, and we covered 10 hours out of every 24 hours. And since then, our department of pediatric pharmacy has grown, and we now cover almost 18 hours out of the day, and they're the most important, busiest hours.

So I'm coming up on 10 years in March.

Well, congratulations. I know it's really hard to, you know, switch careers and especially going to a career like pediatric pharmacy, which, as you know, doesn't excite most of most of your other pharmacy colleagues, and which is a big reason why I brought you here today, because last week we Talked about the 2020 Adult AHA Guidelines on Cardiac arrest. And then this week, I wanted to focus on the pediatric aspect of that. And who better than a pediatric pharmacist to talk about this? I personally don't see too many of these. So thank you again for coming on the show and sharing your knowledge with us.

Absolutely. I know that pediatric pharmacy is very scary for a lot of people. None of my peers in my pharmacy school class were super excited about PEDs. So it's really good for us to be able to talk about all this today and try and make it a little bit less scary.

Absolutely. So to start and to kind of bridge the gap between adults and pediatrics, I just wanted people to be aware of that. There are some similarities between adult and pediatric patients. So the first one, one of the biggest guideline recommendations was giving epinephrine as soon as possible and ideally within five minutes. And the pediatric guidelines actually cite the fact that there's some studies out there that show that every minute delay in EPI administration led to worse rates of ROSC and survival. So that's one thing that both of the guidelines share in common, is getting that EPI in as quick as possible in your non shockable rhythms.

Also, for shock, refractory V fib and pulseless V tach, the pediatric guidelines also recommend amiodarone or lidocaine to be used in that situation. But remember that neither of these agents is associated with higher rates of ROSC or survival. And as a caveat, in the pediatric world, having a shock, refractory V fib or pulseless V tach rhythm is exceedingly rare. But I still think that it's worth mentioning. The other thing that they share in common is recommending against the use of some agents that we routinely give. And my favorite example is sodium bicarbonate. So just like in the adult world, the pediatric guidelines recommend against the routine use of sodium bicarb outside of the setting, of course, of hyperkalemia or sodium channel blocker toxicity, once again citing studies that showed worse outcomes with routine bicarb use. And then the same goes for calcium. So outside of the settings of hypocalcemia, calcium channel blocker overdose, hypermagnesemia or hyperkalemia, there's actually studies showing worse survival and ROSC with routine use of calcium. So please be mindful when you're thinking about giving these agents that necessarily would not help your patient. And then lastly, there's some guidance and some similarity between the recommendation for naloxone administration. So as we know, in the adult guidelines, they say that you shouldn't routinely give everybody naloxone and cardiac arrest. And I think we understand that. And the same goes in the pediatric world. The opioid crisis has not spared children and even neonates. So there is a strong possibility that respiratory arrest could cause cardiac arrest. But the guidelines say that outside of the setting of respiratory arrest, we shouldn't prioritize the administration of naloxone. We should still focus on quality CPR, calling 911, and shocking if it's a shockable rhythm. And that we shouldn't prioritize giving naloxone in this setting because there is no benefit in terms of ROSC or survival with just routinely giving naloxone. And although the pediatric guidelines don't specifically discuss flumazenil, I'm assuming it's the same in both adults and pediatrics, where, once again, you don't want to routinely give flumazenil in the setting of undifferentiated coma because this agent is associated with a lot of Lot of side effects. Rebecca, is there anything else that I've missed in terms of what you see as big similarities between the two?

No, I think those are the main points that are similar between the two. Yep.

Perfect. And now I'll kind of kick it on over to you. What are some major changes in these new pediatric guidelines?

So one of the biggest changes that I read in the guidelines and kind of wanted to look a little bit further into is they now recommend. So let me clarify. This is going to be for the pediatric cardiac arrest algorithm and it's going to be in patients who have an advanced airway. The recommendation previously was the same as for bls, which is one breath every second, six seconds. And they're changing that now for an advanced airway to be one breath every two to three seconds, accounting for age and clinical condition. And new data is showing that higher rates of ventilation are associated with higher ROSC and survival rates. And this was from a small multi center observational study of intubated patients that was sort of retrospective. They already looked at patients and what their rates were that they were getting. And this just seems to be in alignment with what normal respiratory rate is for pediatric patients, with it being higher than your typical 12 to 20 in infants and children. Once you get to adolescent age, it's much more similar to adult. And the next one is recommending a more tailored fluid bolus amount of either 10 or 20 or 10 to 20 mils per kilo, instead of just going with the usual 20 mils per kilo in the previous guidelines. I know that septic shock guidelines have come out in the last couple of years as well that have talked about how to treat. But this is nice that this is in there because we've always taken into consideration the age of the patient with neonatal maybe needing less fluids.

Children with cardiovascular problems. So usually that's our congenital heart patients would need less fluid and then potentially some of our renal patients. So it really, you know, 20 mils per kilo is still our standard, but honestly, it depends on why we're giving the fluids. You know, hypovolemia and dehydration versus septic shock versus something else and then who we're giving it to. So some may end up needing three boluses in the end that are 20 mils per kilo for a total of 60. But what we do is watch for signs of fluid overload and assess the patient after getting each bolus to make sure that there is not an increase in pulmonary edema or hepatomegaly or anything else. So just basically observing caution and knowing who you're giving it to.

Sure. And that kind of makes sense on taking that tailored approach, because, like you had mentioned, you know, when we talked previously, that a lot of these guidelines and these recommendations, kind of the answer a lot of times is it depends. Right. So it depends on the setting, and it depends on your specific patient population and the specific patient in front of you at that moment when you're talking about either fluid bolus volumes or rates of respirations.

Exactly. And that's my answer to my students and any new ED pharmacists coming in. It depends on a lot of things.

Right, right. So, yeah, And I think that's good to know, too. I mean, everything we discuss is taken with a grain of salt because every patient might be slightly different.

Right.

All right. And then the next question is, what are some key differences between adults and pediatrics who are in cardiac arrest?

Okay. So, you know, I recently went through acls, so I got firsthand, you know, rather than just seeing pediatric patients. And you see a lot of primary cardiac arrest in adults. That's very rare for us in kids. And when we do see it, it's either in some anomaly that we didn't know that a child had, or it's in one of our patients that have some congenital heart defect. But the primary reason for cardiac arrest in children, and I'll read this from the guidelines that I saw, is untreated progressive tissue. Hypoxia related to respiratory distress. Failure or shock is the cause of the majority of cardiac arrests that occur in children. So it's secondary to respiratory failure, and it's usually a progressive process. So we have a lot of places where we can intervene if we can catch it early. Some statistics about pediatric cardiac arrest is there's about 20 over 20,000 cardiac arrests per year in infants and children. 6,000 of them are in hospital cardiac arrest, where they just decompensated.

The thing about kids is they compensate very, very well until they just can't compensate anymore. If we see a child come in with respiratory distress, that looks like it's headed towards respiratory failure, we intervene very quickly and address any issues that we can so that we can prevent cardiac arrest.

There were some stats from 2015 where 11.4% of out of hospital patients survived to discharge. So it's very difficult for an out of hospital cardiac arrest to try to intervene and save those kids in hospital. The survival rate to discharge is 41%. So if they progress and arrest in front of us, we have an opportunity, a big opportunity to save their life. Some of the things one of my favorite sort of teaching tools to use for pediatrics is a patient with altered level of consciousness because it could literally be anything. And it could be one of those that could turn into arrest had they not gotten to us sooner. So ingestion, airway disease, like asthma, seizures.

Respiratory infections, drownings, trauma, all of that, it's really different what we get coming through our door in pediatrics.

Another big one is atropine. We hardly ever use atropine, and that's in the bradycardia protocol for ACLs.

You were asking about that. Do we give it and when do we give it? Just to note, in the pediatric bradycardia algorithm, both atropine and EPI are listed. EPI is listed first. So if you know nothing else. Epi, epi, epi in cardiac arrests and peds.

So atropine, you know, we'll rarely use it. I've seen it once in a stable bradycardic patient, occasionally for pre intubation in neonates. If we think it's going to be a prolonged intubation, we might have it on hand in case they brady down because of the vagal response when we're intubating. But usually if we can intervene in the airway, the patients usually will take care of it themselves. They'll rebound themselves without the need to give atropine. And then. So we talked before about the epinephrine. Epinephrine for cardiac arrest, but also for bradycardia.

This one, there was a study that was referenced From April of 2019 in the.

In the AHA guidelines, and it was published in circulation that looked at patients who were in the hospital who either came to the hospital in arrest or decompensated to cardiac arrest during their stay. And it was talking about the different results of giving, you know, starting CPR before they actually become pulseless. It's still pretty rare situation for us to actually start CPR if the patient has a pulse. But this was really interesting study to kind of take a look at that. In what instances that would happen for bls. Just looking at those guidelines, you know, if you've got. I'm trying to think of an example, right? So if you have a patient that you know, or a child that choked on something in front of you, and you're doing your back thrusts and front, front slaps, and then the patient becomes response non responsive, you're going to start cpr. So that might be an instance, like where they don't have A pulse. But like I said, there's so many things that we can do ahead of time in the inpatient scenario. And the key here is perfusion. We need to find a way to perfuse the body. And if they are progressing and we're taking care of their airway, we're giving them oxygen, they're intubated, and they're become brave to cardic and they're not perfusing, then that would be really kind of the only instance to. To consider starting CPR before you actually no longer have a pulse.

Sure. Yeah. And those are such interesting points for me. You know, I'm in the adult world and I don't see too many pediatric arrests, thankfully. But even going through, like, the PALS course and kind of going back to the atropine, one thing that I remember my PALS provider saying is that we should typically only use atropine if we cause the bradycardia. So, like, through suctioning or like intubation, Is that kind of a fair assessment of the overall atropine use in these children?

Absolutely. I mean, that's at least in the. From the ED perspective, that would be the case. And like I say, most of the time, the kids bounce back. We give them a second, you know, let the oxygen all catch up to them from the intubation and see if they can rebound on their own. But there have been times that I've drawn it up just to have on hand just as a. Just in case.

And haven't had a need to use it. So the only times I've really used it is in pre intubation, if we want to make sure that that doesn't happen. But that's becoming more and more rare.

Sure. Yeah. And then going back to the other thing that just kind of boggles my mind is in these pediatric patients who come in with bradycardia that we actually give epinephrine, like full dose epinephrine, which obviously we would never do in the adult world. But like you said, you know, sometimes you start CPR before you have to go that EPI route.

And so do you see that often where you're giving, you know, full dose epinephrine for. For kiddos that are bradycardic, or do you usually go the c, like, chest compression route first?

You know, honestly, we don't do really either.

Because, like I say, we're able to intervene. Why are they bradycardic to begin with? If it's secondary to some respiratory issue, which the majority of the time it is, we're Opening the airway. We're considering the H's and T's. Like we're, you know, do we need to give them Narcan? Was it an exposure that we didn't, you know, have in our differential originally? And then. But if a patient is decompensating in front of my eyes, I'm going to draw a bepi. Because like, like we talked about, the very best thing that you can do is get it in the system right away if a patient goes into cardiac arrest. So if I see that we're supporting their airway and they're bradying down, I'm going to grab it and have it ready. So we're all sort of all hands on deck anyway. And all these things sort of happen at the same time because we've got everybody there to help out.

Sure.

It's the benefit of being in a hospital.

Perfect.

Great. And then my last question was, what are just some common tips and tricks that you use that would be helpful for all of our listeners, be they providers, pharmacists and nurses that you use on a daily basis?

Okay. So the very first thing is we absolutely have to know the weight. You cannot put in an order as a provider in our hospital without having a weight in the computer, which is good and bad. Sometimes it's. They're totally blocked in cpoe. Yeah. So we have to know the weight. Now, how are we going to know the weight? Let's say that we get a call in and we know that we're getting a full code in a 1 year old child and they're coming and they're going to be there in five minutes. Now, if you don't deal with this very often, you know you're going to be panicked. Right. So you need to have something to go off of, like, what do I need to do to prepare? So you're not behind the eight ball when they walk through the door with this child and they're doing chest compressions on them. So there's a couple different methods and these were referenced in the AHA guidelines too, or at least links to articles about it. The hand heavy method is an age based method. And you use your hand looking at your hand. Each from the thumb to the pinky represents an age and a corresponding weight. So it goes up by twos for the age. It's 1 starting at your thumb, 3, 5, 7, 9. And then the weight starts at 10 kilos with your thumb and it goes up by 5 kilos. So 10, 15, 20, 25, 30. So 1 kilo or I'm sorry, a one year old baby, we would say 10 kilos now and then once you get beyond, you know, once you get to like age 11, we basically say 40 kilos and that's almost an adult. And in a lot of cases you can just go off of adult dosing. Obviously in pediatric world, we're very nuanced and specific and we don't necessarily generalize that way, but it's something to just keep top of mind if you don't deal with it a lot. The problem with this method is it's ideal body weight. And so, you know, it's not necessarily going to be accurate if your child is either, if the child's either cachectic or overweight. The next one is the braslow method. And this one, we actually keep the braslow tape, you know, pulled out in a sheet of plastic, hard plastic that's laid on the bed, always present, so we can quickly measure, get a weight and then set that aside out of our way. It's better than the hand heavy method and was equal along with parent report of weight. But again, it doesn't count for anything besides ideal body weight. And then of course, scales, we weigh everybody that can stand, we can weigh them in the bed as well, but that's not practical if you are doing active chest compressions or if you have a lot of equipment on the bed.

If you have a patient coming in, you say, okay, doc, can we go off of 10 kilos? Ask the physician or whoever is going to be in charge of the code what weight we're going to go off of. And then that way you can start to prepare ahead of time. What I do is I say, hey, does this sound like a reasonable weight to start with until we see them come through the door? And then I'll draw five epidoses right out the gate and label them and have them ready to go. And then as soon as the patient walks in the door, I find out, when was the last epidose given, was it given? And we go from there. The other thing for providers to know is don't be afraid of putting in an IO if it's going to take a lot of time to get an IV because they're hypovolemic and they're clamped down or they've been coding for a while, put in an IO. We've started that practice, you know, in the last few years, not being afraid to progress to that so that we can get that epidose in while another nurse is also putting in, you know, an IV we can also get out fluids and prep those if we know the weight, either putting it on a pressure bag or drawing the fluids out. And then we can also start to think of other things that we might need. Hypertonic saline, mannitol, an epidrip, that sort of thing. And then also anticipate what you might need. So your algorithms know them, know your dosing, and have your drugs easily available. And we also have all the weight based dosing sheets for code drugs on our code carts. There is a folder on every single one and you can pull out a sheet. So if we say 10 kilos, that's what we're going into the assumption of. And there's no need to sit there and do math because all of your doses for your codes are on that 10 kilo sheet. And it's under the understanding that that's what you're going off of unless the provider asks for something different. So that helps make it as smooth as possible and decrease the tension around trying to do math in the trauma.

In the recess room, which is a lot. It's like an extreme sport, right? Like trying to calculate your, your milligram dose and then your mils.

It is. And I got a couple, a couple tips on that one. The one I wanted to share about actually drawing up meds is we have this handy dandy rapid fill lure to lure connector that we fondly refer to as a spaceship.

Yeah, it kind of does look like a spaceship. I googled an image of it and I instantly saw why I got that.

Yeah, so it's red and it kind of looks like one of the spaceships from Star Wars.

But what you can do is so in the adult world, you just grab an abiget, pull it out of the box, put it together, hand it to the nurse, they push the whole thing done.

Yep.

In peds, we have a 10 kilo baby. Right. So we need 0.1 mls of epi per kilo. So that's 1 milliliter. And you've got this 10 milliliters Abidjax. So we hook it up together the same way, take off the top, attach the spaceship, and then we can get our 3cc syringes and draw out a bunch of doses about the have them labeled and handy right there. Which, by the way, we do have labels for all our common code drugs. On every med cart, we have a specific pharmacy med cart that's in the trauma bays. So we're able to quickly, you know, and they're color coded too, so that you can easily identify them. From anything else. So yeah, we'll be prepared with all of those.

Yeah, that's, that's a super useful one. I mean I know you guys have the spaceships. If people aren't familiar with what that is, different sites might have like what we have, which is the three way stopcock, which works the same way. You know, you put your abidject epinephrine together, you take off the yellow top and then you put the three way stopcock on top of that and then you plug in your like Rebecca was saying like a 3 mil or 6 mil syringe to the other end of it and you can just squirt some of that EPI into that syringe using that stopcock. And, and this is such, I think it's like one of the greatest inventions because if you're actually trying to pull out a dose of epinephrine from one of those abige using a needle and a syringe, it's almost impossible. I mean you got to go through that really heavy plastic, that blue plunger. And then to make things worse, once you actually start pulling drug out, the plunger actually moves up. So you get to a point where you'll never get the full 10 mils out. There's always going to be some leftover. So I see a lot of people, including myself, struggling with that aspect of it. And then the instant you mentioned something like a spaceship or a three or a three way stopcock, it just changes people's lives.

It really does. And being that we were new in the department back then, my colleague and I, some of these things we also learned the hard way.

Yeah, yeah. Oh I definitely learned that the hard way.

So. And then along that same note, if you're going to be doing a bolus for a 10 kilo child, you're not going to do hang a whole bag. Right. So we keep dispensing pins at the ready in the cart as well that we can put into, you know, we could spike a 1 liter bag with that. And then again you've got the Luer lock connection that you can draw out fluids into 60cc syringes. So I can pull those out and, and have it ready and hand to the nurse and relieve the bedside nurse from that responsibility. If you're absolutely. And if you're talking about a really small infant, we have been known to use saline flushes. There are 10 MLS apiece. If you have a kilo kid, you know, that's 5. Well, depending on your 10 to 20 milliliters bolus, that's 5 to 10 saline flushes. Sure. So for math tips, right, the epi is 0.1 mils per kilo. So knowing it in milliliters instead of milligrams is helpful. And that's the 1 to 10,000 concentration. Of course.

And you know, then I've learned a couple other tricks. Okay, so amiodarone, we rarely give, but that does happen to have the same math. Right. 0.1 mils per kilo with a 15 milligram per milliliter vial. Fentanyl. How much do I want to give? This isn't code specific, but kind of helpful. So if you have a 20 kilo kid, you take the weight, multiply by two, divide by 100. So a 20 kilo kid multiplied by two is 40, divided by 100 is 0.4 MLS.

For 50 microgram per milliliter concentration. It's easier than trying to take 20 and divide by 50. I mean that one's not so hard. But you know, if you're in a high stress situation, it's much easier to multiply by two and then just move the decimal point.

So and then intubations. We use Versed and ROC a lot of times in our more stable kids. So not necessarily codes. But it happens to be that if you use the 1 mig per 1 ML versed and then 10 per ML, it ends up being the same number of MLS. So you just can't stress enough to if you're dealing with more than one medication to make sure that you label it. So even if we're going off of a standard dose or kilo weight to at least have some distinguishing feature like our color coded scheme, you know, to be able to label the difference between those. Because obviously very important to give Roc after giving the first ed.

Yes.

Well, Rebecca, thank you so much for your time. Thanks for joining us. I know this is really educational for me and these are definitely going to be some tips that I'm going to start using in my practice right away. Hopefully I don't have to use them too often. I'm hoping that I avoid the pediatric cardiac arrests if I can, but any little thing helps and I think this was really useful for all of our listeners.

I appreciate your time. Thank you so much for inviting me. It's been an honor.