Author: rebecca isles

Moussa Issa

 

A&E Consultant, an accomplished author, a dedicated researcher, and a seasoned entrepreneur, he derives great satisfaction from his academic pursuits and aspires to disseminate medical expertise to underserved nations.

 

Foolish the doctor who despises the knowledge acquired by the ancients.
Hippocrates.

Minimal and Moderate Paediatric Sedation

The depth and type of sedation required in children depends on the procedure to be carried out.

Sedation is described as:

Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

Deep – Drug induced depression of consciousness during which patients are asleep and cannot be easily roused, respond to painful stimuli.

Dissociative – Ketamine Sedation produces a trance like state.

 

Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

 

Minimal and Moderate Sedation

Painless procedures such a diagnostic imaging do not require Ketamine or Opioids therefore drugs such as oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

Who can preform minimal/moderate sedation?

  • Senior medical staff (ST3+) with paediatric life support training
  • Must have done at least 6 months of anaesthetics/ICU
  • Familiar with giving medication of choice
  • Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
  • Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.

Contraindications

Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

  • Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
  • Raised intra cranial pressure or depressed conscious level
  • History of obstructive sleep apnoea
  • Major organ dysfunction including congenital cardiac anomalies
  • Moderate to severe gastro oesophageal reflux disease
  • Neuromuscular disorders
  • Bowel obstruction
  • Intercurrent respiratory tract infection
  • Known allergy to sedative drug / previous adverse reaction
  • Multiple trauma
  • Refusal by parent / guardian / child
  • Corrected age < 1 year because of severe prematurity
  • ASA 3 or more

Fasting

  • For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
  • Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
    • 2 hours for clear fluids
    • 4 hours for breast milk
    • 6 hours for solids and formula milk

Medications

Chloral Hydrate

Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

Dose: –

Minimal Sedation: 30-50 mg/kg Maximum 1g

Moderate Sedation: 100mg/kg Maximum 2g

Side Effects

Gastric irritation including nausea and vomiting reported.

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

There is NO reversal agent available

Buccal Midazolam

Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth

Dose: –

1-9 years:  0.2mg – 0.3mg/kg; Maximum 5mg

10-18 years:  6mg – 7mg; Maximum 8mg if 70kg or over

Side Effects

Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

Beware respiratory depression / hypotension / loss of airway reflexes at high doses.

Can lead to a distressing paradoxical excitement in children

Reversal agent: Flumazenil

Flumazenil dose: 10 microgram/kg [Max 200 microgram], repeat at 1 minute intervals up to 5 times.

 

Post sedation care

  • Observe for 1-2 hours until:
    • Conscious and responding appropriately
    • Able to walk unassisted (older children)
    • Vital signs are within normal limits
    • Respiratory status not compromised
    • Pain and discomfort addressed
  • No food or drink for 2 hours after discharge (risk of nausea and vomiting)
  • Supervise child closely for 24 hours no driving for older children
  • Give advice leaflet to parents/carer
  • Ensure that sedation documented on EPR and drugs are signed for in CD book

Full trust policy is available on intranet here

Non-Site Specific Referrals

This is the pathway for patients in whom there is a significant concern about malignancy or other serious pathology but who do not meet the pathway for a site specific referral e.g lung cancer pathway etc.

Patients must be haemodynamically stable and suitable for discharge from the ED to have their investigations as an  urgent outpatient.

Exclusion Criteria:
• Patient has specific alarming symptoms warranting referral onto a site-specific two week
wait pathway
• Patient is too unwell or unable to attend as an outpatient or needs acute admission
• Patient is likely to have a non-cancer diagnosis suitable for another specialist pathway
• Patient is currently being investigated for the same problem by another specialist team
• Please consider whether a referral to frailty might be more appropriate

How to complete the referral via EPR

Once referral is completed the team will pick it up and arrange further investigations.

Ensure the patient contact details on EPR are up to date and they know the team will be contacting them.

Intranasal Fentanyl

There is currently a national shortage of Intranasal Diamorphine therefore we are using Intranasal Fentanyl as a replacement.

Dose is 1.5micrograms/Kg for the initial dose and 0.75micrograms/kg 10 minutes later if required.

Drug Delivery

Draw up the appropriate dose plus 0.1ml to allow for the dead space in the Mucosal Atomizer Device

Attach the MAD to the syringe

Sit the child at 45 degrees insert MAD loosely into the nostril and press the plunger

Doses greater than 0.5ml should be split between 2 nostrils

 

Contraindications

  • Blocked nose due to upper respiratory illness or epistaxis
  • Respiratory depression
  •  Hypovolaemia
  • Altered consciousness
  • Hypersensitivity to fentanyl
  •  Children below 1 year old

Full Intranasal Fentanyl SOP

Obstetric Emergencies at HRI

Pregnant patients with Severe Life threatening conditions e.g serious trauma, cardiac arrest, serious medical condition

  • Manage as per ALS/ATLS/MOET guidance (Don’t forget uterine displacement manually).
  • Complete triage of patient and assess fetal gestation and viability. This is not primarily to assess fetal well-being but to influence maternal management
  • Obstetric/Gynae Registrar to be fast bleeped and to attend resus as soon as possible. If they are not contactable or unable to immediately attend, contact the on-call obstetric consultant.
  • Phone the midwifery LDRP coordinator on Tel 01422 223524
  • Senior midwife to accompany SpR.
  • Prepare resus area for emergency caesarean section (equipment in ED).
  • Call the obstetric consultant on call if not already done.
  • Contact the neonatal unit if delivery is imminent. (But do not delay delivery awaiting neonatal team’s arrival)

 

Pregnant patients with a major medical illness potentially requiring admission, e.g. severe asthma/suspected PE

  • Manage as per normal protocols for that condition.
  • Obstetric/Midwifery input may be required, therefore contact the LDRP Coordinator telephone 01422 223524.
  • Dependent on the clinical situation, appropriate specialty team to review and/or inform the consultant of admission.
  • Daily review/status check of the patient in relevant clinical areas.

 

Minor injury or medical illness not necessarily requiring admission, e.g. minor fracture or mild asthma attack

  • Manage as per normal protocols and treat as appropriate.
  • If there are no fetal or obstetric concerns, discharge as appropriate.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit( EPAU)
  • All pregnant women attending ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) as soon as possible.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a knock to the abdomen or abdominal pain or concerns or anxiety; then an antenatal review would be indicated by an obstetric/gynae doctor or midwife.
  • It may be appropriate for the women to be reviewed in ED or Maternity Assessment Centre (MAC) after discussion with a midwife, the obstetric registrar or SHO on call. If the woman is to be reviewed in MAC or other maternity areas she should be escorted to the area.
  • NB: have a low threshold for suspected thromboembolic disease and possibly escalate

 

Stable women with an obstetric problem with no other issues, e.g. labour, PV bleeding, abdominal pain, reduced foetal movements, raised blood pressure, or headache

  • All pregnant women attending with reduced ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) or Antenatal Day Unit (ANDU) as soon as possible.
  • Contact the maternity unit via the midwifery co-ordinator on LDRP Tel 01422 223524
  • Transfer to ANDU/MAC/LDRP as advised by above.
  • If the woman is to be reviewed in ANDU/ MAC/ LDRP she should be escorted to the area.
  • Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit (EPAU)
  • Ensure the woman has booked for maternity care. If she has not booked for care she should be asked to arrange the booking appointment

 

If these women have presented during working hours the on call registrar (bleep 509) can assess if the patient can be managed in ANDU at HRI depending on gestation and severity of symptoms. Out of hours contact MAC or LDRP at CRH.

 

Pregnant patients who have attempted suicide or presented with a psychiatric problem

  • Contact the mental health liaison team to come and review the patient
  • Psychiatric services to be contacted following the Guideline for. The Care of Pregnant Women Suffering Maternal Mental Health Problems available on the Intranet.
  • Associated injuries/illness to be treated appropriately as per previous categories.
  • If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of abdominal trauma or abdominal pain, call the obstetric Registrar on call for advice and possible review.
  • The on call team should inform the patient’s consultant or assign a consultant as per unit policy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to inform community midwifery team and Perinatal Mental Health Lead.
  • Antenatal follow-up (with community midwife or consultant as appropriate) appointment to be arranged within 10 days of discharge from hospital or psychiatric care.

 

Pregnant patients who present as victims of domestic abuse (suspected or confirmed)

  • Treat any injuries sustained as discussed depending on the category.
  • If there are any obstetric concerns, a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a trauma to the abdomen or abdominal pain; or concerns raised by the woman then please contact the maternity unit via LDRP for advice and possible review.
  • Safeguarding protocols should be enacted, even if this is her first pregnancy.
  • Contact the LDRP co-ordinator Tel 01422 223524 to ensure community midwifery follow-up
  • Provide support and information, explaining that violent assault by a partner represents a real potential threat to her life in the future, the willingness of police to protect her and the availability of domestic abuse support organisations
  • Please refer to the Trust Midwifery Domestic Abuse Guideline available on the Intranet.

Suspected Cauda Equina Syndrome CES

1. Red Flags: Has the patient developed any of the following?

  • Difficulty initiating micturition or impaired sensation of urinary flow
  • Altered perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horses’ saddle (subjectively reports or objectively tested)
  • Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  • Loss of sensation of rectal fullness
  • Sexual dysfunction (achievement of erection or ability to ejaculate, loss of genital sensation)

If Yes to ANY proceed to 2.

If NO to ALL consider other diagnosis and possibility of GP follow-up

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