ED consultant, Visiting Professor, Associate Dean at NHS England, and also President of Resuscitation Council UK.
“We are all stories in the end – just make it a good one”, Matt Smith (Dr Who)
ED consultant, Visiting Professor, Associate Dean at NHS England, and also President of Resuscitation Council UK.
“We are all stories in the end – just make it a good one”, Matt Smith (Dr Who)
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.
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
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.
Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:
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: 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.
Full trust policy is available on intranet here
If anybody is symptomatic after button battery ingestion they need referral to the Surgical team for urgent endoscopic removal Read more
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.
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
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.
Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.
Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions. These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.
Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.
Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.
Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.
AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.
Try to obtain a history of what and how much has been concealed
Look for toxidromes suggestive of package leak –
ECG
Body Stuffers should be observed for signs of toxicity for a minimum 6 hours, consider activated Charcoal
Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.
Toxidromes should be treated as per toxbase guidelines Toxbase
Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.
Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines