Paediatric emergencies, stadium IID

The course is given by the Department of Paediatrics and the section for Paediatric Anaesthesia and Intensive care, St. Olav University Hospital and NTNU

Course management, autumn 2023: Professor Henrik Døllner (Paediatrics); Professor Eirik Skogvoll (Anaesthesia); Assoc. professor Thorstein Sæter (Paediatric surgery); Assoc. professor Kristine Grünewaldt (Paediatrics)

Background

Paediatric emergencies occur relatively often and consitute a large work load for general practicioners (GP) on call. While most situations are reasonably easy to handle;  providing care for critically ill children is a demanding task. We feel doctors should be prepared for paediatric emergencies for at least three reasons:

• For the child – to receive the best care at a crucial moment when time is limited;
• For the parents – to see that their child is taken care of in a professional way;
• For the doctor – to be prepared, and to be able to cope with even a poor outcome.

Proper communication between doctor and parents requires that the doctor can handle the stressful situation. Personal insecurity will be quite visible and can not be compensated for by resorting to ”psychology” or ”communication techniques". We aim to prepare the students theoretically and to a limited degree practically in order to work as on-call GP and intern (aka. house officer); not as a paediatrician or anaesthetist. The course is not compulsory, but we provide opportunity for all students to attend the skill stations.

Expected knowledge and skills to be mastered after the course

     * Efficient use of mask, ventilation bag and oxygen in respiratory arrest

     * Treatment of severe asthma and anaphylaxis

* Practical use of adrenaline in different settings (formulation/ dose/ administration - see below)

* Fluid therapy (type/ amount/ administration) in hypovolaemia

Modes of teaching

• Lectures, including slides and video demonstrations
• Lectures on fluid and electrolytes
• Problem based learning through case discussions in groups. The cases originate from any paediatric emergency situation, such as:

Asthma, accidental hypothermia, febrile convulsions, sepsis, congenital diaphragmatic hernia, anaphylaxis, epiglottitis, diabetes, laryngitis, hyperventilation/ panic attack, head injury, status epilepticus, airway obstruction, delivery during transport, dehydration , gastroenteritis, cardiac arrest, heart failure, drowning, non-accidental injury, trauma, adder snakebite, meningitis, pneumonia, premature birth, poisoning, inhalation injury, neonatal transportation, sudden infant death syndrome, pyloric stenosis, intestinal obstruction.

• Skill stations with training in neonatal resuscitation (led by neonatologists) and paediatric resuscitation (led by anaesthetists) are arranged thorughout the semester, according to separate plan for clinical clerkship.

Preparation for the course: literature review

International and European guidelines for CPR in children and neonates were updated in 2021. Consult http://www.cprguidelines.eu for the complete documents.

Current Norwegian guidelines are found here:

http://nrr.org/index.php/retningslinjer/norske-retningslinjer-2021

You may read the relevant chapters of the Paediatric textbook of your choice. Below are some links to relevant literature. Some are a few years old but still valid.

Tilnærming til det akutt syke barnet

(Approach to the acutely ill child. In Norwegian)
Trond Markestad
Tidsskr Nor Lægeforen 2001; 121: 608-11

Advanced Paediatric Life Support: A Practical Approach to Emergencies, Seventh Edition

Well-known, comprehensive textbook, which forms the core curriculum for the APLS courses that are arranged worldwide (www.alsg.org). In English.
Publisher: John Wiley & Sons (Wiley-Blackwell)
ISBN Number: 978-1-119-71613-6 (Print) / ISBN: 978-1-119-71617-4 (E-book)

Spotting the sick child

British website (free but requires registration) Includes videos, learning points etc. in relation to acutely sick children.

Establishing intraosseous access (video from The New England Journal of Medicine)

Use of adrenaline [= epinephrine] in various settings

Adrenaline for injection

Preparation:     1 mg/ml and 0,1 mg/ml (= 100 µg/ml, ”Katastrofe-adrenalin®”)

Indications and dosage:
Cardiac arrest:  10 µg/kg i.v.
Asthma and anaphylaxis: 5-10 µg/kg i.m. or s.c.  [not i.v.]

Adrenaline for inhalation

Preparation:      1 mg/ml

Indication:        Asthma, laryngitis, post extubation laryngeal stridor

Dose:              0,1 mg/kg in NaCl to 2-3 ml [i.e. 0.1 ml/kg, or 1 ml/10 kg, added to 2-3 ml NaCl]

Racemic adrenaline for inhalation

Preparation:      20 mg/ml or 22.5 mg/ml (depends on manufacturer)

Indication:       Asthma, laryngitis, post extubation laryngeal stridor
Dose:              0,2 mg/kg in NaCl to 2-3 ml [i.e. 0.01 ml/kg, or 0.1 ml/10 kg, added to 2-3 ml NaCl]

Organization of the case discussions

Students are divided into groups of about 6 to 10. You will have about 10 minutes to discuss the case from different points of view:

1. Basics: Aetiology, physiology/ pathophysiology, anatomy
2. Clinical: History, clinical examination, supplementary investigations (lab, X-ray, monitoring etc.), clinical management

The discussion is finally summed up in a plenary session, but we are currently experimenting with Team based learning techniques and Kahoot as well.

Feedback

Please tell us what you think about "Paediatric Emergencies". Former student initiatives have led us to make changes, both with respect to organization and to topics covered.