Podcast 076, Severe Pediatric Trauma With Dr. Michael McGonical, June 24, 2012 by Dr. Scott Weingart of EMCrit. [This link is to the podcast and show notes.]
The information on how to safely place a chest tube in pediatric patient is invaluable. But it is only one of a number of great tips. You can’t review this podcast too often.
Dr. McGonical’s instruction on how to safely place a pediatric chest tube is contained in the first nine minutes of the podcast. So I have embedded a link to the podcast.
IV access in critically ill pediatric patients often requires an intraosseous line placement. And yet when we review the thoughtful listener comments we learn that an IO line can lead to horrendous complications. See Comments below.
And therefore perhaps bedside ultrasound can help prevent complications in pediatric vascular access.
From my post Use of Ultrasound To Confirm Correct Pediatric Intraosseous Placement
Posted on October 25, 2016:
In Case 45: Severe Dehydration in a 12-month-old male, from Pediatric Emergency Care and Critical Ultrasound 2013, the use of point-0f-care ultrasound to confirm correct placement and functioning of an intraosseous access needle.
The following is from that case study pp 207 – 209 of the above book: [See post for details].
Pediatric Emergency Care and Critical Ultrasound also has two other outstanding cases detailing the use of bedside ultrasound for pediatric vascular access.
The first is Case 43: Urospesis and no IV access in a 5 year old. In this case the use of ultrasounnd guided catheterization of the femoral vein is discussed.
And the second case, Case 44: Dehydration and difficult IV access in a 10-month-old male. In this case the ultrasound probe is used to facilitate peripheral venous access.
Minh Le Cong comments 5 years and 4 months ago (at the time of this post):
Scott, Michael, thanks for a brilliant discussion on paediatric trauma management. I am glad you raised the controversy of whether concepts such as haemostatic resuscitation and whether to use crystalloid are still applicable in children. the truth is still out there but Michael gave a very reasonable approach. I would raise one point of caution in regard to IO use. My opinion is that we must approach IO use for fluid resuscitation with care. True it might be the only line we can get to start with but I would be doing all I could to find another access point and minimising the fluid admin through the IO. There are numerous case reports of compartment syndrome and leg amputations as a result of overreliance upon the sole tibial IO line during a resuscitation. Sometimes you have no choice but it should not be through want of trying to find further access. I used to believe that IO lines are like central venous access. This was not correct thinking and I teach now use of IO for fluid resuscitation as short a period as possible and then removal as soon as alternative access achieved.
Don Diakow comments 5 years and 4 months ago:
Minh….were the complications of the Ped IO’s due to the tibia being a small confined space and infused crystalloid under pressure leaking?
We have had one ped IO complication here in Calgary that was reported to end in the child losing the lower leg as well.
And Dr. Le Cong replies 5 years and 4 months ago:
Don, we have had two recent cases with similar results. I cite some of the literature and case reports in this podcast I did on PHARM
I still advocate IO in emergency resuscitation but advise seeking alternative access ASAP and minimising volumes of fluid through the IO especially if its a tibial site. If its over a compartment space, be careful.
And Rebecca comments 5 years and 4 months ago:
I’m a critical care paramedic and up until very recently I spend 95% of my time working in pediatric critical care transport.
Tibial IO in small peds (<10kg) can be tricky if you don’t do a lot of them. When everyone learned to insert EZIOs in adults, they were probably taught to drill until they felt a ‘pop’, then stop…then promptly forgot this direction and drilled until the hub of the catheter was resting on tissue. In adults, this usually doesn’t lead to problems due to the size of the medullary space. In small pediatric patients however, sinking the IO to the hub will result in the needle passing THROUGH the tibia. If this is not recognized upon insertion or upon fluid administration it can lead to the complications mentioned by others above.
Everything that I’m about to say is purely my opinion based on my experiences:
– Let someone who knows what they are doing put the EZIO in. We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill. (Some of our attendings didn’t even really belong on that list, that was just a politics thing.) We rarely had any issues after that. The point is, just like airway, if you don’t do it a lot in small kids, you probably aren’t going to be great at it.
– If you don’t put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn’t working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis because they have an adjustable flange so you can set the maximum depth.
– Once you get the IO in, flush vigouorously, look for an signs of infiltration, then SECURE THE HECK OUT OF IT. Any movement of the catheter increases the risk of infiltration. Be vigilant about checking for infiltration and checking distal perfusion.
– As Minh suggested, an IO is only a temporary solution. As soon as the patient is stable enough or has enough intravascular volume get a peripheral or central line in them as their status warrants.
– Some people have suggested that the proximal humerus might be a prefered site both for flow rates and patient comfort. I have no experience with this, but I wonder if, in peds, it might lead to a lower infiltration rate due to the larger medullary space.
The following is from the EMCrit 76 Show notes:
Pediatric Glasgow Score
Best eye response: (E)
4. Eyes opening spontaneously
3. Eye opening to speech
2. Eye opening to pain
1. No eye opening or response
Best motor responses: (M)
6. Infant moves spontaneously or purposefully
5. Infant withdraws from touch
4. Infant withdraws from pain
3. Abnormal flexion to pain for an infant (decorticate response)
2. Extension to pain (decerebrate response)
1. No motor response
Best verbal response: (V)
5. Smiles, oriented to sounds, follows objects, interacts.
4. Cries but consolable, inappropriate interactions.
3. Inconsistently inconsolable, moaning.
2. Inconsolable, agitated.
1. No verbal response.
Any combined score of less than eight represents a significant risk of mortality.
Dr. McGonical blogs at The Trauma Pro, a website highly recommended by Dr. Weingart.