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FSHP 2017 ANNUAL MEETINGFSHP 2017 ANNUAL MEETING

Small People in Big Trouble:Small People in Big Trouble:

Pharmacotherapy of Common Pediatric EmergenciesKatie Wassil, PharmD, BCPS

2017 ANNUAL MEETING

#FSHP2017

DisclosureDisclosure

I do not have (nor does any immediate family member have) a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation.

2017 ANNUAL MEETING

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ObjectivesObjectives

• Review the differences in drug disposition between the adult and pediatric patient

• Describe the most common critical conditions leading to hospital admission and their treatment in the pediatric patient

• Discuss differences from adults and therapeutic options for pediatric patients in cardiac or respiratory emergency

• Discuss tools available to decrease risk of medication errors during pediatric emergencies

• Evaluate the most useful drug information resources for pediatric drug information

2017 ANNUAL MEETING

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Technician ObjectivesTechnician Objectives

• Recognize differences in drug formulations between the adult and pediatric patient

• Discuss the differences between adult and pediatric treatment options for the most common pediatric emergencies

• Discuss tools available to decrease risk of medication errors during pediatric emergencies

• Identify the most useful drug information resources for pediatric drug information

2017 ANNUAL MEETING

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WHAT HAPPENED?“Children are not

small adults”

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With permission; Kearns et al NEJM 2003. 349;12With permission; Kearns et al NEJM 2003. 349;12With permission; Kearns et al NEJM 2003. 349;12

2017 ANNUAL MEETING

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Out with the OldOut with the Old

Young’s rule:

(Age in years * Adult dose)(Childs age in years + 12 years)

Clark’s rule:

(Wt in pounds * Adult dose)150 pounds

Asthma• 7.1 million (9.6%) children in United States• Exacerbations account for 640,000 emergency room visits

annually• Most common diagnosis of hospitalization• $56 billion per year in cost of disease

• ED visit- 8%• Hospitalizations- 50%

2017 ANNUAL MEETING

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Pardue et al. J of Asthma 2016; 53(6)

Mortality by Age Group

CDC Advance Data; 381: Dec. 12 2006.

Asthma Mortality 2015Asthma Mortality 2015

Dea

th R

ate

per 1

,000

,000

www.cdc.gov/asthma/most_recent_data.html

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2017 ANNUAL MEETING

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Who is at risk?Who is at risk?

• Previous severe exacerbation (intubation or ICU admission)

• In the past year• > 2 hospitalizations for asthma • > 3 ER visits

• Using more than 2 SABA canisters/month• Poor perceiver • Low socioeconomic status• CV, chronic lung or psychiatric disease

Management

• NAEPP guidelines• Last udpated 2007

• GINA guidelines• Evaluated biannually• Updated annually

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Mild Moderate Severe Resp Arrest Imminent

Breathlessness While walkingCan lie down

While at restPrefers sitting

While at restSits upright

Talks in Sentences Phrases Words

Alertness May be agitated

Usually agitated Agitated Drowsy or Confused

Respiratory Rate

Increased Increased > 30/min

Accessory Muscles

Usually not Commonly Usually Paradoxical thoracoabdominal movement

Wheeze Moderate, often only end expiratory

Loud: throughout exhalation

Usually loud: throughout inhalation and exhalation

Absence of wheeze

Pulse < 100 100‐120 >120 Bradycardia

Asthma Exacerbation Severity

Adapted from NAEPP guidelines

FSHP 2017 ANNUAL MEETING

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Status Asthmaticus

Pathophysiology

NAEPP Asthma Guidelines 2007

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Management

• 3 principle goals• Correct hypoxemia

• Supplemental O2- usually in mod-severe• Reverse airflow obstruction

• SABA (short acting B2 agonist)• Early systemic steroids- if not responding to SABA

• Reduce likelihood of relapse• Short course of oral steroid

2017 ANNUAL MEETING

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Beta Agonists• Beta agonists- mediate bronchodilation by stimulating B2 receptor

on bronchial smooth muscle• Agents

• Albuterol- nebulized• Terbutaline- IV• Levalbuterol-nebulized• Epinephrine- SubQ

• Long acting B2 agonists are contraindicated in status asthmaticus

2017 ANNUAL MEETING

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Beta Agonists

• Adverse Effects• Tachycardia• QT prolongation• Dysryhthmias• Hyper/Hypotension• Tremor• Hypokalemia

2017 ANNUAL MEETING

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Albuterol

• Continuous neb vs MDI• MDI

– 4-8 puffs q20 min for 3 doses then q1-4h PRN– Affords parent/patient teaching on proper technique and use

• Nebulized– 0.15 mg/kg (min 2.5 mg) q 20 min then 0.15-0.3 mg/kg (max dose

10 mg) q1-4h PRN– 0.5 mg/kg/hr (10-40 mg/hr)

2017 ANNUAL MEETING

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Ipratropium

• Diminishes cholinergic bronchomotor tone, decreases mucosal edema and secretions

• Given in conjunction with albuterol, not single agent• 0.25-0.5 mg neb up to 3 doses

• Improves lung function and decreases hospitalizations in moderate to severe exacerbations

• Only effective in ED setting

2017 ANNUAL MEETING

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Steroids

• Decrease inflammation and mucous production• Enhance efficacy of bronchodilators• Moderate-Severe exacerbations

– Prednisone • 1-2 mg/kg/day for 3-10 days (max 60 mg/day)

– Dexamethasone• 0.3-0.6 mg/kg/day 1-2 doses (max 16 mg/day)

• Short bursts of steroids have shown no effect on bone density, height or adrenal function

2017 ANNUAL MEETING

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Prednisolone vs. Dexamethasone

• Meta analysis of 6 RCT comparing the two– Determine if single dose IM/PO dexamethasone was equivalent

to 5 day course of prednisolone

• Primary outcome was unscheduled return visits– Clinic, ER, hospital admission

• Secondary outcome- vomiting in the ER or home

2017 ANNUAL MEETING

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Keeney et al. Pediatrics 2014;133(3):493-99.

Incidence of Relapse

• Group 1

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Incidence of Vomiting in ER

• Group 1

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Incidence of Vomiting at Home

• Group 1

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Conclusions

• No difference in primary outcome• Fewer patients experienced vomiting

• Oral dexamethasone dosing possible benefits:

• Increase parent/patient satisfaction• Increase compliance

• Group 1

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IV Magnesium

• In severe exacerbations that have failed conventional therapies (still severe after 1 hour of treatment):

– Improvement in pulmonary function– Decrease in hospitalization

• MOA:– Smooth muscle relaxant– Blocks Calcium entry into cell and release from endoplasmic

reticulum• Dose: 25-75 mg/kg (up to 2 grams) IV over 20 minutes

2017 ANNUAL MEETING

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2017 ANNUAL MEETING

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Baby BrownBaby Brown

BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed.

2017 ANNUAL MEETING

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Differential

• Hypovolemic or Septic Shock• ABCs• Fluids• Pressors• ATB

• Covering neonatal meningitis bugs and HSV

SHOCK

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Shock

Type Preload Contractility Afterload

Hypovolemic Decreased Normal or Increased

Increased

Septic Decreased Normal to Decreased

Variable

Cardiogenic Variable Decreased Increased

AHA; PALS Provider Manual 2015AHA; PALS Provider Manual 2015

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Septic ShockSeptic Shock

• 20,000 inpatient admissions and 800 deaths per year• 2001- Early Goal Directed Therapies improves survival in

adults• 2009- Pediatric guidelines • 2012- Surviving Sepsis Campaign guidelines updated

• Adult and pediatric

Workman et al. Pediatr Crit Care Med 2016;17:e451-8.2017 ANNUAL MEETING

#FSHP2017Pediatric SSC Guidelines- Early Goal Directed TherapiesPediatric SSC Guidelines- Early Goal Directed Therapies

• Within first hour• Fluids• Antibiotics• Vasoactives

• Goals • Capillary refill of less than 2 seconds• Normal BP for age • Normal pulses• Warm extremities• Normal mental status • UOP > 1 ml/kg/hr

Dellinger et al Crit Care Med 2013; 41(2)

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2017 ANNUAL MEETING

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Let’s Save Lives…Anyone Can Do it!

• Successful shock reversal by community physicians prior to transport

• 96% survival• >9 fold increase in odds of survival

• Each hour of persistent shock associated with >2 fold increase in odds of mortality

Pediatrics 2003; 112:793-99.Pediatrics 2003; 112:793-99. 2017 ANNUAL MEETING

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Fluids

• Normal Saline, Lactated Ringers• 20-30 ml/kg• 5-10 ml/kg

• If heart or lung issues suspected

• Administer over 5-20 min• Administer as needed to support BP and perfusion

2017 ANNUAL MEETING

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Hypotension in pediatrics

• Systolic• neonates

• < 60 mmHg• 1 mo-12 mo

• <70 mmHg • 1 yo-10 yo

• <70 mmHg + (2 X age in years) • >10 yo

• <90 mmHg

AHA; PALS Provider Manual 2015AHA; PALS Provider Manual 2015 2017 ANNUAL MEETING

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Vasoactives

• Norepinephrine– 1st line for fluid refractory warm shock– 0.05-0.1 mcg/kg/min

• Epinephrine– Cold shock

• Inotropic- beta effects• SVR- alpha effects

– 0.1 mcg/kg/min

2017 ANNUAL MEETING

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Baby Brown

• BB is a 6 day old, 38 week GA that went home after uneventful delivery. 4 days later parents called EMS b/c the baby was found blue with minimal respirations and weak pulses in his crib 5 minutes after they put him to bed.

2017 ANNUAL MEETING

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Differential

• Non-accidental Trauma• Support ABCs• Fluids• Protect brain

• Normalize sodium• 3%NaCl, mannitol, pentobarbital

• If evidence of increased ICP• Monitor for seizures

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2017 ANNUAL MEETING

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Neuroprotective Strategies

• Normalize Sodium• NS in IVF• 3%NaCl

• 0.513 meq/ml• Dose: 2-4 ml/kg over 30 minutes• Dose: 0.1-1 ml/kg/hr- titrate to ICP• Central line or IO

2017 ANNUAL MEETING

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Baby Brown


• Post resuscitation and intubation child now having facial twitching and arm movement.

2017 ANNUAL MEETING

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Status epilepticus

• Seizure lasting > 5 minutes

• Meds “STAT”

Sem Ped Neuro 2010; 17:169-75.Sem Ped Neuro 2010; 17:169-75. 2017 ANNUAL MEETING

#FSHP2017Benzodiazepines

Fosphenytoin/Phenytoin

Phenobarbital

Valproic acid

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Benzodiazepines

• Lorazepam (IV)• 0.1 mg/kg up to 4 mg

• Diazepam (IV)• 0.2 mg/kg up to 5 mg• 0.5 mg/kg IV form given rectally

• Midazolam• Buccal, Intranasal- 0.2 mg/kg

Lexi Comp Pediatric Dosing Handbook 23rd editionLexi Comp Pediatric Dosing Handbook 23rd edition 2017 ANNUAL MEETING

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• Load with 15-20 mg PE /kg• Fosphenytoin max- 3 mg PE/kg/min (150 mg PE/min)• Phenytoin 1 mg/kg/min (50 mg/min)

• Does not treat seizures due to toxin ingestions

Lexi Comp Pediatric Dosing Handbook 23rd editionLexi Comp Pediatric Dosing Handbook 23rd edition

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• Fosphenytoin• IV or IM • Dilute with NS or D5W to < 25 mg/ml

• Phenytoin• IV only• Dilute with NS to < 10 mg/ml


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Levetiracetam (Keppra)

• Loading Dose- 30 mg/kg• Administration rate- 5 mg/kg/min

• Preparation:• Comes as 500 mg vial (100 mg/ml)

• Dilute 1:1 with NS

Sem Ped Neuro 2010; 17:169-75.Sem Ped Neuro 2010; 17:169-75.

2017 ANNUAL MEETING

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Phenobarbital

• 20mg/kg load• Max rate 1 mg/kg/min

• Adverse Effects• Sedation• Respiratory depression• Hypotension


#FSHP2017Review of 5 AEDs in Benzodiazepine Resistant Status Epilepticus• Phenytoin• Phenobarbital• Valproic Acid• Levetiracetam• Lacosamide

• Primary outcome: cessation of seizure

Efficacy Summary

Seizure 2014; 23:167-74. 2017 ANNUAL MEETING

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Baby Brown


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2017 ANNUAL MEETING

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Differential• Undiagnosed CHD

• Fluids• Start lower if suspecting heart failure

• Support CO and BP • Epinephrine• Dopamine

• Alprostadil STAT

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Alprostadil (Prostin)

• Preparation:• 500 mcg/ml diluted in 49 ml NS or D5W

• Usual Dose:• 0.05-0.1mcg/kg/min

• Prostaglandin E1- relaxes smooth muscle of ductus arteriosus

2017 ANNUAL MEETING

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2017 ANNUAL MEETING

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TZ

• TZ is a 3 yo previously healthy WM found down at home. CPR initiated by mom and rescue is en route with patient.

• What medications should you prepare?

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Questions to think about

• What weight or Broselow color is the patient?• Are we all talking in the same units? • Double check all calculations

Access

• Intraosseous (IO)• Fluids• Blood products• Catecholamines

• Endotracheal- last line• “LANE”

• Lidocaine, Atropine, Naloxone, Epinephrine

AHA; PALS Provider Manual 2015AHA; PALS Provider Manual 2015

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Epinephrine• Epi- 1:10,000 prefilled syringe (0.1 mg/ml)

• Dose- 0.1 ml/kg (0.01 mg/kg) IV push

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What is different?

• Cardiac arrest is usually due to respiratory failure or shock in pediatrics

• Exceptions• Congenital heart disease• Witnessed arrest or collapse

• Dilated cardiomyopathy• Long QT syndrome• Ingestion• Sharp blow to the chest• Myocarditis

cAB versus Cab

2015 AHA Guidelines

Causes of Pediatric Cardiac Arrest

Cardiac Arrest

Respiratory FailureUpper Airway ObstructionLower Airway Obstruction

Disordered Control of BreathingLung Tissue Disease

HypotensionMetabolic/Electrolyte Hypovolemic Shock

Distributive ShockCardiogenic Shock

Toxicologic

Arrhythmia

Respiratory FailureUpper Airway ObstructionLower Airway Obstruction

Disordered Control of BreathingLung Tissue Disease

HypotensionHypovolemic ShockCardiogenic ShockDistributive Shock

Arrhythmia

Out of Hospital In Hospital

adapted from PALS Guidelines

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Caring for children in the emergency setting is especially prone to error due to

environmental and human factors.

Pediatrics 2007; 120(6):1367-75. 2017 ANNUAL MEETING

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To Err is Human

• High stress• High activity• Constant urgency• Missing information

• Capturing errors during a true emergency is difficult• Strategies to decrease errors difficult to define

Larose et al. Pediatrics 2017;139(3)

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What makes the ER unique?• Hectic, chaotic, interruptions• Communication

• Handoffs, lots of cooks in the kitchen• Verbal orders

• Minor issues ➡ Life and death situations• Language barriers

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What makes pediatric patients unique

• Manual dosing• Lots of nurse mixing of partial vials

• Few standard dosing• Weight based dosing

• Weight errors• Inability of the child to communicate problems

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What’s the weight?

• Dosing in mg/kg

• Kilograms vs pounds • 1 kg = 2.2 lb

• Computer errors

• Common sense

What’s the dose?

• mg/kg dosing• Keep adult maxes in mind

• Excel spreadsheets• Broselow tape• Broselow carts

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E Broselow

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Phone a Friend

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High-Reliability Organization

• High risk environment that maintains low risk of harm

• Mishap is possible at any time with the right circumstances• Keep in mind no person or organization is perfect

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Conclusions

• Don’t let pediatric patients intimidate you • References• Calculators• Experienced nurses• Pharmacists

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