Instruments

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carotid 1 Femoral pukation periodically .

constitution
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Epinephrine
.

1) If HRC 60 : n

spontaneously .

# Endotracheal Intubation .

→ Indication :

babies )
11 When trachea tuition req leg
Non
vigorous
BMV
2) Prolonged Cl1
ineffective herein-
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3) BMV > AMBU

sus
Diayhipnatik
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41

Before starting
cc
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6) For administering highrise

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# Adrenaline procedure
 Pediatric Critical Care 725

pediatric Advanced Life

Support (PALS) Table 28.5: Size of ET tube and suction catheter in infants
PALS refers
to the assessment and support of pulmonary Age; weight Tracheal tube Suction catheter
and circulatory function in the periods before, during and
after an arrest. PALS targets
Fr
the prevention of causes of 5
arrest and early newborn; <1 kg 2.5
detection and treatment of cardio- Premature

pulmonary compromise and arrest in Premature newborn; 1-2 kg 3.0 5-6

critically ill or
injured children. Newborn; 2-3 kg 3.0-3.5 6-8

Components of PALS are: (i) Basic life support; (ii) use of Newborn; >3 kg 3.5-4.0

equipment and techniques to establish and maintain effec- Infant 3.5-4.0 8

tive oxygenation, ventilation and perfusion; (iii) clinical An appropriate sized endotracheal tube is used
and
ECG monitoring with arrhythmia detection and
the size of the tube is:
management; (iv) establishing and maintaining vascular (Table 28.5). Beyond 1 year,
access; (v) identification and treatment of reversible causes (Age in year)
of cardiopulmonary arrest; (vi) emergency treatment N Tracheal tube size (in mm) + 4

of patients with cardiac and respiratory arrest; and Tubes 0.5 mm smaller and 0.5 mm larger than the
(vii) treating patients with trauma, shock, respiratory estimated size should be available for use. The size of
failure or other pre-arrest conditions. suction catheter is usually twice the internal diameter of
the tracheal tube in mm, e.g. 8 Fr suction catheter for
Adjuncts for Airway and Ventilation tracheal tube of size 4 mm. Cuffed tubes are preferred in
Oxygen should be given to all seriously ill or injured
patients with poor lung compliance, high airway
children with respiratory insufficiency, shock and trauma. resistance and large glottic air leak.
During mouth-to-mouth rescue breathings, only 16-17% The depth of insertion of the tube is approximately three
times its inner diameter. In neonates, the endotracheal tube
oxygen is delivered, with alveolar oxygen pressure of
80 mm Hg, and optimal external chest compressions
is inserted to depth of:
provide only a fraction of the cardiac output, resulting in Depth of insertion (cm) = birth weight (kg) + 6
In children >2-year-old, the depth of insertion of the
reduced tissue perfusion and oxygen delivery. Ventilation- -

endotracheal tube is:

⑧
perfusion mismatch during CPR and underlying
respiratory disorders causes right-to-left shunting that
O
(Age in years)
reduces Depth of insertion (cm) = + 12
oxygenation.
Tube placement is confirmed by looking for
Endotracheal Intubation symmetrical chest rise and auscultating for air entry on
If used properly, this is the most effective and reliable both sides. Auscultation over upper abdomen is required
method of ventilation. The advantages of endotracheal to rule out esophageal intubation. Other markers of proper
intubation are: (i) it ensures adequate ventilation; (i) reduced tube placement are improving heart rate, color, perfusion
risk of aspiration of gastric contents; (iii) inspiratory time and oxygen saturation. The position of the tube should be

and peak inspiratory pressure can be controlled; (iv) suction confirmed on chest radiograph.

can be done to keep airway patent; and (v) positive end-

However, a skilled Vascular Access
expiratory pressure can be provided.

person is required for intubation. Hence, it is recommended During CPR, the preferred access is the largest easily
that bag and mask ventilation should be continued in accessible vein, cannulating which does not require
children who require ventilatory support in the out-of- interruption of resuscitation. Central venous lines provide
hospital setting, when transport time is short or whenfor secure access, rapid action, higher peak drug levels, and

expert 1s not available for intubation. Indications permit administration of drugs that might injure
endotracheal intubation are listed in Table 28.4. peripheral veins (vasopressors, calcium gluconate,
hypertonic solutions like sodium bicarbonate). Femoral
Table 28.4: Indications for endotracheal intubation vein is the safest and easiest to access (Chapter 29). Agents
with short half-life such as vasopressors, adrenaline and
Excessive work of breathing leading to fatigue
respiratory adenosine act better, if given through central venous
Inadequate neurologic control of ventilation, and poor access. Catheter lengths of 5 cm in infant, 8 cm in a young
effort
child and 12 cm in an older child are usually suitable.
anatomical airway obstruction
Functional or Intraosseous access should be tried in patients, if the
or positive end
Need for high peak inspiratory pressure central or peripheral venous assess is not achieved. The
expiratory pressure usual site for intraosseous access is upper end of tibia
Lack of protective airway reflexes medial to tibial tuberosity (Chapter 29). Other sites include
For prolonged duration cardiopulmonary resuscitation the distal end of femur, lower end of tibia above medial
 726 Essential Pediatrics

of crystalloids. Dextrose solutions

malleolus and anterior superior iliac spine. Drugs like infusing 40-60 mL/kg
should not be used for initial resuscitation
as they do not
adrenaline, adenosine, and vasopressors can be transfused
effectively and may
by this route. Samples for chemical analysis, blood expand the intravascular volume
to osmotic diuresis and
grouping and crossmatching may be taken from these cause hyperglycemia, leading
sites. vicious cycle of polyuria and hypovolemia. Hypo-
Tracheal route is not a preferred route of administration glycemia, if suspected or documented, should be managed
of medications even in emergencies. If intravenous or rapidly with intravenous glucose and measures to prevent
intraosseus access is not established, the tracheal route recurrence.

may be used for lipid-soluble agents like lidocaine,

Arrhythmias
epinephrine, atropine and naloxone.
Mostpediatric arrhythmias are the consequence of
hypoxemia, acidosis or hypotension. Children
Post-arrest Care with
Fever is common after cardiac arrest and should be myocarditis, cardiomyopathy or following cardiac surgery
controlled aggressively. After return of spontaneous are also at risk of arrhythmia. Drugs in therapeutic or toxic
circulation, hypoxia or hyperoxia should be avoided and doses can cause arrhythmia. About 10% of pediatric
oxygen saturation should be maintained between 94 and cardiac arrest patients have ventricular fibrillation (VF)
100%. Continuous arterial pressure monitoring is done to or pulseless ventricular tachycardia (VT).

maintain blood pressure above the 5th centile. Table 28.6 Bradyarrhythmia: Hypoxemia, hypothermia, acidosis,
shows doses for commonly used drugs during resuscitation. hypotension and hypoglycemia depress sinus node
function and slow conduction through the myocardium.
Fluid Therapy
Excessive vagal stimulation, raised intracranial pressure
Early restoration of the circulating blood volume is or brainstem compression may cause bradycardia. Sinus

important to prevent progression to refractory shock or bradycardia, sinus node arrest with junctional or
cardiac arrest. An initial fluid bolus of 20 mL/kg is idioventricular rhythm and AV blocks are usually
recommended in shock, and after each bolus, the patient preterminal rhythms. All slow rhythms resulting in
is reassessed. Volume expansion is best achieved with
hemodynamic instability require immediate treatment.
isotonic crystalloid fluids, such as Ringer lactate or normal Epinephrine is the most useful drug in treating
saline. Blood replacement is indicated in patients with
symptomatic bradycardia, unless due to heart block or
severe hemorrhagic shock who remain in shock despite vagal overtone. For bradycardia due to vagal overtone,

atropine is Doc .

Table 28.6: Drugs used during cardiopulmonary resuscitation

Drug Indications Dosage Remarks

Epinephrine Symptomatic bradycardia, IV/10: 0:01 mg/kg (1:10,000; 0.1 mL/kg) Tachyarrhythmia and hypertension may
pulseless arrest ET: 0.1 mg/kg (1:1000 flush with 1-2 mL occur

of saline); repeat 3-5 minutes, if required

Atropine Bradyarrhythmias 0.02 mg/kg Tachycardia, pupil dilatation may occur
Calcium Hypocalcemia, 1 mL/kg IV or 10 (slow push)
Monitor heart rate; flush line with saline
hypermagnesemia,
before and after infusing calcium
(10%, 9 mg/mL hyperkalemia
gluconate; avoid extravasation
calcium)
Glucose Suspected, documented 0.5-1 g/kg Avoid hyperglycemia

Sodium Severe metabolic acidosis, mEg/ kg IV/IO slowly Use once ventilation is adequate;
bicarbonate hyperkalemia
dilute 1:1 with 5% dextrose
Adenosine Supraventricular tachycardia 0.1 mg/ kg; repeat dose 0.2 mg/kg;
rapid bolus IV/O
Monitor ECG during dose; give through
vein close to heart
Pulseless VF or VT 5 mg/kg IV/IO
Monitor ECG during dose
Lidocaine VF or VT mg/kg IV/IO; follow by infusion
at 20-50 ug/kg/min
Monitor ECG during dose
Opioid intoxication 0.1 mg/kg IV/IO/ET
Repeated doses may be requirer
Magnesium Torsades, suspected 25-50 mg/kg rapid push for first
hypomagnesemia, Watch for respiratory depression
two indications; infusion over 30 min hypotension
severe asthma for asthma

ET: Endotracheal; IO: Intraosseous; IV:

Intravenous; VF: Ventricular fibrillation; VT: Ventricular tachycardia
 Slender Malleable
Bore Moodle

- Needle proper

stylus
-
.

Enrollees .

tyrol✗ irradiation
Sol
. →
→ stew
 Intermittent
32 BEDSIDE CLINICS IN MEDICINE

-3Mt
cloudy →

god IN
0
End to Clear

Rolling for
INSULIN SYRINGE
g.
You ¥00 Needs

[Link] s - loves

Fig. 1.10 : Insulin syringe with needle

# Description
This is a syringe with capacity of 1 ml.)
cylinder has markings on its outer surface indicating the
amount of insulin in units, present distal to the piston. Insulin syringe resembles tuberculin syringe
though the piston is white in colour (not blue).
Insulin is available in India as
40 units/ml or 80 units/ml commonly, or 100 units/ml as available
in abroad and thus, 1 ml is graduated into 40, 80 or 100 units.

Different uses
To inject insulin in the subcutaneous (S.C) ute in
diabetic patients.
In neonates, insulin syringe may
serve the purpose of a hypodermic syringe' for giving injec-
tions by I.M or S.C route.
3. Sometimes it is used to give a test-dose on
the forearm before administering a drug (e.g., test of
hypersensitivity reaction Defore giving injection penicillin).
" 'tuberculin syringe' (1ml

→
A
syringe with a blue pistion; used for Mantoux test) may also be
neonates used in
for giving injection by I.M or S.C route. Mantoux test is a
tivity reaction to tuberculoprotein. 1 tuberculin unit (TU) is type IV or delayed type of hypersensi-
equal to mg0.00002 International Standard
PPD (purified protein derivative). Usually 1 TU is
injected (0.1 ml PPD) intradermally on volar
the forearm aspect
(junction of mid and upper third). The result is read of
after 72 hours
induration' (thickening) across the transverse axis (3rd day). If the skin
is < 10 mm, the test is negative and
regarded as positive. The amount of
if 10 mm, it is
erythema
f-

(redness) present is not important.

- -

-
presumptive evidence of current (active) or prior (old) mycobacterial infection; the larger positive test is
A

induration (e.g., >

20 mm), the greater the support for the diameter of
possibility of tuberculosis for a positive diagnosis. A negative
-
test rules out the
practical purposes. But in a child below 3 years
positive test is commonly associated with (non BCG-vaccinated). a
the Mantoux test may be negative in- active progressive disease. It should also be remembered that
fulminant, -
miliary and - meningeal
low general condition, measles, lymphoma, sarcoidosis,
- -
- -
tuberculosis, tuberculosis
- with
leukaemia and in-
therapy, AIDS etc);-
technical error (S.C. immunosuppression (steroid
injection instead of intradermal) may give rise to negative result.
WHO advocates a PPD tuberculin known as PPD-RT-23 with Tweer 80. In AIDS,
The

of mm
or more signifies a positive Mantoux test. f-
-
an induration
f-
g
Different uses of insulin:
Diabetes mellitus_
a) All type
1 DM patients.
Diabetic ketoacidosis.
Diabetes
In
with pregnancy, labour and delivery.
periods
of stress e.g., acute infection, major
medical illness, stroke, acute injury, while surgery, acute myocardial infarction, any acute
on
glucocorticoid treatment
In type 2
DM-Secondary failure of oral hypoglycaemic agents; or inadequate control
complications like painful peripheral
ence
of
failure or respiratory failure. neuropathy/retinopathy:
with pres-

renal failure, hepatic

Pre-renal transplantation diabetic patients.
Hyperkalaemia.
Insulin test or Hollander's test
3.

duodenal ulcer patient. Increase

(not
used now-a-days) To know
indicates incomplete in 20 meq/1 of acidity above the the completeness of vagotomy in a
basal level after injection of
(insulin-induced insulin

presence of intact hypoglycaemia

vagus nerve). stimulates
the neurogenic
phase of
acid
secretion in stomach in the
 INSTRUMENTS AND PROCEDURES 33

Who first used insulin ?

On 23rd January 1922, Banting and Best first used pancreatic extract on severely diabetic patient
a

named Leonard Thompson. Banting received The Nobel Prize along with another physician JJR Macleod
in the year 1923 for the discovery of insulin.

Table 3 : Available insulin preparations

Time of action

Preparations Onset Peak Duration

Short-acting
min 0.5-1.5 h 3-4 h

Aspart 5 min 0.5-1.5 h 3-4 h

5 min 0.5-1.5 h 3-4 h

Regular 30 min 2-3 h 4-61

Intermediate-acting
NPH (isophane insulin) 1-3 h 3-8 h 7-14 h
Lente 1-3 h 3-8 h 7-14 h

Long-acting
1-4 h None 24 h

Ultralente 4-6 h 1- he 10-181 16-24 h

1-4 h 2-12 h 12-20 h
Mixtures

70/30, 50/50, 75/25 30 min 7-12 h 10-16 h

Values (time of action) are highly variable among individuals. Even in an individual, values vary

depending on the site and depth of injection, skin temperature and exercise.
** Insulin combinations : 70/30 (70% NPH, 30% regular); 50/50 (50% NPH, 50% regular), and 75/25
(75% protamine lispro, 25% lispro), 70/30 (70% protamine aspart, 30% aspart) and 50/50 (50% prota-
mine lispro, 50% lispro) are different combinations used in clinical practice.

Insulin analogues :
These insulin preparations are generated by modifying (i.e., changing the amino acid sequence by
recombinant DNA technology) human insulin, and are useful in patients having repeated attacks of
hypoglycaemia or show hyperglycaemia during some parts of the day while on regular insulin therapy.
Among the five insulin analogues, three are short-acting or rapid-acting (lispro, aspart, and glulisine)
and two are long-acting (glargine and detemir) preparations.

Insulin secretagogues and sensitisers .

Insulin secretagogues : sulphonylureas and non-sulphonylurea (repaglinide and nateglin).

Incretin mimetics : a) GLP-1 analogues exenatide and liraglutide b) DPP-4 inhibitors sitagliptin
and vildagliptin.
GLP-1 = glucagon like peptide 1. DPP-4 dipeptidyl peptidase 4
Main types of therapeutic insulins :
Bovine

1. Species Porcine

Human

Conventional

2. Purity Single peak

Highly purified
Short-acting
3. Duration of action Intermediate-acting
Long-acting

57 of 355
34 BEDSIDE CLINICS IN MEDICINE

Bovine
immunogenic, i.e., in relation to immunogenicity (antigenicity),
>
Bovine insulin is more
Porcine > Human insulin. Animal preparations (bovine or porcine) are no longer used.

Goals of insulin therapy :

1. Alleviation of primary glycosuric symptoms.

•vention of ketoacidosis and hyperosmolar coma; brings back the lost lean body mass.
3. Improvement in physical performance as well as sense of well being.
4 Diminution in foeto-maternal morbidity, foetal malformations.
5. Reduction in recurrent infections.
6. Delay, prevent or arrestation of micro- and macrovascular complications.

Uses of soluble or regular insulin

emergencies, it is the insulin of choice, i.e., ketoacidosis, infection, surgery, pregnancy,

trauma.
1. In

2. To supplement depot insulin effects, if necessary.

3. Patients requiring >150 units of insulin/day.
Patients not controlled properly with depot insulins.

Different insulin regimens :

1. Conventional insulin therapy.
2. Multiple subcutaneous injections (MSI).
3. Continuous subcutaneous insulin infusion (CSII).

How to [Link]

Patient's education regarding insulin administration is important in treating diabetes mellitus.

1. Preferably, asepsis is maintained. Required dose of insulin is drawn into the syringe through a

hypodermic needle.
2. A small, fine-bore hypodermic needle is now attached to the nozzle (or already attached) of the
insulin syringe.
3. Preferable sites of injection are abdomen, (arm, thigh, buttock, back. The site is properly
cleansed with spirit.
Now, a foldof skin and subcutaneous tissue is pinched-up by left thumb and index finger, and
from the top into the subcu-
the hypodermic needle is introduced in the skinfold by right hand,

taneous tissue. Insulin is injected and the needle is taken out with care (insulin leakage should
be avoided).
5. Injection site is now covered and lightly pressed by a piece of cotton (rubbing should be avoided).

The rotation of injection site shofild also be taught to the patient. Repeated injections in one site
predispose to lipohypertrophy. Insulin injections are to be given deep subcutaneously. The sites have to
be rotated so that a second injection does not fall within 1-2 cm of the previous injection site within 1
month of time.

Alternative methods of insulin delivery system

I. Jet injectors,
^ert devices.

III._ Insulin infusion pumps

a) 'Open' loop Continuous subcutaneous insulin infusion (CSII).
b) 'Closed' loop (Biostator) - Artificial pancreas.
IV. Nasal, oral, rectal insulin Not effective in practice at present.
Pancreas transplantation-Whole pancreas, segmental pancreas, islet transplant.
Microprocessor based implantable pumps are now available which are more acceptable than CSII.

Open' loop can be used by S.C, I.V or intraperitoneal route,

Define brittle diabetes and insulin resistance

(A) Brittle diabetes-A small proportion of Type 1 DM patients (1-2 % of diabetic patients in practice) are
unstable and difficult to control, and referred to brittle diabetes. Actually, brittle diabetic is a patient
 see ends @ dlz
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rite cleaned
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or TILT .

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O
25
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gauge · THE
Intrathecal
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s 7
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in ALL

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Ig .

① Imf
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bukocytou's
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,
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obtaining Bicgeydifpiint as more

mangy
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Reached parter
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t
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Tapering
& suit &
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③ Bone
ing E # ,
subcutaneous Imq , osteomyelitis
Procedure :

Farting 3 -4 has
folding eheet below it
→ Phone i
pace
ride itutilize pelvis c- .

@
leg flexed
knee
tibia then
→
Ip
.
.

& ketamine → Monitor & Oz

→ sedate i N midazolam
→ clean site i Chalkercidire d betadiu .

into
2mL 1% lidocaine periodem
-

→ s c
of
.
.

→ Index finger as
guard .

→
twisting
'
motion
crime
'
→
way attache
Removed 20mL lyuiinege
.

stylus
→ →

0.5mL
Agitate
→ Slides .

→
Biceps in formalin
 Fixed orifice device
.

I Vel
preemie , High
.

0 a vow
.
 → side holes
per suction
→ lead
e

Panagia ✗ Ray .

as
heavy
-

E- = Se