Hi, my name is Kyle and we're here to discuss the pediatric patient who is experiencing respiratory distress. So when a patient is coming into the ER experiencing respiratory distress, it's important to recognize the signs. Our patient will give us objective signs and their vital signs, physiologic visuals in their work of breathing, and their obvious across from assessments. Things we're going to see with the vital signs, we may see a patient who is tachypneic with rapid shallow respirations. We may also see hypoxia. We may also see elevated heart rate. Our patient will be positioning themselves in a way that we describe as air hungry. So that may be a sniffing position with their nose upright, they may be leaning forward if they're a little bit older. Our patients will appear mottled because of poor perfusion or oxygenation, may have weak thready pulse. We may have adventitious breath sounds, either wheezing or stridor. So it's important to intervene early as this is the number one cause of pediatric demise and cardiac arrest in this population. So in identifying the need to intervene, being able to anticipate our trajectory and escalation of care, and being proactive in the approach, we ideally can avoid intubation with these patients, but we'll go over discussing our minimally invasive interventions and escalating through the trajectory of care. So non-invasive, we have options such as nasal cannula, non-rebreather, simple face mask. If our patient is experiencing hypoxia, these are great options. However, these will only provide our patient with additional FiO2. For our patient who's experiencing work of breathing, if we see those retractions, the sniffing position, visual distress, they may need some positive pressure to support their work of breathing. And in those instances, it would be prudent to place them on something such as a high-flow nasal cannula, a ram cannula, or BiPAP early to try and ease their work of breathing and give them a rest. In a patient where we have provided these interventions, but we haven't seen resolution of their vital signs or their overall comfort, or a patient who looks like they're becoming tired or listless, we may need to start making preparations for advanced airway interventions. So with that patient, we would want to make sure that we are making preparations for intubation and making preparations to provide bag valve mask ventilation. If that patient is becoming tired or in the event that patient who comes in unresponsive, unconscious, not breathing, we would be able to intervene immediately. So in identifying some of the important pieces, we want to go back to our BLS, right? Good old-fashioned bag valve mask ventilations. We want to make sure that we have an appropriate size bag for our baby. We have infant, this is a child-size bag, and then an adult bag. We also want to identify our mask. We want to measure from the bridge of the nose to the chin, and we can see that this one is slightly big. But we want to make sure that we have the appropriate size mask to provide a quality seal for our patient. Whenever we are bagging a pediatric patient, we want to utilize PEEP. We also want to have a pressure manometer. These are also important when we're bagging directly to an endotracheal tube. So in addition to correct size equipment, we want to make sure that our patient is positioned optimally. Pediatric patients have an anterior airway, they have a large head, and they also will have a chin tuck position when laid flat on their back. So a towel roll is important to elevate the shoulders, get them off the bed, and allow their head to fall back, opening that airway. So in doing so, we would be able to provide quality ventilations. We want to make sure that we are picking a rate that is appropriate to the patient's size. If we have an infant somewhere in the 30 to 40 range, somebody who's a toddler or preschooler would be in the range of the 20s. And then older children, something physiologic, that would be 10 to 12 if they're larger. We would see more in line with our adults. In line with our adults. Okay, to facilitate our bagging efforts, we also want to use oral or nasal adjuncts. These are oral airways. To measure, we want to take the airway, size it up from the corner of the mouth to the angle of the jaw, like so, and then insert into the back of the oral pharynx. That'll keep the tongue out of the way so that we can bag more appropriately. So we're measuring here, going to open the mouth, insert the airway, and that keeps everything out of the way for us to bag. So an appropriate patient for an oral airway would be one that is unconscious, unresponsive, does not have a gag reflex. In the event that our patient still maintains its gag reflex, we have nasal airways. This one's large for this, but for demonstration purposes, you would take and measure from the nose to the tragus of the ear. These are designed with the bevel to go toward the septum. The natural curvature is made to go into the right nare. It can be placed in the left, but you still want to maintain the bevel to the septum, which may make it a little more difficult to insert. But if this be more patent nare, with a little bit of effort, it should slide in. So now at this point, we've established that our patient is becoming respiratory compromised, so we want to make preparations to also intubate. Because while bag valve mask ventilations may be effective and can help buy time to prepare our patient for intubation, it's not sustainable. So some things we want to gather in preparing for the intubation. We want to make sure that we have an appropriate size blade. An infant is going to use, pediatrics typically use Miller blades. These are going to be long, straight blades. They're used to hook on top of the epiglottis, pull everything out of the way to visualize our vocal cords. Your typical infant would use a Miller 1, a little smaller neonate may use Miller 0. We want to make sure we have an appropriately sized ET tube. Here I have a 4.0 tube. You also want to make sure, as a backup, you have one size smaller. When you insert the laryngoscope, you may find out that you don't have as much space as you anticipated. So that's for the immediate intubation and that equipment. You want to make sure that you have suction readily available, a yank hour. Even if vomit isn't present, you want to make sure that you're able to clear the airway of any secretions to optimize your visualization of the cords. You want to make sure that you have something available to secure the tube after intubation. A less plastic tape works wonderfully. With smaller neonates and smaller tubes, this little side works well, sticks to the side of the mouth and wraps around candy cane style up the tube, or you can use a little X here. This would go across the entire bridge of the mouth, and then the other side would wrap up the length of the ET tube. We also want to make sure we have something available to confirm placement. Colometric will turn yellow if it's detecting CO2, and while that is a good quick way, the gold standard for tube placement is going to be your waveform capnography. It'll give you a real-time measurement of your CO2 value to facilitate ventilation, and it will also confirm your tube placement. Some adjunct equipment to have ready would be McGill forceps. For a patient who came in unconscious, unresponsive, we may not be sure the cause of their respiratory distress, and it could be a foreign body. Having these nearby would be very helpful if you were to open the airway and see a foreign body present. Okay, with all our primary intubating equipment, we also want to have a contingency plan. With that, we have equipment such as a bougie. A bougie can be used in place of or as a backup to a traditional stylet, and then also there's a place for supraglottic airways. Many ERs are using this, whether that is an IGEL, King Airway, or an LMA. These can be utilized if the patient doesn't tolerate intubation or if intubation isn't readily attainable because of anatomy difficulties or what have you. After your equipment is all collected, your patient is currently being bagged with good quality BLS bagging. We are bagging just enough to make sure that there is adequate chest rise. We're watching our manometer to make sure that we're staying less than a peak pressure of 30, and we are trying to avoid gastric distention. If your patient becomes difficult to bag, you want to readjust your mask. You want to readjust your patient. You want to go ahead and squeeze. It's possible that gastric distention may be taking place. This also may happen during intubation if you're having difficulty finding tube placement or difficulty bagging when the tube is placed. You may need to insert an OG to decompress the belly. This is a great time to take a pause and utilize your pre-intubation check sheet. This gets everybody on the team on the same page, and your documenting nurse is a great person to go ahead and facilitate this as your intubator is going to be focusing on the equipment, double checking to make sure we have everything present. Whoever is responsible for RSI medications is going to be drawing those up. Your pre-intubation checklist should double check to make sure that all equipment necessary is provided and present, make sure that suction is on and working, making sure that pre-oxygenation is taking place, making sure that we have a mechanical ventilator ready, and making sure a post-intubation plan is present and clarifying all of the roles of everyone in the room participating in the evolution. After everybody's taken that small break, gotten on the same page, then you can proceed with the intubation. While ED nurses are typically not intubating, they're very much present during the intubation process, so watching what an intubator is doing and being able to assist in that process as well as some tips and tricks is what we are going to go ahead and show. So the intubator is going to take the blade in their left hand, they're going to insert into the mouth, sweeping the tongue out of the way. Taking the Miller blade, coming over the top of our epiglottis, and lifting up and away, being mindful not to rock back on the top of the patient's mouth. So if the intubator is having difficulty visualizing the cords, they can ask their assistant to elevate the patient's shoulders at this time, provide a jaw thrust to have more clearance within the mouth, or while we don't routinely do cricoid pressure, there is the BERT method, which is displacing the trachea backward, upward, and rightward pressure. At this point, when I have a good visual, I will ask my assistant to hand the ET tube into my right hand. The intubator will go ahead and pass the ET tube through the vocal cords and maintain positive pressure on the tube. After that, I will ask my assistant to withdraw my stylet while maintaining positive control, and then place the bag with colometric onto the tube and provide ventilations. We're watching for a color change to yellow to make sure that we have positive placement, as well as listening to breath sounds to make sure they're equal bilaterally. At this point, you can either continue bag ventilating or placing the patient on the ventilator while securing the tube with your tape. This being a two-person process, one person maintaining positive control of the tube, the other individual applying the tape. So the tape will be applied across the top lip and across the face, while the loose ends of the tape are wrapped in a candy cane fashion up the length of the tube. Now your ET tube is secured, you can continue mechanical ventilation, and your colometric should be treated for waveform capnography to continue to confirm tube placement, as well as appropriately titrate your mechanical ventilation to optimize the patient. So remember, when we're managing a child in respiratory distress, let's not forget our basics, let's anticipate what our escalation will be, but not rush to get there. Give our patient adequate time to turn around and be proactive in their care. If you do have to intubate your patient, make sure you stop and check before it's done so the evolution isn't rushed and you have everything and everyone present. Hi, my name is Carolina, and today I'll be talking about an attached worksheet that's called the Sick Kiddo Down and Dirty. This worksheet has some tidbits that I thought would be really helpful and I wish I would have known when I worked in the ER. So first, we're going to talk about making your MedMeth a little bit easier. So a couple things I didn't know was that diluting medications and using a stopcock will make your life so much easier when you're working with pediatric patients. So we're going to talk about some sedation and diluting some epi. So first, we'll talk about fentanyl. The concentration that we typically use is 100 mics and 2 mls. So here, I've drawn up my medication, and I will attach it to a stopcock. So first, we'll start by making a fentanyl drip. So you will get your fentanyl vial. Mine is 100 mics and 2 mls. I've already drawn it up in my syringe here. I'm going to grab a stopcock, and I will attach it here. I've taken a normal saline syringe, and I've taken out 2 mls, so I only have 8 cc's in the syringe. I am going to simultaneously push my fentanyl and pull it in to the syringe. So now, this is going to yield 100 mics from this vial in 10 cc's. So this is now going to be a concentration of 10 mics per 1 ml. And this is good if you want to give a fentanyl bolus or if you want to start an infusion on a syringe pump. Next we'll do midazolam, which is the same concept. My concentration is 5 mg per 1 ml. So I will draw it up. So next we'll do Midazolam, which is Versed. My concentration is 5 mg per 1 ml. I already have it here in my syringe. I'm going to do the same thing. I'm going to take my Stopcock. I'm going to put my Versed on one side. I already have a normal saline syringe, and I'm going to take out 6 cc's. So I'm left with 4 ml's in here. I will attach that here. I'm going to open my Stopcock. Then I will simultaneously push in the medication while pulling back on my flush. And this is going to yield this vial, which is 5 mg in 1 ml, which is now going to be 5 mg in 5 ml's, or a concentration of 1 mg to 1 ml. We'll move on to Epi. First we'll work on our Codose Epi. So we have a 1 mg per 10 ml syringe here attached to a Stopcock. I have a 1 cc syringe because Codose Epi is typically a pretty small volume. So say that we have a 3 kg baby. We're going to give 0.1 ml's per kg of Epi. So with this syringe, I have it closed off this way. I'm just going to pull back here to 0.3, and we have our Codose Epi. Next on Epi, I'm going to work on making a spritzer. So some hospitals carry spritzers that are pre-made. A spritzer is 10 mgs per ml. So to make this, you take your Codose Epi, and you take a normal saline syringe. I'm going to take out 1 cc. So now I have 9 ml's of normal saline. I'm going to attach that here. So I am going to look very closely, and I'm going to pull back until I have 1 ml to yield 10. And I will disconnect that. Then I have my spritzer, or lower dose Epi, which is 10 mgs per ml. Another trick that I learned, and that some facilities use, especially in user pediatric ERs, is a push-pull method for volume resuscitation. You might have, if you're lucky, push-pull tubing, which is pretty short tubing with essentially a stopcock at the end. If you don't have it, you can do what we're doing here today, which is just grabbing normal IV tubing and spiking a 0.9 bag. Again, using your stopcock, you're going to put it at the end, and you're going to grab a 20 or a 60 cc flush. I'm just going to take some out really quickly. Taking the air bubbles out. So I will attach that here. And from here, I'm just going to fill up my syringe all the way until I have 60. And then when I'm ready to give it, you'll attach the patient's IV right here. We'll close it off to the bag, and then you will just inject this into the patient's IV. Another thing to remember when you're working in the ER is to use your resources. So if you've been in the ER for a bit, you're really familiar with the Brasil Tape. Never be embarrassed or ashamed to pull it out to reference your things. It's a really good resource for medications that are commonly used or not commonly used, depending on what kind of ER you're working in. I'm also a really big fan of using my phone. It's a double and triple-channel phone, I'm also a really big fan of using my phone to double and triple-check my med math and equipment. So you can get some really good ones for free that have good resources. There's also some out there that you may have to pay for, but I have a few, and I think they are very much worth it. So next, we will be talking about shock and the different types of the pediatric patient. So shock is when there's inadequate tissue perfusion to meet metabolic demands. and poor oxygen delivery. The goal is to improve the patient's systemic perfusion and delivery of oxygen to the vital organs. Something important to remember in pediatrics is that a patient could be normal-tensive, but still be in shock. If they're showing signs of poor cardiac output with poor perfusion, this patient may be normal-tensive, but they can just be compensating and be in a shock state. So we'll talk about the different types of shock. So we have cardiogenic, obstructive, distributive, and hypovolemic. So in terms of cardiogenic shock, the kids that may present with this are kids that have a history of CHD, which is congenital heart disease. Kids with a history of myocarditis, any type of arrhythmias, or cardiomyopathies. Your obstructive shock patients are those that may present after a trauma. Those with tension pneumo, a cardiac tamponade, or those kids that might present after having a PE, pulmonary embolism. Children with distributive shock are patients that might have sepsis, anaphylaxis, or be in neurogenic shock. And then lastly, kids that are in hypovolemic shock may have had gastroenteritis with poor PO intake for several days. They could be vomiting. They could have diarrhea. It also classifies those hemorrhage patients that come in after a trauma, that have a lot of volume loss. One thing to keep in mind that I think is very easily overlooked is that respiratory patient that is breathing 80 to 90 times a minute and has been breathing this way for hours on end. It's really easy to forget that insensible losses also cause a decrease and can contribute to hypovolemic shock. So next we will talk about the treatment for these shocks, medications, and why we use the types of medications. So I wish I knew why I was starting epi or norepi when I was in the ER. They all hit different receptors, which I think is really interesting. So epinephrine hits your alpha, your beta-1, and your beta-2s. So this medication hits alpha and betas, but it primarily is going to hit your beta receptors. It causes relaxation of the bronchial tree, which is why it's a really good medication when you use it in asthma or anaphylaxis. In small doses, which is typically less than 0.3 mics per kilo, it is an inotrope, so it really helps with that cardiac contractility. In higher doses, it's going to hit a little bit more alpha, and you're going to have some basal constriction with this medication. Next we'll talk about norepinephrine. So this is going to hit your beta-1 and your alpha receptors, but it's primarily going to hit those alphas. So with this, it's going to increase your contractility. It's going to increase your heart rate. It may not increase it as much as epinephrine does, but you'll still see a little jump in there. And since it's primarily an alpha, you'll see a lot of basal constriction and thereby an increase in your blood pressure that way. So dopamine is going to hit three different receptors, dopaminergic, alpha, and your betas. This is kind of an interesting drug because at three different doses, it hits a variety of these receptors. So low-dose dopamine is usually 1 to 5 mics per kilo, and this is typically used to increase renal perfusion. This is a little bit old school and maybe out of practice, but if you see it, it's because they want to try to get that urine output up to increase renal perfusion. In the higher dose, which is 5 to 15 mics per kilo, it's going to hit your dopaminergic and your beta-1 receptors. So this is going to cause cardiac stimulation and renal perfusion. And then in your large dose, which is 15 to 20 mics per kilo, it's going to hit primarily alpha. So when you think of alpha, think of basal constriction, and that's why your blood pressure is coming up. Dobutamine. So dobutamine isn't used super frequently, or at least not as frequently as the other medications. You'll see it more so in cardiogenic shock. So this is different than the others in that it's used primarily for a patient with normal blood pressure but poor perfusion. So if your goal is to increase that blood pressure, dobutamine is not the drug for you. Next, we're going to talk about this purple box, which is a pretty good estimate of what tubes you should be using after your patient's been intubated. So to calculate your endotracheal tube, you will take the number 16, you're going to add the patient's age, and then you'll divide that number by 4. So if your patient is 4, 16 plus 4 is 20, you divide that by 4, and your endotracheal tube size should be 5. This is for a cupped tube. If it's uncupped, you're going to increase that by 0.5. So when you're placing your Foley, an OG or an NG, you should take that ET tube size and multiply it by 2. And if you need a chest tube, multiply that number by 5. So now we'll talk about a patient after you've resuscitated them. What do we do now? So first we'll talk about oxygenation. You want to maintain saturations between 94% and 99%. If they're sitting at 100% for a while, or if your ABG comes back and their O2 is pretty high, you can try working on weaning their FiO2 down, just to maintain 94% to 99%. You want to make sure that you're really closely monitoring their hemodynamics. So maintaining age-appropriate vital signs is really important. Adults usually trend the maps, but for kids, you really look at that systolic. So if you have a baby, so an infant less than 1, you want a systolic greater than 70. If the kiddo is 1 to 9, you want a systolic of 70, plus their age times 2. If they're 10 years old, you want a systolic of at least 90. You also really want to focus on neural protection. Again, remember, this is a post-survest kit. We may or may not know how long this kit was down for and what kind of anoxic kit they took and brain injury they might now have. So for neural protection, we want to avoid hypothermia and aggressively treat a fever. A fever increases your cerebral metabolic demand, and this is a time where we really want the brain to relax and not do any more work than it has to do. You also want to avoid hyponatremia and maintain normal sodium levels. So think about it. When you have a low sodium level, your cell tends to swell. If you're post-survest and you're concerned about cerebral edema and your sodium is low, your cerebral cells are going to swell, and you don't want to exacerbate something that's already happening. You also want to maintain an N-tidal or your CO2 on your APG within normal limits, 35 to 45, and you may want to be on the lower side of normal, 35 to 40. This is important for a few reasons. If you're hypocapnic, you're vasoconstricting, and your blood flow to the brain is compromised, and so you're not going to be perfusing your brain as efficiently as you can. On the other end of the spectrum, if you're hypercapnic and your CO2 is too high, you are vasodilating and causing a lot of blood flow to go to the brain, and you might cause some venous congestion and increase your ICP if you're worried about cerebral edema. The last thing we'll talk about is sedation. So depending on the kiddo, if they're post-survest, they may or may not need sedation. If you're needing sedation, I like to use fentanyl and Versed, but you can use whatever is available in your facility. Some things to look for is tearing, especially if they're paralyzed or they're not able to move. Tearing paired with tachycardia is pretty common. We want to also prevent shivering to protect that brain, and also get a good pupillary exam. If their pupils are really big and brisk, they might be awake under that paralytic. Taking care of kids is really scary. I have been that new ER nurse in the ER with my colleagues who are also scared of taking care of kids, and I wish I would have known some of the things that I know today. So I hope that these tidbits and these practice pearls will help you become more comfortable and more confident in taking care of kids, and I hope that you will spread the knowledge with your friends to make them more comfortable as well. Hi, I'm Jean, and I'm going to be talking about the circulation portion of the ABCs. So I think a lot of times when people jump to ACLS before going to BLS, they're forgetting that BLS saves lives. So a lot of people in the trauma bay jump to grabbing supplies, they want to intubate, they want to do all these things, and they've forgotten that this patient is bleeding out and they need hemorrhage control. So in trauma, we always prioritize C-ABC, and we're going to focus on the circulation first and make sure that there's not an uncontrolled hemorrhage. So you might be wondering, what is this strange log I have with me? Well, this is our leg demonstration. So as you can see, we've got a wound here, and imagine your patient comes in the trauma bay and they're bleeding out from this wound. The first thing you're going to do is grab your hemostatic gauze, and first you're going to apply direct pressure. If that isn't cutting it, that's when you grab your gauze, and you're going to pack the wound. The point of doing this is to cause a tamponade in the wound, and it seems like a comically large amount of gauze that you're going to put in there and just keep stuffing. You're going to really just pack this in there, and then once you pack this in completely, you're going to take, if you have extra part of your gauze, you're just going to kind of bunch that up and try to put a pressure dressing on this. If your patient is still bleeding out, even after packing the wound and putting direct pressure, this is when you're going to grab your tourniquet. Placing your tourniquet like so. This initial part is going to be taut against the skin, but you can only get it so tight, but try to get it as tight as possible. And then once you have this in place, you're going to twist this at least three times, sometimes up to five times, and if your patient is alert and oriented, they're going to be yelling at you. Tell them, I'm just trying to save your life. So keep on twisting. You're going to pack this in here. All the tourniquets come with this slip on here that has the time. What you want to do is document the time that you placed the tourniquet and twisted the tourniquet so that you stopped the bleeding. This is really important for the trauma surgeons to know. Whenever you end up at that level one trauma center, they're going to want to know what time this tourniquet was placed, and it's very tempting to want to peek and see if it's working and see what happens, but you really don't want to do that. The only person that should take down this tourniquet is the trauma surgeon. If you place this first tourniquet and you still have bleeding out that wound, grab a second one and put it about two to three inches above the first. Now that we've talked about stopping the bleed, we're going to be talking about now the pipes have been fixed, but we want to fill the pipes back up with blood. That requires access. How many times have you had a pediatric patient and you are having 10 different people try to stick the patient? No one can get that IV. It's so hard. We've realized, oh, 30 minutes has gone by and we still don't have access on this patient. This is where we want to drill. Your facilities will probably have you take a class specific for your institution about how to drill with the IO. I'm just going to talk about tips and tricks to keep you on your toes. We've all made mistakes, and so I'm trying to help you learn from the mistakes I have made. When you are picking the size needle to use, as you can see here, this one, we want the needle to touch the bone before we start drilling, but you wanna see the black line, which is the five millimeter line, above the skin before you start drilling. So this one, as you can see, is too small. So this needle, this is already touching the bone here, and then you can see the five millimeter mark, so you know this is an appropriate size needle. When it comes to placement of the IOs, we really like the humeral head, but for kids under seven, a lot of times we prefer to use the proximal tibia. Whether you are using the proximal tibia or the humeral head, you want to make sure that your limb, whichever is being used, is stabilized and then not moved after you place the IO. So what does every trauma patient get is a PAN scan. So you have your humeral head IO, and you have your arm across your chest, you have the IO in place, and then you go to CAT scan and they wanna lift your arms. Make sure they don't do that. So if you have to put a limb alert band on there to make sure no one moves it, you can do that. Or just make sure you tell them, please don't move the arm. If you're using the proximal tibia, you can use an arm board or something and make sure that the leg stays nice and still. And then you really wanna make sure that your IO is in place throughout the whole time you're using it. So if you're infusing, you're checking around and checking for any swelling. But what a lot of people forget is to check behind the knee and check for swelling there. And if you feel like hard skin, any sort of swelling, you know that that IO is probably infiltrated. So following the algorithm for Stop the Bleed, we start with direct pressure. If that's not enough, that's when we grab our hemostatic gauze, and we're gonna shove this in here, and you really wanna pack this wound. It's a comically large amount that you're gonna be able to fit in here, even though it looks like a small wound. And you're gonna keep packing because you're trying to tampen out that bleed. And once you pack so much that you literally cannot fit any more gauze in there, if you have a little tail like this, just take the rest of this, bunch it up and put a pressure dressing here. If that is not enough to stop the bleed, that's when we're gonna grab our tourniquet. So you place the tourniquet around the limb, and you're gonna go about two to three inches above the wound. This is gonna get as tight as you can, flush against the skin here. And obviously this is not enough to tampen on here, so we're gonna take this twist, and you're gonna go at least three times, sometimes up to five. And if your patient is alert and oriented, they're gonna be yelling at you. Just tell them, sorry about it, just trying to save your life. And then when you flip this down, this has the time portion on here, just make sure to write the time and let the trauma surgeons know. In terms of picking an IO needle to use, you wanna be familiar with whatever your institution has available. So just be familiar with the product that you use in your ER, and then know that there will be different sizes for pediatric through adult. The main thing when you're choosing which needle size to use, is that you should be able to puncture through the skin, the needle should touch the bone, and you should still see that five millimeter mark above the skin. For example, this one works, and then this needle here, when you puncture through the skin, you hit the bone, you can't actually really see that five millimeter mark above the skin, so this would be too small of a needle to use. So something you're always concerned about with IO placements is dislodgement. When you have an IO in the tibia, you wanna be checking that calf. A lot of people just look around the IO site and check for swelling, but you really wanna check that calf. If it feels hard, you're probably likely dislodged. And then in terms of a humeral IO, again, check for swelling around the IO, but then check behind the shoulder, and you're gonna try to palpate if it's firm. You can also use the other side if it doesn't have an IO, to kind of compare both in the legs and in the arms. So circulation, obviously for trauma patients, we prioritize that before the ABCs, just in terms of external hemorrhage. You wanna make sure that you take care of that, because you have to plug the holes before you fill them. And your institution will have their own IO drill that they use, so be speaking with your facilities about what is available. And then also, if you're at a facility that doesn't allow nurses to perform IOs, talk to your shared governance and try to make that happen for you. Hi, everybody. Thank you so much for coming to this educational session. My name is Terri Campbell. First of all, I wanna send some love to all my ED nurses out there that are true animal lovers. For this demonstration, we are going to be using pig cadaveric tissue so we can demonstrate certain skills. I wanna reassure everybody that for the purpose of this lab, the animal tissue that we're using came from a meat processing lab. It's a meat processing department. And these parts actually would have been thrown out. So it truly is beneficial for us as ED nurses to be able to use this animal tissue as it very closely mimics human tissue. So let's talk about P, positive end expiratory pressure. We hear about it all the time, but what's the purpose? So if we think of our alveoli, our alveoli are these grape-like clusters, airbags, and we need to keep them distended. We want those alveoli to stay inflated so they can literally connect here to our capillaries and that's where we can have our gas exchange. So it's very important for patients that have pneumonia, that have atelectasis, that have pulmonary contusions, that that alveoli, it's either gonna be collapsed or it's gonna be moving further away from the capillary, interfering with that gas exchange and causing pulmonary shunting. So the capillaries and the blood vessels in the lungs are smart. They're looking for a place to have gas exchange. And if I've got a bunch or a cluster of alveoli that are collapsed and not perfusing, that blood is gonna be shunting to organs where they can have that gas exchange. So the good thing about PEEP is that it can increase our chances of having that gas exchange, but there's also consequences with PEEP. If I have too much PEEP, I'm actually increasing the thoracic pressures that are inside the chest much higher than normal pressures that are naturally in the chest. This is gonna then cause a decrease in venous return to the heart. So let's remember our anatomy and physiology. Our superior vena cava, our inferior vena cava, they're meeting here at the right atrium. If I've increased pressures inside the chest so much, it's gonna be compressing on these vessels that are gonna interfere with the amount of blood that's gonna go to the right atrium. If I can't get blood into the pump, I can't get blood out of the pump. So when we have patients that have these high thoracic pressures, we're gonna see a decrease in blood pressure because I've got decreased blood in, decreased blood out. And reflexively, I'm gonna see a tachycardia because we're gonna increase our heart rate, trying to circle the amount of blood that we have. So let me show you a demonstration using our animal parts. Here's my lungs and the heart. On my PFALV, I have this down to 20. So we're doing this for demonstration purposes. But again, that's the idea. We're gonna make it dramatic. So as I'm bagging, look at what's happening to the pig lungs. They are quickly recruiting alveoli and they're expanding quite a bit. So if I've got a patient that has atelectasis or pneumonia or something where they are very dependent on high amounts of pain, and then the physician says, hey, Terry, can you take that patient to the CAT scan? And I say, no, because that's where patients go to die. We don't want that to happen, right? So what's happening? Look at again how expanded my lungs are when I take the patient off the mechanical ventilation and I disconnect so I can hook up my ambu bag. Look at how immediately these lungs are gonna be de-recruiting. Now I have an otherwise healthy pig. If I start bagging, I can re-recruit those lungs. But again, remember your patient population. If you have a patient that has a pneumonia, a large amount of atelectasis, or more importantly, pulmonary contusions, which are very, very common in trauma in pediatric patients. So this is kind of an example, this bruising here. So we're not gonna have good gas exchange in this area. So keeping those alveoli are gonna be very important. Now, great things that we can have with PEEP, but there's also gonna be iatrogenic or negative consequences for having that high PEEP. As you can see, when I'm bagging like crazy, I'm gonna poke fun at my respiratory therapist. Sometimes they get a little excited and they're doing VTAC on my ambu bag. You can see, imagine if I've got the lungs behind the thoracic cavity here, how this is gonna cause that increase of pressure inside the chest. And again, it's gonna have the same physiologic effect as a tension pneumothorax, in the sense that it's compressing those vassals, decreasing venous return to the heart. Remember, if I can't get blood into the pump, I can't get blood out of the pump. So some of our signs, we're gonna see hypotension, we're gonna see tachycardia, and you may ultimately see your SpO2 and your blood pressure drop. So we have to remember what the purpose of our PEEP is. Our PEEP is to expand that alveoli, but not to the point where I'm gonna be compromising my patient's blood pressure. Certainly with our critically ill patients, we find that we've got this teeter-totter. We're trying to increase their O2 sats, but not bottom out their blood pressure. So it's very common in the ED with these critical patients that you may be having to titrate the amount of PEEP that you have, or you might have to be adding pressors if you need to maintain your blood pressure. So I hope that gives you a better understanding of PEEP. Okay, guys, so the next demonstration that I'm gonna show you is demonstrating physiologically what's happening during a tension pneumothorax. So we know anatomically, our chest is supposed to be a negative cavity. As that diaphragm flattens out, it causes more negative pressure, and we've got inspiration. On expiration, that diaphragm is becoming dome-shaped, and we've got air that is exiting the lungs. That's great. That's how it's supposed to be with normal physiology. But if we have a pneumothorax, and we've got air that belongs inside the lung going into the thoracic cavity, we've changed our pressure dynamics. Our negative chest of the thoracic cavity now is becoming a positive cavity. So I have my lungs inside that have been cut, and they've been damaged. So as I'm gonna be bagging, my thoracic cavity, which is normally a negative chest, a negative cavity, is now going to become positive because the air that I'm pushing into the lungs is now escaping out into the thoracic cavity. So our little blue bag here is gonna be simulating our thoracic cavity. Now remember, in real life, we've got ribs that are over here. So our bag or our thoracic cavity can only expand so much. As that thoracic cavity continues to expand against those lungs, it's increasing that thoracic pressure. And again, that will be causing a decrease in venous return to the heart. It will be kinking off my great vessels and not allowing that right atrium to fill. So again, maintaining a lot of peep here just for the demonstration. You can see my little piggy lungs are trying to expand here. And as I'm bagging, watch the blue bag because you're gonna see that it's gonna be filling up with more and more air. So certainly the larger the pneumo, the faster that our negative cavity is going to become positive. So I'm continuing to bag. And again, look at that blue bag just getting more and more taut. So what is our correction? What is our immediate temporizing intervention that we're gonna do to make this tension pneumothorax better? We're gonna do a needle decompression. And again, remember, that is second to third intercostal space, midclavicular line. And we're going over the top of the lungs because the vein, artery, and nerves live underneath the lungs. So again, look in my demonstration and look at how much air that we puffed into that cavity, making it now a positive cavity and not a negative cavity. And anatomically, what's gonna happen is the deflated part of the chest is gonna be shoving over, kinking off those great vessels on the side of the chest that's unaffected. So again, think of that, the mediastinum. So you've got your great vessels that are in the center of the chest, but if one of your lungs is deflated, filling up with all this positive pressure, it's gonna shove all of those anatomic pressures over to the unaffected side. But remember, here's where the plumbing comes in. Your superior and inferior vena cava that are filling up your right atrium, instead of being in an anatomic lie, they're gonna be more kinked like this, kind of like you're kinking a garden hose. We have the exact same problem that we were talking about earlier. If I can't get blood into my pump, I can't get blood into my right atrium, I'm not gonna have enough volume to get blood out my left ventricle. So what are my signs of a tension pneumothorax? So my patients may have some air hunger. They're gonna be tachycardic. They're gonna be hypotensive. We talk about having JVD. So what does that come from? Remember from the superior vena cava, that blood is coming from the head and from the arms. So as it's trying to come down and fill up the right atrium, because that tubing is kinked, that blood is gonna be pooling, and that's where our JVD is going to be coming from. What is our solution? An immediate temporizing is to do a needle decompression, and then our providers or our physicians are going to be putting in a chest tube, again, maintaining that that positive pressures that have accumulated in the chest, that air will be evacuated, the lung can re-expand as we're maintaining negative pressures that belong in the chest. So again, remember as ER nurses, all the actions that we do that are beneficial can also have consequences. So understand your treatments, why you're doing them, how to assess them, and how to make them better. Thanks.

respiratory distress

pediatric patients

early intervention

intubation

cardiac arrest

non-invasive interventions

positive pressure interventions

advanced airway interventions