Colette C. Mull

Technical tipsIntraosseous Access

BACKGROUND Vascular access is of paramount importance in the care of the critically ill patient. When central or peripheral intravenous access cannot be accomplished in a timely manner, intraosseous access and infusion is a rapid and safe alternative for the delivery of fluids, medications, and blood products. The resurgence of the use of intraosseous access in the 1980s led to the development of new methods and devices that facilitate insertion. OBJECTIVES This article discusses general indications, contraindications, and complications of intraosseous access and infusion, focusing on new devices and their insertion. DISCUSSION Current research is focused on product innovation and improving drug delivery using intraosseous autoinjectors, finding new anatomic sites for placement, and expanding the use of different intraosseous devices to the adult population. CONCLUSIONS/SUMMARY New, improved intraosseous systems provide health care providers with choices beyond traditional manual intraosseous access for administering fluids.

Preventing medical errors in pediatric emergency medicine.

ILLUSTRATIVE CASES A 3-year-old girl received treatment in a pediatric Emergency Department (ED). Nurses in the ED had drawn up saline flush syringes from multiple dose vials of saline to clear her intravenous (IV) line. Apparently, syringes of vecuronium had been prepared for another patient who was treated before the 3-year-old arrived at the hospital. One syringe filled with vecuronium had gone unused and it was somehow mixed with the saline supplies. The syringe was hand labeled similarly to the saline syringes. As a result, a syringe containing vecuronium was used to flush the IV line of the 3-yearold girl. The child quickly became frightened and then flaccid. When all respiratory efforts ceased, she was immediately intubated and ventilated. Personnel identified the error after closer inspection of the syringes. The patient was treated supportively and fortunately suffered no permanent harm. The child’s father who was present at the time of the incident reported it to the local press and the event received extensive local media attention. A 5-year-old boy received ketamine for a laceration repair in the ED. The physician ordered 5 mg/kg; the patient received 50 mg/kg due to a ‘‘math error.’’ Although the patient experienced no respiratory depression, the physician chose to intubate the child as a precaution. He was discharged from the ED awake and alert 5 hours after receiving the medication. Fortunately, he suffered no long-term sequelae. A 4-year-old boy was given ketamine in the ED for a fracture reduction. The order was written for 1 mg/kg of ketamine; the child received 10 mg/kg of the drug due to inadvertent use of the 100-mg/mL formulation of ketamine instead of the 10-mg/mL formulation. Two minutes after injection of the medication, the child experienced respiratory distress with oxygen desaturation to 65%. Ventilation was assisted for 9 minutes, and was then followed by normal spontaneous respirations. The patient was observed in the ED for 3 hours following receipt of the drug. He was well at discharge and suffered no long-term sequelae from the medication error.

Ketamine/Midazolam Versus Etomidate/Fentanyl: Procedural Sedation for Pediatric Orthopedic Reductions

Background: Orthopedic reductions are commonly performed procedures requiring sedation in the pediatric emergency department (PED). Ketamine is a widely used agent for pediatric procedural sedation, but its use may present difficulties in select populations, such as those with psychiatric diagnoses. In such a case, alternative agents that are safe and effective are needed. Etomidate is a commonly used induction agent for rapid-sequence intubation in the PED. Several retrospective and few prospective studies support etomidates safety and efficacy in pediatric procedural sedation. Objective: The objective was to compare etomidate/fentanyl (E/F) with ketamine/midazolam (K/M) for procedural sedation during orthopedic reductions in the PED. Methods: Prospective, partially blinded, randomized controlled study comparing intravenously administered K/M with intravenously administered E/F. A convenience sample of patients, aged 5 to 18 years, presenting to an urban PED with fracture requiring reduction was enrolled. Outcome measures included guardian and staff completion of visual analog scale and Likert scales for observed pain and satisfaction, blinded OSBD-r (Observational Scale of Behavioral Distress-Revised) scoring of digital recordings of reductions, and sedation and recovery times. Descriptive tracking of adverse effects, adverse events, and interventions were recorded at the sedation. Results: Twenty-three patients were enrolled, 11 in the K/M group and 12 in the E/F group. The K/M group had significantly lower mean OSBD-r scores compared with the E/F group (0.08 vs 0.89, P = 0.001). Parents rated lower visual analog scale scores with K/M than with E/F (13.7 vs 50.5, P = 0.003) and favored K/M on a 5-point satisfaction scale (P = 0.004). The E/F group had significantly shorter total sedation times (49.6 vs 77.6 minutes, P = 0.003) and recovery times (24.7 vs 61.4 minutes, P = 0.000). There were no significant differences with respect to procedural amnesia and orthopedic practitioner satisfaction. Adverse effects noted in the K/M group included dysphoric emergence reaction and vomiting. Vomiting, injection-site pain, myoclonus, airway readjustment, and supplemental oxygen use were observed in the E/F group. Conclusions: This is a small study that strongly suggests that, for pediatric orthopedic reductions, K/M is more effective at reducing observed distress than E/F, although both provide equal procedural amnesia. With its significantly shorter sedation and recovery times, E/F may be more applicable for procedural sedation for shorter, simpler procedures in the PED.

Prolonged QT syndrome in children: An uncommon but potentially fatal entity☆

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.