ANAPHYLACTIC SHOCK: A PEDIATRIC PERSPECTIVE Deborah Chasco, CCRN, DNP, CNS

Transcription

1 ANAPHYLACTIC SHOCK: A PEDIATRIC PERSPECTIVE Deborah Chasco, CCRN, DNP, CNS

2 OBJECTIVES Upon completion of the scenario and clinical simulation, the participant will: Recognize signs and symptoms of anaphylaxis n the pediatric population Perform focused respiratory and cardiovascular assessments Initiate respiratory support utilizing assistive oxygen delivery devices and respiratory assistance as needed Recognize the urgency for central venous access Implement safe administration of epinephrine as a primary treatment for anaphylaxis Educate patient and family on: 1. Identification and removal/avoidance of allergen 2. Emergency plan for recurrent symptoms Communication with health care team members and others regarding allergies and preventive care

3 Environment Simulation Lab Set-Up- ED pediatric bed Manikin Set-Up-Bobbie to be set up for 4 stages 2 minutes apart for each stage ECG with normal sinus rhythm initial set up with PVCs on second stage and SVT on third stage with survival at normal sinus rhythm. If Bobbie does not survive-asystole on ECG CXR with central line placement will be shown with the scenario Equipment: ED bedside equipment such as pediatric resuscitation cart with oxygen, airway adjuncts, latex (actually latex free gloves marked as latex gloves along with latex free gloves marked appropriately), central line kit, Foley catheter for placement Medications: Epinephrine 1:1000 solution; Epinephrine 1:10,000 solution; Normal Saline vials and IV bag; Lactated Ringers IV bag; Diphenhydramine; Albuterol; D10W IV bag-pediatric Resuscitation Cart Lab simulation personnel in control room for simulation of manikin along with personnel to act as concerned/angry mother refusing intubation once intubation is assessed Audience (volunteers) to participate in simulation: nurse, RT or another nurse, or MD- One of the RNs needs to create a latex reaction if not announced initially; second nurse or RT managing the airway, suctioning, oxygenation, intubation; MD or NP for intubation, central venous line placement and management of child

4 Scenario Background Presentation: A concerned mother arrives to the ED with her 6 year old son. Mother states her son began breathing funny after playing ball with siblings. She states she could hear a strange sound each time her son took a breath in. The child s temperature is C (97.5); pulse is 85, respirations 20; B/P is 109/70 with a Sat of 94% on room air. {Care provider reaches for the latex gloves and creates an exposure}. Past Medical History: Respiratory Distress Syndrome at birth due to prematurity (30 weeks gestation) born by C-Section. Readmissions to the hospital throughout the first 3 years of life due to respiratory distress and pneumonia. Medications: Current medications-none prescribed; mom states she gives her son herbs (Buckthorn) due to occasional constipation. Immunizations: Immunizations are current. Allergies: Initially unknown Allergies: Care provider calls primary care physician about the child. The following allergies are faxed from the primary care provider (PCP): ALLERGY TO: Penicillin, Amoxicillin, Sulfa, Cephalosporins, Latex Family/Social assessment: Child lives with parents and 2 older siblings (10 and 12 years of age).

5 Scenario Conditions Patient is awake, but eyes are mostly closed and offers no verbalization of pain initially. The child presents with intercostal retractions and cyanosis; oxygen is administered; a rash develops on the child s trunk. The nurse announces, There is a rash developing on the chest and abdomen. ; hypotension develops and the child s respirations become more labored. The nurse speaks to the mother on the possibility of any other allergies. The mother states that about a year ago, she was told the child had a Latex allergy. She was uncertain of what this meant. The nurse states, The PCP faxed the allergy list and Latex was one of the allergens listed. The pulse oximeter SAT drops from 94% in room air to 80%. The child s cyanosis increases and the child becomes lethargic and limp. ECG identifies PVCs and the heart rate increases to 210. The child is isolated from further latex exposure. The physician prepares for intubation and the mother refuses her child to be intubated as she has heard that there are complications from intubation. After further discussion and explanation to the mother, the patient is intubated and placed on 100% oxygen. Attempts at IV access occur and are not successful. A central line is placed and epinephrine is given with response. In addition, an IV fluid bolus is administered with response. Ventilation is stabilized and the oxygen is weaned slowly from 100%. The child is admitted to PICU.

6 Algorithm Initial Presentation: Vital signs Stable, Afebrile, 94% SATs Oxygen is given for stridor and SATs increase to 96% Latex reaction with hypotension, wheezing, urticarial rash, SATs decrease to 80%, SVT at 210 Intubation with ventilatory support and oxygen at 100% Fluids given Hypertension improves but not completely Epinephrine given Hypotension improves; rash improves, SATS improve

7 Intubation

8 Central Line Placement