Pediatric emergency medicine trisk 0175 0175
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cerebroprotective properties, the primary source of proof for this and
substantiation in human studies are difficult to find.
Benzodiazepines are generally considered to be safe with anticonvulsant and
amnestic effects, reversibility (flumazenil), and less cardiovascular depression.
However, its dosing is variable in that a standard dose of a benzodiazepine (e.g.,
0.1 mg/kg) does not reliably result in inducing unconsciousness in a child. Higher
doses (e.g., 0.3 to 0.4 mg/kg) are often required for induction and have a slower
onset which places the patient at higher cardiovascular risk.
It should be noted that all sedatives can result in cardiovascular collapse in
patients with marginal cardiovascular function such as in hypotension,
hypovolemia, myocardial dysfunction, and sepsis. In severe hemodynamic
compromise (e.g., hemorrhagic shock, septic shock), consider that a very low
dose or no sedative administration might be preferable, especially if the patient is
already unconscious, to prevent cardiovascular collapse.
Dexmedetomidine, remifentanil, and combinations of propofol/remifentanil
have been studied in RSI outside of the ED. More studies are needed to determine
their role in RSI in pediatric emergency medicine.
Neuromuscular-Blocking Agent (Paralyzing Agent)
The NMBA used to facilitate intubation should render the patient completely
flaccid, negating the effects of laryngeal reflexes on laryngoscopy and passage of
an ETT ( Table 8.4 ). The ideal agent should have a rapid-onset and short
duration to allow the rapid return of spontaneous ventilation in case the patient
cannot be successfully intubated. However, return of spontaneous ventilation is
frequently not a sufficient “rescue” given the patient is generally being intubated
for significant airway/ventilation impairment.
Succinylcholine is often considered the standard since it is the oldest and has
the longest track record of use. It has a rapid-onset time of 30 to 60 seconds and a
duration of 3 to 8 minutes. It is a “depolarizing” paralyzing drug, causing muscle
fasciculations prior to the onset of paralysis. This can cause muscle pain in
muscular patients, myoglobin release (myoglobinuria), potassium release
(hyperkalemia), histamine release, and a higher risk of malignant hyperthermia. It
can result in transient bradycardia, particularly when used with inhaled
anesthetics; atropine premedication is sometimes recommended to minimize this
effect. Succinylcholine carries a “black box” warning of hyperkalemic cardiac
arrest that results from a series of children with unknown skeletal muscle
myopathies. This is rare and succinylcholine remains in widespread use in
pediatrics.
