ED Muskoka Physicians - Living the Dream

Peds Asthma simulation follow-up: November 24/25 2022

Hi Team –

We ran a simulation of a pediatric asthma case in both ER departments this week (Dr. Sawula led in Bracebridge and Dr. Jewell in Huntsville) and wanted to share a few learning points that came out of the case. Thanks to everyone who participated at both sites. There was some great discussion! The following info has been circulated to our nursing team at both sites as well.

This was a case of a 2 year old boy presenting with a severe asthma exacerbation, unresponsive to usual initial therapies (Ventolin/Atrovent/Steroids) i.e. Status Asthmaticus, progressing towards respiratory failure.

Learning points:

  1. PRAM Score – a really useful scoring tool to help quantify severity, track progress over time in ER, and create a common language to speak with our pediatricians. We do not currently use a formal asthma clinical pathway or orderset in our ER, however, we should be ensuring our management reflects this standard of care. A copy of the PRAM scoring tool is posted on the wall in Triage in Huntsville
  2. IV Magnesium Sulfate – is a 3rd line agent (after Ventolin/Atrovent/Steroids) – consider using if moderate to severe score and not improving after 1st hour of treatment. Dose is 25-50mg/kg/dose (max 2g) over 20-30 min, watch for hypotension and bradycardia. Must be on continuous cardiac monitoring.
  3. IV Ventolin (Salbutamol) – option in severe cases unresponsive to above therapies (including no response to continuous nebulized Ventolin) and possibly progressing towards respiratory failure. Ottawa Manual has a resource for how to dilute/administer this uncommonly used drug. YES we have it available. Sick Kids PICU doc should be contacted if this is being considered as this is an ICU-level therapy but can get started while waiting for transfer team. Generally Sick Kids recommends NO loading dose, but starting maintenance dose at 1-2mcg/kg/min and titrating q10min up to 5mcg/kg/min (Max 20mcg/min)
  4. Oxygenation/Ventilation – for impending respiratory failure, consider Heated/Humidified High Flow Nasal Cannulae. We have nasal prongs and flow rates appropriate for smallest kids so this is a good option. RT can set this up for us. We do NOT have masks small enough to do BiPap/CPAP on kids <20kg. We do have neonatal CPAP/PPV via the Neopuff T-piece resuscitator, which can technically work up to 10kg, but this does require hands on ventilation. **There is a high risk of mortality with intubation (high risk pneumothorax, impaired venous return, CV collapse… all sorts of badness), so last resort of management.

See this SickKids Webinar for more education on managing a severe asthma exacerbation pending transfer to a tertiary care hospital

Hope these brief summaries after simulations help keep us on the same page. As always, if there are any topics you want reviewed please let Heather, Emma or I know. Stay tuned for December dates!

Pediatric Sepsis


A review of the CPS Practice Point on Pediatric Sepsis (2020)

Fortunately, pediatric sepsis is relatively rare. We all treat adults with sepsis multiple times a month, but a child in septic shock is a rare, and terrifying, presentation in our community ER. However, sepsis is a major cause of morbidity and mortality in children, and requires prompt recognition and treatment. Just like in adults, sepsis care guidelines have focused on creating a systematic approach to these cases. This ‘practice point’ article put out by the CPS in 2020 uses 4 cases to succinctly review current global guidelines (including the Surviving Sepsis Campaign’s Pediatric Subgroup’s 2020 update). It’s worth a quick read. Not a classic journal club article as I’m not going through critical appraisal of the literature, but thought it was worth a quick review! Also, ties into the sim we ran this month – see below 🙂

We ran a simulated case this morning in Huntsville that highlighted a few practical points:

Case was a 7mo boy with ALL on chemo, presents with a fever, tachycardia, poor perfusion and altered mental status.

Key points : 

1. Early recognition of sepsis is key!  Worth regularly reviewing normal vitals in peds (chart in CPS article). Also we will be laminating a copy of a chart of normal pediatric vitals to hang on the side of the Peds crash carts (along with the NRP cards). Remember: a hypotensive septic kid is peri-arrest!

2. Practicalities of administering a fluid bolus in a baby – NEVER hang fluid by gravity (risk of too much or too little fluid) can put on pump or (preferably) do a push-pull method (draw off IV line with 60cc syringe, then push calculated amount over 5 minutes)   – R/A for response/fluid overload after each 20cc/kg bolus, aim for 60cc/kg in first hour of resuscitation and think about adding a vasopressor if not responding after 2nd bolus.

3. Vasopressors: 1st line is traditionally dopamine (which we have pre-mixed in crash cart) but this has changed officially in 2020  – Epinephrine (cold shock) or Norepinephrine (warm shock) is preferred, but these will need to be mixed up. (Look in dosing book on top of peds cart and be aware concentrations are vastly different from the way we mix it for adults!!)

4. Antibiotics – give early, give as IV push. Typically will be Ceftriaxone (100mg/kg) unless need broader coverage for risk MRSA/pseudomonas/immunosuppression etc.

5. Hydrocortisone – use more liberally in peds than adults, for fluid-refratory shock in sepsis, especially if history of steroid use (asthma/chemo etc). Dose = 2mg/kg IV push.

6. Hypoglycemia – more common in septic kids than adults. Remember D50 is caustic on veins, and not preferred in peds <2y. Can use D10W (1L bag kept1 in side of crash cart)  or dilute the D50 that is kept on the crash cart down to D25 with equal volume NS. Dose = 2.5-5mL/kg D10 IV push  OR 4ml/kg D25 IV

Great website for resources to review this topic including videos and a pdf algorithm which I’ve tried to attach:


What do you think the biggest barrier is in our department to providing excellent pediatric care? Do you have any suggestions for how we can improve?

PECARN Febrile infant tool

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Ultrasound and Honey

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Pediatric Vitals: Forget PALS and APLS

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Paediatric Head Injury Rules: PECARN Wins

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Paediatric Vomiting and Diarrhea Care Pathway

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