In Situ ED & ITU Simulation - Paediatric Diabetic Ketoacidosis (first presentation) with cerebral oedema

Learning Objectives

Learning objectives - Non clinical

• Team leadership and team-working in paediatric resus
• Multi-Specialty collaboration including referral to tertiary centre
• Familiarity with environment
• Communication of specific skill sets

Learning objectives - Clinical (Medical)

• Identification of DKA
• How to calculate fluid requirements
• Initial management of DKA as per protocol
• Recognition of cerebral oedema
• Management of cerebral oedema
• Management of raised intracranial pressure/liaise with PICU

Learning objectives - Clinical (Nursing)

• Calculations required for fluids; drug dosing; make up of unfamiliar drugs
• Setting up appropriate insulin/fluids
• Task prioritisation and allocation
• Neuroprotective measures

Faculty - Alex Belcher, Ben Short, Ben Atkinson, Tom Talbot

RCEM Curriculum Coverage Topics (SLOs)

SLO 2 – Support the ED team by answering clinical questions and making safe decisions
SLO 5 – Care for children of all ages in the ED, at all stages of development and children with complex needs
SLO 7 – Deal with complex or challenging situations in the workplace

FICM Curriculum Coverage Topics (HiLLOs)

HiLLO 13. A specialist in adult Intensive Care Medicine is competent to recognise, provide initial stabilisation and manage common paediatric emergencies until expert advice or specialist assistance is available. They are familiar with legislation regarding safeguarding children in the context of Intensive Care Medicine practice.

The Case

• 14 year old presents with abdominal pain and nausea (patient actor initially)
• Polydipsia and polyuria
• Dehydrated and clinically shocked
• Required two fluid boluses
• Dropped GCS due to resultant cerebral oedema and subsequent deterioration
• Swapped to manikin
• Requiring RSI
• Referral to PICU

Take Home Points

• Access guidelines through hospital intranet or dedicated referral centres eg SORT rather than “Google”
• USe of paediatric specific RSI checklist
• Assign complex tasks to specific individuals eg calculating fluids so that not everyone gets ‘sucked in’ to the task
• Consider bigger cannulae in a resus situation
• Communicate clearly if you are asked to perform a task outside your knowledge/unfamiliar to you

Latent Threats identified

• RSI guidelines laminated are the adult ones, not paediatric
• No front-of-neck access pack for paediatrics
• No clock easily visible
• No phone in room

Some comments from participant feedback from own reflections:

• Sort, dka paeds calculator, staff required to manage situation
• PAED guidelines for DKA, How to find them, fluids calculations.
• Check what size of IV access
• Assess when to step back and when to escalate to keep overview and patient safety
• SORT, DKA, paeds calculator, who should be present.
• Better communication, how to find paeds DKA protocol, type of cannula to be used in paeds in emergency
• How to access the new dka calculator
• Confirm shocked or not shocked
• Be more confident in maintenance fluid calculations
• Consider using a larger gauge cannulas for venous access in paediatric DKA due to fluid requirements
• Management of cerebral oedema
• SORT has a calculator, icu transfer nurse can come and help, get another member of staff to hold the airway to keep myself free

Suggested improvements from participants:

• More simulations please
• To have a pause to catch up and state where everyone is
• Being organised and proper delegating, knowing where to find the guideline.
• Consider having the more concise guidelines readily available/having a poster to inform where calculators are etc
• Having knowledge of how paeds DKA is run and what to access.
• Bigger room,
• 10 seconds for 10 minutes
• Names on labels
• Thank you this was really helpful
• That was excellent thank you
• I previously worked in an ICU that had both a medical and nursing team leaders. The nursing team leader is great at knowing nursing skill mix and helping to organise these staff

Faculty Debrief:

• Limit the whole in situ to an hour to ensure future buy-in from staff/avoid over-taxing a busy hospital
• Need to establish how a paediatric patient presents so that has a better fidelity start

Future sessions:

• Session in March-April time

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