Urgent elective intubation

NHS Tayside ED Guidance
NHS Tayside

Patient requires urgent elective intubation and ventilation:

Intubation (call anaesthetist and consult PICU): see section BM 5 in Management of bacterial meningitis in children and young people

  • Consider using: atropine 20 mcg/kg (max 600 mcg) and ketamine 1-2 mg/kg in shock or thiopental (thiopentone) 3-5 mg/kg in RICP and suxamethonium 2 mg/kg (caution, high potassium). ETT size = age/4 +4, ETT length (oral) = age/2 + 12 (use cuffed ET tube if possible). Then: morphine (100 mcg/kg) and midazolam (100 mcg/kg) every 30 min.
  • Immediate bolus of 20 ml/kg of 0.9% saline or 4.5% human albumin over 5-10 minutes and reassess immediately. Continue boluses if necessary with repeated clinical and laboratory assessments including blood gas measurements. Fluid resuscitation should be guided by lactate, tachycardia, perfusion, hepatomegaly to avoid fluid overload and determine need for inotropes.
  • Start peripheral inotropes (dopamine); if IO access start adrenaline:
    • Dopamine at 10-20 mcg/kg/min: make up 3 x weight (kg) mg in 50 ml 5% dextrose and run at 10 ml/hr = 10 mcg/kg/min. (These dilute solutions can
      be used via a peripheral vein).
    • Start Adrenaline via a central or IO line only at 0.1 mcg/kg/min.
    • Start Noradrenaline via a central or IO line only at 0.1 mcg/kg/min. for ‘warm shock’.
    • Adrenaline & noradrenaline: make up 300 mcg/kg in 50 ml of normal saline at 1 ml/hour = 0.1 mcg/kg/min.
  • ET tube (cuffed if possible) and CXR
  • Anticipate pulmonary oedema ensure adequate PEEP (at least 5cm H20)
  • Central venous access
  • Urine catheter to monitor urine output
  • Start adrenaline infusion (central) if continuing need for volume resuscitation & inotropes
  • For warm shock: warm peripheries, bounding pulses and low diastolic pressure, give noradrenaline (central)

Anticipate, monitor and correct:

  • Hypoglycaemia
  • Acidosis
  • Hypokalaemia
  • Hypomagnesaemia
  • Anaemia
  • If bleeding or performing invasive procedure (i.e.central line insertion) treat coagulopathy with FFP/cryoprecipitate/platelets

Transfer to intensive care by paediatric intensive care retrieval team.

Hypoglycaemia

Hypoglycaemia (glucose below 3 mmol/l): 2 ml/kg 10% Dextrose bolus IV.

Acidosis

Correction of metabolic acidosis pH below 7.2:

  • Give half correction bicarb IV.
  • Volume (ml) to give = (0.3 x weight in kg x base deficit ÷2) of 8.4% bicarb over 20 mins, or in neonates, volume (ml) to give = (0.3 x weight in kg x base deficit) of 4.2% bicarb.

Hypokalaemia

If K+ below 3.5 mmol/l:

  • give 0.25 mmol/kg over 30 mins IV with ECG monitoring.
  • Central line preferable.
  • Caution if anuric.

Hypocalcaemia

If total calcium below 2 mmol/l or ionized Ca++ below 1.0:

  • Give 0.1 ml/kg 10% CaCl2 (0.7 mmol/ml) over 30 mins IV (max 10 ml) or 0.3 ml/kg 10% Ca gluconate (0.22 mmol/ml) over 30 mins IV (max 20 ml).
  • Central line preferable.

Hypomagnesaemia

If Mg++ below 0.75 mmol/l:

  • Give 0.2 ml/kg of 50% MgSO4 over 30 mins IV (max 10 ml).

Notify public health

Urgently notify public health of any suspected case of meningitis or meningococcal disease.

Prophylaxis of household contacts of MD (goo.gl/1NTbck):

  • Preferred:ciprofloxacin single dose
    • under 5yrs 30 mg/kg up to max 125 mg;
    • 5-12yrs 250 mg; 
    • over 12yrs 500 mg or 
  • Rifampicin bd for 2 days:
    • under 1yr 5 mg/kg;
    • 1-12yrs 10 mg/kg;
    • over12yrs 600 mg or
  • Ciprofloxacin, ceftriaxone or azithromycin may be used for pregnant and breast-feeding contacts of cases.

For index case not treated with ceftriaxone, prophylaxis when well enough.
Hib: prophylaxis may be indicated – consult public health

Long term management

See BM7 on Management of bacterial meningitis in children and young people.