Prescribing Resuscitation IV Fluids Assess for hypovolaemia (ABCDE) Treat Reassess (ABCDE) Refer - Dr. Ashley Miller @icmteaching #Resuscitation

Prescribing Maintenance IV Fluids Assess • Can the patient meet their fluid needs orally or enterally? If so no IV fluid • Consider fluid and electrolyte needs: History, Examination, Fluid balance, U&Es, Hb, Weight chart Prescribe (modify as below) • 1.2 ml/kg/h 4% glucose 0.18% sodium chloride + 20-40 mmol K per L (25-30 ml/kg/d water - 1 mmol/kg/d Na, K, Cl - 50-100g/d glucose) Modify - Complex fluid or electrolyte replacement issues or losses? Reassess at least daily - Stop IV fluid when no longer needed. Aim to switch to oral or enteral ASAP. - Dr. Ashley Miller @icmteaching #Maintenance #IVFluids #Prescribing #management

PocketPEM - IV Fluids - Bolus, Maintenance #Management #Peds #EM #IVF #IVFluids #Maintenance #Bolus #Dose #PocketCard #PocketPEM

Hypothermic Cardiac Arrest Management "Not dead until 32° and dead" 1) Start ACLS + Rewarming 2) Should this code be run? Consider reasons to terminate resuscitation. 3) Call ECMO Centre ASAP: ECMO is gold standard, rewarms at 10+°/hour. 4) Measure core temp: place lower esophageal probe 5) No ECMO? Prepare for prolonged resuscitation with invasive rewarming strategies. How to Rewarm: 1) Remove wet clothes 2) Warm blanket 3) Bair Hugger 4) Warmed O2 (1°/hr) 5) Warmed IV Fluids 6) Bladder Irrigation (1°/hr) 7) Thoracic Lavage (3-6°/hr) 8) Hemodialysis (3°/hr) Dr. Sarah Foohey @SarahFoohey #Hypothermic #Cardiac #Arrest #Management #hypothermia #resuscitation #rewarming #management #treatment #checklist

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis - Kupperman et al. NEJM 2018 https://www.nejm.org/doi/full/10.1056/NEJMoa1716816 Study bottom line: Our traditionally cautious approach to fluid resuscitation in DKA is not supported. Though the very young and the very sick (generally our biggest causes for concern) may be lost in this cohort, the evidence that IV fluid administration is not the cause of brain injury in DKA is now stronger than anything that previously suggested it was. More interestingly it is perhaps now time to stop arguing over fluids and start trying to figure out what does cause brain injury in DKA. Visual Abstract by Dr. Tessa Davis @TessaRDavis #EBM #VisualAbstract #Peds #Pediatrics #DKA #IVFluids #Infusion #Rates #NEJM

WETFLAG Mnemonic for Pediatric Resuscitation Weight Energy Tube Fluid Lorazepam Adrenaline Glucose Dr. Sam Birks @ BirksMD #WETFLAG #Mnemonic #Pediatric #Resuscitation #CriticalCare #Management

Neonatal Resuscitation - Preparation and Overview Preparation: - All health professionals dealing with newborn infants should be proficient in basic resuscitation; i.e. Airway, Breathing with mask ventilation, Circulation with cardiac compressions - Additional skilled assistance is needed if the baby does not respond rapidly and should be called without delay - A person proficient in advanced resuscitation (Airway, Breathing via tracheal ventilation, Circulation, Drugs) should be on site and available at short notice in a maternity unit at all times - The need for resuscitation can usually be anticipated and a person proficient in advanced resuscitation should be in attendance at all high-risk deliveries - A clock should be started at birth for accurate timing of changes in the infant's condition - Keep the infant warm. Dry, remove wet towel and replace with dry one. This will also provide stimulation. Can place directly on mother's chest and covered if crying, good tone and colour and desired by the mother - Resuscitation should be performed under a radiant warmer - If preterm and weeks' gestation, to avoid heat loss, place the infant in a plastic bag without drying but under a radiant warmer and on a warming mattress. Leave the head exposed and cover with a woollen hat. - Assess the infant's condition. Is the baby breathing or crying, good heart rate (120-160 beats/min, best assessed by listening with a stethoscope), good colour and muscle tone? - If not, commence neonatal resuscitation Overview: - Dry the baby - Remove any wet towels and cover, Start-the clock or note the time - Assess tone, breathing and heart rate - If gasping or not breathing: - Open the airway - Give 5 inflation breaths - Consider SpO2 monitoring - Re-assess - If no increase in heart rate look for chest movement - If chest not moving: - Recheck head postion - Consider 2-person airway control and other airway manoeuvres - Repeat inflation breaths - Consider SpO2 monitoring - Look for a response - If no increase in heart rate look for chest movement - When the chest is moving: - If heart rate is not detectable or slow (< 60 / min) - Start chest compressions - 3 compressions to each breath - Reassess heart rate every 30 s - If heart rate is not detectable or slow (< 60 / min) consider venous access and drugs #Neonatal #Resuscitation #Preparation #peds #management #pediatrics

Buprenorphine Initiation for the Uninitiated 1) WAIT FOR MODERATE WITHDRAWAL SYMPTOMS - Precipitated withdrawal can be caused by buprenorphine displacing a full opioid agonist. To avoid precipitated withdrawal, begin initiation during moderate withdrawal. - Moderate withdrawal symptoms: e.g. COWS Score 6-10 or substantial patient discomfort. - Consider the BUP Home Induction app for guidance. 2) START LOW DOSE BUPRENORPHINE - Begin with a first dose of 4mg for patients in moderate withdrawal. - Consider starting with 2mg for patients at higher risk of precipitated withdrawal. - Pro tip: Rx 8mg BID, then have the patient cut the film in half for the first day's doses. 3) WAIT 4 HOURS, GIVE 4MG - If the first dose is well tolerated, the patient can take a second 4mg dose later that day. 4) UPTITRATE & REASSESS - The following day, start 8mg BID - reassess adequacy after 7 days. - A majority of patients do well on a total dose of 16mg buprenorphine daily for maintenance therapy. #Buprenorphine #Initiation #Prescribing #Addiction #Management

ZERO POINT SURVEY (ZPS) - STEPUP Mnemonic Dubbed the ‘Zero Point Survey’ (ZPS), so called because first contact with a patient is rarely ‘Time Zero’ for a prehospital mission or hospital resuscitation case; there is invariably time for preparation of oneself, one’s team, and the environment (including equipment) prior to the primary survey and commencement of resuscitation. Following the assessment and management of STEP (self, team, environment & patient), the team should be regularly Updated on patient status and informed of the Priorities PRE-RESUSCITATION S - Self - Physical Readiness: I'M SAFE - Cognitive Readiness: Breathe, Talk, See, Focus T - Team - Leader identified - Roles allocated - Briefing E - Environment - Danger, Space, Light, Noise, Crowd control RESUSCITATION COMMENCED P - Patient - Primary Survey ABCDE U - Update - Share mental model of patient status P - Priorities - Identify team goals and set mission trajectory #ZPS #ZeroPointSurvey #STEPUP #STEPS #Mnemonic #Resuscitation #Management #CriticalCare #Arrest #Preshospital

Neonatal Resuscitation Program (NRP) for the Non-Neonatologist MR. SOPA: - Mask Adjust - Reposition Airway - Suction - Open mouth - Pressure increase - Alternate: LMA/ETT (NG first) Compressions: - Thumbs on sternum - 1/3 chest diameter Post-Resus Targets (STABLE): - Sugar (4-6) - Temp (36.5-37.5) - Airway - Breathing - Labs (C02 45-55) - Emotional support Dr. Sarah Foohey @SarahFoohey #NRP #Neonatal #Resuscitation #Program #management #peds #pediatrics

Acute Non-Variceal Upper GI Bleeding Pre-Endoscopy Management: • Hemodynamic resuscitation • No routine NG tube • Risk stratification using the Glasgow Blatchford scale • Pre-endoscopy IV PPI? • Restrictive blood transfusion policy • Anti-thrombotic management — anti-platelet agents, anti-coagulants • Promotility agents - IV erythromycin ? • 'Early endoscopy' within 24 hours Post-Endoscopy Management: • High dose IV PPI x 72 hours • Initiate clear liquids • If peptic ulcer bleeding, test and treat H. Pylori • Anti-thrombotic management • Rescope if bleed with/without hemostasis • Transcatheter angiographic embolization if endoscopy fails • Surgery rarely needed today Dr. Enrik Aguila @enrrikke #NonVariceal #Upper #GIBleed #management #gastroenterology #UGIB