NENC PCC & SiC Operational Delivery NetworkCOVID-19

Support, Education and Information Pack for Paediatric Staff

Acknowledgement – many thanks to the North Thames Paediatric Network PIC & SiC Division

Version 1.0 13th April 2020

All information is relevant as of the date shown above

Introduction & Document purpose

Never before has the NHS been faced with such a challenge, with this in mind, we as Health Care Professionals are likely to experience our most testing time to date. This may require us all to work out of our normal scope of practice, but most certainly will require us to pull together in a way not experienced by many before now and support one another and our patients through the difficult time ahead.

The purpose of this document is to compile and share relevant information, documents, support

materials and signposting to useful resources with colleagues. With special thanks to those

Professionals/ Trusts who have kindly shared their work to improve the experience of their

colleagues. (Please see the acknowledgements throughout document).

Referrals of sick patients within the region should still follow normal pathways via NECTAR. We do

however appreciate that during the current Covid 19 pandemic the immediate availability of

anaesthetic team assistance may not be available and that paediatric colleagues may have to

manage patients longer. This document aims to provide information and resources to help safe

patient management.

About COVID - 19

According to WHO (2020) Coronaviruses are a large family of viruses that cause illness ranging from the common cold to more severe diseases. A novel coronavirus is a new strain that has not been previously identified in humans. Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.

Most people infected with the COVID-19 virus will experience mild to moderate respiratory illness

and recover without requiring special treatment. Older people and those with comorbidity like

cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop

serious illness and mortality. The best way to prevent and slow down the transmission of the COVID

-19 virus is to be well informed on details of the disease it causes and how it spreads.

The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an

infected person coughs or sneezes, so it is vital that staffs are protecting themselves and their

patients by following the guidance on PPE and by washing your hands or using an alcohol based rub

frequently and not touching your face.

At this time, there are no specific vaccines or treatments for COVID-19. However, there are many on-

going clinical trials evaluating potential treatments.

Resources for CoVID specific advice and changes to practice:

Please access latest advice with the following links

Paediatric resuscitation: https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-resources-paediatrics/?utm_source=tw_date=010420

Paediatric Critical Care Society: https://picsociety.uk/wp-content/uploads/2020/02/PICS-Covid-19-guidance-27Feb2020-v2.0.pdf

NHS England paediatric specific advice: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/Specialty-guide_paediatrics-and-coronavirus_V1_17-March.pdf

Transport group guidance: https://picsociety.uk/wp-content/uploads/2020/03/PICS-ATG-COVID19-Statement-v1.0-17Mar2020.pdf

Safeguarding guidance: https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-vulnerable-children-and-young-people/coronavirus-covid-19-guidance-on-vulnerable-children-and-young-people

Advanced Management of the AirwayIndications for Intubation Airway protection/patency Respiratory failure Cardiovascular support Neuroprotection Facilitate procedure/ analgesia

Intubation for Cardiovascular Stability (CVS): Grunting - needs respiratory support Anticipate CVS instability on induction Commence peripheral adrenaline and givevolume Avoid propofol if CVS instability

Equipment for Intubation

• Laryngoscope handle ( small or large depending on the size of the child)• Blade. There are two types of blade curved and straight. Straight blades (numbers 0 and

1) are usually preferred for infants (<1 year) and neonates. Curved blades are preferred in children and adolescents ( numbers 0,1 and 2 for infants and children then 3 and 4 for adolescents and adults)

• ET Tube – Tube sizes are based on internal diameter in millimetres: Formula for size and length next page Ventilator

Extra equipment required

• Drugs :- Ketamine, fentanyl, rocuronium ( see NECTAR drug chart for dose guidance)• Self-inflating bag system with oxygen supply or ambu bag• Oropharyngeal/nasopharyngeal airway• Stylet• Magill forceps• Suction• Yankauer• Suction catheters. Catheter(Fr) is double the size(mm) of the ET Tube (ie Size 8 for 4.0

ETT)• Nasogastic tube inserted and placed on free drainage• ETCO2 monitoring• Pre intubation checklist:

http://www.newcastle-hospitals.org.uk/downloads/NECTAR/NECTAR_Pre-intubation_checklist_v1.pdf

Verification of ET Tube Placement

• ETCO2 -The CO2 cuvette should be placed as close to the ET Tube as possible. There should always be a wave form.

• Observe for chest movement• Listen for air entry on both sides of the chest• Listen for absence of bubbling noise over the stomach• Chest x-ray ET Tube should sit at T2-T3• Ventilated child checklist:

http://www.newcastle-hospitals.org.uk/downloads/NECTAR/NECTAR_ventilated_patient_transfer_checklist_v1.1.pdf

Intubation

Box A “tube length”   valid only   from 1 year of age. There is a formula also for less than one year (oral 8 cm + Weight/ 2   and   nasal 9 cm + Weight/2)  

Difficult Airway

Try to anticipate difficult airways, guidelines for difficult airway can be found as listed below

https://das.uk.com/files/APA1-DiffMaskVent-FINAL.pdf - difficult mask ventilation

https://das.uk.com/files/APA2-UnantDiffTracInt-FINAL.pdf - difficult tracheal intubation

https://das.uk.com/files/APA3-CICV-FINAL.pdf - cannot intubate, cannot ventilate

NECTAR CoVID Intubation checklist

Oral ET Tube Securing

Procedure for securing ET tube

1. Cut a length of Elastoplast appropriate to the size of the child’s face. In neonate and child < 6 months Elastoplast will have to be reduced in size.

2.

Segment A should reach from the ET Tube to the middle of the cheek Segments C and D should be the length from the ET Tube to the lobe of the opposite ear.

3. Assess the child’s sedation level, discuss with lead clinician on whether top up doses of sedation and paralysis are required.

4. Document the length of the ET Tube at the lips5. Place Segment A on the side of the face that is next to the ET Tube6. Point B should sit next to the ET Tube7. Segment C should rotate over and under the ET Tube twice ensuring the 15mm connector joint is not covered.

After two rotations segment C should then be secured across the top lip.8. Segment D should rotate in the opposite direction over ET Tube twice then across lower lip and place on

opposite cheek.

Equipment needed

Two professionals are required to strap a tube securely

Elastoplast (Pink tape) Scissors APPEEL adhesive removal wipes Emergency airway equipment (Face mask,

anaesthetic T-Piece, EtCO2 monitoringsame size ETT and one smaller, laryngoscope & blade and Magill’s forceps)

Suction Top up drugs of sedatives and paralysis.

Sudden deterioration of the intubated patient

D displacement of the ET Tube (eg accidental extubation or the tube is in the right main bronchus)

O Obstruction of the tube (secretions or kinking)

P Pneumothorax

E Equipment failure (check oxygen source, ventilator or ventilation bag)

S Stomach (distension can alter diaphragm mechanics)

If unable to intubate/ventilate follow DAS Difficult Intubation Guidelines

A B CD

VentilationBasicsAim to achieve sufficient surface area for gas exchange and move gas to and from this surface. We do this by inflation pressure opening the airway (PIP), preventing collapse by stenting them open (PEEP) and generating a minute ventilation with inspiratory time (Ti) and rate Two modes of ventilation are pressure and volume. Each of these have multiple ventilation types which are have various names on different machines. Mode of ventilation should be pressure with the exception of head injury where volume ventilation is better for neuro-protection (allows closer control of CO2).

PIP - Peak Inspiratory PressureUse enough to visibly move the chest and the pressure needed to do this will depend on the underlying lung condition. With normal lungs this could be as low as 14-15cmH2O but in severe disease 25+. If require 25-30cmH2O you may need another form of ventilation and this should be discussed with NECTAR. Adequate PIP will control CO2 and should be adjusted to achieve this.

PEEP – Positive End Expiratory PressureKeeps the airways open and improves oxygenation. Usual to start around 5cmH2O however if there is a lot of white on the x-ray or underlying lung disease expect this to be more. Titrate to achieve lower FiO2 with max 8-10cmH2O. If Oxygen use still high (>80% oxygen) at this pressure may need to consider use of inhaled nitric oxide or alternative ventilation and should be discussed with NECTAR.

Ti – Inspiration timeThe time that the ventilator applies the PiP pressure during a breath cycle. Needs to be long enough for air to reach the alveoli. Too short and gas will not reach before expiration and too long will reduce number of breaths per minute reducing the minute ventilation. Initial set up as in table below. Careful not to set this too high such that the I:E ratio is inversed.

I:E RatioRation between inspired portion of the breath cycle and expired portion. Inspiration need to be long enough for gas to enter the lungs and expiration long enough for gas to leave the lungs. Normally set at 1:2. Expiration may need to be longer in obstructive respiratory failure (asthma/bronchiolitis). May need 1:1.5 or 1:1 ratio to improve oxygenation (Discuss with NECTAR).

Vte – Exhaled Tidal VolumeThis is an important number to monitor as gives information on how much air is entering the lungs with each breath, using the expired is more accurate as is not affected by leak. Aim for 5-8mls/kg. if this is too low you need to increase PIP, if too high reduce the PIP.

Resource:https://static.draeger.com/trainer/draeger_academy_2013/index.html?cid=lt-uk-2020-03-17-training

Suggested Initial Ventilator Settings Lung Compliance PiP PEEP Ti -I:E Rate Sa02 ETCo2

Compliant lung settings 16 5 0.7-1:2 15-20 >95% 4-6Kpa

Moderately decreased lung compliance setting

20 5 1:2 15-25 >90% 6-8Kpa

Severely decreased lung compliance

>28 8 1:1.5 15-30 >85% 6-10Kpa

Ventilation cannot cure but can harm. It is therefore imperative to use the least pressure for the shortest time possible. Complications arise from over sedation, ETT and mechanical damage from ventilation and toxicity from high Oxygen concentrations:

Sedation: required to allow for tube comfort by supressing the cough reflex but are not without side effects. Ideal sedation is enough to stop the patient pulling out the ETT and allow the ventilator to work. Over sedation causes reduced blood pressure and movement causing peripheral oedema.

ETT: Ensure not oversized or cuff overinflated - can cause ischemia, increased oedema or even fibrosis.

Ventilation: use of high pressures/volumes cause barotrauma or volu-trauma and high oxygen is toxic and both cause inflammatory reactions. This can be reduced by use of permissive hypercapnia (pH > 7.25, CO2 8-9) to reduce this and the use of lower saturation targets (SpO2 88-92%)

If Ventilator difficulties

1. Exclude ETT issues - Use D O P E S2. Ensure patient is adequately sedated- Recommended

Morphine- 20mcg/kg/hrMidazolam- 2mcg/kg/min

3. If patient not synced/fighting ventilator use boluses’ of paralysis – 1mg/kg Rocuronium or Rocuronium infusion 1mg/kg/hr (Recommended)

Use NECTAR drug infusion guide

http://www.newcastle-hospitals.org.uk/downloads/NECTAR/NECTAR_Critical_Care_Drug_Infusions_V2.4.pdf

Ventilated patients are to have continuous waveform ETCO2 monitoring

Oxylog VentilatorModel Nos - 3000 and 3000+ (additional functionality)

The specific blue paediatric disposable hose set must be used.

Ventilation modes 1. VC-CMV / VC-AC 2. VC-SIMV3. SpnCPAP4. PC-BIPAP

Ventilation parameter controls:1. Inspiratory tidal volume VT [mL],2. Ventilation respiratory rate RR [/min],3. Maximum inspiratory pressure Pmax[mbar],4. O2 concentration FiO2 [%]

Rotary Knob- confirming selections

Key values- changes screen setting

Key settings- will show ventilator parameters

Key Alarms

On/off Switch

Set Up1. Ensure ventilator is plugged in and attached to Oxygen2. Turn on ventilator do not touch Rotary knob3. Ventilator will do self- test4. Hose type will display on screen- select paediatric- ensure you have correct hose5. To activate ventilation mode- hold down PC SIMV button for 3secs 6. Set ventilator settings using ventilator parameter controls (volume doesn’t work in PC mode),

you can use rotary knob as well navigating the screen to set PEEP, PIP, pressure support (same as PIP). Press the setting button to set i-time.

7. Ensure you confirm any ventilator changes by pushing in the rotary knob

Helpful guides:https://youtu.be/7kRf2VGG3Fohttps://www.intensivecareonline.com/ClinicalResources/DeviceTutorials?FolderID=44

Baby Pac Ventilator

Function Selector Switch

Alarm Pressure

Set-up Check O2 & air cylinders are full and turned on (you may only have an oxygen cylinder) Place bacterial filter over blue outlet & connect breathing circuit to filter& silver outlet Block port on Y-piece with attached bung Leave yellow bung in place Connect O2 & air hoses to cylinders [as appropriate] Set rate using I:E times from this grid [also on top of vent]

T exp▼ Frequency0.50 80 70 601.00 48 44 40 35 302.00 27 26 24 22 20 154.00 14 14 13 13 12 10T ins ► 0.25 0.35 0.50 0.70 1.00 2.00

1. Set FiO2 from O2% dial- for FiO2 21-70% - use both the O2 & the air cylinders and follow yellow line2. For FiO2 50-100% - use only the O2 cylinder – and read from the white line3. Select CMV + ACTIVE PEEP with Function Selector dial4. Set PEEP & PIP as appropriate5. Set ALARM PRESSURE > PIP until the alarm is silent in normal

operation6. Remove yellow bung & connect HME7. Connect patient & check ABG after 20 minutes if possible

Resources:

https://youtu.be/Wmc6rjN-oyQ

Variable Relief Valve

Inspiratory and Expiratory Times

Function Selector Switch

Pip Inspiratory Pressure

PEEP/CPAP Control

Supply Gas Failure Alarm

Patient Pressure Manometer

OxygenConcentration

A blood gas is a test that helps determine respiratory function, particularly how well a child's body is exchanging oxygen and carbon dioxide, as well as the acid/base status (pH) of the blood.

Why do we take blood gas?

Acid–base balance is regulated by intracellular & extracellular buffers and by the renal and respiratory systems. Normal pH is necessary for the optimal function of cellular enzymes and metabolism. Disorders of acid–base balance can interfere with these physiological mechanisms leading to acidosis or alkalosis and can be potentially life threatening.

To assess the effectiveness of ventilation, circulation and perfusion Blood gas indicate the effectiveness of gas exchange in the lungs How much energy the child is using for metabolism

Indications for a blood gas Clinical features of hypoxia or hypercarbia Shock Sepsis Decreased cardiac output Renal failure Ideally any baby on oxygen therapy Inborn errors of metabolism

What we look at in a gas PH -Potential hydrogen (basically

acid/alkaline)-7.35-7.45 PaC02-Carbon dioxide in blood -4.5-6kpa Pa02-oxygen in blood -10-13kpa HC03 -Standard bicarbonate -22-26mmol/l SBE -Base excess –2 to+ 4mmol/l

Types of PH acidosis or alkalosis Acidosis is an accumulation of acid in the body the PH is below 7.35 Alkalosis is accumulation from acid loss in the body, PH is above 7.45

Uncompensated- the PH is out of range Compensated - the PH could be within range of slightly out, the bicarbonate or etco2 is out of range to compensate this. Interpreting a blood GasFirst Step- Identify if it is acidosis or alkalosis Second Step- Identify if it is respiratory or metabolic Third Step- Identify compensated or uncompensated

Blood Gas Analysis

UNCOMPENSATED PH PC02 HC03 COMPENSATED PH PC02 HC03Respiratory

Acidosisnormal Respiratory

Acidosisnormal

MetabolicAcidosis

normal MetabolicAcidosis

normal

RespiratoryAlkalosis

normal RespiratoryAlkalosis

normal

MetabolicAlkalosis

normal MetabolicAlkalosis

normal

Circulatory failure and ShockCompensated shock- May have a normal blood pressure, but signs of abnormal perfusion, tachycardia, poor skin perfusion (prolonged CRT) weak peripheral pulse, tachypnea and reduced urine output.

Decompensated Shock- Hypotension vital organ perfusion is compromised. Prolonged CRT.

Hypotension indicates imminent cardiorespiratory arrest

Recognition of Circulatory Failure

Parameters to assess are: Heart rate Pulse volume Capillary refill time Blood pressure Filling pressure-liver size End organ perfusion

How to Treat Circulatory Failure1. Attach monitoring (BP Cycle BP every 5 mins, ECG, Saturations)2. Gain IV/IO access3. Blood tests- U&E, Full blood count, coagulation, Blood Gas with Blood Sugar.4. Fluid bolus 20mls/kg (10mls/kg for cardiac, DKA, trauma)5. Reassess6. Further fluid bolus 20mls/kg (10mls/kg for cardiac, DKA, trauma)7. Reassess8. Further fluid bolus 20mls/kg (think about intubation) (10mls/kg for cardiac, DKA, trauma)9. Prepare inotrope, adrenaline is the recommended inotrope-

This should be started prior to intubation if patient is in circulatory failure

Drug Infusion Rate of infusion Dosing range

Peripheral adrenaline 0.3mg/kg in 500ml 5% Dextrose

10ml/hr = 0.1mcg/kg/min

0.1-1mcg/kg/min

Central Strength adrenaline (only use if central access or IO)

0.3mg/kg in 50mls 5% dextrose

1ml/hr=0.1mcg/kg/min 0.1-1mcg/kg/min

Caution there are 2 strengths of adrenaline 1:1000 (1mg/1ml) and 1:10,000 (1mg/10mls) you can use either but the volume will either be more or less depending on what strength you use!

Commencing Inotropes

1. Draw up infusion into 50ml syringe2. Clearly label infusion3. Attach IV extension line and a triple lumen IV extension to end of line4. Place syringe into syringe driver and purge line at least 2mls Ensuring 3 way extension is purged5. Set dose on syringe driver and start infusion at 0.1mcg/kg/min6. Attach end of triple lumen IV extension to cannula 7. Monitor blood pressure and titrate infusion as required

Circulatory AccessEstablish IV access within first few minutes of resuscitation or signs of shock.If in a cardiorespiratory arrest or severe shock IO route should be usedChildren who remain responsive to pain IV access is preferred over IO if possible.

For acute transfers NECTAR would like 2 points of IV access):Types of IO needles

Insertion of Intraosseous Cannula

The most common site for insertion is the Proximal Tibia. Do not use if patient has osteogenesis imperfecta, haemophilia,

EZ-IO powered needle device, EZ-IO should be kept on the resus trolley in a yellow bag. In the bag there should be dressing in and a line extension, with appropriate size needles, remember the colours(sizes) are opposite way round to that of peripheral cannulas, with yellow being the biggest size. They include a size 15 gauge but in different lengths which are shown in the different colour. See pictures.

Manual IO intraosseous cannula and Trocar.

They include 18-gauge, 16 gauge and 14 gauge.

LandmarkOlder children and adolescents2-3cm below and medial to tibial tuberosity on anteromedial surface of the tibia.

LandmarkNewborns, infants and small childrenInsertion site is located approximately 1cm (one fingerbreadth) below and 1cm (1 fingerbreadth) medial to the tibia tuberosity on the anteromedial surface of the tibia

Technique for Insertion of IO needleWhat you need

IO needle 10ml 0.9% Sodium Chloride flush Sterile 10ml luer-lock syringe Gloves Frepp (2% chlorhexidine gluconate in 70% isopropyl alcohol) Clean blue ANTT tray 3-way tap/50ml syringe (for insertion of drugs) Pressure bag (for infusion of fluids)

EZ-IO Intraosseous Cannula and Trocar

Clean skin with alcohol-based solution Clean skin with alcohol-based solution

Immobilise the limb with your non-dominant hand-ensure no hands under the limb

Immobilise the limb with your non-dominant hand-ensure no hands under the limb

Use dominant hand, hold drill at 90-degree angle on the skin

Hold needs and position at 90-degree angle on the skin

Push the needle set tip through the skin until the tip rests against the boneThe 5 mm mark must be visible above the skin for confirmation of adequate needleset length

Using a firm rotating action the needle should be advanced until loss of resistance is felt

Gently drill, immediately release the trigger when you feel the loss of resistance

do NOT pull back on the driver when releasing the trigger

Unscrew and withdraw the trocar

Hold the hub in place and pull the driver straight off; continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations; catheter should feel firmly seated in the bone.

Attach 3-way tap and IV extension tubing, aspirated marrow/blood

Place the EZ-Stabilizer® Dressing over the hub Flush IO with 5- 10mls of 0.9% saline

Attach a primed extension set to the catheter hub, firmly secure by twisting clockwise

Secure IO with dressing

Aspirate for blood/bone marrow and flush with 5-10mls of Saline

Complications- (although rare) Extravasation Embolism Infection Compartment syndrome Skin necrosis Fracture

Cardiac ArrhythmiaAcute illness in children can result in cardiac arrhythmias although rare. SVT is the most common cardiac arrhythmia observed in children. It is paroxysmal, regular rhythm with narrow complexes. Below is an example of SVT

CVS stable - Vagal Manoeuvres Soaking a flannel in ice and then briefly placing it over their face In children they could blow through a drinking straw or imagine they are blowing out candles on a

birthday cake Carotid massage

If no effect call NECTAR

CVS unstable - Adensoine Dosage: Start at 100 mcg/kg, ↑ by 100mcg/kg if no response to max 500 mcg/kg (neonates

resistant to lower doses) Should be given as a rapid bolus through a cannula as close to the heart as possible, Flush with 2-

5ml of saline ECG must be continuously recording (preferably 12 lead but defib is ok if unstable), mark when

adenosine doses given Side effects: BP, bronchospasm, sinus arrest, chest pain, tachycardic acceleration, treatment failure

Caution when using with heart transplant patients and asthmaticsCardiovascular unstable -Cardioversion

1. If child infant is decompensated no sedation required, if conscious sedation and airway management will be required

2. Ensure defibrillator is set to synchronised cardioversion3. Pads are correct size and placed in correct position4. First shock energy level should be 1 J/kg5. Second shock energy level should be 2 J/kg6. Amiodarone infusion may be commenced if no change in rhythm

ST SVTHistory Pyrexia, fluid

lossNon-specific, previous arrhythmia

Heart Rate(beats min)

Infant <220min Child <180

Infant >220minChild >180

P wave Present and normal

Absent or abnormal

Beat-to-beat variability (R-R interval)

Yes – altered with simulation

None

Onset and end Gradual AbruptOnce child has been diagnosed with SVT clinical status will determine the management. Treatment can include vagal manoeuvres, adenosine or cardioversion.

Management of A Duct Dependant Lesion

Disability

Full ABCDE Assessment

Extra observations you need:• Pre and Post Ductal Saturations • ECG• 4 Limb Blood Pressure• Blood Gas • Chest x-ray • ECHO

Think Cardiac Lesion if: Cyanosis not responding to oxygen Poor or absent femoral pulses Heart murmur present, or cardiomegaly Pre/post ductal saturations more than 10% difference 4 limb BP with a significant gradient Start Dinoprostone (Prostin) will be kept in fridge on SCBU:

Requires urgent cardiology review-call NECTAR to arrange call conference with cardiologist

Side Effects of Dinopostone (Prostin)

Apnoea Hypotension may occur with high dose Lack of response

Intubate and ventilate

1.Preductal sats < 70%

2. Grunting / acidosis / poor pulses/ apnoea

3. Transferring on Dinoprostone (prostin) > 15ng/kg/min

Cautious fluid resuscitation- Stop if increasing liver size

Preparation of Prostin (dose is in nanograms (ng):1. Add 500 microg Prostin to 500mL 5% glucose2. Draw off 50mL of the mixture into a syringe3. 0.6mL/kg/hour = 10 nanograms/kg/min

What to start infusion at 5 ng/kg/min if clinically well 20 ng/kg/min if unstable or absent femoral pulses 50 ng/kg/min if no response

Do not infuse with any other drugs or infusions

Patient needs 2 points of IV access

Seizures

Time

0 mins (1st step)

Seizure starts

Check ABC, high flow O2 if available

Check blood glucose5 mins (2nd step) Midazolam 0.5 mg/kg buccally or

Lorazepam 0.1 mg/kg if intravenous access established

15 mins (3rd step) Lorazepam 0.1 mg/kg intravenously25 mins (4th step) Phenytoin 20 mg/kg by intravenous

infusion over 20 minsor Levetiracetam (as per BNFC)Phenobarbital 20 mg/kg intravenously over 5 mins Call NECTAR

45 mins (5th step) Rapid sequence induction of anaesthesia using thiopental sodium 4 mg/kg intravenously

Causes

Febrile convulsions and known epilepsy are most common.

CNS infection, hyponatraemia, hypoglycaemia, hypomagnesemia, head injury, brain abnormalities, space occupying lesion, blocked VP shunt, hypoxia, ischaemia, poisoning, inborn error of metabolism

A generalised seizure lasting more than 5 minutes will most likely need active management.

A seizure lasting more than 30 minutes in known as status epilepticus.

Follow algorithm until seizure is terminated

Consider further investigations:

Blood glucose FBC, sodium, calcium, magnesium, urea, creatinine, CRP Ammonia (newborn) Toxicology (teenagers) CT possible trauma, VP shunt complications