IMPORTANT: PLEASE READ THIS END USER LICENSE AGREEMENT AND PRIVACY POLICY (this "EULA") CAREFULLY. THIS EULA IS BETWEEN YOU ("You" or "Your") AND GEISINGER CLINIC ("We" or "Us" or "Our"). BY TAPPING ON THE "I ACCEPT" BUTTON WITHIN THIS APPLICATION, YOU ACKNOWLEDGE THAT YOU AGREE TO BE BOUND BY THE TERMS OF THIS EULA. IF YOU DO NOT AGREE TO ALL OF THE TERMS AND CONDITIONS SET FORTH BELOW, YOU ARE NOT PERMITTED TO USE THIS APPLICATION (the Application).

License and Restrictions

We grant You a limited, non-exclusive, non-sublicensable, non-transferable license to use the Application, solely for Your personal, non-commercial use in accordance with the instructions and documentation set forth in this EULA or any parts of the Application (collectively, the "Documentation"). Unless expressly otherwise set forth in this EULA, You may not: (a) modify, translate or create derivative works of the Application or the Documentation; (b) decompile, reverse engineer or reverse assemble any portion of the Application or attempt to discover any source code or underlying ideas or algorithms of the Application; (c) sell, assign, sublicense, rent, lease, loan, provide, distribute or otherwise transfer all or any portion of the Application or the Documentation; (d) make, have made, reproduce or copy the Application or the Documentation; (e) remove or alter any trademark, logo, copyright or other proprietary notices associated with the Application or the Documentation, or make available the Application without reproducing all proprietary notices; (f) cause or permit any other party to do any of the foregoing; or (g) engage in any conduct that, directly or indirectly, violates the terms of this EULA or has a harmful impact on the Application.

Use of the Application

You represent that You are at least eighteen (18) years old. We reserve the right to terminate Your use of the Application at any time, with or without any reason. The Application is provided solely for informational purposes and reliance on the Application is purely at Your own risk. Geisinger Clinic does not warrant the accuracy or completeness of the content contained in the Application. You will be solely responsible for Your use of and reliance on the content contained in the Application and for all decisions or actions resulting from Your use of the Application. The Application is not a substitute for the medical judgment of a physician or other licensed health care professional. The Application is not intended to replace or overrule the judgment or diagnosis of a physician or licensed health care professional and must not be used as the basis for making any diagnosis or treatment recommendation.

Ownership

The Application and the Documentation, including all images, photographs, animations, text and other audiovisual materials, and any and all patents, copyrights, moral rights, trademarks, trade secrets and any other form of intellectual property rights recognized in any jurisdiction, including applications and registrations for any of the foregoing embodied therein are owned by Us or Our licensors. The Application and the Documentation are licensed, and not sold, to You for use only under the terms of this EULA. We reserve all rights not expressly granted to You. You will not use publicly for publicity, promotion, or otherwise, any logo, name, trade name, service mark, or trademark belonging to Us or Our affiliates or licensors, including, but not limited to the word "Geisinger," or any simulation, abbreviation, or adaptation of the same, or the name of any Geisinger Clinic employee or agent, without Our prior, written, express consent.

Term and Termination

The effective date of this EULA is the date on which You install the Application. This EULA is effective until terminated. You may terminate this EULA at any time by deleting the Application from Your device. This EULA will terminate immediately without notice from Us if You fail to comply with any provision of this EULA. Upon termination, You must delete the Application from Your desktop, laptop, tablet, phone and/or other device on which the Application is installed.

DISCLAIMER OF WARRANTIES

THE APPLICATION IS PROVIDED TO YOU ON AN "AS IS" OR "AS AVAILABLE" BASIS WITHOUT ANY REPRESENTATIONS, WARRANTIES, COVENANTS OR CONDITIONS OF ANY KIND. WE AND OUR SUPPLIERS DO NOT WARRANT THAT ANY OF THE APPLICATION WILL BE FREE FROM ALL BUGS, ERRORS, OR OMISSIONS. WE AND OUR SUPPLIERS DISCLAIM ANY AND ALL OTHER WARRANTIES AND REPRESENTATIONS (EXPRESS OR IMPLIED, ORAL OR WRITTEN) WITH RESPECT TO THE APPLICATION WHETHER ALLEGED TO ARISE BY OPERATION OF LAW, BY REASON OF CUSTOM OR USAGE IN THE TRADE, BY COURSE OF DEALING OR OTHERWISE, INCLUDING ANY AND ALL (A) WARRANTIES OF MERCHANTABILITY, (B) WARRANTIES OF FITNESS OR SUITABILITY FOR ANY PURPOSE (WHETHER OR NOT WE KNOW, HAVE REASON TO KNOW, HAVE BEEN ADVISED, OR ARE OTHERWISE AWARE OF ANY SUCH PURPOSE), (C) WARRANTIES OF NONINFRINGEMENT OR CONDITION OF TITLE, OR (D) WARRANTIES THAT THE APPLICATION WILL OPERATE WITHOUT INTERRUPTION OR ERROR. YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE RELIED ON NO WARRANTIES WHEN MAKING YOUR DECISION TO USE THIS APPLICATION. THIS DISCLAIMER AND EXCLUSION WILL APPLY EVEN IF THE EXPRESS WARRANTY DISCLAIMER SET FORTH ABOVE FAILS OF ITS ESSENTIAL PURPOSE.

LIMITATION OF LIABILITY

IN NO EVENT WILL WE BE LIABLE TO YOU OR ANY OTHER PARTY FOR ANY LOSS OF PROFITS, LOSS OF USE, LOSS OF REVENUE, LOSS OF GOODWILL, ANY BODILY OR MENTAL INJURY, MALPRACTICE, INTERRUPTION OF BUSINESS, OR FOR ANY INDIRECT, SPECIAL, INCIDENTAL, EXEMPLARY, PUNITIVE OR CONSEQUENTIAL DAMAGES OF ANY KIND (INCLUDING, BUT NOT LIMITED TO, PHYSICAL LOSSES, MENTAL LOSSES OR ANY FINANCIAL LOSSES) ARISING OUT OF OR IN CONNECTION WITH THE APPLICATION, OR YOUR USE OF THE APPLICATION, REGARDLESS OF THE FORM OF ACTION, WHETHER IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE, EVEN IF WE HAVE BEEN ADVISED OR ARE OTHERWISE AWARE OF THE POSSIBILITY OF SUCH DAMAGES. OUR TOTAL CUMULATIVE LIABILITY (INCLUDING, BUT NOT LIMITED TO, ANY LIABILITY WITH RESPECT TO ANY LOSS OF PROFITS, LOSS OF USE, LOSS OF REVENUE, LOSS OF GOODWILL, ANY BODILY OR MENTAL INJURY, MALPRACTICE, INTERRUPTION OF BUSINESS, OR FOR ANY INDIRECT, SPECIAL, INCIDENTAL, EXEMPLARY, PUNITIVE OR CONSEQUENTIAL DAMAGES OF ANY KIND (INCLUDING, BUT NOT LIMITED TO, PHYSICAL LOSSES, MENTAL LOSSES OR ANY FINANCIAL LOSSES) ARISING OUT OF OR IN CONNECTION WITH THE APPLICATION OR YOUR USE OF THE APPLICATION, TO YOU OR ANY THIRD PARTY, WHETHER IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE, WILL NOT EXCEED THE AMOUNT PAID BY YOU TO US. MULTIPLE CLAIMS WILL NOT EXPAND THIS LIMITATION. CERTAIN LAWS DO NOT ALLOW LIMITATIONS ON IMPLIED WARRANTIES OR THE EXCLUSION OR LIMITATION OF CERTAIN DAMAGES. IF THESE LAWS APPLY TO YOU, SOME OR ALL OF THE ABOVE DISCLAIMERS, EXCLUSIONS, OR LIMITATIONS MAY NOT APPLY TO YOU, AND YOU MIGHT HAVE ADDITIONAL RIGHTS.

Disclaimer of Tort Liability

The foregoing remedies are exclusive, and You waive and release all other warranties, obligations, and liabilities of Us and all other remedies, claims, and rights that You may have relating in any way to the Application covered by the terms of this EULA, whether arising from contract, warranty, strict liability or tort or from Our negligence, tort, or other fault, including claims for loss of or damage to the Application.

Indemnification

You will indemnify, defend and hold harmless Us, Our affiliates, and Our and their respective trustees, officers, directors, agents, independent contractors, employees, consultants, service providers, and applicable third parties (such as licensors and partners) (collectively, the "Indemnified Parties") from and against any actual or threatened suit, demand or claims, damages, costs, liabilities and expenses (including, but not limited to, damage awards, settlement amounts, and reasonable attorney fees) brought against any Indemnified Parties, arising out of or relating to: (a) Your use of the Application; (b) Your conduct; (c) Your failure to perform Your obligations under this EULA (including, but not limited to, Your violation of this EULA); (d) Your violation of the rights of any third party; and/or (e) use of the Application by anyone else on Your device.

General

This EULA constitutes the entire agreement between You and Us, and supersedes any and all prior proposals, agreements or communications, written or oral with respect to the subject matter hereof. This EULA may not be modified, altered or amended, except by written instrument executed by both Us. You may not assign or otherwise transfer this EULA to anyone. All disputes arising from or relating to this EULA will be within the exclusive jurisdiction of the state and/or federal courts located within the Commonwealth of Pennsylvania and You hereby consent to such exclusive jurisdiction and waive objections to venue therein. You and We hereby disclaim the Application of the 1980 U.N. Convention on Contracts for the International Sale of Goods. If any provision of this EULA is found invalid or unenforceable by an arbitrator or a court of competent jurisdiction, the remaining portions will remain in full force and effect, and the invalid provision will be partially enforced to the maximum extent permitted by law to effectuate the purpose of this EULA. If You use any third party services that are accessed through or embedded in the Application, Your use of those services will be governed by the terms of use of those services.

Other Geisinger Clinic Products and Services

While using the Application You may be given the opportunity to purchase other Geisinger Clinic products and services. These products and services may contain different or additional terms of use or privacy policies. If You choose to purchase any of those products and services, Your use of them will be governed by those terms and policies.

Third Party Services

If You use any other third party services that are embedded in, or accessed through, the Application, Your use of those services is subject to the terms of use and privacy policy of those third party services.

I ACCEPT
GCS: 
  ---  
Log
PTS: 
  ---  
Log
Term (3.5 KG)
RR Min-Max (RPM)
Pulse Min-Max (BPM)
Syst. BP Min-Max (mmHg)
ETT (mm ID)
ETT lip mark (cm)
Laryng. Blade
Suction and NG Cath (FR)
Foley Catheter (FR)
Chest Tube (FR)
Range
Energy
0.5 - 1 J/kg
if not effective, increase to 2 J/kg
2 J/kg
 
 
Rate
Energy
First Shock
2 J/kg
 
Second Shock
4 J/kg
 
Subsequent Shock
Maximum up to adult (360 J)
10 J/kg
 

"ABC DID I Check eyes"

Airway - c-spine if injury

Breathing - assure oxygenation and ventilation

Circulation - R/O HTN, maintain MAP

Dextrose - rapid bedside determination

Imaging - CT

Differential (the I's)

Ingestion Inborn error
Infection (meningitis, encephalitis) (hypoglycemia, NH3)
Intracranial hemorrhage or mass Injury (i.e. occult, SBIS) Inhalation (CO, huffing)
Ictal (post ictal seizure) Intussusception
Imbalance of lytes/gluc (DKA) Ischemic/Infarction Intentional

Eyes

Mydriasis: sympathomimetics, anticholinergics (TCA, antihistamines), Jimson, LSD, botulism

Miosis: opioids, barbiturates, clonidine, organophosphates, phenothiazine, meperidine, mushrooms

Initial therapies for asthma exacerbation.

Albuterol
2.5 mg - 5 mg neb q 20 min
Ipatropium
125 - 500 mcg neb per dose
Methylprednisolone
Calculated Dose:
Dosing: 2 mg/kg IV (max dose = 80 mg)
Rehydrate, monitor potassium

If no improvement, begin continuous albuterol at 10 - 15 mg/hr

If refractory to above:
PICU transfer and consider:
Helium:Oxygen
70:30 mixture

Terbutaline infusion
Calculated Dose:
Dosing: 0.1 - 4 mcg/kg/min IV

Mag Sulfate
Calculated Dose:
Dosing: 50 mg/kg IV (2 gm max) over 20 min

Ketamine
Calculated Dose:
Dosing: 0.5 mg/kg

Aminophylline
Calculated Dose:
Dosing: load 6 mg/kg over 20 min

Aminophylline Infusion
6 wk - 6 month: 0.5 mg/kg/hr
  Dosing: 0.5 mg/kg/hr
6 month - 1 yr: 0.7 - 0.9 mg/kg/hr
  Dosing: 0.7 - 0.9 mg/kg/hr
1 yr - 9 yr: 1 mg/kg/hr
  Dosing: 1 mg/kg/hr
>9 yr: 0.75 mg/kg/hr
  Dosing: 0.75 mg/kg/hr
Therapeutic level
10 - 20 mg/L

ABC's

Oxygen, IV access, monitors, trendelenberg
Albuterol nebulized
Epinephrine nebulized

Diphenhydramine
1 mg/kg (max 50 mg)
Epinephrine (1:1,000)
0.01 mg/kg IM (max 0.3 mg) or pediatric autoinjector 0.15 mg IM if less than 30 kg, or adult autoinjector 0.3 mg IM if over 30 kg.
Fluids
20 ml/kg NS for hypotension

Pressors for fluid refractory shock
Epinephrine IV infusion (1:10,000)
0.1 mcg/kg/min and titrate up as needed
Methylprednisolone
2 mg/kg IV
H2 Blockers

Click on areas with second- and third-degree burns.

BurnCalculator
SVT
ABCD's
Evaluate rate and rhythm

SVT likely if:

Treatment:

  1. Consider vagal maneuvers
  2. Adenosine 0.1 mg/kg rapid IV bolus (max 6 mg dose)
  3. May double adenosine if no response (max 12 mg dose)
  4. If refractory to adenosine or hemodynamic compromise, then
    1. Sedate if possible
    2. Sync. Cardioversion 0.5 - 1 J/kg (up to 2 J/kg)
Neonatal congenital heart disease
If ductal dependent congenital heart disease (CHD) ABCD, c/s cardiology, STAT ECHO

Prostaglandin E 0.05 mcg/kg/min IV monitor for apnea, hypotension, hypoglycemia

ABCD's
Rapid Bedside Glucose
Assess degree of dehydration and hemodynamics
  1. Obtain 2 peripheral IVs
  2. Assess chemistries, pH, urine
  3. Rehydration based on hemodynamic status
  4. Generally, 1st hour NSS 10 - 15 ml/kg (max 1L) and 2nd hour 10 ml/kg (max 500 mL), 3rd hour on 2 x maintenance.
  5. Arrange for transport
  6. Usually hold insulin infusion until hour 3
  7. Do not bolus insulin.
  8. Do not routinely give bicarbonate
  9. Serial hemodynamic and neurologic exams
ABCDs
Continuous Monitoring
Identify and treat underlying cause.
  1. Hyperkalemia
    1. Causes: pseudohyperkalemia (i.e. hemolyzed sample), severe acidosis, tumor lysis, rhabdomyolysis, excessive K+ administration, renal failure, medications (ACE inhibitors, digoxin toxicity), congenital adrenal hyperplasia, malignant hyperthermia.
    2. Treatment:
      1. Calcium gluconate 50 - 100 mg/kg IV over 3 - 5 min
      2. Albuterol 5 mg nebulized
      3. NaHCO3 1 - 2 mE/kg IV over 5 - 10 min
      4. Insulin 0.1 U/kg with D25W 2 ml/kg (0.5 mEq/kg) IV over 30 min
      5. Kayexalate 1 gm/kg PO/PR
  2. Hypokalemia
    1. Causes: renal or GI loss, malnutrition, medications (diuretics, amphotericin, beta-agonists, theophylline, laxatives), metabolic alkalosis, hypomagnesemia, periodic paralysis.
    2. Treatment:
      1. Correct intravenously if symptomatic and / or K+ less than 2.5 meq/l with 0.5 - 1 meq/kg/dose over 1-2 hours at a rate of 0.5 meq/kg/ hr.
      2. May consider oral supplementation in potassium between 2.5 meq/L and 3.5 meq/L if K+
      3. Correct hypomagnesemia
  3. Hyponatremia
    1. Causes: water intoxication, SIADH, renal or extra renal sodium losses, cerebral salt wasting
    2. Treatment:
      1. If symptomatic (seizures) use 3% saline to raise Na to goal 125
      2. Na deficit (mEq) = (Desired Na - Current Na) x kg x 0.6.
  4. Hypoglycemia
    1. Causes: ingestion, sepsis, inborn error, CAH
    2. Treatment:
      1. Neonate: 2 - 4 ml/kg D10W IV
      2. Child: 2 - 4 ml/kg D25W IV
      3. Adolescent: 50 ml (1 amp) D50W IV
Upper airway obstruction (UAO)
Identify cause: FB, croup, post extubation, poor airway reflexes (neuro impairment), epiglottitis, angioedema, retropharyngeal abscess

If UAO secondary to subglottic edema (i.e. croup, angioedema): If progressive UAO or epiglotitis suspected, alert anesthesia/ENT
ABCD's - O2, positioning, monitor, identify cause
Lorazepam or midazolam 0.1 mg/kg IV/IM repeat q 10 - 15 min prn OR Diazepam 0.5 mg/kg PR

Long acting AED:
Support ABCD's.
Obtain blood cultures prior to antibiotics, if possible.
Monitor for signs of progressive sepsis (follow distal perfusion, hemodynamics, urine output, lactate).

Sepsis - Vancomycin + Ceftriaxone

CNS infections - Vancomycin + Ceftriaxone Also consider Acyclovir

Pneumonia - Vancomycin + Ceftriaxone

Intrabdominal source - Ampicillin + Gentamicin + Clindamycin

Neutropenic patients - Vancomycin + Cefepime or Ceftazidime

Antibiotics
Initial doses:

Save Note