10 The Abc S Of Pediatric Emergencies

The ABC’s of The ABC’s of Pediatric Pediatric

EmergenciesEmergenciesClass of 2009 Intern Core Class of 2009 Intern Core

CurriculumCurriculum

-Erin Fortune, PL3-Erin Fortune, PL3

-Dr. Susan Duthie, Pediatric -Dr. Susan Duthie, Pediatric IntensivistIntensivist

A Night On Call on the A Night On Call on the Wards…Wards…

Your first admission: Your first admission: Luis is a 19 yo male with Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, the ER, he was found to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You that your patient “does not look good.” You immediately go into the room and find a tall, immediately go into the room and find a tall, overweight young man leaning forward in the chair. overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is He is pale, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”mumbling, “Dr. Kadota…lives near Japan…”


What do you do, What do you do, doctor?doctor?

A Night On Call on the A Night On Call on the Wards…Wards… Option #1Option #1

Go review his chart in the computer so you Go review his chart in the computer so you can get a good history since he doesn’t can get a good history since he doesn’t

seem like he’ll be much help.seem like he’ll be much help.

A Night On Call on the A Night On Call on the Wards…Wards… Option 2


Option 3

The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies

Goals: Offer a basic approach to emergenciesGoals: Offer a basic approach to emergencies Learning to recognize the “sick” patientLearning to recognize the “sick” patient Learning initial steps in stabilizing the “sick” Learning initial steps in stabilizing the “sick”

patientpatient Become aware of resources available to you in Become aware of resources available to you in

caring for the “sick” patientcaring for the “sick” patient Understand the different levels of care at CHHCUnderstand the different levels of care at CHHC Brief review of common emergenciesBrief review of common emergencies


Learning to recognize the Learning to recognize the “Toxic,”“Toxic,” “Crashing”“Crashing” or or “Sick”“Sick” patient. patient.

Identify risk factors, signs, Identify risk factors, signs, symptoms in the following symptoms in the following

patients:patients: Luis is a 19 yo male with relapsed ALL who had Luis is a 19 yo male with relapsed ALL who had

a fever of 101.7 at home. In the ER, he was found a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately patient “does not look good.” You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”

Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following

patients:patients: Luis is a 19 yo male with Luis is a 19 yo male with relapsed ALLrelapsed ALL who had who had

a a feverfever of 101.7 at home. In the ER, he was found of 101.7 at home. In the ER, he was found to have an to have an ANC of 100ANC of 100, received 1 L NS and , received 1 L NS and CefepimeCefepime 2 grams IVx1. When you get to the 2 grams IVx1. When you get to the Heme-OncHeme-Onc floor, the nurse tells you that your floor, the nurse tells you that your patient patient “does not look good.”“does not look good.” You immediately You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is man leaning forward in the chair. He is pale, pale, tachypneic, and diaphoretictachypneic, and diaphoretic. He is mumbling, . He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”


patients:patients: Ryan is a 16 mo with SBS and is TPN

dependent. You admitted him yesterday for fever/increased stool output. During pre-rounds, you noted his vitals: Tmax 99.5, HR 95-150 (trend ), BP 86-100/55-65. His Labs: Hb 108, Platelets 135 70. On exam, he smiles and is vigorous, but his mom looks worried and tells you, “His stool looks darker than normal for him.”

What is Luis and What is Luis and Ryan’s most likely Ryan’s most likely

diagnosis?diagnosis?

SHOCK!SHOCK!

SHOCK!SHOCK!

Definition: Progressive state of circulatory dysfunction in which blood flow is insufficient to meet oxygen and metabolic needs of the tissues.

3 Phases1. Early, compensated (BP, UOP near normal)

2. Late, uncompenstated (BP begins to fall)

3. Irreversible (cells die, multiple organ failure)

SHOCK!SHOCK!

Signs and Symptoms: Tachycardia Tachypnea or labored breathing Delayed Capillary refill Hyperdynamic or weak peripheral pulses Decreased End-Organ perfusion

Decreased UOP Skin-cool, poorly perfused (can be warm if low SVR) Altered mental status

Hypotension is a LATE, OMINOUS sign

SHOCK!SHOCK!

What’s unique about kids? Cardiac Output = Stroke Volume x Heart rate

Kids have limited ability to increase stroke volume… Thus, kids in shock usually maintain adequate CO by

becoming TACHYCARDIC Improved ability to maintain their SVR/BP Thus, in kids, TACHYCARDIA IS A SIGN OF

SHOCK, and HYPOTENSION IS A LATE, OMINOUS sign


Learning initial steps in stabilizing the Learning initial steps in stabilizing the “Toxic,”“Toxic,” “Crashing”“Crashing” or or “Sick”“Sick” patient. patient.


Initial Treatment: Take a breath and THINK about what your patient

needs RIGHT NOW. Start with the ABC’s Get additional help If you have an acutely sick, “crashing” patient, he

or she takes precedence over all other duties (finishing pre-rounding, being on time to morning report, etc…)

Back to YourBack to YourNight on the Wards…Night on the Wards…

Let’s go back to Luis’s room…Let’s go back to Luis’s room…

Back to Your, Back to Your, Night on the Wards…Night on the Wards…

Luis is a 19 yo male with relapsed ALL who had Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately patient “does not look good.” You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”


Don’t forget to use pathophysiology:

Def of shock: “blood flow is insufficient to meet oxygen and metabolic needs of the tissues”

Thus, initial goals are to: Optimize oxygen deliveryRestore blood volume

SHOCK!SHOCK!

Restoring blood volume Fluid resuscitation

Start with Crystalloid (NS, LR, Hypertonic Saline): 20ml/kg rapidly and repeat as needed.

TBW= 2/3 intracellular +1/3 extracellular Extracellular= ¼ Intravascular + ¾ Interstitial

Crystalloid distributes rapidly from IV to interstitial, thus you often need to replace 3-4 times the fluid deficit

After ~60ml/kg, consider: Colloid (Albumin, blood products) as they distribute less rapidly AND reassess diagnosis if not improving (i.e. Cardiogenic Shock)

Back to Your, Back to Your, Night on the Wards…Night on the Wards…

Luis is now lying in bed with a Luis is now lying in bed with a bedside monitor, face mask bedside monitor, face mask

oxygen and the nurse is hanging oxygen and the nurse is hanging the NS bolus. the NS bolus.

His BP is 80/45.His BP is 80/45.Who you gonna call???Who you gonna call???


Become aware of resources available to Become aware of resources available to help you care for a help you care for a “sick”“sick” patient patient


Where can you get help? 1. Bedside or Available Nurse2. Charge Nurse3. **Your Senior Resident**4. Any available Senior Resident (i.e. MOLE…)5. The patient’s Attending6. Any available Attending7. PICU Fellow on Call*8. Code Blue (alarm vs x5555)


How to do a PICU Consult:How to do a PICU Consult: If the answer to any of the “ABC’s” is “no” or If the answer to any of the “ABC’s” is “no” or

acutely decompensating, call a Code Blueacutely decompensating, call a Code Blue For less acute patients, For less acute patients,

Consult with your Senior resident firstConsult with your Senior resident first Consult with the patient’s attending firstConsult with the patient’s attending first Page PICU Fellow On Call through operatorPage PICU Fellow On Call through operator Have a concise summary of the patient Have a concise summary of the patient

including relevant vitals and your clinical including relevant vitals and your clinical question/diagnosisquestion/diagnosis


You help transfer Luis to the ICU in You help transfer Luis to the ICU in care of the PICU fellow. care of the PICU fellow.

You are informing Luis’s attending You are informing Luis’s attending of the transfer and his condition of the transfer and his condition when you get a page for your when you get a page for your next admission…next admission…

Back to Your Night on the Back to Your Night on the Wards…Wards…

Shenaya is a 2 mo old girl with bronchiolitis Shenaya is a 2 mo old girl with bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with retractions and makes an “uhh” sound with every breath.every breath.

Identify the signs of Identify the signs of distress:distress:

Shenaya is a Shenaya is a 2 mo old2 mo old girl with girl with bronchiolitis bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to to Med-SurgMed-Surg. The CHET RN tells you that she . The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NCDespite deep suctioning and high flow NC, her , her WOB has continued to worsenWOB has continued to worsen en route. On en route. On exam, her exam, her RR is in the 80’sRR is in the 80’s, she has , she has deep deep retractionsretractions and makes an and makes an “uhh” sound with “uhh” sound with every breathevery breath..


patient:patient: Meanwhile, down in the ER, your co-intern Meanwhile, down in the ER, your co-intern

reviews his next patient’s triage sheet. reviews his next patient’s triage sheet. Bryce is a 3 year old male with CC: fever, Bryce is a 3 year old male with CC: fever, abd pain and “funny” breathing. His vitals abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They explain His parents appear anxious. They explain he’s had a cold with intermittent fever for he’s had a cold with intermittent fever for a week, but today developed abd pain and a week, but today developed abd pain and started breathing more rapidly. Bryce started breathing more rapidly. Bryce appears pale, dehydrated and is markedly appears pale, dehydrated and is markedly tachypneic with deep retractions. tachypneic with deep retractions.


patient:patient: Bryce is a 3 year old male with CC: Bryce is a 3 year old male with CC:

feverfever, abd pain and , abd pain and “funny” breathing“funny” breathing. . His vitals are: His vitals are: T101, HR 130, RR 52, O2 T101, HR 130, RR 52, O2 Sat 98% RASat 98% RA. His parents appear . His parents appear anxious. They explain he’s had a cold anxious. They explain he’s had a cold with intermittent fever for a week, but with intermittent fever for a week, but today developed abd pain and today developed abd pain and started started breathing more rapidlybreathing more rapidly. Bryce appears . Bryce appears pale, dehydrated pale, dehydrated and isand is markedly markedly tachypneic with deep retractions. tachypneic with deep retractions.

What do Shenaya and What do Shenaya and Bryce have in Bryce have in

common?common?

RESPIRATORY RESPIRATORY DISTRESSDISTRESS

Respiratory DistressRespiratory Distress

Signs of DistressSigns of Distress TachypneaTachypnea Nasal flaringNasal flaring RetractionsRetractions Head bobbingHead bobbing GruntingGrunting StridorStridor Prolonged expirationProlonged expiration Cyanosis is a late, Cyanosis is a late,

inconsistent findinginconsistent finding


Differential Diagnosis:Differential Diagnosis: Upper airway obstruction (FB, Croup)Upper airway obstruction (FB, Croup) Lower airway obstruction (Asthma, Bronchiolitis)Lower airway obstruction (Asthma, Bronchiolitis) Parenchymal lung disease (PNA)Parenchymal lung disease (PNA) Cardiac (CHF, Myocarditis)Cardiac (CHF, Myocarditis) Central (Increased ICP)Central (Increased ICP) Acidosis (shock, DKA)Acidosis (shock, DKA) ……


Goal: Prevent Progression to Respiratory Failure:Goal: Prevent Progression to Respiratory Failure: inadequate oxygenation of the blood and/or inadequate inadequate oxygenation of the blood and/or inadequate

elimination of CO2.elimination of CO2. Signs of impending respiratory failure:Signs of impending respiratory failure:

Decreased aerationDecreased aeration Slowed respirationsSlowed respirations CyanosisCyanosis Depressed level of consciousness/toneDepressed level of consciousness/tone Metabolic acidosis/shockMetabolic acidosis/shock

Respiratory DistressRespiratory Distress Assess Airway patencyAssess Airway patency

Awake patient usually Awake patient usually assumes optimal assumes optimal position for airway position for airway patencypatency

Obstructions: Obstructions: secretions, FB, soft secretions, FB, soft tissuetissue

Assess OxygenationAssess Oxygenation Color, mental status, Color, mental status,

pulse Oxpulse Ox Assess VentilationAssess Ventilation

WOB, aeration, blood WOB, aeration, blood gasgas

Blood gasesBlood gases

Purpose of ordering blood gases:Purpose of ordering blood gases:1.1. Assess Acid/Base status (pH, base Assess Acid/Base status (pH, base

deficit/excess)deficit/excess)2.2. Assess oxygenation (PaO2)Assess oxygenation (PaO2)3.3. Assess ventilation (CO2)Assess ventilation (CO2)4.4. Quick lytes (Na, K, Cl)Quick lytes (Na, K, Cl)

Ways of obtaining blood gasesWays of obtaining blood gases1.1. Arterial—pH, O2, CO2Arterial—pH, O2, CO22.2. Venous—pH, (CO2 trend)Venous—pH, (CO2 trend)3.3. Capillary—pH, CO2, O2Capillary—pH, CO2, O2

Interpreting Blood gasesInterpreting Blood gases

Goal is to Goal is to determine determine primary/secondary primary/secondary process: process:

Respiratory Respiratory AcidosisAcidosis

Respiratory Respiratory AlkalosisAlkalosis

Metabolic AcidosisMetabolic Acidosis Metabolic AlkalosisMetabolic Alkalosis

Interpreting Blood gasesInterpreting Blood gases

1.1. Look at the pHLook at the pH-if <7.4, the primary process is acidosis-if <7.4, the primary process is acidosis

-if>7.4, the primary process is alkalosis-if>7.4, the primary process is alkalosis

2.2. Calculate the Anion Gap = Na-(Cl+HCO3)Calculate the Anion Gap = Na-(Cl+HCO3)-if AG > 14, then you have a metabolic acidosis-if AG > 14, then you have a metabolic acidosis

3.3. Calculate the “Delta Gap”= AG-nl gap Calculate the “Delta Gap”= AG-nl gap (i.e. 12)(i.e. 12)

4.4. Add HCO3 + “Delta GapAdd HCO3 + “Delta Gap-if >30, also have a metabolic alkalosis-if >30, also have a metabolic alkalosis

-if <24, also have a non-gap metabolic acidosis-if <24, also have a non-gap metabolic acidosis


Why bother doing all the calculations???Why bother doing all the calculations??? Let’s go back to Bryce: 3 year old male with Let’s go back to Bryce: 3 year old male with

CC: fever, abd pain and “funny” breathing. CC: fever, abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They 98% RA. His parents appear anxious. They explain he’s had a cold with intermittent explain he’s had a cold with intermittent fever for a week, but today developed abd fever for a week, but today developed abd pain and started breathing more rapidly. pain and started breathing more rapidly. Bryce appears pale, dehydrated and is Bryce appears pale, dehydrated and is markedly tachypneic with deep retractions. markedly tachypneic with deep retractions.


Bryce’s ABG (FiO2 100% NRB)Bryce’s ABG (FiO2 100% NRB) 7.05/480/20/8/-18 Na 148 Cl 1127.05/480/20/8/-18 Na 148 Cl 112 pH/PaO2/PCO2/HCO3/BEpH/PaO2/PCO2/HCO3/BE

Bryce has: Bryce has: 1.1. Primary process? AcidosisPrimary process? Acidosis

2.2. AG = 28, thus has AG metabolic acidosisAG = 28, thus has AG metabolic acidosis

3.3. Delta gap + HCO3 = 16+12, thus no other Delta gap + HCO3 = 16+12, thus no other metabolic processmetabolic process

4.4. Compensation: Respiratory alkalosisCompensation: Respiratory alkalosis

Bryce’s Diagnosis???Bryce’s Diagnosis???

Hint: a bedside finger stick test leads Hint: a bedside finger stick test leads to the diagnosis…to the diagnosis…

Diabetic Ketoacidosis!Diabetic Ketoacidosis!


Let’s go back to Shenaya’s Let’s go back to Shenaya’s room…room…


Shenaya is a 2 mo old infant with bronchiolitis Shenaya is a 2 mo old infant with bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with retractions and makes an “uhh” sound with every breath.every breath.


Her Venous Blood Gas: Her Venous Blood Gas:

pH 7.20pH 7.20

PCO2 76PCO2 76

BD -4BD -4


Linda, the Med-Surg Charge Linda, the Med-Surg Charge Nurse, comes up to you and Nurse, comes up to you and

tells you, “That baby needs to tells you, “That baby needs to go the IMU. Write transfer go the IMU. Write transfer

orders now.”orders now.”


Understanding the different levels of care Understanding the different levels of care at CHHCat CHHC


Patient Care Unit Hierarchy at CHHCPatient Care Unit Hierarchy at CHHC Ortho RehabOrtho Rehab Med/SurgMed/Surg Heme-OncHeme-Onc IMUIMU PICUPICU

Make sure your patient is at the appropriate Make sure your patient is at the appropriate level of carelevel of care


Your Senior Resident agrees with Your Senior Resident agrees with your plan to transfer Shenaya to your plan to transfer Shenaya to

the IMU. the IMU. You updated the Attending. You updated the Attending.

She is on NCPAP and her WOB is a She is on NCPAP and her WOB is a little improved.little improved.

Whew! You can finally tuck Whew! You can finally tuck Shenaya away for the night…Shenaya away for the night…

A Night on the Wards…A Night on the Wards…

Not quite…Not quite…

““Sick” patients need constant Sick” patients need constant re-assessment!re-assessment!

A Night on the Wards…A Night on the Wards… How to Re-assess when I still have 4 How to Re-assess when I still have 4

admits coming?!?admits coming?!? Communicate with the Bedside Nurse: Communicate with the Bedside Nurse:

Document your name and pager on the Document your name and pager on the chartchart

Give strict, clear “Call HO” parametersGive strict, clear “Call HO” parameters Communicate with your Senior Resident: Communicate with your Senior Resident:

Agree on who will re-assess the patient Agree on who will re-assess the patient and whenand when

Communicate if patient’s condition worseCommunicate if patient’s condition worse Set your pager alarm and ask RN to page youSet your pager alarm and ask RN to page you

Your Night on the Your Night on the Wards…Wards…

Setting your pager alarm to re-Setting your pager alarm to re-check Shenaya reminds you that check Shenaya reminds you that

you should check on Ryan…you should check on Ryan…


Ryan is the 16 mo with SBS. He was admitted yesterday for increased stool output. You peek at his flow sheet and notice that his last three stools have been heme + with the most recent with streaks of blood…

What do you do for a GI bleed?What do you do for a GI bleed?

GI BleedGI Bleed

General Principles for Treatment:General Principles for Treatment: NPONPO Change meds to IV when possibleChange meds to IV when possible PPI (Pantoprazole)PPI (Pantoprazole) Give adequate fluids (deficit + Give adequate fluids (deficit +

maintenance + ongoing losses)maintenance + ongoing losses) NG or GT lavageNG or GT lavage NG or GT to gravity (for monitoring)NG or GT to gravity (for monitoring)

GI BleedGI Bleed General Principles for Treatment (cont)General Principles for Treatment (cont)

Send Type and Screen earlySend Type and Screen early Check for coagulopathy—optimize Check for coagulopathy—optimize

coagulabilitycoagulability Thrombocytopenia—platelet transfusionThrombocytopenia—platelet transfusion Prolonged PT—FFPProlonged PT—FFP Low fibrinogen—CryoprecipitateLow fibrinogen—Cryoprecipitate

Serial CBC’s—transfuse early if ongoing losses Serial CBC’s—transfuse early if ongoing losses likelylikely

Severe or refractory GI Bleeds:Severe or refractory GI Bleeds: Octreotide—Somatostatin analog, ↓ GI blood flowOctreotide—Somatostatin analog, ↓ GI blood flow Endoscopy/SurgeryEndoscopy/Surgery


You quietly walk into Ryan’s room. You quietly walk into Ryan’s room. With your penlight, you look at With your penlight, you look at his GT bag and find bright red his GT bag and find bright red blood steadily filling the bag…blood steadily filling the bag…

Now what?!?Now what?!?


Remember: Take a breath and THINK about what your patient

needs right now. Start with the ABC’s Get additional help


The PICU fellow teaches you how The PICU fellow teaches you how to push blood as you help escort to push blood as you help escort Ryan to join Luis in the PICU…Ryan to join Luis in the PICU…

Will this night ever end?!?Will this night ever end?!?


Finally, a chance to catch up on Finally, a chance to catch up on dictations. Just as you are dictations. Just as you are

finishing your last dictation, your finishing your last dictation, your Senior pages…Senior pages…

““An easy Gastro admit in room An easy Gastro admit in room 221”221”


Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes when the nurse puts in an IV, but quickly goes back to sleep.back to sleep.


Are you sure this is just Gastro? Are you sure this is just Gastro?

Review the case:Review the case:

Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes when the nurse puts in an IV, but quickly goes back to sleep.back to sleep.

Review the case:Review the case:

Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of had 2 days of emesis, inability to tolerate poemesis, inability to tolerate po, , last urinated ~2 hrs agolast urinated ~2 hrs ago. She’s had . She’s had no F/D, no no F/D, no known sick contacts known sick contacts but is in daycare. Parents but is in daycare. Parents note she’s been note she’s been excessively sleepyexcessively sleepy. Her admit . Her admit vitals are: T99, vitals are: T99, HR 100, BP 120/75, RR 45HR 100, BP 120/75, RR 45, , O2 100% RA. She is sleepy, O2 100% RA. She is sleepy, cries brieflycries briefly when the nurse puts in an IVwhen the nurse puts in an IV, but quickly goes , but quickly goes back to sleep.back to sleep.


What must be “ruled out” in this What must be “ruled out” in this patient immediately? patient immediately?

Increased Intracranial Increased Intracranial Pressure!Pressure!

Increased Intracranial Increased Intracranial PressurePressure

Results from an Results from an increase in increase in volume of volume of cerebral contents cerebral contents within a rigid within a rigid cranial cranial compartmentcompartment

Can be due to Can be due to bleeding, edema, bleeding, edema, mass or CSFmass or CSF


Symptoms:Symptoms: HeadacheHeadache VomitingVomiting Sleepy/LethargySleepy/Lethargy IrritabilityIrritability Vision changesVision changes


SignsSigns Increased toneIncreased tone Decreased LOCDecreased LOC Bulging fontanelBulging fontanel Cranial nerve palsyCranial nerve palsy Cushing’s triad:Cushing’s triad:

HypertensionHypertension BradycardiaBradycardia Irregular Irregular

respirationsrespirations Papilledema/ Papilledema/

decreased venous decreased venous pulsationspulsations


TreatmentTreatment Step 1: Step 1: Recognize it early!Recognize it early!

Who are the patients at risk? Who are the patients at risk? Head injuryHead injury MeningitisMeningitis Brain tumorBrain tumor HydrocephalusHydrocephalus Immune-compromisedImmune-compromised


Brain is dependent Brain is dependent on aerobic on aerobic metabolismmetabolism

Thus, depends on Thus, depends on cerebral blood flow cerebral blood flow for viabilityfor viability

Goal of Goal of autoregulation/ autoregulation/ therapy is to therapy is to maintain adequate maintain adequate CBFCBF

Step 2: Step 2: Understand Understand the the pathophysiology…pathophysiology…


What would you do for Emily? What would you do for Emily?


Immediate treatment for increased ICP:Immediate treatment for increased ICP: ABC’s (intubate for GCS </= 8)ABC’s (intubate for GCS </= 8) Raise head of bed to 15-30 degreesRaise head of bed to 15-30 degrees


Get Help (Senior Resident, Notify Get Help (Senior Resident, Notify attending)attending)

PICU Consult--PICU Consult--All patients with All patients with suspected ↑ ICP should be in PICUsuspected ↑ ICP should be in PICU

Head CT (hold on LP)Head CT (hold on LP) Common TherapiesCommon Therapies

Hyperventilation (bag and mask)Hyperventilation (bag and mask) Hypertonic Saline (3%)Hypertonic Saline (3%) Mannitol—beware of hypovolemiaMannitol—beware of hypovolemia Decadron—tumor or bacterial meningitisDecadron—tumor or bacterial meningitis

The ABC’s of Pediatric The ABC’s of Pediatric Emergencies…Parting Emergencies…Parting

ThoughtsThoughts One of the goals of Intern Year is to learn to One of the goals of Intern Year is to learn to

recognize the “Sick” patientrecognize the “Sick” patient If you are concerned, get a second opinion earlyIf you are concerned, get a second opinion early Better to over-react than to under-reactBetter to over-react than to under-react Assume every patient is “sick” until proved Assume every patient is “sick” until proved

otherwiseotherwise If you missed recognizing a “sick kid,” review the If you missed recognizing a “sick kid,” review the

case and learn for the next patientcase and learn for the next patient Most important part of “Emergency Care” is Most important part of “Emergency Care” is

PREVENTIONPREVENTION Recognizing sick patients earlyRecognizing sick patients early Giving appropriate treatment earlyGiving appropriate treatment early

Follow your ICU transfers peripherally to Follow your ICU transfers peripherally to learnlearn

ReferencesReferences

http://www.emedicine.com/ped/topichttp://www.emedicine.com/ped/topic929.htm929.htm

http://www.emedicine.com/ped/topichttp://www.emedicine.com/ped/topic3082.htm3082.htm

http://pedsccm.wustl.edu/http://pedsccm.wustl.edu/ Duthie, Susan. “Respiratory Failure” Duthie, Susan. “Respiratory Failure” Duthie, Susan. “Shock in the Duthie, Susan. “Shock in the

Pediatric Patient”Pediatric Patient” Pearson, Gale. “Handbook of Pearson, Gale. “Handbook of

Paediatric Intensive Care.”Paediatric Intensive Care.”

10 The Abc S Of Pediatric Emergencies

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