Updates in Pediatrics

Mimi Lu MD

Clinical Assistant Professor

Director Pediatric Emergency Medicine Education

University of Maryland School of Medicine

Baltimore Maryland

No relevant financial disclosures

Outline

Recent literature pertaining to

Acute respiratory illnesses

Sepsis

Abdominal disorders

Questions mluemumarylandedu

RESPIRATORY

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

No relevant financial disclosures

Outline

Recent literature pertaining to

Acute respiratory illnesses

Sepsis

Abdominal disorders

Questions mluemumarylandedu

RESPIRATORY

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Outline

Recent literature pertaining to

Acute respiratory illnesses

Sepsis

Abdominal disorders

Questions mluemumarylandedu

RESPIRATORY

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

RESPIRATORY

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Bronchiolitis

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Clinical Practice Guideline

Diagnosis

Based on HampP

No routine labs or radiographs

Risk factors

age lt 12 weeks prematurity underlying CP

disease immunodeficiency

Ralston et al Pediatrics 2014

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Clinical Practice Guideline

Treatment

Albuterol

Epinephrine

Steroids

Hypertonic saline

Ralston et al Pediatrics 2014

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Clinical Practice Guideline

Treatment

Supplemental oxygen

Continuous pulse oximetry

Antibiotics

Fluids

Ralston et al Pediatrics 2014

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

PED to PICU with ARI over 4 years

HFNC success rates 84-88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or mean

duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

HFNC vs nCPAP

Metge et al Eur J Pediatr 2014 Jul

Retrospective review

French PICU

2 consecutive bronchiolitis seasons

Conclusion

No difference between RR HR FiO2 CO2

in management of severe bronchiolitis in PICU

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

Largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Asthma and steroids

Conclusion

Early steroid administration decreases time to

clinical improvement and discharge and reduced

admission rates in children presenting with

moderate to severe acute asthma

exacerbations

Steroids in asthma

Dexamethasone vs prednisone

Keeney et al Pediatrics 2014

Redman Arch Dis Children 2013

Williams et al Clin Pediatr 2013

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Consider high flow nasal cannula in

patients with acute respiratory illness

Early steroids for asthma

Dexamethasone gt prednisone

SEPSIS

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Steroids in asthma

Dexamethasone vs prednisone

Keeney et al Pediatrics 2014

Redman Arch Dis Children 2013

Williams et al Clin Pediatr 2013

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Consider high flow nasal cannula in

patients with acute respiratory illness

Early steroids for asthma

Dexamethasone gt prednisone

SEPSIS

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Consider high flow nasal cannula in

patients with acute respiratory illness

Early steroids for asthma

Dexamethasone gt prednisone

SEPSIS

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Take home points

Consider high flow nasal cannula in

patients with acute respiratory illness

Early steroids for asthma

Dexamethasone gt prednisone

SEPSIS

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

SEPSIS

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Case Altered Mental Status

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Case

65 yo ldquonot acting rightrdquo

rsaquo vomiting diarrhea fevers

PMHx None

Meds None

VS

T 392 P 118 RR 24 BP 8051 100 RA

101

128 38 7551187 58 6038

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Recognition

Bimodal distribution

Predisposing conditions

Recent surgery

Unexplained tachycardia

Impaired perfusion

Delayed capillary refill

Lethargy

Irritability

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Physiology differences

Decr O2 delivery

Clinical exam

More myocardial

dysfunction

High CO low SVR

Low CO high SVR

(60)

Low CO low SVR

(20)

Decr O2 extraction

Lab parameters

Hypotension

High CO low SVR

Peds Adults

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Definition SIRS

36˚C gt T gt 385˚C

HR gt 2SD or lt10th

RR gt 2SD

WBC age-specific or

gt10 bands

36˚C gt T gt 38˚C

HR gt 90

RR gt 20

WBC lt 4000 or

gt12000 or gt10

bands

Peds Adults

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Age-specific vital signs and lab values

Age group Tachycardia Bradycardia RR WBC

x103mm3

SBP

mmHg

Newborn gt180 lt100 gt50 gt34 lt65Neonate gt180 lt100 gt40 gt195 or lt5 lt75

Infant gt180 lt90 gt34 gt175 or lt5 lt100

Toddler gt140 - gt22 gt155 or lt6 lt94

Child gt130 - gt18 gt135 or lt45 lt105

Adolescent gt110 - gt14 gt11 or lt45 lt117

Goldstein Ped Crit Care Med 2005

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Septic Shock Criteria

CV dysfunction despite gt 40 mlkg

Hypotension

Vasoactive drugs

ge 2 signs of hypoperfusion

Base Deficit gt 5

Lactate gt 2 x normal

UOP lt 05 mlkghr

CR gt 5 sec

Core to peripheral temp gap gt 3degC

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90[2 x age] + 70

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Clinical practice parameters

Children with septic shock

Proportionately larger fluid quantities

First hour fluid resuscitation

Inotrope and vasodilator therapies

Hydrocortisone

ECMO for refractory shock

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Clinical practice parameters

Children with septic shock

Earlier use of inotropic support through

peripheral access (incl intraosseous)

High flow humidified oxygen

Antibiotics within 1 hour

Therapeutic endpoints

Brierley et al Crit Care Med 2009Dellinger et al Crit Care Med 2013

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Brierley Crit Care Med 2009

Infa

nts

an

d c

hild

ren

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Brierley Crit Care Med 2009

Neo

nat

es

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

The Golden Hour

FIRST HOUR

Rapid access

HFNC

IVF bolus

Inotropes

Antibiotics

Prostaglandin

until ductal-dependent lesion ruled out

Hydrocortisone for adrenal insufficiency

Kissoon et al Pediatr Emerg Care 2010

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Fluids

Early intraosseous

Aggressive resuscitation

60 mlkg in 1 hour

Central line

Restrictive strategy

30 mlkg

Maitland K et al NEJM 2011de Caen AR et al Circulation 2015

20 mlkg with freq reassess

Peds Adults

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Antimicrobials

Vancomycin

Ceftriaxone

Neonates

Ampicillin +

cefotaxime plusmn

Vancomycin

Acyclovir

Vancomycin

Zosyn

Peds Adults

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Shock

Cool cyanotic

extremities

Diminished pulses

Capillary refill gt 2 sec

Hypotension

Narrow PP

Warm dry

extremities

Bounding pulses

ldquoFlashrdquo capillary refill

BP maintained

Wide PP

Cold shock Warm shock

Dopamine + Epinephrine

Norepinephrine

Ventura AMC Crit Care Med 2015

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Vasopressors

Epinephrine= 1st line

Cold shock vs warm

shock

Peripheral or IO

Norepinephrine

No dopamine

Central line

Ventura AMC Crit Care Med 2015

Peds Adults

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Adjuncts

Dextrose

Vasopressin

Hydrocortisone

ECMO

Prostaglandin

Inhaled NO

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Labs

VBG

Glucose

CBC

CMP

Lactate

Urinalysis culture

Blood culture

CRP

Procalcitonin

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Intubation ventilation

Induction ketamine

Atropine (lt 1 year)

Avoid etomidate

Paralytic agent

Tidal volume 6-8

mlkg

Plateau pressure

lt 30 mmHg

Jones P Pediatr Crit Care Med 2013Jones P PLoS One 2013de Caen AR et al Circulation 2015Fastle RK Pediatr Emerg Care 2004

Different Same

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Optimize cardiovascular status prior to intubation

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Goals

Normalization of vitals

Improved perfusion

Capillary refill UOP gt 1 mlkghr mental status

Lactate clearance

ScvO2 gt 70

Transfusion

Ranjit Pediatr Crit Care Med 2014Sankar Pediatr Crit Care Med 2014

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Differences

Unexplained tachycardia

Cold shock

Epinephrine

Adrenal insufficiency

More fluids ()

Hypotension

Warm shock

Norepinephrine

Peds Adults

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Summary

Understand age-specific parameters

Hypotension is a late sign

Time-specific goals

Early (and aggressive) fluid management

Early antibiotics

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

ABDOMINAL DISORDERS

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Ultrasound

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Appendicitis

Clinical Scores

Alvarado A Ann Emerg Med 1986

Samuel M J Pediatr Surg 2002

Escriba Pediatr Emer Care 2011

Salo M Surg Res Pract 2014

Pogorelic et al Pediatr Emer Care 2015

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Alvarado score

Retrospective study

in adults

Sensitivity 75

Specificity 84

Prospective

validation in kids

Sensitivity 72-90

Specificity 72-79

Migration of pain 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Rebound pain 1

Elevation in temperature

(gt373˚C)

1

Leukocytes gt10000uL 2

Segmented neutrophilia

gt75

1

Alvarado Ann Emerg Med 1986

MANTRELS

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Pediatric Appendicitis Score

Migration 1

Anorexia 1

Nausea vomiting 1

Tenderness RLQ 2

Coughhoppingpercus

sion tenderness in

RLQ

2

Pyrexia 1

Leukocytes

gt10000uL

1

Polymorphonuclear

neutrophilia gt75

1

1170 children age 4-15 yrs

Score ge 6 - appendicitis

Sensitivity 100

Specificity 92

PPV 96

NPV 90

Samuel J Ped Surg 2002Salo M Surg Res Pract 2014

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Scoring systems

Score 1-3 no

appendicitis

Score 4-7 further

imaging (ultrasound)

Score 8-10 +appendicitis

Score 1-4 no

appendicitis

Score 5-8 further

imaging (ultrasound)

Score 9-10 +appendicitis

Alvarado score Pediatric Appendicitis Score

Escriba Ped Emerg Care 2011

Sens 933Spec 100

Sens 972Spec 976

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Appendicitis

Timing

Narsule CK et al Am J Emerg Med 2011

Mendeville et al Pediatr Emer Care 2015

Analgesia

Delaney et al Pediatr Emer Care 2015

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Appendicitis

Imaging

Aspelund G et al Pediatrics 2014

Sivitz AB et al Ann Emerg Med 2014

Elikashvili I et al Acad Emerg Med 2014

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

ABDOMINAL TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Low risk

Ann Emerg Med 2012

Prospective observational cohort

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Blunt abdominal injuries

Prediction rule

No abdominal wall trauma or seat belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

FAST in pediatrics

Less well defined vs adults

Poor sensitivity

may miss injury without associated fluid

Positive with IAI often non-operative

FF suprapubic region if prepubertal

Part of clinically integrated picture

Fox JC et al Acad Emerg Med 2011Scaife et al J Pediatr Surg 2013Menaker et al J Trauma Acute Care Surg 2014Mahajan et al Acad Emerg Med 2015Ben-Ishay et al World J Emerg Surg 2015

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Blunt abdominal injuries

Conclusion

A prediction rule based on HampP (without

laboratory or ultrasonographic information)

identifies children with blunt torso trauma who

are at very low risk for intra-abdominal injury

CT scan rarely misses clinically important blunt

abdominal traumatic injuries

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Intussusception

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Intussusception plain films

Roskind et al Pediatr Emerg Care 2012

Conclusion

Findings on the 3-view abdominal radiograph

can decrease and potentially exclude the

diagnosis of ileocolic intussusception

In children with low pretest probability of

intussusception 3-view radiographs may obviate

the need for additional studies

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Intussusception disposition

Chien et al J Emerg Med 2013

Retrospective chart review

98 children

10 recurrences in 7 children

Overall recurrence rate 71

Early recurrence rate 2

No adverse events

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Intussusception disposition

Conclusion

ED observation for 6 hours is safe alternative

to inpatient management for enema-reduced

intussusception

Colo-colonic reduced intussusception may have

an increased risk for recurrence

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Summary

Ultrasound

Ultrasound

Ultrasound

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Point-of-Care Ultrasound for Pediatric ShockPark Daniel Presley Bradley Cook Thomas Hayden GeoffreyPediatric Emergency Care 31(8)591-598 August 2015

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the diagnosis of

abuse

Obtain SS in infants lt6 months with suspected

abuse

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Take home points

Respiratory

HFNC

Early steroids (dexamethasone)

Sepsis

Early recognition fluids antibiotic

Abdominal disorders

LFTs for blunt abdominal trauma

Ultrasound

Be vigilant about NAT

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Questions

mluemumarylandedu

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Resuscitation pearls

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Airway endotracheal tube

Children gt 2 yearsETT size (Age4) + 4

ETT depth (lip) ETT size x 3

Cuffed tube okay

Except newborns (lt30 days)

ETT size (Age4) + 35

Uncuffed tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Airway pre-term tube sizes

ETT = uncuffed endotracheal tube size

20-25 week gestation

25-30 week gestation

30-35 week gestation

35-40 week gestation

20-25 ETT

25-30 ETT

30-35 ETT

35-40 ETT

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Breathing

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Normal RR may reflect fatigue

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Delayed cap refill thready pulses cool extremities

Hypotension is a LATE sign

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

[2 x age] + 90

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Dextrose

Ill patients with depressed mental status are

hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Vital signs

[2 x age] + 10 kg

Estimate weight in kilograms

Broselow tape

PAWPER tape

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Apps

PalmPEDi

BlueCardCNMC

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube

Resuscitation Numbers

SBP (2 x age) +90

Wt (2 x age) + 10 kg

RR 603015 rule

1 x ETT (Age4) + 4

2 x ETT NGOGFoley

3 x ETT Depth

4 x ETT Chest tube