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10 The Abc S Of Pediatric Emergencies
 

10 The Abc S Of Pediatric Emergencies

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    10 The Abc S Of Pediatric Emergencies 10 The Abc S Of Pediatric Emergencies Presentation Transcript

    • The ABC’s of Pediatric Emergencies Class of 2009 Intern Core Curriculum -Erin Fortune, PL3 -Dr. Susan Duthie, Pediatric Intensivist
    • A Night On Call on the Wards…
      • Your first admission: Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”
    • A Night On Call on the Wards…
      • What do you do, doctor?
    • A Night On Call on the Wards…
      • Option #1
      • Go review his chart in the computer so you can get a good history since he doesn’t seem like he’ll be much help.
    • A Night On Call on the Wards…
      • Option 2
    • A Night On Call on the Wards…
      • Option 3
    • The ABC’s of Pediatric Emergencies
      • Goals: Offer a basic approach to emergencies
        • Learning to recognize the “sick” patient
        • Learning initial steps in stabilizing the “sick” patient
        • Become aware of resources available to you in caring for the “sick” patient
        • Understand the different levels of care at CHHC
        • Brief review of common emergencies
    • The ABC’s of Pediatric Emergencies
      • Learning to recognize the “Toxic,” “Crashing” or “Sick” patient.
    • Identify risk factors, signs, symptoms in the following patients:
      • Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”
    • Identify the signs/symptoms of distress in the following patients:
      • Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100 , received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic . He is mumbling, “Dr. Kadota…lives near Japan…”
    • Identify the signs/symptoms of distress in the following patients:
      • Ryan is a 16 mo with SBS and is TPN dependent. You admitted him yesterday for fever/increased stool output. During pre-rounds, you noted his vitals: Tmax 99.5, HR 95-150 (trend  ) , BP 86-100/55-65. His Labs: Hb 10  8, Platelets 135  70. On exam, he smiles and is vigorous, but his mom looks worried and tells you, “His stool looks darker than normal for him.”
    • Identify the signs/symptoms of distress in the following patients:
      • Ryan is a 16 mo with SBS and is TPN dependent . You admitted him yesterday for fever/increased stool output . During pre-rounds, you noted his vitals: Tmax 99.5, HR 95-150 (trend  ) , BP 86-100/55-65. His Labs: Hb 10  8 , Platelets 135  70 . On exam, he smiles and is vigorous, but his mom looks worried and tells you, “His stool looks darker than normal for him.”
    • What is Luis and Ryan’s most likely diagnosis?
      • SHOCK!
    • SHOCK!
      • Definition : Progressive state of circulatory dysfunction in which blood flow is insufficient to meet oxygen and metabolic needs of the tissues.
      • 3 Phases
          • Early, compensated (BP, UOP near normal)
          • Late, uncompenstated (BP begins to fall)
          • Irreversible (cells die, multiple organ failure)
    • SHOCK!
      • Signs and Symptoms:
        • Tachycardia
        • Tachypnea or labored breathing
        • Delayed Capillary refill
        • Hyperdynamic or weak peripheral pulses
        • Decreased End-Organ perfusion
          • Decreased UOP
          • Skin-cool, poorly perfused (can be warm if low SVR)
          • Altered mental status
        • Hypotension is a LATE, OMINOUS sign
    • SHOCK!
      • What’s unique about kids?
        • Cardiac Output = Stroke Volume x Heart rate
          • Kids have limited ability to increase stroke volume…
          • Thus, kids in shock usually maintain adequate CO by becoming TACHYCARDIC
        • Improved ability to maintain their SVR/BP
        • Thus, in kids, TACHYCARDIA IS A SIGN OF SHOCK, and HYPOTENSION IS A LATE, OMINOUS sign
    • The ABC’s of Pediatric Emergencies
      • Learning initial steps in stabilizing the “Toxic,” “Crashing” or “Sick” patient.
    • The ABC’s of Pediatric Emergencies
      • Initial Treatment:
        • Take a breath and THINK about what your patient needs RIGHT NOW.
        • Start with the ABC’s
        • Get additional help
        • If you have an acutely sick, “crashing” patient, he or she takes precedence over all other duties (finishing pre-rounding, being on time to morning report, etc…)
    • Back to Your Night on the Wards…
      • Let’s go back to Luis’s room…
    • Back to Your, Night on the Wards…
      • Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”
    • The ABC’s of Pediatric Emergencies
        • Don’t forget to use pathophysiology :
        • Def of shock: “blood flow is insufficient to meet oxygen and metabolic needs of the tissues”
        • Thus, initial goals are to:
          • Optimize oxygen delivery
          • Restore blood volume
    • SHOCK!
      • Restoring blood volume
        • Fluid resuscitation
          • Start with Crystalloid (NS, LR, Hypertonic Saline): 20ml/kg rapidly and repeat as needed .
            • TBW= 2/3 intracellular +1/3 extracellular
              • Extracellular= ¼ Intravascular + ¾ Interstitial
          • Crystalloid distributes rapidly from IV to interstitial, thus you often need to replace 3-4 times the fluid deficit
          • After ~60ml/kg, consider: Colloid (Albumin, blood products) as they distribute less rapidly AND reassess diagnosis if not improving (i.e. Cardiogenic Shock)
    • Back to Your, Night on the Wards…
      • Luis is now lying in bed with a bedside monitor, face mask oxygen and the nurse is hanging the NS bolus.
      • His BP is 80/45.
      • Who you gonna call???
    • The ABC’s of Pediatric Emergencies
      • Become aware of resources available to help you care for a “sick” patient
    • The ABC’s of Pediatric Emergencies
      • Where can you get help?
        • Bedside or Available Nurse
        • Charge Nurse
        • **Your Senior Resident**
        • Any available Senior Resident (i.e. MOLE…)
        • The patient’s Attending
        • Any available Attending
        • PICU Fellow on Call*
        • Code Blue (alarm vs x5555)
    • The ABC’s of Pediatric Emergencies
      • How to do a PICU Consult:
        • If the answer to any of the “ABC’s” is “no” or acutely decompensating, call a Code Blue
        • For less acute patients,
          • Consult with your Senior resident first
          • Consult with the patient’s attending first
          • Page PICU Fellow On Call through operator
          • Have a concise summary of the patient including relevant vitals and your clinical question/diagnosis
    • Back to Your Night on the Wards…
      • You help transfer Luis to the ICU in care of the PICU fellow.
      • You are informing Luis’s attending of the transfer and his condition when you get a page for your next admission…
    • Back to Your Night on the Wards…
      • Shenaya is a 2 mo old girl with bronchiolitis brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with every breath.
    • Identify the signs of distress:
      • Shenaya is a 2 mo old girl with bronchiolitis brought from her PMD’s office by CHET team to Med-Surg . The CHET RN tells you that she looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC , her WOB has continued to worsen en route. On exam, her RR is in the 80’s , she has deep retractions and makes an “uhh” sound with every breath .
    • Identify the signs/symptoms of distress in the following patient:
      • Meanwhile, down in the ER, your co-intern reviews his next patient’s triage sheet. Bryce is a 3 year old male with CC: fever, abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They explain he’s had a cold with intermittent fever for a week, but today developed abd pain and started breathing more rapidly. Bryce appears pale, dehydrated and is markedly tachypneic with deep retractions.
    • Identify the signs/symptoms of distress in the following patient:
      • Bryce is a 3 year old male with CC: fever , abd pain and “funny” breathing . His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA . His parents appear anxious. They explain he’s had a cold with intermittent fever for a week, but today developed abd pain and started breathing more rapidly . Bryce appears pale, dehydrated and is markedly tachypneic with deep retractions.
    • What do Shenaya and Bryce have in common?
      • RESPIRATORY DISTRESS
    • Respiratory Distress
      • Signs of Distress
        • Tachypnea
        • Nasal flaring
        • Retractions
        • Head bobbing
        • Grunting
        • Stridor
        • Prolonged expiration
        • Cyanosis is a late, inconsistent finding
    • Respiratory Distress
      • Differential Diagnosis:
        • Upper airway obstruction (FB, Croup)
        • Lower airway obstruction (Asthma, Bronchiolitis)
        • Parenchymal lung disease (PNA)
        • Cardiac (CHF, Myocarditis)
        • Central (Increased ICP)
        • Acidosis (shock, DKA)
    • Respiratory Distress
      • Goal: Prevent Progression to Respiratory Failure:
        • inadequate oxygenation of the blood and/or inadequate elimination of CO2.
      • Signs of impending respiratory failure:
        • Decreased aeration
        • Slowed respirations
        • Cyanosis
        • Depressed level of consciousness/tone
        • Metabolic acidosis/shock
    • Respiratory Distress
      • Assess Airway patency
        • Awake patient usually assumes optimal position for airway patency
        • Obstructions: secretions, FB, soft tissue
      • Assess Oxygenation
        • Color, mental status, pulse Ox
      • Assess Ventilation
        • WOB, aeration, blood gas
    • Blood gases
      • Purpose of ordering blood gases:
        • Assess Acid/Base status (pH, base deficit/excess)
        • Assess oxygenation (PaO2)
        • Assess ventilation (CO2)
        • Quick lytes (Na, K, Cl)
      • Ways of obtaining blood gases
        • Arterial—pH, O2, CO2
        • Venous—pH, (CO2 trend)
        • Capillary—pH, CO2, O2
    • Interpreting Blood gases
      • Goal is to determine primary/secondary process:
        • Respiratory Acidosis
        • Respiratory Alkalosis
        • Metabolic Acidosis
        • Metabolic Alkalosis
    • Interpreting Blood gases
        • Look at the pH
          • -if <7.4, the primary process is acidosis
          • -if>7.4, the primary process is alkalosis
        • Calculate the Anion Gap = Na-(Cl+HCO3)
          • -if AG > 14, then you have a metabolic acidosis
        • Calculate the “Delta Gap”= AG-nl gap (i.e. 12)
        • Add HCO3 + “Delta Gap
          • -if >30, also have a metabolic alkalosis
          • -if <24, also have a non-gap metabolic acidosis
    • Blood gases
      • Why bother doing all the calculations???
      • Let’s go back to Bryce: 3 year old male with CC: fever, abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They explain he’s had a cold with intermittent fever for a week, but today developed abd pain and started breathing more rapidly. Bryce appears pale, dehydrated and is markedly tachypneic with deep retractions.
    • Blood gases
      • Bryce’s ABG (FiO2 100% NRB)
        • 7.05/480/20/8/-18 Na 148 Cl 112
        • pH/PaO2/PCO2/HCO3/BE
      • Bryce has:
        • Primary process? Acidosis
        • AG = 28, thus has AG metabolic acidosis
        • Delta gap + HCO3 = 16+12, thus no other metabolic process
        • Compensation: Respiratory alkalosis
    • Bryce’s Diagnosis???
      • Hint: a bedside finger stick test leads to the diagnosis…
      • Diabetic Ketoacidosis!
    • Back to Your Night on the Wards…
      • Let’s go back to Shenaya’s room…
    • Back to Your Night on the Wards…
      • Shenaya is a 2 mo old infant with bronchiolitis brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with every breath.
    • Back to Your Night on the Wards…
      • Her Venous Blood Gas:
      • pH 7.20
      • PCO2 76
      • BD -4
    • Back to Your Night on the Wards…
      • Linda, the Med-Surg Charge Nurse, comes up to you and tells you, “That baby needs to go the IMU. Write transfer orders now.”
    • The ABC’s of Pediatric Emergencies
      • Understanding the different levels of care at CHHC
    • The ABC’s of Pediatric Emergencies
      • Patient Care Unit Hierarchy at CHHC
        • Ortho Rehab
        • Med/Surg
        • Heme-Onc
        • IMU
        • PICU
      • Make sure your patient is at the appropriate level of care
    • Back to Your Night on the Wards…
      • Your Senior Resident agrees with your plan to transfer Shenaya to the IMU.
      • You updated the Attending.
      • She is on NCPAP and her WOB is a little improved.
      • Whew! You can finally tuck Shenaya away for the night…
    • A Night on the Wards…
      • Not quite…
      • “ Sick” patients need constant re-assessment!
    • A Night on the Wards…
      • How to Re-assess when I still have 4 admits coming?!?
        • Communicate with the Bedside Nurse:
          • Document your name and pager on the chart
          • Give strict, clear “Call HO” parameters
        • Communicate with your Senior Resident:
          • Agree on who will re-assess the patient and when
          • Communicate if patient’s condition worse
        • Set your pager alarm and ask RN to page you
    • Your Night on the Wards…
      • Setting your pager alarm to re-check Shenaya reminds you that you should check on Ryan…
    • A Night on the Wards…
      • Ryan is the 16 mo with SBS. He was admitted yesterday for increased stool output. You peek at his flow sheet and notice that his last three stools have been heme + with the most recent with streaks of blood…
      • What do you do for a GI bleed?
    • GI Bleed
      • General Principles for Treatment:
        • NPO
        • Change meds to IV when possible
        • PPI (Pantoprazole)
        • Give adequate fluids (deficit + maintenance + ongoing losses)
        • NG or GT lavage
        • NG or GT to gravity (for monitoring)
    • GI Bleed
      • General Principles for Treatment (cont)
        • Send Type and Screen early
        • Check for coagulopathy—optimize coagulability
          • Thrombocytopenia—platelet transfusion
          • Prolonged PT—FFP
          • Low fibrinogen—Cryoprecipitate
        • Serial CBC’s—transfuse early if ongoing losses likely
        • Severe or refractory GI Bleeds:
          • Octreotide—Somatostatin analog, ↓ GI blood flow
          • Endoscopy/Surgery
    • Back to Your Night on the Wards…
      • You quietly walk into Ryan’s room. With your penlight, you look at his GT bag and find bright red blood steadily filling the bag…
      • Now what?!?
    • A Night on the Wards…
      • Remember:
        • Take a breath and THINK about what your patient needs right now.
        • Start with the ABC’s
        • Get additional help
    • A Night on the Wards…
      • The PICU fellow teaches you how to push blood as you help escort Ryan to join Luis in the PICU…
      • Will this night ever end?!?
    • A Night on the Wards…
      • Finally, a chance to catch up on dictations. Just as you are finishing your last dictation, your Senior pages…
      • “ An easy Gastro admit in room 221”
    • A Night on the Wards…
      • Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes back to sleep.
    • A Night on the Wards…
      • Are you sure this is just Gastro?
    • Review the case:
      • Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes back to sleep.
    • Review the case:
      • Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po , last urinated ~2 hrs ago . She’s had no F/D, no known sick contacts but is in daycare. Parents note she’s been excessively sleepy . Her admit vitals are: T99, HR 100, BP 120/75, RR 45 , O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV , but quickly goes back to sleep.
    • A Night on the Wards…
      • What must be “ruled out” in this patient immediately?
      • Increased Intracranial Pressure!
    • Increased Intracranial Pressure
      • Results from an increase in volume of cerebral contents within a rigid cranial compartment
      • Can be due to bleeding, edema, mass or CSF
    • Increased Intracranial Pressure
      • Symptoms:
        • Headache
        • Vomiting
        • Sleepy/Lethargy
        • Irritability
        • Vision changes
    • Increased Intracranial Pressure
      • Signs
        • Increased tone
        • Decreased LOC
        • Bulging fontanel
        • Cranial nerve palsy
        • Cushing’s triad:
          • Hypertension
          • Bradycardia
          • Irregular respirations
        • Papilledema/ decreased venous pulsations
    • Increased Intracranial Pressure
      • Treatment
        • Step 1: Recognize it early!
      • Who are the patients at risk?
        • Head injury
        • Meningitis
        • Brain tumor
        • Hydrocephalus
        • Immune-compromised
    • Increased Intracranial Pressure
      • Brain is dependent on aerobic metabolism
      • Thus, depends on cerebral blood flow for viability
      • Goal of autoregulation/ therapy is to maintain adequate CBF
      • Step 2: Understand the pathophysiology…
    • Back to Your Night on the Wards…
      • What would you do for Emily?
    • Increased Intracranial Pressure
      • Immediate treatment for increased ICP:
        • ABC’s (intubate for GCS </= 8)
        • Raise head of bed to 15-30 degrees
    • Increased Intracranial Pressure
      • Get Help (Senior Resident, Notify attending)
      • PICU Consult-- All patients with suspected ↑ ICP should be in PICU
      • Head CT (hold on LP)
      • Common Therapies
        • Hyperventilation (bag and mask)
        • Hypertonic Saline (3%)
        • Mannitol—beware of hypovolemia
        • Decadron—tumor or bacterial meningitis
    • The ABC’s of Pediatric Emergencies…Parting Thoughts
      • One of the goals of Intern Year is to learn to recognize the “Sick” patient
        • If you are concerned, get a second opinion early
        • Better to over-react than to under-react
        • Assume every patient is “sick” until proved otherwise
        • If you missed recognizing a “sick kid,” review the case and learn for the next patient
      • Most important part of “Emergency Care” is PREVENTION
        • Recognizing sick patients early
        • Giving appropriate treatment early
      • Follow your ICU transfers peripherally to learn
    • References
      • http://www.emedicine.com/ped/topic929.htm
      • http://www.emedicine.com/ped/topic3082.htm
      • http://pedsccm.wustl.edu/
      • Duthie, Susan. “Respiratory Failure”
      • Duthie, Susan. “Shock in the Pediatric Patient”
      • Pearson, Gale. “Handbook of Paediatric Intensive Care.”