Pediatric Case Studies
Jana A. Stockwell, MD, FAAP
Pediatric Critical Care Medicine
Children’s Healthcare of Atlanta @Egle...
Case #1
• He is sleeping but arouses to stimulation.
• Vital signs: T 39.2ºC, HR 220, RR 55, BP
75/40, SpO2 99% on 2L NC, ...
Case #1
Shortly after arriving on the ward, the
child develops difficulty breathing and
an elevated heart rate. The rhythm...
Case #1
How fast is the heart beating?
Use the 300-150-75 rule
300 150
Start here
and count
boxes
So, a little less
than 3...
Case #1
• What should you do next?
• Determine if the child is clinically stable
or unstable
SupraVentricular Tachycardia
...
Case #1
• In SVT, if the child is clinically stable,
try:
 Inducing the Dive Reflex by applying an ice
bag to the face
 ...
Case #1
• You suspect SVT
& the child is clinically
unstable…
 Place an IV
 Give IV bolus of ADENOSINE
Very short t (1...
Case #1
• You suspect SVT…
& the child is very clinically unstable…
 If an IV cannot be started quickly OR
 If the patie...
Case #1 Summary
• Things are not always what they are
advertised to be
• Be aware that multiple therapies may be
available...
Case #2
• You are admitting a 6 year old male with no
significant past medical history who presented
at an outlying physic...
Case #2
What is wrong with this child?
This child is in uncompensated shock, most
likely from hypovolemia
What is the firs...
Case #2
• After giving 20 cc/kg of NS, what
should be done?
 Re-assess the child’s clinical status
Check pulses and hear...
Case #2
• VS: HR 150, RR 32, BP 70/50, SpO2 97% on
RA
• There is good air exchange in all lung fields,
peripheral pulses a...
Case #2
• VS: HR 140, RR 30, BP 90/60, SpO2 97%
on RA. There is good air exchange in all
lung fields, peripheral pulses ar...
Case #2
• The child’s VS are HR 100, RR 22, BP
98/65, SpO2 94% on RA. There is good
air exchange in all lung fields, perip...
Case #2 Summary
• When the tank is low, it may take a lot
of fluid to fill it back up!
• Remember, being 10% dehydrated me...
Case #3
• You are transporting a 13 year old male
who presented to an outlying ER with
nausea and bilious vomiting. He has...
Case #3
• During transport, the child begins to
speak in incomprehensible sentences.
• VS: T36.8ºC, P 162, RR 38, BP 70/42...
Case #3
• After receiving a total of three 20
cc/kg boluses of crystalloid, the child
remains hypotensive.
• What should b...
Case #3
• Dopamine added
 What dose should you start?
 You titrate the dose to 12 mcg/kg/min and the
child is still hypo...
Case #3
• What are the clinical features of “warm” vs.
“cold” septic shock?
Warm Cold
CR time Brisk Prolonged
Warm Cool
Nm...
Case #3
• How do these findings guide the next
phase of therapy?
 In warm septic shock, the underlying
problem is decreas...
Case #3 Summary
• The stage of shock will determine which
drugs are most appropriate for
resuscitation -- the list of choi...
Case #4
• You are transporting a 4 year old male
who fell out of a 4th story window. His
head CT reveals small contusions....
Case #4
Case #4
• Recognizing the hypotension, a medic has
already administered three boluses of NS
at 20 cc/kg, but the child rem...
Case #4
• What is neurogenic shock?
 It is a condition characterized by loss of
sympathetic tone to the peripheral vascul...
Case #4
How does this occur?
A lesion occurs in the cervical
region of the spinal cord
This cuts off the connection
betwee...
Case #4
• How is this treated?
 The use of pure α-agonist (e.g.
neosynepherine) agents is preferred
Case #4 Summary
• Not all shock secondary to trauma is due
to blood loss!
Case #5
• You are working on Transport, when a 16
year old male, who was riding a
motorcycle when he lost control, flipped...
Case #5
• Prior to transport, the child has been
intubated for respiratory distress and altered
mental status.
• A left ch...
Case #5
• During transport, the child becomes
progressively tachycardic. What do you do
now?
 Check all vitals and perfor...
Case #5
• Now the teenager’s pulse is 185 and he is
becoming hypotensive to 50/20. You
check the pupils because heart rate...
Case #5
• This is not Cushing’s Triad what else
could it be? Your quick physical
examination finds the following:
 Neck v...
Case #5
• What is happening?
Cardiac tamponade
• How is this treated?
 20 cc/kg fluid push
 Emergent pericardiocentesis
...
Cardiac tamponade
occurs when blood
or other fluid
accumulates in the
pericardial space.
This creates
increased pressure
a...
Case #5
• What are the signs of cardiac tamponade?
 Tachycardia
 Hypotension
 JVD
 Decreased cardiac output
 Pulsus p...
“Blind” Pericardiocentesis - Technique
• Subxiphoid Approach
• Position the patient so the chest is
at a 30-degree angle
•...
“Blind” Pericardiocentesis - Technique
• Depress the needle so the
needle points toward the left
shoulder
• Using a slow, ...
“Blind” Pericardiocentesis - Complications
• Laceration of a coronary artery
• Laceration or perforation of either ventric...
Case #6
• Your 3 y.o. patient’s mother calls out
that something is wrong.
• You find the child lying on the bed with
his r...
Case #6
• What is your first impression of this
situation?
 Child with …
Complex focal seizure
Hypoxic respiratory dist...
Case #6
• What are the first things you should
assess?
 Airway
 Breathing
 Circulation
Appears patent
Ineffective, chil...
Case #6
• Does this child need intubation?
 Not at this time. While the child is hypoxic,
repositioning and oxygen by fac...
Case #6
• What medications should be given and by
which routes?
 Diazepam (Valium): onset in 2-10 minutes
Rectal gel (Di...
Case #6
• What medications should be given and by
which routes?
 Lorazepam (Ativan): onset in 2-5 minutes
Neonates: 0.05...
Case #6
• What medications should you consider if
the first line agents fail to control the
seizures?
 Phenobarbital
 Ph...
Case #6
• The child stops twitching after
lorazepam is given. His respirations are
shallow & his SpO2 in 100% on NRB FM at...
Case #7
• You are working in the ER when a 13 year
old unresponsive female is brought in.
• Her little brother states the ...
Case #7
• A: abuse or alcohol
• E: encephalopathy or
endocrine
• I: insulin/
hypoglycemia/
metabolic disorder
• O: opiates...
Case #7
• D: dehydration
• P: poisoning
• T: trauma
• O: occult trauma
• P: post-ictal or post-
anxoia
• V:VP shunt infect...
Case #7
• The sibling states that she takes
injections in her leg. What is the most
likely diagnosis?
Diabetic ketoacidosis
Case #7
• You check a blood gas which
demonstrates …
 pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base
deficit -27
 Na+
133, K...
Case #7
• Should you give NaHCO3 to correct the
acidosis?
 No. NaHCO3 should only be given in the setting of
cardiovascul...
Case #7
• Why is the K+
elevated?
 Elevated serum hydrogen ion is counter-
transported across the RBC membrane with
potas...
Case #7
• Why is Na+
low?
 The hyperosmolality of diabetes attracts
more water into the intravascular space.
This causes ...
Case #7
• What IVF should be given and how
much?
 0.9% NaCl at 20 cc/kg unless in
uncompensated shock. Excess IVF has bee...
Case #8
• You are admitting a 6 year old male who is
coughing uncontrollably.
• VS: T 37.2ºC, HR 140, RR 40, SpO2 85% on
r...
Case #8
• What is this child’s problem?
Asthma is a chronic inflammatory
pulmonary disorder that is characterized
by rever...
Case #8
• What is the 1st step in treatment?
 Provide oxygen
• What is the next step?
 Provide nebulized bronchodilators
Case #8
• How would the diagnosis change if the
child had a right-sided, wheeze heard
best on inspiration, with decreased ...
Case #8
• Physical examination of the child reveals
a palpable liver edge 5 cm below the
right costal margin. Why is this?...
Case #8
• What agents are used in the treatment
of asthma and why?
 β-agonist agents
Increase cAMP which leads to decrea...
Case #8
 Agents…
 Anticholinergic agents
 Inhibit the acetylcholine receptor thereby decreasing the
intracellular cGMP ...
Case #8
• Agents…
 Magnesium sulfate:
Competitively inhibits intracellular calcium and
leads to smooth muscle relaxation...
Case #9
• A 7 week old female infant is being seen for
unresponsiveness after being found face down
in the bed by her pare...
Case #9
• What are the first things you should do?
 Airway & Breathing
Bagging this child with 100% oxygen increased the...
Case #9
• What should be done next?
 Disability
This child is hypothermic and should be placed
under warming lights or w...
Case #9
• What components of the history should
be obtained?
 Birth history:
Full term or premature?
Discharged right a...
Case #9
 ID:
Any fever?
Any rash?
Any sick contacts?
 Medical:
Is the child on any medication?
When was the last vi...
Case #10
• You arrive at your night shift on a community hospital
inpatient floor. One of your patients is a 9 month old,
...
Case #10
• Different parts of the respiratory tree may be
contributing to this infant’s problems
 Nasal Passages: obstruc...
Case #10
• Name different ways to overcome these airway
problems
 Nasal Passages: suction, α-agonists (i.e. Afrin)
 Orop...
Case #11
• You are transporting a 14 year old male with
bilateral frontal contusions after a MVC.
• The child has also sus...
Case #11
• During transport, the child develops a BP of 180/120 &
pulse 65. What might be happening?
 The bradycardia and...
Case #11
• Now his sats are falling...
• You begin to manually bag him and notice
that it is much more difficult to obtain...
Case #11
• You check for displacement by auscultation
bilaterally
 No air exchange in the right lung fields with good
air...
Case #11
• You check for a possible pneumothorax
 There is no air exchange on the right side
 There is no chest rise on ...
Case #12
• You arrive at an ER to transport a 5 year old
male who was intubated for respiratory failure
secondary to shock...
Case #12
• En route, the becomes hypotensive to
55/20. While pushing volume, the IO
displaces. What should you do next?
 ...
Case #12
• The child remains hypotensive despite a
20 cc/kg bolus (60 cc/kg total given
since presentation). What should y...
Case #12
• You obtain a arterial blood gas which
demonstrates: pH 7.20, PaCO2 60, PaO2
75. What is happening and what shou...
Case #12
• You have attempted to titrate the dopamine to
keep the MAP > 65. It is now at 18 mcg/kg/min
but the hypotension...
Case #13
• You are transporting a 16 year old male from a
peripheral ER who is suspected of taking PCP.
He was combative a...
Case #13
• What other drugs can commonly cause
this reaction?
 Metoclopromide (Reglan)
 Prochlorperazine (Compazine)
• H...
Case #13
• You arrive at the ER of a rural medical center
to transport a 13 month old child who has
respiratory distress f...
Note the
increased
cardiac to
thoracic ratio
Case #13
• The diagnosis of acute myocarditis is
made. While transporting the child, he
develops the following rhythm:
• W...
Case #13
• What should you do next?
 Check for a pulse
If no pulse present, initiate CPR and PALS
pulseless arrest algor...
Case #13
• What should you do next? (Con’t)
 Check for a pulse
If pulse present with adequate perfusion:
– Consider medi...
Case #14
• You arrive at a physician’s office to transport
a 4 year old child with a suspected acute
abdomen.
• The child ...
Case #14
• While en route, the child falls asleep and
appears comfortable.
• The BP cycles and determines that the
BP is n...
Case #14
• The child’s SpO2 is beginning to fall
(84%). Examination demonstrates
shallow respirations. What should you
do ...
CASESCASES
Transport_Cases.ppt
Transport_Cases.ppt
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Transport_Cases.ppt

  1. 1. Pediatric Case Studies Jana A. Stockwell, MD, FAAP Pediatric Critical Care Medicine Children’s Healthcare of Atlanta @Egleston Atlanta, Georgia jana.stockwell@CHOA.org
  2. 2. Case #1 • He is sleeping but arouses to stimulation. • Vital signs: T 39.2ºC, HR 220, RR 55, BP 75/40, SpO2 99% on 2L NC, CR ~4 sec • You receive a 4 month old male from another ER who is suffering from respiratory distress • His CXR is read as “no infiltrate”
  3. 3. Case #1 Shortly after arriving on the ward, the child develops difficulty breathing and an elevated heart rate. The rhythm strip is shown below...
  4. 4. Case #1 How fast is the heart beating? Use the 300-150-75 rule 300 150 Start here and count boxes So, a little less than 300 bpm!!!
  5. 5. Case #1 • What should you do next? • Determine if the child is clinically stable or unstable SupraVentricular Tachycardia You suspect SVT... HOW?
  6. 6. Case #1 • In SVT, if the child is clinically stable, try:  Inducing the Dive Reflex by applying an ice bag to the face  Bearing down (i.e. Valsalva maneuver)  Eyeball pressure & carotid massage, may be harmful and are discouraged
  7. 7. Case #1 • You suspect SVT & the child is clinically unstable…  Place an IV  Give IV bolus of ADENOSINE Very short t (10 sec) & must be given rapidly Continuous rhythm strip during attempted conversion Potential side effects include hypotension, bronchospasm, and flushing
  8. 8. Case #1 • You suspect SVT… & the child is very clinically unstable…  If an IV cannot be started quickly OR  If the patient fails to convert with IV adenosine OR  Patient becomes unconscious or unresponsive  Then, cardiovert using 0.5 - 1 joule/kg
  9. 9. Case #1 Summary • Things are not always what they are advertised to be • Be aware that multiple therapies may be available and choice depends upon clinical situation
  10. 10. Case #2 • You are admitting a 6 year old male with no significant past medical history who presented at an outlying physician’s office with a decreased level of consciousness. He has been having massive amounts of emesis and diarrhea. • VS: T 38.2ºC, HR 150, RR 28, BP 70/30, SpO2 97% on Room Air • There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~4 sec
  11. 11. Case #2 What is wrong with this child? This child is in uncompensated shock, most likely from hypovolemia What is the first logical step in management of this child? Crystalloid (NS, LR) at 20 cc/kg bolus
  12. 12. Case #2 • After giving 20 cc/kg of NS, what should be done?  Re-assess the child’s clinical status Check pulses and heart rate Check blood pressure Evaluate capillary refill time Evaluate mental status Auscultate chest to determine if heart can handle volume load -- rales, gallop
  13. 13. Case #2 • VS: HR 150, RR 32, BP 70/50, SpO2 97% on RA • There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~ 4 sec • Now that the BP has improved, is this child still in shock? Yes, the child is in uncompensated shock!! Repeat the NS bolus at 20 cc/kg What should you do now?
  14. 14. Case #2 • VS: HR 140, RR 30, BP 90/60, SpO2 97% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is ~3 sec • Now that the BP has improved, is this child still in shock? Yes, it is now compensated shock Repeat the NS bolus at 10-20 cc/kg What should you do now?
  15. 15. Case #2 • The child’s VS are HR 100, RR 22, BP 98/65, SpO2 94% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is < 2 sec • Now that the VS have improved, is this child still in shock?  No. The fluid resuscitation has brought this child out of hypovolemic shock
  16. 16. Case #2 Summary • When the tank is low, it may take a lot of fluid to fill it back up! • Remember, being 10% dehydrated means 10% of the body weight is lost due to fluid ouput/poor intake
  17. 17. Case #3 • You are transporting a 13 year old male who presented to an outlying ER with nausea and bilious vomiting. He has a past history of BMT for CML. He also has a history of recurrent bowel obstructions. • In the ER, VS are T 35.7ºC, HR 110, RR 32, BP 90/45, SpO2 98% on RA. His extremities are warm and well perfused.
  18. 18. Case #3 • During transport, the child begins to speak in incomprehensible sentences. • VS: T36.8ºC, P 162, RR 38, BP 70/42, SpO2 95% on RA, he is having rigors. • What should be done next? This child is in uncompensated shock. He should receive 20 cc/kg of crystalloid
  19. 19. Case #3 • After receiving a total of three 20 cc/kg boluses of crystalloid, the child remains hypotensive. • What should be the next course of action? Pharmacological support of his BP
  20. 20. Case #3 • Dopamine added  What dose should you start?  You titrate the dose to 12 mcg/kg/min and the child is still hypotensive... • What exam findings are important in guiding therapy at this time?  Capillary refill time  Tactile temperature of the extremities  Mental status  Peripheral and central pulses
  21. 21. Case #3 • What are the clinical features of “warm” vs. “cold” septic shock? Warm Cold CR time Brisk Prolonged Warm Cool Nml/↑activity Nml/↓activity Bounding Nml/Thready Skin temp Precordium Pulses
  22. 22. Case #3 • How do these findings guide the next phase of therapy?  In warm septic shock, the underlying problem is decreased SVR, therefore an agent with mostly vasopressor activity should be started (i.e. norepinephrine)  In cold septic shock, the underlying problem is decreased CO, therefore an agent with inotropic activity and/or afterload reduction should be started (i.e. epinephrine, milrinone, nipride)
  23. 23. Case #3 Summary • The stage of shock will determine which drugs are most appropriate for resuscitation -- the list of choices is long dopamine dobutamine milrinone epinephrine nipride neosynephrine norepinephrine
  24. 24. Case #4 • You are transporting a 4 year old male who fell out of a 4th story window. His head CT reveals small contusions. He is in a C-collar. • VS: HR 65, RR 20, BP 60/30, SpO2 98% on RA, CR ~4 sec. His neck films are shown.
  25. 25. Case #4
  26. 26. Case #4 • Recognizing the hypotension, a medic has already administered three boluses of NS at 20 cc/kg, but the child remains hypotensive. • Repeat VS: HR 55, RR 25, BP 65/30, SpO2 98% on RA, CR ~4 sec. • What is unique about these vital signs?  There is no compensatory tachycardia for the hypotension • What does this suggest?  The child may have neurogenic shock
  27. 27. Case #4 • What is neurogenic shock?  It is a condition characterized by loss of sympathetic tone to the peripheral vascular bed and to the heart • What is the hallmark of this type of shock?  There is marked hypotension without compensatory tachycardia following a CNS injury
  28. 28. Case #4 How does this occur? A lesion occurs in the cervical region of the spinal cord This cuts off the connection between the heart and the brain Now the brain cannot control the heart and the heart functions independently from the rest of the circulation
  29. 29. Case #4 • How is this treated?  The use of pure α-agonist (e.g. neosynepherine) agents is preferred
  30. 30. Case #4 Summary • Not all shock secondary to trauma is due to blood loss!
  31. 31. Case #5 • You are working on Transport, when a 16 year old male, who was riding a motorcycle when he lost control, flipped, and smashed into a guard rail, is brought in to a referring ED. He was wearing a helmet. • He was found to have a multiple rib fractures an and underlying hemothorax. • His chest x-ray is as follows.
  32. 32. Case #5 • Prior to transport, the child has been intubated for respiratory distress and altered mental status. • A left chest tube has been placed. CT’s of the head, chest, abdomen, and pelvis are negative for additional pathology. • VS: T 38.2ºC, HR 108, RR 20, BP 90/60, SpO2 98%. • He is currently intubated, sedated, and paralyzed. He is stable and he is loaded onto the ambulance for transport.
  33. 33. Case #5 • During transport, the child becomes progressively tachycardic. What do you do now?  Check all vitals and perform quick, focused clinical exam accessing airway, breathing, and circulation  You determine that there is no immediately life- threatening cause of the tachycardia and suspect pain and under sedation for which you administer fentanyl and lorazepam.
  34. 34. Case #5 • Now the teenager’s pulse is 185 and he is becoming hypotensive to 50/20. You check the pupils because heart rate and BP changes are part of Cushing’s Triad. What is Cushing’s Triad?  Bradycardia  Hypertension  Altered respirations
  35. 35. Case #5 • This is not Cushing’s Triad what else could it be? Your quick physical examination finds the following:  Neck vein distension  Tachycardia with decreased heart sounds  Hypotension  Thready pulses
  36. 36. Case #5 • What is happening? Cardiac tamponade • How is this treated?  20 cc/kg fluid push  Emergent pericardiocentesis Removal of even a small volume of fluid is the definitive treatment & can rapidly improve BP & cardiac output -- may ultimately prove to be lifesaving
  37. 37. Cardiac tamponade occurs when blood or other fluid accumulates in the pericardial space. This creates increased pressure around the heart and interferes with heart function.
  38. 38. Case #5 • What are the signs of cardiac tamponade?  Tachycardia  Hypotension  JVD  Decreased cardiac output  Pulsus paradoxus - >10 mmHg change between inspiratory and expiratory systolic BP  Narrow pulse pressure  Muffled heart tones
  39. 39. “Blind” Pericardiocentesis - Technique • Subxiphoid Approach • Position the patient so the chest is at a 30-degree angle • Insert an 18-gauge spinal needle attached to a 20-ml syringe into the left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin • While aspirating constantly, advance the needle directly into the inner aspect of the rib cage
  40. 40. “Blind” Pericardiocentesis - Technique • Depress the needle so the needle points toward the left shoulder • Using a slow, cautious, turning action of the fingers, advance the needle until fluid is aspirated • Observe the cardiac monitor for arrhythmias • Successful removal of fluid confirms the needle's position
  41. 41. “Blind” Pericardiocentesis - Complications • Laceration of a coronary artery • Laceration or perforation of either ventricle • Laceration or perforation of the right atrium • Perforation of the stomach or colon • Pneumothorax • Arrhythmias • Tamponade • Hypotension (perhaps reflexogenic)
  42. 42. Case #6 • Your 3 y.o. patient’s mother calls out that something is wrong. • You find the child lying on the bed with his right arm in extension with his hand twitching & his eyes dancing horizontally. Mom states that she has been trying to arouse the child without success. • VS: T 39.2ºC, HR 180, BP 110/70, RR 38 and irregular, SpO2 82% on room air.
  43. 43. Case #6 • What is your first impression of this situation?  Child with … Complex focal seizure Hypoxic respiratory distress Tachycardia Fever
  44. 44. Case #6 • What are the first things you should assess?  Airway  Breathing  Circulation Appears patent Ineffective, child is cyanotic Child is tachycardic with good pulses & brisk capillary refill time
  45. 45. Case #6 • Does this child need intubation?  Not at this time. While the child is hypoxic, repositioning and oxygen by face mask can improve oxygenation.  Additionally, treatment of the child’s seizures may restore regular respirations and improve the oxygenation status.
  46. 46. Case #6 • What medications should be given and by which routes?  Diazepam (Valium): onset in 2-10 minutes Rectal gel (Diastat) – Infants <6 months: Not recommended – Children <2 years: Not been studied – Children 2-5 years: 0.5 mg/kg – Children 6-11 years: 0.3 mg/kg – Children 12 years and Adults: 0.2 mg/kg – Round doses to nearest 2.5, 5, 10, 15, and 20 mg/dose
  47. 47. Case #6 • What medications should be given and by which routes?  Lorazepam (Ativan): onset in 2-5 minutes Neonates: 0.05 mg/kg IV/IM Infants, Children, and Adolescents: 0.1 mg/kg (max 4 mg) IV/IM May repeat up to 3 times before considering a non-benzodiazepine agent
  48. 48. Case #6 • What medications should you consider if the first line agents fail to control the seizures?  Phenobarbital  Phenytoin (Dilantin) Fosphenytoin if peripheral IV questionable
  49. 49. Case #6 • The child stops twitching after lorazepam is given. His respirations are shallow & his SpO2 in 100% on NRB FM at FiO2 1.0 • What reflexes should be evaluated to see if this child requires intubation?  Gag to evaluate airway protection.
  50. 50. Case #7 • You are working in the ER when a 13 year old unresponsive female is brought in. • Her little brother states the girl has been sick all day. She was really thirsty having consumed four 2 liter bottles of Coke in the last 8 hours. • VS: T 36ºC, HR 165, BP 80/palp RR 25 and very deep, SpO2 99% on room air.
  51. 51. Case #7 • A: abuse or alcohol • E: encephalopathy or endocrine • I: insulin/ hypoglycemia/ metabolic disorder • O: opiates • U: uremia • T: trauma/ tumor • I: infection/ intussusception • P: poisoning • S: sepsis/ seizure/ shock What is the differential diagnosis? "AEIOU - TIPS”
  52. 52. Case #7 • D: dehydration • P: poisoning • T: trauma • O: occult trauma • P: post-ictal or post- anxoia • V:VP shunt infection • H: hypoxia/ hyperthermia • I: intussusception • B: brain mass • M: meningitis • M: metabolic • R: Reye’s syndrome What is the differential diagnosis? “DPT - OPV - HIB - MMR”
  53. 53. Case #7 • The sibling states that she takes injections in her leg. What is the most likely diagnosis? Diabetic ketoacidosis
  54. 54. Case #7 • You check a blood gas which demonstrates …  pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27  Na+ 133, K+ 6.5, Glucose ***, iCa++ 4.5 mg/dL
  55. 55. Case #7 • Should you give NaHCO3 to correct the acidosis?  No. NaHCO3 should only be given in the setting of cardiovascular dysfunction, i.e. arrhythmias. Its use has been associated with the development of cerebral edema in patients wth DKA. (N Engl J Med 2001;344:264-9) pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27 Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
  56. 56. Case #7 • Why is the K+ elevated?  Elevated serum hydrogen ion is counter- transported across the RBC membrane with potassium in an effort to buffer the acidosis pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27 Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
  57. 57. Case #7 • Why is Na+ low?  The hyperosmolality of diabetes attracts more water into the intravascular space. This causes a “ficticious hyponatremia”. pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27 Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
  58. 58. Case #7 • What IVF should be given and how much?  0.9% NaCl at 20 cc/kg unless in uncompensated shock. Excess IVF has been associated with cerebral edema. (4 liters/M2 ) pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27 Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
  59. 59. Case #8 • You are admitting a 6 year old male who is coughing uncontrollably. • VS: T 37.2ºC, HR 140, RR 40, SpO2 85% on room air. • He has nasal flaring, supra-sternal, intercostal, and subcostal retractions. • By auscultation, you hear expiratory wheezes bilaterally with a prolonged expiratory time.
  60. 60. Case #8 • What is this child’s problem? Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways Acute exacerbation of asthma
  61. 61. Case #8 • What is the 1st step in treatment?  Provide oxygen • What is the next step?  Provide nebulized bronchodilators
  62. 62. Case #8 • How would the diagnosis change if the child had a right-sided, wheeze heard best on inspiration, with decreased air exchange on the right side, and tracheal deviation to the left?  This would suggest the presence of a foreign body.  Remember, all that wheezes is not asthma!
  63. 63. Case #8 • Physical examination of the child reveals a palpable liver edge 5 cm below the right costal margin. Why is this?  Hyperinflation related to obstructive airway disease in asthma has pushed the liver inferiorly into the abdomen.
  64. 64. Case #8 • What agents are used in the treatment of asthma and why?  β-agonist agents Increase cAMP which leads to decreased intracellular calcium and smooth muscle relaxation. Albuterol nebs or MDI, terbutaline nebs or SQ, epinephrine SQ
  65. 65. Case #8  Agents…  Anticholinergic agents  Inhibit the acetylcholine receptor thereby decreasing the intracellular cGMP which leads to decreased intracellular calcium and smooth muscle relaxation.  Ipratroprium bromide nebs  Steroids  Acutely, they may lead to β-receptor upregulation and sub-acutely/chronically have been shown to decrease the inflammatory response in asthma
  66. 66. Case #8 • Agents…  Magnesium sulfate: Competitively inhibits intracellular calcium and leads to smooth muscle relaxation  Ketamine: Binds sigma opiate receptors to cause dissociative amnesia and relaxation. Causes secondary release of endogenous epinephrine which causes smooth muscle relaxation. Can cause excessive secretions.
  67. 67. Case #9 • A 7 week old female infant is being seen for unresponsiveness after being found face down in the bed by her parents. • VS: T 35.2ºC, HR 68 & thready, RR 13, BP 65/40 with SpO2 unable to trace, and CR ~5 sec. She responsive to painful stimulation. • The physician seeing the patient is concerned about sepsis and gave the child IM antibiotics because no IV access has been obtained.
  68. 68. Case #9 • What are the first things you should do?  Airway & Breathing Bagging this child with 100% oxygen increased the heart rate to 180 bpm  Circulation This child is in shock. An attempt at IV access should be made. If no access is obtained in 90 seconds or after 3 attempts, an IO needle should be placed. After this, the child should receive 20 cc/kg of crystalloid solution
  69. 69. Case #9 • What should be done next?  Disability This child is hypothermic and should be placed under warming lights or wrapped in a blanket
  70. 70. Case #9 • What components of the history should be obtained?  Birth history: Full term or premature? Discharged right after birth or was there a prolonged stay?  GI: Has the child been taking good PO? Making good UOP? Diarrhea or vomiting?
  71. 71. Case #9  ID: Any fever? Any rash? Any sick contacts?  Medical: Is the child on any medication? When was the last visit to the doctor? Are the vaccinations up to date?
  72. 72. Case #10 • You arrive at your night shift on a community hospital inpatient floor. One of your patients is a 9 month old, former 25 week male premie who is respiratory distress. • The nurse signing out to you states that the child has developmental delay and cerebral palsy. • The child presented to your facility with fever and rhinorrhea for 3 days, with progressively increasing work of breathing. The child has been receiving albuterol nebs Q 2 hours around the clock for the last 2 days without relief. • VS: 38.3ºC, HR 195, RR 60, BP 100/57, SpO2 89% on 5L FM, and CR <2 sec
  73. 73. Case #10 • Different parts of the respiratory tree may be contributing to this infant’s problems  Nasal Passages: obstruction from rhinorrhea, adenoid hypertrophy  Oropharynx: inability to clear secretions, pharyngeal hypotonia with obstruction, tonsillar hypertrophy  Trachea: Stenosis, malacia, vocal cord paralysis, viral croup  Small Conducting Airways: Reactive airway disease, bronchopulmonary dysplasia  Alveoli: pneumonia, bronchopulmonary dysplasia
  74. 74. Case #10 • Name different ways to overcome these airway problems  Nasal Passages: suction, α-agonists (i.e. Afrin)  Oropharynx: suction, BVM to give CPAP with 100% oxygen, intubation  Trachea: racemic epinephrine nebs, Heliox, BVM to give CPAP with 100% oxygen, intubation  Small Conducting Airways: albuterol, ipratroprium, BVM to give CPAP with 100% oxygen, intubation  Alveoli: BVM to give CPAP with 100% oxygen, intubation
  75. 75. Case #11 • You are transporting a 14 year old male with bilateral frontal contusions after a MVC. • The child has also sustained pulmonary contusions and a liver laceration. He was intubated for a GCS of 6. His pupils are 4mm and sluggish. • VS: T 37.2ºC, HR 108, BP 90/45 with SpO2 100%. • Vent settings are VT 400 cc, PEEP 5, IMV 12, FiO2 1.0.
  76. 76. Case #11 • During transport, the child develops a BP of 180/120 & pulse 65. What might be happening?  The bradycardia and elevated BP suggest Cushing’s Triad (altered respirations is the third component) which suggests impending herniation. • What is the next most appropriate step in management?  Hyperventilation: decreases PCO2 causing cerebral vasoconstriction leading to decreased blood flow decreasing cerebral edema.  Hyperosmotic agents:  Mannitol or 3% NaCl: removes water from brain and can relieve edema  Elevation of head.
  77. 77. Case #11 • Now his sats are falling... • You begin to manually bag him and notice that it is much more difficult to obtain chest rise than previously. • What should you think of next?  “DOPE” Displacement Obstruction Pneumothorax Equipment Failure
  78. 78. Case #11 • You check for displacement by auscultation bilaterally  No air exchange in the right lung fields with good air exchange in the left lung fields.  Could the ETT have slipped and led to left main- stem intubation? This is unlikely as the right main- stem is straighter and the tube is still taped at the original position. • You check for obstruction of the ETT by passing a suction catheter into the ETT  Suction catheter passes without difficulty
  79. 79. Case #11 • You check for a possible pneumothorax  There is no air exchange on the right side  There is no chest rise on the right side  The trachea is deviated to the left  These findings suggest a right sided pneumothorax • You quickly access for equipment failure  The BVM is connected to 100% oxygen  The anesthesia bag inflates correctly • You suspect a right sided PTX and perform a needle thoracotomy in the 2nd ICS at the mid- clavicular line and hear a whoosh of air
  80. 80. Case #12 • You arrive at an ER to transport a 5 year old male who was intubated for respiratory failure secondary to shock. • His VS are 39.2ºC, P 140, RR 32, BP 90/30, SpO2 93% on 100% O2. • The child received 40 cc/kg LR, vancomycin, & ceftriaxone prior to intubation. • There is an IO in the left tibia (attempt at a right IO failed). There is an a-line in the right radial artery.
  81. 81. Case #12 • En route, the becomes hypotensive to 55/20. While pushing volume, the IO displaces. What should you do next?  Place an IO in either femur, just proximal to the knee. Placement of the IO in either of the tibias may result in extravisation of fluid out of the previous IO attempt sites
  82. 82. Case #12 • The child remains hypotensive despite a 20 cc/kg bolus (60 cc/kg total given since presentation). What should you do next?  Begin dopamine at 5 mcg/kg/min • How do you make a drip using the rule of 6’s?  Wt(kg) x 60, 6, or 0.6 = # mg/100 cc to make a drip that at 1 cc/hr = 10, 1, or 0.1 mcg/kg/min
  83. 83. Case #12 • You obtain a arterial blood gas which demonstrates: pH 7.20, PaCO2 60, PaO2 75. What is happening and what should you do?  The patient is suffering from a respiratory acidosis and you should increase the ventilation rate or tidal volume • How can you estimate the change in pH from the change in PCO2?  For every 10 change in PCO2, a change of 0.08 in pH will be seen
  84. 84. Case #12 • You have attempted to titrate the dopamine to keep the MAP > 65. It is now at 18 mcg/kg/min but the hypotension persists.  Which agent should you consider if the child has a CR < 2, peripheral pulses +3, and a hyperdynamic precordium? This child is in warm septic shock. Norepinephrine should be started.  Which agent should you consider if the child has a CR ~ 4 and the peripheral pulses are thready? This child is in cold septic shock. Epinephrine should be started.
  85. 85. Case #13 • You are transporting a 16 year old male from a peripheral ER who is suspected of taking PCP. He was combative and received IM haloperidol which controlled his temperament adequately. • During transport, he develops muscle spasms, eye dancing, a stiff neck, and an inability to open his jaw. What is happening?  Acute dystonic reaction from haloperidol
  86. 86. Case #13 • What other drugs can commonly cause this reaction?  Metoclopromide (Reglan)  Prochlorperazine (Compazine) • How is this reaction treated?  Diphenhydramine (Benadryl)  Benztropine (Cogentin)
  87. 87. Case #13 • You arrive at the ER of a rural medical center to transport a 13 month old child who has respiratory distress for the last 3 days. • He is now significantly worse. VS T 39.8ºC, HR 198, RR 55, BP 65/30, SpO2 93% on 5L FM. • The child appears physically exhausted. • Physical examination demonstrates rales on auscultation bilaterally, distant heart sounds, and increased liver size. • His pulses are thready and CR ~3 sec. • The CXR is shown on the next slide.
  88. 88. Note the increased cardiac to thoracic ratio
  89. 89. Case #13 • The diagnosis of acute myocarditis is made. While transporting the child, he develops the following rhythm: • What is the diagnosis of this rhythm?  Ventricular tachycardia
  90. 90. Case #13 • What should you do next?  Check for a pulse If no pulse present, initiate CPR and PALS pulseless arrest algorithm If pulse present with poor perfusion: – STAT defibrillation 2 J/kg. – Consider alternative medications » Amiodarone 5 mg/kg IV over 20 minutes or » Lidocaine 1 mg/kg IV – Intubation
  91. 91. Case #13 • What should you do next? (Con’t)  Check for a pulse If pulse present with adequate perfusion: – Consider medications » Amiodarone 5 mg/kg IV over 20 minutes or » Lidocaine 1 mg/kg IV » Cardioversion with 0.5 to 1.0 J/kg
  92. 92. Case #14 • You arrive at a physician’s office to transport a 4 year old child with a suspected acute abdomen. • The child has had bilious emesis for 2 days along with loss of appetite. • VS: T 40.1ºC, HR 140, RR 45, BP 80/40, SpO2 100% on room air, CR < 2 sec. • The physician has given the child 4 doses of morphine (2 mg) with minimal pain relief.
  93. 93. Case #14 • While en route, the child falls asleep and appears comfortable. • The BP cycles and determines that the BP is now 60/20 with the heart rate elevated to 180. • What should you do now?  Consider a crystalloid bolus of 20 cc/kg
  94. 94. Case #14 • The child’s SpO2 is beginning to fall (84%). Examination demonstrates shallow respirations. What should you do next?  Place the child on 100% FM • The SpO2 continues to fall after oxygen. Should you intubate this child?  No. This child is probably suffering from a depressed respiratory drive, try naloxone (Narcan).
  95. 95. CASESCASES

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