Download - 10 The Abc S Of Pediatric Emergencies
The ABC’s of The ABC’s of Pediatric Pediatric
EmergenciesEmergenciesClass of 2009 Intern Core Class of 2009 Intern Core
CurriculumCurriculum
-Erin Fortune, PL3-Erin Fortune, PL3
-Dr. Susan Duthie, Pediatric -Dr. Susan Duthie, Pediatric IntensivistIntensivist
A Night On Call on the A Night On Call on the Wards…Wards…
Your first admission: Your first admission: Luis is a 19 yo male with Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In relapsed ALL who had a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, the ER, he was found to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When received 1 L NS and Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you you get to the Heme-Onc floor, the nurse tells you that your patient “does not look good.” You that your patient “does not look good.” You immediately go into the room and find a tall, immediately go into the room and find a tall, overweight young man leaning forward in the chair. overweight young man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is He is pale, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”mumbling, “Dr. Kadota…lives near Japan…”
A Night On Call on the A Night On Call on the Wards…Wards…
What do you do, What do you do, doctor?doctor?
A Night On Call on the A Night On Call on the Wards…Wards… Option #1Option #1
Go review his chart in the computer so you Go review his chart in the computer so you can get a good history since he doesn’t can get a good history since he doesn’t
seem like he’ll be much help.seem like he’ll be much help.
A Night On Call on the A Night On Call on the Wards…Wards… Option 2
A Night On Call on the A Night On Call on the Wards…Wards…
Option 3
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Goals: Offer a basic approach to emergenciesGoals: Offer a basic approach to emergencies Learning to recognize the “sick” patientLearning to recognize the “sick” patient Learning initial steps in stabilizing the “sick” Learning initial steps in stabilizing the “sick”
patientpatient Become aware of resources available to you in Become aware of resources available to you in
caring for the “sick” patientcaring for the “sick” patient Understand the different levels of care at CHHCUnderstand the different levels of care at CHHC Brief review of common emergenciesBrief review of common emergencies
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Learning to recognize the Learning to recognize the “Toxic,”“Toxic,” “Crashing”“Crashing” or or “Sick”“Sick” patient. patient.
Identify risk factors, signs, Identify risk factors, signs, symptoms in the following symptoms in the following
patients:patients: Luis is a 19 yo male with relapsed ALL who had Luis is a 19 yo male with relapsed ALL who had
a fever of 101.7 at home. In the ER, he was found a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately patient “does not look good.” You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”
Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following
patients:patients: Luis is a 19 yo male with Luis is a 19 yo male with relapsed ALLrelapsed ALL who had who had
a a feverfever of 101.7 at home. In the ER, he was found of 101.7 at home. In the ER, he was found to have an to have an ANC of 100ANC of 100, received 1 L NS and , received 1 L NS and CefepimeCefepime 2 grams IVx1. When you get to the 2 grams IVx1. When you get to the Heme-OncHeme-Onc floor, the nurse tells you that your floor, the nurse tells you that your patient patient “does not look good.”“does not look good.” You immediately You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is man leaning forward in the chair. He is pale, pale, tachypneic, and diaphoretictachypneic, and diaphoretic. He is mumbling, . He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”
Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following
patients:patients: Ryan is a 16 mo with SBS and is TPN
dependent. You admitted him yesterday for fever/increased stool output. During pre-rounds, you noted his vitals: Tmax 99.5, HR 95-150 (trend ), BP 86-100/55-65. His Labs: Hb 108, Platelets 135 70. On exam, he smiles and is vigorous, but his mom looks worried and tells you, “His stool looks darker than normal for him.”
Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following
patients:patients: Ryan is a 16 mo with SBS and is TPN
dependent. You admitted him yesterday for fever/increased stool output. During pre-rounds, you noted his vitals: Tmax 99.5, HR 95-150 (trend ), BP 86-100/55-65. His Labs: Hb 108, Platelets 135 70. On exam, he smiles and is vigorous, but his mom looks worried and tells you, “His stool looks darker than normal for him.”
What is Luis and What is Luis and Ryan’s most likely Ryan’s most likely
diagnosis?diagnosis?
SHOCK!SHOCK!
SHOCK!SHOCK!
Definition: Progressive state of circulatory dysfunction in which blood flow is insufficient to meet oxygen and metabolic needs of the tissues.
3 Phases1. Early, compensated (BP, UOP near normal)
2. Late, uncompenstated (BP begins to fall)
3. Irreversible (cells die, multiple organ failure)
SHOCK!SHOCK!
Signs and Symptoms: Tachycardia Tachypnea or labored breathing Delayed Capillary refill Hyperdynamic or weak peripheral pulses Decreased End-Organ perfusion
Decreased UOP Skin-cool, poorly perfused (can be warm if low SVR) Altered mental status
Hypotension is a LATE, OMINOUS sign
SHOCK!SHOCK!
What’s unique about kids? Cardiac Output = Stroke Volume x Heart rate
Kids have limited ability to increase stroke volume… Thus, kids in shock usually maintain adequate CO by
becoming TACHYCARDIC Improved ability to maintain their SVR/BP Thus, in kids, TACHYCARDIA IS A SIGN OF
SHOCK, and HYPOTENSION IS A LATE, OMINOUS sign
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Learning initial steps in stabilizing the Learning initial steps in stabilizing the “Toxic,”“Toxic,” “Crashing”“Crashing” or or “Sick”“Sick” patient. patient.
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Initial Treatment: Take a breath and THINK about what your patient
needs RIGHT NOW. Start with the ABC’s Get additional help If you have an acutely sick, “crashing” patient, he
or she takes precedence over all other duties (finishing pre-rounding, being on time to morning report, etc…)
Back to YourBack to YourNight on the Wards…Night on the Wards…
Let’s go back to Luis’s room…Let’s go back to Luis’s room…
Back to Your, Back to Your, Night on the Wards…Night on the Wards…
Luis is a 19 yo male with relapsed ALL who had Luis is a 19 yo male with relapsed ALL who had a fever of 101.7 at home. In the ER, he was found a fever of 101.7 at home. In the ER, he was found to have an ANC of 100, received 1 L NS and to have an ANC of 100, received 1 L NS and Cefepime 2 grams IVx1. When you get to the Cefepime 2 grams IVx1. When you get to the Heme-Onc floor, the nurse tells you that your Heme-Onc floor, the nurse tells you that your patient “does not look good.” You immediately patient “does not look good.” You immediately go into the room and find a tall, overweight young go into the room and find a tall, overweight young man leaning forward in the chair. He is pale, man leaning forward in the chair. He is pale, tachypneic, and diaphoretic. He is mumbling, tachypneic, and diaphoretic. He is mumbling, “Dr. Kadota…lives near Japan…”“Dr. Kadota…lives near Japan…”
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Don’t forget to use pathophysiology:
Def of shock: “blood flow is insufficient to meet oxygen and metabolic needs of the tissues”
Thus, initial goals are to: Optimize oxygen deliveryRestore blood volume
SHOCK!SHOCK!
Restoring blood volume Fluid resuscitation
Start with Crystalloid (NS, LR, Hypertonic Saline): 20ml/kg rapidly and repeat as needed.
TBW= 2/3 intracellular +1/3 extracellular Extracellular= ¼ Intravascular + ¾ Interstitial
Crystalloid distributes rapidly from IV to interstitial, thus you often need to replace 3-4 times the fluid deficit
After ~60ml/kg, consider: Colloid (Albumin, blood products) as they distribute less rapidly AND reassess diagnosis if not improving (i.e. Cardiogenic Shock)
Back to Your, Back to Your, Night on the Wards…Night on the Wards…
Luis is now lying in bed with a Luis is now lying in bed with a bedside monitor, face mask bedside monitor, face mask
oxygen and the nurse is hanging oxygen and the nurse is hanging the NS bolus. the NS bolus.
His BP is 80/45.His BP is 80/45.Who you gonna call???Who you gonna call???
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Become aware of resources available to Become aware of resources available to help you care for a help you care for a “sick”“sick” patient patient
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Where can you get help? 1. Bedside or Available Nurse2. Charge Nurse3. **Your Senior Resident**4. Any available Senior Resident (i.e. MOLE…)5. The patient’s Attending6. Any available Attending7. PICU Fellow on Call*8. Code Blue (alarm vs x5555)
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
How to do a PICU Consult:How to do a PICU Consult: If the answer to any of the “ABC’s” is “no” or If the answer to any of the “ABC’s” is “no” or
acutely decompensating, call a Code Blueacutely decompensating, call a Code Blue For less acute patients, For less acute patients,
Consult with your Senior resident firstConsult with your Senior resident first Consult with the patient’s attending firstConsult with the patient’s attending first Page PICU Fellow On Call through operatorPage PICU Fellow On Call through operator Have a concise summary of the patient Have a concise summary of the patient
including relevant vitals and your clinical including relevant vitals and your clinical question/diagnosisquestion/diagnosis
Back to YourBack to YourNight on the Wards…Night on the Wards…
You help transfer Luis to the ICU in You help transfer Luis to the ICU in care of the PICU fellow. care of the PICU fellow.
You are informing Luis’s attending You are informing Luis’s attending of the transfer and his condition of the transfer and his condition when you get a page for your when you get a page for your next admission…next admission…
Back to Your Night on the Back to Your Night on the Wards…Wards…
Shenaya is a 2 mo old girl with bronchiolitis Shenaya is a 2 mo old girl with bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with retractions and makes an “uhh” sound with every breath.every breath.
Identify the signs of Identify the signs of distress:distress:
Shenaya is a Shenaya is a 2 mo old2 mo old girl with girl with bronchiolitis bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to to Med-SurgMed-Surg. The CHET RN tells you that she . The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NCDespite deep suctioning and high flow NC, her , her WOB has continued to worsenWOB has continued to worsen en route. On en route. On exam, her exam, her RR is in the 80’sRR is in the 80’s, she has , she has deep deep retractionsretractions and makes an and makes an “uhh” sound with “uhh” sound with every breathevery breath..
Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following
patient:patient: Meanwhile, down in the ER, your co-intern Meanwhile, down in the ER, your co-intern
reviews his next patient’s triage sheet. reviews his next patient’s triage sheet. Bryce is a 3 year old male with CC: fever, Bryce is a 3 year old male with CC: fever, abd pain and “funny” breathing. His vitals abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They explain His parents appear anxious. They explain he’s had a cold with intermittent fever for he’s had a cold with intermittent fever for a week, but today developed abd pain and a week, but today developed abd pain and started breathing more rapidly. Bryce started breathing more rapidly. Bryce appears pale, dehydrated and is markedly appears pale, dehydrated and is markedly tachypneic with deep retractions. tachypneic with deep retractions.
Identify the signs/symptoms Identify the signs/symptoms of distress in the following of distress in the following
patient:patient: Bryce is a 3 year old male with CC: Bryce is a 3 year old male with CC:
feverfever, abd pain and , abd pain and “funny” breathing“funny” breathing. . His vitals are: His vitals are: T101, HR 130, RR 52, O2 T101, HR 130, RR 52, O2 Sat 98% RASat 98% RA. His parents appear . His parents appear anxious. They explain he’s had a cold anxious. They explain he’s had a cold with intermittent fever for a week, but with intermittent fever for a week, but today developed abd pain and today developed abd pain and started started breathing more rapidlybreathing more rapidly. Bryce appears . Bryce appears pale, dehydrated pale, dehydrated and isand is markedly markedly tachypneic with deep retractions. tachypneic with deep retractions.
What do Shenaya and What do Shenaya and Bryce have in Bryce have in
common?common?
RESPIRATORY RESPIRATORY DISTRESSDISTRESS
Respiratory DistressRespiratory Distress
Signs of DistressSigns of Distress TachypneaTachypnea Nasal flaringNasal flaring RetractionsRetractions Head bobbingHead bobbing GruntingGrunting StridorStridor Prolonged expirationProlonged expiration Cyanosis is a late, Cyanosis is a late,
inconsistent findinginconsistent finding
Respiratory DistressRespiratory Distress
Differential Diagnosis:Differential Diagnosis: Upper airway obstruction (FB, Croup)Upper airway obstruction (FB, Croup) Lower airway obstruction (Asthma, Bronchiolitis)Lower airway obstruction (Asthma, Bronchiolitis) Parenchymal lung disease (PNA)Parenchymal lung disease (PNA) Cardiac (CHF, Myocarditis)Cardiac (CHF, Myocarditis) Central (Increased ICP)Central (Increased ICP) Acidosis (shock, DKA)Acidosis (shock, DKA) ……
Respiratory DistressRespiratory Distress
Goal: Prevent Progression to Respiratory Failure:Goal: Prevent Progression to Respiratory Failure: inadequate oxygenation of the blood and/or inadequate inadequate oxygenation of the blood and/or inadequate
elimination of CO2.elimination of CO2. Signs of impending respiratory failure:Signs of impending respiratory failure:
Decreased aerationDecreased aeration Slowed respirationsSlowed respirations CyanosisCyanosis Depressed level of consciousness/toneDepressed level of consciousness/tone Metabolic acidosis/shockMetabolic acidosis/shock
Respiratory DistressRespiratory Distress Assess Airway patencyAssess Airway patency
Awake patient usually Awake patient usually assumes optimal assumes optimal position for airway position for airway patencypatency
Obstructions: Obstructions: secretions, FB, soft secretions, FB, soft tissuetissue
Assess OxygenationAssess Oxygenation Color, mental status, Color, mental status,
pulse Oxpulse Ox Assess VentilationAssess Ventilation
WOB, aeration, blood WOB, aeration, blood gasgas
Blood gasesBlood gases
Purpose of ordering blood gases:Purpose of ordering blood gases:1.1. Assess Acid/Base status (pH, base Assess Acid/Base status (pH, base
deficit/excess)deficit/excess)2.2. Assess oxygenation (PaO2)Assess oxygenation (PaO2)3.3. Assess ventilation (CO2)Assess ventilation (CO2)4.4. Quick lytes (Na, K, Cl)Quick lytes (Na, K, Cl)
Ways of obtaining blood gasesWays of obtaining blood gases1.1. Arterial—pH, O2, CO2Arterial—pH, O2, CO22.2. Venous—pH, (CO2 trend)Venous—pH, (CO2 trend)3.3. Capillary—pH, CO2, O2Capillary—pH, CO2, O2
Interpreting Blood gasesInterpreting Blood gases
Goal is to Goal is to determine determine primary/secondary primary/secondary process: process:
Respiratory Respiratory AcidosisAcidosis
Respiratory Respiratory AlkalosisAlkalosis
Metabolic AcidosisMetabolic Acidosis Metabolic AlkalosisMetabolic Alkalosis
Interpreting Blood gasesInterpreting Blood gases
1.1. Look at the pHLook at the pH-if <7.4, the primary process is acidosis-if <7.4, the primary process is acidosis
-if>7.4, the primary process is alkalosis-if>7.4, the primary process is alkalosis
2.2. Calculate the Anion Gap = Na-(Cl+HCO3)Calculate the Anion Gap = Na-(Cl+HCO3)-if AG > 14, then you have a metabolic acidosis-if AG > 14, then you have a metabolic acidosis
3.3. Calculate the “Delta Gap”= AG-nl gap Calculate the “Delta Gap”= AG-nl gap (i.e. 12)(i.e. 12)
4.4. Add HCO3 + “Delta GapAdd HCO3 + “Delta Gap-if >30, also have a metabolic alkalosis-if >30, also have a metabolic alkalosis
-if <24, also have a non-gap metabolic acidosis-if <24, also have a non-gap metabolic acidosis
Blood gasesBlood gases
Why bother doing all the calculations???Why bother doing all the calculations??? Let’s go back to Bryce: 3 year old male with Let’s go back to Bryce: 3 year old male with
CC: fever, abd pain and “funny” breathing. CC: fever, abd pain and “funny” breathing. His vitals are: T101, HR 130, RR 52, O2 Sat His vitals are: T101, HR 130, RR 52, O2 Sat 98% RA. His parents appear anxious. They 98% RA. His parents appear anxious. They explain he’s had a cold with intermittent explain he’s had a cold with intermittent fever for a week, but today developed abd fever for a week, but today developed abd pain and started breathing more rapidly. pain and started breathing more rapidly. Bryce appears pale, dehydrated and is Bryce appears pale, dehydrated and is markedly tachypneic with deep retractions. markedly tachypneic with deep retractions.
Blood gasesBlood gases
Bryce’s ABG (FiO2 100% NRB)Bryce’s ABG (FiO2 100% NRB) 7.05/480/20/8/-18 Na 148 Cl 1127.05/480/20/8/-18 Na 148 Cl 112 pH/PaO2/PCO2/HCO3/BEpH/PaO2/PCO2/HCO3/BE
Bryce has: Bryce has: 1.1. Primary process? AcidosisPrimary process? Acidosis
2.2. AG = 28, thus has AG metabolic acidosisAG = 28, thus has AG metabolic acidosis
3.3. Delta gap + HCO3 = 16+12, thus no other Delta gap + HCO3 = 16+12, thus no other metabolic processmetabolic process
4.4. Compensation: Respiratory alkalosisCompensation: Respiratory alkalosis
Bryce’s Diagnosis???Bryce’s Diagnosis???
Hint: a bedside finger stick test leads Hint: a bedside finger stick test leads to the diagnosis…to the diagnosis…
Diabetic Ketoacidosis!Diabetic Ketoacidosis!
Back to YourBack to YourNight on the Wards…Night on the Wards…
Let’s go back to Shenaya’s Let’s go back to Shenaya’s room…room…
Back to YourBack to YourNight on the Wards…Night on the Wards…
Shenaya is a 2 mo old infant with bronchiolitis Shenaya is a 2 mo old infant with bronchiolitis brought from her PMD’s office by CHET team brought from her PMD’s office by CHET team to Med-Surg. The CHET RN tells you that she to Med-Surg. The CHET RN tells you that she looked well in the office with RR in the 60’s. looked well in the office with RR in the 60’s. Despite deep suctioning and high flow NC, her Despite deep suctioning and high flow NC, her WOB has continued to worsen en route. On WOB has continued to worsen en route. On exam, her RR is in the 80’s, she has deep exam, her RR is in the 80’s, she has deep retractions and makes an “uhh” sound with retractions and makes an “uhh” sound with every breath.every breath.
Back to YourBack to YourNight on the Wards…Night on the Wards…
Her Venous Blood Gas: Her Venous Blood Gas:
pH 7.20pH 7.20
PCO2 76PCO2 76
BD -4BD -4
Back to YourBack to YourNight on the Wards…Night on the Wards…
Linda, the Med-Surg Charge Linda, the Med-Surg Charge Nurse, comes up to you and Nurse, comes up to you and
tells you, “That baby needs to tells you, “That baby needs to go the IMU. Write transfer go the IMU. Write transfer
orders now.”orders now.”
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Understanding the different levels of care Understanding the different levels of care at CHHCat CHHC
The ABC’s of Pediatric The ABC’s of Pediatric EmergenciesEmergencies
Patient Care Unit Hierarchy at CHHCPatient Care Unit Hierarchy at CHHC Ortho RehabOrtho Rehab Med/SurgMed/Surg Heme-OncHeme-Onc IMUIMU PICUPICU
Make sure your patient is at the appropriate Make sure your patient is at the appropriate level of carelevel of care
Back to YourBack to YourNight on the Wards…Night on the Wards…
Your Senior Resident agrees with Your Senior Resident agrees with your plan to transfer Shenaya to your plan to transfer Shenaya to
the IMU. the IMU. You updated the Attending. You updated the Attending.
She is on NCPAP and her WOB is a She is on NCPAP and her WOB is a little improved.little improved.
Whew! You can finally tuck Whew! You can finally tuck Shenaya away for the night…Shenaya away for the night…
A Night on the Wards…A Night on the Wards…
Not quite…Not quite…
““Sick” patients need constant Sick” patients need constant re-assessment!re-assessment!
A Night on the Wards…A Night on the Wards… How to Re-assess when I still have 4 How to Re-assess when I still have 4
admits coming?!?admits coming?!? Communicate with the Bedside Nurse: Communicate with the Bedside Nurse:
Document your name and pager on the Document your name and pager on the chartchart
Give strict, clear “Call HO” parametersGive strict, clear “Call HO” parameters Communicate with your Senior Resident: Communicate with your Senior Resident:
Agree on who will re-assess the patient Agree on who will re-assess the patient and whenand when
Communicate if patient’s condition worseCommunicate if patient’s condition worse Set your pager alarm and ask RN to page youSet your pager alarm and ask RN to page you
Your Night on the Your Night on the Wards…Wards…
Setting your pager alarm to re-Setting your pager alarm to re-check Shenaya reminds you that check Shenaya reminds you that
you should check on Ryan…you should check on Ryan…
A Night on the Wards…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?What do you do for a GI bleed?
GI BleedGI Bleed
General Principles for Treatment:General Principles for Treatment: NPONPO Change meds to IV when possibleChange meds to IV when possible PPI (Pantoprazole)PPI (Pantoprazole) Give adequate fluids (deficit + Give adequate fluids (deficit +
maintenance + ongoing losses)maintenance + ongoing losses) NG or GT lavageNG or GT lavage NG or GT to gravity (for monitoring)NG or GT to gravity (for monitoring)
GI BleedGI Bleed General Principles for Treatment (cont)General Principles for Treatment (cont)
Send Type and Screen earlySend Type and Screen early Check for coagulopathy—optimize Check for coagulopathy—optimize
coagulabilitycoagulability Thrombocytopenia—platelet transfusionThrombocytopenia—platelet transfusion Prolonged PT—FFPProlonged PT—FFP Low fibrinogen—CryoprecipitateLow fibrinogen—Cryoprecipitate
Serial CBC’s—transfuse early if ongoing losses Serial CBC’s—transfuse early if ongoing losses likelylikely
Severe or refractory GI Bleeds:Severe or refractory GI Bleeds: Octreotide—Somatostatin analog, ↓ GI blood flowOctreotide—Somatostatin analog, ↓ GI blood flow Endoscopy/SurgeryEndoscopy/Surgery
Back to YourBack to YourNight on the Wards…Night on the Wards…
You quietly walk into Ryan’s room. You quietly walk into Ryan’s room. With your penlight, you look at With your penlight, you look at his GT bag and find bright red his GT bag and find bright red blood steadily filling the bag…blood steadily filling the bag…
Now what?!?Now what?!?
A Night on the Wards…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…A Night on the Wards…
The PICU fellow teaches you how The PICU fellow teaches you how to push blood as you help escort to push blood as you help escort Ryan to join Luis in the PICU…Ryan to join Luis in the PICU…
Will this night ever end?!?Will this night ever end?!?
A Night on the Wards…A Night on the Wards…
Finally, a chance to catch up on Finally, a chance to catch up on dictations. Just as you are dictations. Just as you are
finishing your last dictation, your finishing your last dictation, your Senior pages…Senior pages…
““An easy Gastro admit in room An easy Gastro admit in room 221”221”
A Night on the Wards…A Night on the Wards…
Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes when the nurse puts in an IV, but quickly goes back to sleep.back to sleep.
A Night on the Wards…A Night on the Wards…
Are you sure this is just Gastro? Are you sure this is just Gastro?
Review the case:Review the case:
Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of emesis, inability to tolerate po, had 2 days of emesis, inability to tolerate po, last urinated ~2 hrs ago. She’s had no F/D, no last urinated ~2 hrs ago. She’s had no F/D, no known sick contacts but is in daycare. Parents known sick contacts but is in daycare. Parents note she’s been excessively sleepy. Her admit note she’s been excessively sleepy. Her admit vitals are: T99, HR 100, BP 120/75, RR 45, vitals are: T99, HR 100, BP 120/75, RR 45, O2 100% RA. She is sleepy, cries briefly O2 100% RA. She is sleepy, cries briefly when the nurse puts in an IV, but quickly goes when the nurse puts in an IV, but quickly goes back to sleep.back to sleep.
Review the case:Review the case:
Emily is an 8mo admitted from an outside ER Emily is an 8mo admitted from an outside ER with a diagnosis of AGE, dehydration. She’s with a diagnosis of AGE, dehydration. She’s had 2 days of had 2 days of emesis, inability to tolerate poemesis, inability to tolerate po, , last urinated ~2 hrs agolast urinated ~2 hrs ago. She’s had . She’s had no F/D, no no F/D, no known sick contacts known sick contacts but is in daycare. Parents but is in daycare. Parents note she’s been note she’s been excessively sleepyexcessively sleepy. Her admit . Her admit vitals are: T99, vitals are: T99, HR 100, BP 120/75, RR 45HR 100, BP 120/75, RR 45, , O2 100% RA. She is sleepy, O2 100% RA. She is sleepy, cries brieflycries briefly when the nurse puts in an IVwhen the nurse puts in an IV, but quickly goes , but quickly goes back to sleep.back to sleep.
A Night on the Wards…A Night on the Wards…
What must be “ruled out” in this What must be “ruled out” in this patient immediately? patient immediately?
Increased Intracranial Increased Intracranial Pressure!Pressure!
Increased Intracranial Increased Intracranial PressurePressure
Results from an Results from an increase in increase in volume of volume of cerebral contents cerebral contents within a rigid within a rigid cranial cranial compartmentcompartment
Can be due to Can be due to bleeding, edema, bleeding, edema, mass or CSFmass or CSF
Increased Intracranial Increased Intracranial PressurePressure
Symptoms:Symptoms: HeadacheHeadache VomitingVomiting Sleepy/LethargySleepy/Lethargy IrritabilityIrritability Vision changesVision changes
Increased Intracranial Increased Intracranial PressurePressure
SignsSigns Increased toneIncreased tone Decreased LOCDecreased LOC Bulging fontanelBulging fontanel Cranial nerve palsyCranial nerve palsy Cushing’s triad:Cushing’s triad:
HypertensionHypertension BradycardiaBradycardia Irregular Irregular
respirationsrespirations Papilledema/ Papilledema/
decreased venous decreased venous pulsationspulsations
Increased Intracranial Increased Intracranial PressurePressure
TreatmentTreatment Step 1: Step 1: Recognize it early!Recognize it early!
Who are the patients at risk? Who are the patients at risk? Head injuryHead injury MeningitisMeningitis Brain tumorBrain tumor HydrocephalusHydrocephalus Immune-compromisedImmune-compromised
Increased Intracranial Increased Intracranial PressurePressure
Brain is dependent Brain is dependent on aerobic on aerobic metabolismmetabolism
Thus, depends on Thus, depends on cerebral blood flow cerebral blood flow for viabilityfor viability
Goal of Goal of autoregulation/ autoregulation/ therapy is to therapy is to maintain adequate maintain adequate CBFCBF
Step 2: Step 2: Understand Understand the the pathophysiology…pathophysiology…
Back to YourBack to YourNight on the Wards…Night on the Wards…
What would you do for Emily? What would you do for Emily?
Increased Intracranial Increased Intracranial PressurePressure
Immediate treatment for increased ICP:Immediate treatment for increased ICP: ABC’s (intubate for GCS </= 8)ABC’s (intubate for GCS </= 8) Raise head of bed to 15-30 degreesRaise head of bed to 15-30 degrees
Increased Intracranial Increased Intracranial PressurePressure
Get Help (Senior Resident, Notify Get Help (Senior Resident, Notify attending)attending)
PICU Consult--PICU Consult--All patients with All patients with suspected ↑ ICP should be in PICUsuspected ↑ ICP should be in PICU
Head CT (hold on LP)Head CT (hold on LP) Common TherapiesCommon Therapies
Hyperventilation (bag and mask)Hyperventilation (bag and mask) Hypertonic Saline (3%)Hypertonic Saline (3%) Mannitol—beware of hypovolemiaMannitol—beware of hypovolemia Decadron—tumor or bacterial meningitisDecadron—tumor or bacterial meningitis
The ABC’s of Pediatric The ABC’s of Pediatric Emergencies…Parting Emergencies…Parting
ThoughtsThoughts One of the goals of Intern Year is to learn to One of the goals of Intern Year is to learn to
recognize the “Sick” patientrecognize the “Sick” patient If you are concerned, get a second opinion earlyIf you are concerned, get a second opinion early Better to over-react than to under-reactBetter to over-react than to under-react Assume every patient is “sick” until proved Assume every patient is “sick” until proved
otherwiseotherwise If you missed recognizing a “sick kid,” review the If you missed recognizing a “sick kid,” review the
case and learn for the next patientcase and learn for the next patient Most important part of “Emergency Care” is Most important part of “Emergency Care” is
PREVENTIONPREVENTION Recognizing sick patients earlyRecognizing sick patients early Giving appropriate treatment earlyGiving appropriate treatment early
Follow your ICU transfers peripherally to Follow your ICU transfers peripherally to learnlearn
ReferencesReferences
http://www.emedicine.com/ped/topichttp://www.emedicine.com/ped/topic929.htm929.htm
http://www.emedicine.com/ped/topichttp://www.emedicine.com/ped/topic3082.htm3082.htm
http://pedsccm.wustl.edu/http://pedsccm.wustl.edu/ Duthie, Susan. “Respiratory Failure” Duthie, Susan. “Respiratory Failure” Duthie, Susan. “Shock in the Duthie, Susan. “Shock in the
Pediatric Patient”Pediatric Patient” Pearson, Gale. “Handbook of Pearson, Gale. “Handbook of
Paediatric Intensive Care.”Paediatric Intensive Care.”