pediatric emergency cases melissa joy, rn michael mojica, md todd p chang, md
TRANSCRIPT
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Pediatric Emergency Cases
Melissa Joy, RNMichael Mojica, MDTodd P Chang, MD
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CASE 3A…Peace puts her everywhere…
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Case 3A - Briefing
4-week-old male
Progressive non-bilious vomiting x 3 days
No urine output x 20 hours
Difficult to awaken
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4wk listless vomiting
Temperature (Axillary)
Temperature (Rectal)
Glucose
Blood Gas Lytes Blood Gas
Radiography 2
Laboratory 2 Radiography 1Laboratory 1
go
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4wk listless vomiting
US SI
Na 149 149
K 2.1 2.1
Cl 82 82
HCO3 37 37
BUN 19 6.8
Cr 0.8 61.9
Glucose 55 3.0
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4wk listless vomiting
US SI
WBC 14.8 14.8
Hgb 17.2 10.7
Hct 50.1 0.5
Plt 284 284
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4wk listless vomiting
36.7 C = 98.1 F
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4wk listless vomiting
37.4 C = 99.3 F
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4wk listless vomiting
US SI
Glucose 55 3.0
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4wk listless vomiting
US SI
pH 7.50 7.50
pCO2 48 48
pO2 (cap) 92 92
HCO3 35 35
%sat (cap) 82 82
Na 151 151
K 1.8 1.8
Cl 86 86
Hgb 17.2 10.7
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4wk listless vomiting
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4wk listless vomiting
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PEDIATRIC SHOCK
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Infant Shock
HRb/p
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Infant Shock
HRb/p
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Heart Rates
Age Typical Heart Rates
Newborns 0 – 3 months 100 – 150
Infants 3 – 6 months 90 – 120
Infants 6 – 12 months 80 – 120
Children 1 – 10 years 70 – 130
Adolescents 10+ years 60 – 100
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Blood PressureTotal Gestational
Age (weeks)
=
(Mean Arterial Pressure)
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The pump
The vessels
The tissues
The model
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fluid
!
The Pump
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!
The Fluid
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!
The Vessels
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Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
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Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
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Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip
5b Norepinephrine 0.1 mcg/kg/min to 2
60 minutes IV drip
6 0.9% Normal Saline
Ad lib - IV
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Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip
5b Norepinephrine 0.1 mcg/kg/min to 2
60 minutes IV drip
6 0.9% Normal Saline
Ad lib - IV
7 D5-0.45% NS orD10-0.25% NS
1.5x Maint IV drip
8 Hydrocortisone 50 mg/m2 60 minutes IV
Estimates of body surface area:Newborn (0.25m2) 8 years old (1m2)2 years old (0.5m2) non-obese adult (1.5m2)
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Push-Pull
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PYLORIC STENOSIS…Peace puts her olives everywhere…
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Pyloric Stenosis
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Pyloric Stenosis
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Rule of 6’sIf you are ******** age, and you have a surgical abdomen, then you have…
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks Pyloric Stenosis6 Months
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks Pyloric Stenosis6 Months Intussusception6 Years
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks Pyloric Stenosis6 Months Intussusception6 Years Appendicitis
66 Years
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Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks Pyloric Stenosis6 Months Intussusception6 Years Appendicitis
66 Years Diverticulitis?
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Pyloric Stenosis• Peaks @ 6 weeks• M to F 4 to 1
• Non-bilious emesis• “Projectile” is rare• “Olive” is very rare• Look for vomiting with all feeds
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Pyloric Stenosis• Hypochloremic alkalosis
• Single large stomach Abdominal Xray• Paucity of gas distal of stomach
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Pyloric Stenosis• 3+mm thick
or• 15+mm long
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Pyloric Stenosis
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Pyloric StenosisManagement
Manage Dehydration
Dextrose too
Nasogastric Tube Intermittent low suction
NPO
Surgical consultation
Urgent, not Emergent
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Maintenance FluidsAge Fluid
Infants < 10kg D10 – ¼ NS
All other Peds D5 – ½ NS
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Maintenance FluidsWeight Rate
5kg 20 mL/hr
10kg 40 mL/hr
20kg 60 mL/hr
30kg 70 mL/hr
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Tubes• Endotracheal Tube Size:
4 + (Age (yr) / 4)
• Subtract ½ for the cuff
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TubesETT Multiplier
Tube Corresponding Size (unit)
X 1 ETT Size diameter (mm)X 2 NG Tube size (Fr)X 3 ETT depth from gum/teeth
(mm)X 4 Chest Tube size (Fr)