scary kids - bestemconference.com · scary infants and chidren: ... 6 easy steps if vitals do not...

10/11/2017

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SCARY INFANTS AND CHIDREN:

IT’S NOT THAT COMPLICATED

Richard M. Cantor, MD FAAP/FACEPProfessor of Pediatrics and Emergency Medicine

Director, Pediatric Emergency ServicesMedical Director, CNY Poison Control Center

Golisano Children’s HospitalSyracuse NY

Overview

Cases

CHF

Cyanosis

Pallor

Shock

Objectives

� Present the common critical scenarios

� Outline the most utilized traditional therapies

� Highlight the pitfalls in care

� Describe novel approaches

General Management Principles

Problem: Vascular Access

� Any interventions will necessitate vascular access

� What is available?

� The usual sites

� Hand

� Antecubitus

� Foot

� Saphenous


� Alternative Access in Infancy: Scalp Veins

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� Alternative Access in Infancy: Scalp Veins


� Alternative Access in Infants

Less Than 14 days: Umbilical Vein Approach


� Alternative Access in

Infants Less Than 14 days: Umbilical Vein

Approach


� Alternative Access in Infants Less Than 14 days:

Umbilical Vein Approach

Problem: Vascular Access Problem: Vascular Access

� Intraosseous Approach

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Problem: Airway

� Intubation is indicated

� Regardless of age, RSI is indicated

� ALL drugs (except Etomidate) have been accepted for use in general practice

� Benzos alone are useless

Problem: Airway

Problem: Airway

ALWAYS get the air out!

Other Pitfalls in Infant Stabilization

� You must identify and correct hypoglycemia at the

bedside

� Normothermia must be maintained

� Something ALWAYS goes wrong with the airway!

Case:

An Abject Failure

Case: Shock To The System

� A 3 week old presents with a 1 day history of poor

feeding and apparent respiratory distress

� Birth history and HPI unremarkable

� Afebrile, HR 160, RR 40, BP 50/30, OSAT 90% in RA

� Cool extremities, capillary refill 5 seconds

� All peripheral and central pulses are weak

� Grunting with retractions, poor air entry

� No murmur

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Case Discussion

� This infant is in uncompensated shock

� Unclear etiology at this point

� Septic ?

� Hypovolemic?

� Cardiogenic?

� Accompanying respiratory failure

Case Progression: Circulation

� Could this be distributive or septic shock?

� There is no history of volume loss

� After blood cultures obtained, antibiotics are indicated

� Cefotaxime

� Ampicillin (Listeria)


� Undifferentiated neonatal shock

� Volume is indicated

� 10 - 20 cc/kg NS push

� Repeat up to 60 cc/kg

� Obtain CXR to check heart size as a rough estimate

of vascular status


� Given 60 cc/kg NS

� Respiratory distress increases

� Hepatomegaly

� CXR


� Could this be congenital heart disease?

� NOT the cyanotic variety

� Present early (ie first few days)

� Would fail hyperoxia challenge

� Most likely a ductal dependent lesion

Congenital Heart Disease

Presenting as Failure in Infancy

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Left Sided Outflow Obstruction Case Resolution

� The child is in CHF

� Given Prostaglandin E1

� Perfusion normalizes

� Echocardiogram demonstrates Coarctation of the Aorta with ductal dependent perfusion

� Repaired surgically

Take Home Message

� Infants < 2 weeks presenting in shock deserve

consideration of:

� Volume loss

� Sepsis

� Ductal dependent lesions

� Prostaglandins should always be considered

SHOCK MADE

SIMPLEEasy Steps

Easy Steps

� Administer 20 cc/kg NS FAST

� If ABC’s worsen, immediate CXR (could be cardiogenic) or sono

� If cardiac silhouette is enlarged, consider Prostaglandin PGE1

� If cardiac silhouette is equivocal, room for more fluids

Easy Steps

� If vitals improve administer another 40 cc/kg NS

� If vitals stabilize, relax, consider volume loss or distributive causes

�Consider sepsis, draw blood cultures, administer antibiotics

IF CONSIDERING A HYPOVOLEMIC ETIOLOGY,

IT WOULD BE NICE TO HAVE A CONSISTENT HISTORY

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Easy Steps

� If vitals do not improve, begin pressors

�DON”T forget pallid shock – need RBC not crystalloid

� Volume loading would be harmful in anemic shock

Case:The Definition of Insanity

History

An ALS Radio call is received, in midwinter, announcing the transport of a 3 week old AA male in respiratory distress

He is described as in marked respiratory distress, mildly cyanotic, with good perfusion

Wheezing is heard and, as per protocol, a nebulizedalbuteroltreatment is administered during the 10-minute transport

History

History obtained from the mom on arrival reveals a normal prenatal and birth history

She thinks he has “Sickle Trouble”

He had been well, on proprietary formula, until earlier that day when he developed a cough and became more and more ill appearing

Physical Examination

Vital Signs

• T37.7C• HR 180

• RR 60

• BP 90/70

OSAT 50% in room air

General

• Crying, profoundly cyanotic infant with retractions

Physical Examination

Chest

• Scattered upper airway sounds

• Good air entry

• No murmur

Skin

• Blue

Pulses

• Normal

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Preliminary Results

WBC Normal/HgB 9.7

ABG: 7.30/ pCO2 28/ pO2 50/ BE -8 (in 100% O2)

EKG- Sinus Tachycardia

CXR cardiomegaly

Real Time Case Progression

� Interventions

� Albuterol

� 20 cc/kg NS

� Antibiotics

Reality Based Outcome

� OSAT still 50% (on 100%)

� Still screaming

� Room getting smaller

� More people watching the case

Hyperoxia Test

CXR Time to earn your money

� IV Morphine 0.1 mg/kg

� Calms, respiratory rate decreases

� OSAT jumps to 98% (your heart rate drops below 200)

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TetrologyCongenital Lesions Usually

Associated With Cyanosis

Common Cyanotic Cardiac Lesions

� Tetrology of Fallot

� Transposition of the great vessels

� Truncus arteriosus

� Tricuspid atresia

� TAPVR

Hypoxemic (“TET”) Spells

� Usually self limited (15-30 minutes)

� More common in the AM or after a nap

� May be self perpetuating

Stepwise Treatment of Tet Spells

� Comfort; knee chest position; 100% O2

� Morphine 0.1 mg/kg

� IV fluid resuscitation

� IV Bicarbonate

� IV phenylephrine (increases SVR)

� IV propranolol

Take Home Message

� The secret of mammalian oxygenation:

� You breathe it (pulmonary)

� You pump it (cardiac)

� You carry it (hemoglobin)

� Hints

� Use the hyperoxia test

� OSATs in the mid 80s are often methemoglobinemia

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CYANOSIS

MADE SIMPLEEasy Steps

Easy Steps

�Administer supplemental oxygen

� If OSAT rises, most likely pulmonarydisease

Easy Steps

�Administer supplemental oxygen

� If OSAT does not rise consider Cyanotic Heart Disease OR Methemoglobinemia

�On 100% O2 if pO2 is high and OSAT is low = Methemoglobinemia

� you can dissolve it but NOT carry it

Easy Steps

� Administer supplemental oxygen� If OSAT does not rise consider Cyanotic Heart

Disease OR Methemoglobinemia

� On 100% O2 if pO2 is low and OSAT is low, consider cyanotic heart disease

� The “5 T’s”� Tetralogy (only defect likely to present late)� Tricuspid atresia� Transposition� Truncus arteriosis� Total anomalous venous return

Hyperoxia Test

Am I White?:

Pallor in the Pediatric Patient

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Casper The Friendly Infant

Case

� A 7 month old presents with pallor

� Seen earlier at a PMD who sent the child to a lab for

blood work

� Fingerstick Hgb = 5.5

� Referred for evaluation

Case

� Normal birth history

� Initially formula fed, now on cow’s milk

� No recent change in feeding, activity, behavior

� Immunized

Case

� Vigorous “white as a sheet” infant

� T 37, HR 100, RR 16 BP 90/50 OSAT 98%

� Capillary refill brisk, 2 seconds

� Entire exam unremarkable

Case

� CBC

� H/H 5/15

� WBC, platelets normal

� MCV 55

� RBC LOW

� BMP unremarkable

� Next?

Case Concepts

� Profound anemia WITHOUT physiologic compromise

� Probably an insidious onset

� Further labs

� Reticulocyte count

� Coombs

� Hemoccult

LOW

NEGATIVE

POSITIVE

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Low Reticulocyte Count

USUALLY A LOW RBC COUNT

USUALLY A HIGH RBC COUNT

Most Likely?

� Cow’s milk protein enteropathy

� Insidious LGI bleeding (often not noticed)

� Treatment

� Dietary adjustment

� Iron supplementation

� DO NOT TRANSFUSE (this child is stable)!

What Does This Kid Eat?

Case

� A 7 year old presents with vomiting, irritability for 3

days

� His stools have turned red

� No significant PMH

� Emesis is clear

� No one ill at home

Case

� Tired irritable young child

� Profoundly pale

� Afebrile HR 100 RR 16 BP 90/70 OSAT normal

� Tender abdomen in all quadrants

� Stool red, hemoccult positive

Problem List

� Emesis with a tender abdomen

� LGI bleeding

� Borderline hypoperfusion

� Obvious pallor

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Workup

� H/H 5/15

� MCV normal

� All other cell lines normal

� BMP normal

� Next?

Workup

� Abdominal series normal

� Sonogram demonstrates ileocolic intussusception

� Reduced uneventfully

� BUT……..

� Isn’t this child a bit old?

� How frequent is massive LGI bleeding with

intussusception?

� Are we done?

Workup

� Abdominal CT

� Appendix NOT visualized

� Otherwise unremarkable

� Surgery signs off the case

� Next?

� Pediatric GI consulted

� They order?

MECKEL’S SCAN POSITIVE

Meckel’s

� 2% of the population

� Most common omphalomesenteric duct remnant

� Only 2% of persons with a Meckel's diverticulum manifest any clinical problems

� The most common complication of a Meckel's

diverticulum is a bleeding ulcer

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Omphalomesenteric Duct Meckel’s

Meckel’s

� Ectopic gastric mucosa in such patients is usually present in

the diverticulum

� Currant jelly stools or hemorrhage may be present

� Other modes of presentation include diverticulitis, perforation

with peritonitis, or intussusception as a result of the

diverticulum's serving as a lead point

Meckel’s

� Barium studies usually fail to outline a Meckel's diverticulum

� The imaging modality of choice for detection of ectopic gastric mucosa in a bleeding Meckel's diverticulum is nuclear

scintigraphy

� The accuracy of scintigraphy in detection of ectopic gastric

mucosa in Meckel's diverticula is approximately 95%

Just Another Virus?

Case Four

� A 5 year old girl awakens in the middle of the night

and while walking to her parents room suffers a brief syncopal episode

� Taken to a local ED

� Her parents think she has become ““““extremely pale for the last 3 days, like she has the flu””””

� No fever, medications, injury, PMH

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Case Four Presentation

� 5 year old lethargic, extremely pale child

� Mild Jaundice

� Afebrile

� HR = 150

� BP = 70/40

� No bruising

� Rectal negative for blood

Case Four Questions

� What is the clinical status of this child?

� She is in pallid shock with no history of blood

loss

� What Interventions are indicated?

� Immediate volume resuscitation

� What lab studies are indicated?

� CBC, platelets

� Coombs

� Bilirubin

� Reticulocyte Count

Case Four Progression

� Given 20cc/kg IV push X 2

� Remains pallid, slight improvement of vital signs

� Labs

� WBC and platelets normal

� H/H = 4/12 MCV normal

� Coombs positive

� Bilirubin = 6 (direct = 0.1)

� Reticulocyte Count elevated

� What is indicated at this time?

� Immediate PRBC transfusion

Elevated Reticulocytes

Case Four Progression

� Given 2 units PRBC

� Vitals normalize

� Hematology consult

� Smear demonstrates massive hemolysis

� Bone marrow aspirate WNL

� Final diagnosis

� Autoimmune hemolytic anemia

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States of Shock

Case

� A 12 month old is brought to the PED with a chief

complaint of fever and a rash

� He is unarousable and has petechiae and purpura on his extremities and trunk

� Temp 40C

� HR 180

� BP 60/20

� Capillary refill 4 seconds

The Rash Case Questions

� What is the probable diagnosis and what type of

shock would this be?

� Septic shock

� How would you treat this child?

� Repeated fluid boluses, 20cc/kg X3

� Immediate broad spectrum antibiotics

� If there is no initial response to fluid resuscitation, what are your alternatives?

� Pressors

Case Outcome

� After 3 fluid boluses

� BP 90/50

� HR 140

� Capillary refill 3 seconds

� Dopamine drip begun

� PICU course

� 2 day pressor therapy

� Blood cultures grew Meningococcus

� Recovered uneventfully

A Final Case

� A 10 year old is struck by a car while walking

� He arrives backboarded and crying

� BP 70/30

� HR 140

� Extremities cool

� Bruising on upper abdomen

� Obvious femur fracture

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Case Questions

� What type of shock does he have?

� Hemorrhagic

� What is the treatment?

� Crystalloids >>>>>blood products

� What signs of improvement would you look for?

� Normalization of VS

Case Progression

� Fluid resuscitation in ED (3 liters crystalloid)

� FAST exam noted splenic blood

� Given 4 units whole blood

� CT demonstrated splenic hematoma (encapsulated)

� Managed in PICU conservatively

� Discharged 7 days later

Heme

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