“Chance favors the prepared mind.”

“Chance favors the prepared mind.” Louis Pasteur

PediatricsOn Call G. Waldon Garriss, III, MD, MS, FAAP, FACP Vanderbilt University Medical Center

Outline • Five common calls to see the patient • Signs of respiratory distress • Recognizing sepsis/shock • Rashes • Seizures • Fever • Summary • Bonus: Essential calculation • Questions

“I was wondering if you could come and take a look at this child. . . .” • He/she’s working hard to breathe.

Tachypnea Wheezing Grunting Nasal flaring Retractions Suprasternal Intercostal Subcostal Head bobbing Abdominal breathing Drooling Stridor Poor feeding Lethargy Airway, Airway, Airway(Quickly recognize signs of respiratory distress!)

Respiratory Distress • Oxygenation • How do you evaluate it? • Rx? • Ventilation • How do you evaluate it? • Rx? • Stridor • Rx? • Wheezing • Rx? • Characteristic coughs • Croup • Pertussis • Asthma

“I was wondering if you could come and take a look at this child. . . .” • He/she looks bad.

Recognize Sepsis/Shock “What are plausible reasons for the patient to be so sick?” • General appearance • Pulse (early changes) • BP (changes occur late – maybe too late) • Capillary refill • Volume status – including UOP

Treatment of Sepsis/Shock “What are plausible reasons for the patient to be so sick?” • 20 cc/kg = bolus (NS or LR) • If sepsis, culture(s) and empiric antibiotics • Reassess often • If worsened by bolus, do not repeat it • I/O access, if needed • Pressors, if needed (NICU/PICU)

“I was wondering if you could come and take a look at this child. . . .” • He/she has a rash.

Rash(Usually, blanchable is good!) • Drug induced • Erythema multiforme • Stevens-Johnson Syndrome (EM major) – must include two mucosal surfaces • Petechiae – always think of RMSF, DIC, meningococcemia • Purprua – always think of HSP (JARS), meningococcemia • Vessicles – always think of herpetic lesions

“I was wondering if you could come and take a look at this child. . . .” • He/she is having a seizure.

Seizures • Prior seizures? • Febrile seizures (T >38o, < 15 min, if multiple – not > 30 min, not focal) • Generalized tonic-clonic seizures • Absence seizures (Petit mal) • Partial (focal) seizures • Tonic states (Sandifer’s Syndrome)

Seizures - Treatment • Don’t forget the rectum for Rx delivery • Diazepam dose depends on the age/wt. • Protect the airway • But not by putting something in the child’s mouth • Rescue position • Immediate work up • Glucose, BMP, Ca++, ?LP, O2, neuroimaging, UDS?

“I was wondering if you could come and take a look at this child. . . .” • He/she is having a fever.

Fever(Think about the child’s age.) • Less than 6 - 8 weeks old • Less than 6 months old* • Need to do further work up? • Neonate • Chemotherapy • Recently cultured • Urine or other unrecognized source • Tylenol dosing 10-15 mg/kg po/pr q 4 h • Ibuprofen* 10 mg/kg po q 6 h *For use in children > 6 mo old

Summary/Review • Airway – recognized increased WOB and respiratory distress early • Sepsis/Shock – don’t wait for the BP to fall • Rashes – respect petechiae, purpura, and vessicles • Seizures – protect the airway; don’t forget rectal delivery of benzodiazepines • Fever – age matters; no Ibuprofen if under 6 months old

Bonus: Essential Calculations • 16 oz/lbs • lbs/2.2 = kg • 5cc/tsp • in x 2.54 = cm • Approximately 30 cc/oz

“Chance favors the prepared mind.”