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Pediatrics On-Call. Michael Dale Warren, MD Pediatric Chief Resident Vanderbilt Children’s Hospital. Objectives. Explain approach to two common pediatric on-call situations Review basic physiology as applied to these scenarios. Case #1.
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Pediatrics On-Call Michael Dale Warren, MD Pediatric Chief Resident Vanderbilt Children’s Hospital
Objectives • Explain approach to two common pediatric on-call situations • Review basic physiology as applied to these scenarios
Case #1 • You are called to bedside by nurse because she doesn’t think the patient is doing well. • Patient is 6 year old male • History of vomiting and diarrhea for several days • Low-grade fever (Tmax 101)
Case #1 • You examine the child: • P 180, R 45, BP 105/65, SpO2 100% • T 101 • Mildly ill-appearing child • Eyes sunken, mucous membranes dry • Normal S1/S2, no murmur, cap refill 3-4 seconds • Clear breath sounds • Soft, non-tender abdomen • Extremities cool to touch
:10 What do you think is going on? • Mild dehydration • Moderate dehydration • Severe dehydration • Hypovolemic shock
Hypovolemic Shock • Remember, shock is defined as inadequate tissue perfusion • Clue from this exam: poor cap refill • Blood pressure not a good early indicator of shock • In children, blood pressure is preserved until significant volume depletion occurs
Hypovolemic Shock • Risk factors • Vomiting • Diarrhea • Poor PO intake • Fever
:10 What is your immediate next step? • Bolus 10cc/kg with D5 ½ NS • Bolus 20 cc/kg with NS • Bolus 10 cc/kg with ½ NS • Bolus 20 cc/kg with D5 ½ NS
Management • Obtain IV access • If unable to obtain IV access, may place I/O catheter • Fluid bolus • Always bolus with isotonic fluids • Use 20cc/kg bolus unless child has heart disease • May repeat bolus as needed until clinical improvement occurs • Maintenance fluids • Add dextrose and electrolytes • Remember the 4-2-1 rule for hourly maintenance IV rate • 4 cc/hr for each kg (0-10kg) • 2 cc/hr for each kg (11-20 kg) • 1 cc/hr for each kg above 20 kg
Case #2 • After successfully rehydrating the first child, you head to the call room to get some sleep. Just as you drift off to sleep, you get a page from the charge nurse on 7B, who wants you to come look at a baby who is “having trouble breathing.”
Case #2 • 6-month old male infant • Previously healthy • 3 days of cough, runny nose, low-grade fever • Admitted earlier today for difficulty breathing
Case #2 • You examine the child: • P 180, R 80, BP 95/60, SpO2 88% • T 101.5 • Mildly ill-appearing child • MMM • No murmur, cap refill 2-3 seconds • Coarse breath sounds bilaterally with diffuse end expiratory wheezing, nasal flaring, intercostal and suprasternal retractions • Soft, non-tender abdomen • Extremities warm
:10 What do you think is going on? • Asthma • Respiratory distress • Croup • Bronchiolitis
Respiratory Distress • Respiratory problems are fairly common in pediatric patients • Pediatric cardiac arrest usually preceded by respiratory distress and subsequent respiratory failure • Goal is to prevent this progression
Respiratory Distress • Back to physiology: R∞1/r4 • This means that airway inflammation and edema is going to cause an increase in airway resistance to a greater extent in the child as compared to an adult
:10 What is your immediate next step? • Order tylenol to reduce fever • Call for a chest radiograph • Obtain an arterial blood gas • Reposition baby to most comfortable position
Management • Remember ABC’s • First step should always be to protect/establish airway • Positioning is important • Head tilt or jaw thrust maneuvers • For conscious patient, let them assume position of comfort • Second step is to check breathing • Do you need to provide breaths? • Mouth-to-mouth breaths • Bag-mask ventilation
Management • Oxygen may not always be the right answer • Adjunctive therapies can result in dramatic improvement • Bronchodilators • Racemic epinephrine • Nasopharyngeal suctioning • Fever can cause tachypnea and contribute to increased work of breathing
Management • Be alert for signs of impending respiratory failure • Slow or irregular respiratory rate • Change in mental status • Increased use of accessory muscles
Phrases that should get your attention • “This patient doesn’t look right.” • “I’m worried about this patient.” • “She’s having trouble breathing.” • “Mom thinks he isn’t acting like himself.” • “I think she could be having a seizure.” • “He is vomiting up blood”….“having bloody diarrhea”….(basically blood from any orifice needs your attention.)
Take Home Messages • Children are not little adults • For pediatric patients, fluid/medication dosing is weight-based • Respiratory distress leading to arrest is more common in kids than primary cardiac arrest • Listen to parents and nurses • Reducing fever will often make kids look better