Pediatric Case Studies

1. Pediatric Case Studies Jana A. Stockwell, MD, FAAP Pediatric Critical Care Medicine Children’s Healthcare of Atlanta @Egleston Atlanta, Georgia jana.stockwell@CHOA.org

2. Case #1 • You receive a 4 month old male from another ER who is suffering from respiratory distress • He is sleeping but arouses to stimulation. • Vital signs: T 39.2ºC, HR 220, RR 55, BP 75/40, SpO2 99% on 2L NC, CR ~4 sec • His CXR is read as “no infiltrate”

4. Case #1 Shortly after arriving on the ward, the child develops difficulty breathing and an elevated heart rate. The rhythm strip is shown below...

5. Start here and count boxes 300 150 Case #1 How fast is the heart beating? Use the 300-150-75 rule So, a little less than 300 bpm!!!

6. Case #1 You suspect SVT... • What should you do next? • Determine if the child is clinically stable or unstable SupraVentricular Tachycardia HOW?

7. Case #1 • In SVT, if the child is clinically stable, try: • Inducing the Dive Reflex by applying an ice bag to the face • Bearing down (i.e. Valsalva maneuver) • Eyeball pressure & carotid massage, may be harmful and are discouraged

8. Case #1 • You suspect SVT& the child is clinically unstable… • Place an IV • Give IV bolus of ADENOSINE • Very short t (10 sec) & must be given rapidly • Continuous rhythm strip during attempted conversion • Potential side effects include hypotension, bronchospasm, and flushing • Be prepared to see a flat line EKG!

9. Case #1 • You suspect SVT… & the child is very clinically unstable… • If an IV cannot be started quickly OR • If the patient fails to convert with IV adenosine OR • Patient becomes unconscious or unresponsive • Then, cardiovert using 0.5 - 1 joule/kg

10. Case #1 Summary • Things are not always what they are advertised to be • Be aware that multiple therapies may be available and choice depends upon clinical situation

11. Case #2 • You are admitting a 6 year old male with no significant past medical history who presented at an outlying physician’s office with a decreased level of consciousness. He has been having massive amounts of emesis and diarrhea. • VS: T 38.2ºC, HR 150, RR 28, BP 70/30, SpO2 97% on Room Air • There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~4 sec

12. Case #2 What is wrong with this child? • This child is in uncompensated shock, most likely from hypovolemia What is the first logical step in management of this child? Crystalloid (NS, LR) at 20 cc/kg bolus

13. Case #2 • After giving 20 cc/kg of NS, what should be done? • Re-assess the child’s clinical status • Check pulses and heart rate • Check blood pressure • Evaluate capillary refill time • Evaluate mental status • Auscultate chest to determine if heart can handle volume load -- rales, gallop

14. Case #2 • VS: HR 150, RR 32, BP 70/50, SpO2 97% on RA • There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~ 4 sec • Now that the BP has improved, is this child still in shock? Yes, the child is in uncompensated shock!! What should you do now? Repeat the NS bolus at 20 cc/kg

15. Case #2 • VS: HR 140, RR 30, BP 90/60, SpO2 97% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is ~3 sec • Now that the BP has improved, is this child still in shock? Yes, it is now compensated shock What should you do now? Repeat the NS bolus at 10-20 cc/kg

16. Case #2 • The child’s VS are HR 100, RR 22, BP 98/65, SpO2 94% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is < 2 sec • Now that the VS have improved, is this child still in shock? • No. The fluid resuscitation has brought this child out of hypovolemic shock

17. Case #2 Summary • When the tank is low, it may take a lot of fluid to fill it back up! • Remember, being 10% dehydrated means 10% of the body weight is lost due to fluid ouput/poor intake

18. Case #3 • You are transporting a 13 year old male who presented to an outlying ER with nausea and bilious vomiting. He has a past history of BMT for CML. He also has a history of recurrent bowel obstructions. • In the ER, VS are T 35.7ºC, HR 110, RR 32, BP 90/45, SpO2 98% on RA. His extremities are warm and well perfused.

19. Case #3 • During transport, the child begins to speak in incomprehensible sentences. • VS: T36.8ºC, P 162, RR 38, BP 70/42, SpO2 95% on RA, he is having rigors. • What should be done next? This child is in uncompensated shock. He should receive 20 cc/kg of crystalloid

20. Case #3 • After receiving a total of three 20 cc/kg boluses of crystalloid, the child remains hypotensive. • What should be the next course of action? Pharmacological support of his BP

21. Case #3 • Dopamine added • What dose should you start? • You titrate the dose to 12 mcg/kg/min and the child is still hypotensive... • What exam findings are important in guiding therapy at this time? • Capillary refill time • Tactile temperature of the extremities • Mental status • Peripheral and central pulses

22. Case #3 • What are the clinical features of “warm” vs. “cold” septic shock? WarmCold CR time Skin temp Precordium Pulses Brisk Prolonged Warm Cool Nml/activity Nml/activity Bounding Nml/Thready

23. Case #3 • How do these findings guide the next phase of therapy? • In warm septic shock, the underlying problem is decreased SVR, therefore an agent with mostly vasopressor activity should be started (i.e. norepinephrine) • In cold septic shock, the underlying problem is decreased CO, therefore an agent with inotropic activity and/or afterload reduction should be started (i.e. epinephrine, milrinone, nipride)

24. Case #3 Summary • The stage of shock will determine which drugs are most appropriate for resuscitation -- the list of choices is long norepinephrine neosynephrine dopamine milrinone dobutamine nipride epinephrine

25. Case #4 • You are transporting a 4 year old male who fell out of a 4th story window. His head CT reveals small contusions. He is in a C-collar. • VS: HR 65, RR 20, BP 60/30, SpO2 98% on RA, CR ~4 sec. His neck films are shown.

26. Case #4

27. Case #4 • Recognizing the hypotension, a medic has already administered three boluses of NS at 20 cc/kg, but the child remains hypotensive. • Repeat VS: HR 55, RR 25, BP 65/30, SpO2 98% on RA, CR ~4 sec. • What is unique about these vital signs? • There is no compensatory tachycardia for the hypotension • What does this suggest? • The child may have neurogenic shock

28. Case #4 • What is neurogenic shock? • It is a condition characterized by loss of sympathetic tone to the peripheral vascular bed and to the heart • What is the hallmark of this type of shock? • There is marked hypotension without compensatory tachycardia following a CNS injury

29. How does this occur? A lesion occurs in the cervical region of the spinal cord This cuts off the connection between the heart and the brain Now the brain cannot control the heart and the heart functions independently from the rest of the circulation Case #4

30. Case #4 • How is this treated? • The use of pure -agonist (e.g. neosynepherine) agents is preferred

31. Case #4 Summary • Not all shock secondary to trauma is due to blood loss!

32. Case #5 • You are working on Transport, when a 16 year old male, who was riding a motorcycle when he lost control, flipped, and smashed into a guard rail, is brought in to a referring ED. He was wearing a helmet. • He was found to have a multiple rib fractures an and underlying hemothorax. • His chest x-ray is as follows.

34. Case #5 • Prior to transport, the child has been intubated for respiratory distress and altered mental status. • A left chest tube has been placed. CT’s of the head, chest, abdomen, and pelvis are negative for additional pathology. • VS: T 38.2ºC, HR 108, RR 20, BP 90/60, SpO2 98%. • He is currently intubated, sedated, and paralyzed. He is stable and he is loaded onto the ambulance for transport.

35. Case #5 • During transport, the child becomes progressively tachycardic. What do you do now? • Check all vitals and perform quick, focused clinical exam accessing airway, breathing, and circulation • You determine that there is no immediately life-threatening cause of the tachycardia and suspect pain and under sedation for which you administer fentanyl and lorazepam.

36. Case #5 • Now the teenager’s pulse is 185 and he is becoming hypotensive to 50/20. You check the pupils because heart rate and BP changes are part of Cushing’s Triad. What is Cushing’s Triad? • Bradycardia • Hypertension • Altered respirations

37. Case #5 • This is not Cushing’s Triad what else could it be? Your quick physical examination finds the following: • Neck vein distension • Tachycardia with decreased heart sounds • Hypotension • Thready pulses

38. Case #5 • What is happening? Cardiac tamponade • How is this treated? • 20 cc/kg fluid push • Emergent pericardiocentesis • Removal of even a small volume of fluid is the definitive treatment & can rapidly improve BP & cardiac output -- may ultimately prove to be lifesaving

39. Cardiac tamponade occurs when blood or other fluid accumulates in the pericardial space. This creates increased pressure around the heart and interferes with heart function.

40. What are the signs of cardiac tamponade? Tachycardia Hypotension JVD Decreased cardiac output Pulsus paradoxus - >10 mmHg change between inspiratory and expiratory systolic BP Narrow pulse pressure Muffled heart tones Case #5

41. “Blind” Pericardiocentesis - Technique • Subxiphoid Approach • Position the patient so the chest is at a 30-degree angle • Insert an 18-gauge spinal needle attached to a 20-ml syringe into the left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin • While aspirating constantly, advance the needle directly into the inner aspect of the rib cage

42. “Blind” Pericardiocentesis - Technique • Depress the needle so the needle points toward the left shoulder • Using a slow, cautious, turning action of the fingers, advance the needle until fluid is aspirated • Observe the cardiac monitor for arrhythmias • Successful removal of fluid confirms the needle's position

43. “Blind” Pericardiocentesis - Complications • Laceration of a coronary artery • Laceration or perforation of either ventricle • Laceration or perforation of the right atrium • Perforation of the stomach or colon • Pneumothorax • Arrhythmias • Tamponade • Hypotension (perhaps reflexogenic)

44. Case #6 • Your 3 y.o. patient’s mother calls out that something is wrong. • You find the child lying on the bed with his right arm in extension with his hand twitching & his eyes dancing horizontally. Mom states that she has been trying to arouse the child without success. • VS: T 39.2ºC, HR 180, BP 110/70, RR 38 and irregular, SpO2 82% on room air.

45. Case #6 • What is your first impression of this situation? • Child with … • Complex focal seizure • Hypoxic respiratory distress • Tachycardia • Fever

46. Case #6 • What are the first things you should assess? • Airway • Breathing • Circulation Appears patent Ineffective, child is cyanotic Child is tachycardic with good pulses & brisk capillary refill time

47. Case #6 • Does this child need intubation? • Not at this time. While the child is hypoxic, repositioning and oxygen by face mask can improve oxygenation. • Additionally, treatment of the child’s seizures may restore regular respirations and improve the oxygenation status.

48. Case #6 • What medications should be given and by which routes? • Diazepam (Valium): onset in 2-10 minutes • Rectal gel (Diastat) • Infants <6 months: Not recommended • Children <2 years: Not been studied • Children 2-5 years: 0.5 mg/kg • Children 6-11 years: 0.3 mg/kg • Children 12 years and Adults: 0.2 mg/kg • Round doses to nearest 2.5, 5, 10, 15, and 20 mg/dose

49. Case #6 • What medications should be given and by which routes? • Lorazepam (Ativan): onset in 2-5 minutes • Neonates: 0.05 mg/kg IV/IM • Infants, Children, and Adolescents: 0.1 mg/kg (max 4 mg) IV/IM • May repeat up to 3 times before considering a non-benzodiazepine agent

50. Case #6 • What medications should you consider if the first line agents fail to control the seizures? • Phenobarbital • Phenytoin (Dilantin) • Fosphenytoin if peripheral IV questionable