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 He is sleeping but arouses to stimulation.

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. Case #1 How fast is the heart beating? Use the 300-150-75 rule

6. Case #1 What should you do next? Determine if the child is clinically stable or unstable

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.

12. Case #2 What is wrong with this child?

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?

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?

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 35.7�C, 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: T36.8�C, P 162, RR 38, BP 70/42, SpO2 95% on RA, he is having rigors. What should be done next?

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?

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? Warm Cold

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

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. Case #4 How does this occur?

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 38.2�C, 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

40. Case #5 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

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 39.2�C, 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

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

51. Case #6 The child stops twitching after lorazepam is given. His respirations are shallow & his SpO2 in 100% on NRB FM at FiO2 1.0 What reflexes should be evaluated to see if this child requires intubation? Gag to evaluate airway protection.

52. Case #7 You are working in the ER when a 13 year old unresponsive female is brought in. Her little brother states the girl has been sick all day. She was really thirsty having consumed four 2 liter bottles of Coke in the last 8 hours. VS: T 36�C, HR 165, BP 80/palp RR 25 and very deep, SpO2 99% on room air.

53. Case #7 A: abuse or alcohol E: encephalopathy or endocrine I: insulin/ hypoglycemia/ metabolic disorder O: opiates U: uremia T: trauma/ tumor I: infection/ intussusception P: poisoning S: sepsis/ seizure/ shock

54. Case #7 D: dehydration P: poisoning T: trauma O: occult trauma P: post-ictal or post- anxoia V:VP shunt infection H: hypoxia/ hyperthermia I: intussusception B: brain mass M: meningitis M: metabolic R: Reye�s syndrome

55. Case #7 The sibling states that she takes injections in her leg. What is the most likely diagnosis?

56. Case #7 You check a blood gas which demonstrates � pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27 Na+ 133, K+ 6.5, Glucose ***, iCa++ 4.5 mg/dL

57. Case #7 Should you give NaHCO3 to correct the acidosis? No. NaHCO3 should only be given in the setting of cardiovascular dysfunction, i.e. arrhythmias. Its use has been associated with the development of cerebral edema in patients wth DKA. (N Engl J Med 2001;344:264-9)

58. Case #7 Why is the K+ elevated? Elevated serum hydrogen ion is counter-transported across the RBC membrane with potassium in an effort to buffer the acidosis

59. Case #7 Why is Na+ low? The hyperosmolality of diabetes attracts more water into the intravascular space. This causes a �ficticious hyponatremia�.

60. Case #7 What IVF should be given and how much? 0.9% NaCl at 20 cc/kg unless in uncompensated shock. Excess IVF has been associated with cerebral edema. (4 liters/M2)

61. Case #8 You are admitting a 6 year old male who is coughing uncontrollably. VS: T 37.2�C, HR 140, RR 40, SpO2 85% on room air. He has nasal flaring, supra-sternal, intercostal, and subcostal retractions. By auscultation, you hear expiratory wheezes bilaterally with a prolonged expiratory time.

62. Case #8 What is this child�s problem?

63. Case #8 What is the 1st step in treatment? Provide oxygen What is the next step? Provide nebulized bronchodilators

64. Case #8 How would the diagnosis change if the child had a right-sided, wheeze heard best on inspiration, with decreased air exchange on the right side, and tracheal deviation to the left? This would suggest the presence of a foreign body. Remember, all that wheezes is not asthma!

65. Case #8 Physical examination of the child reveals a palpable liver edge 5 cm below the right costal margin. Why is this? Hyperinflation related to obstructive airway disease in asthma has pushed the liver inferiorly into the abdomen.

66. Case #8 What agents are used in the treatment of asthma and why? ?-agonist agents Increase cAMP which leads to decreased intracellular calcium and smooth muscle relaxation. Albuterol nebs or MDI, terbutaline nebs or SQ, epinephrine SQ

67. Case #8 Agents� Anticholinergic agents Inhibit the acetylcholine receptor thereby decreasing the intracellular cGMP which leads to decreased intracellular calcium and smooth muscle relaxation. Ipratroprium bromide nebs Steroids Acutely, they may lead to ?-receptor upregulation and sub-acutely/chronically have been shown to decrease the inflammatory response in asthma

68. Case #8 Agents� Magnesium sulfate: Competitively inhibits intracellular calcium and leads to smooth muscle relaxation Ketamine: Binds sigma opiate receptors to cause dissociative amnesia and relaxation. Causes secondary release of endogenous epinephrine which causes smooth muscle relaxation. Can cause excessive secretions.

69. Case #9 A 7 week old female infant is being seen for unresponsiveness after being found face down in the bed by her parents. VS: T 35.2�C, HR 68 & thready, RR 13, BP 65/40 with SpO2 unable to trace, and CR ~5 sec. She responsive to painful stimulation. The physician seeing the patient is concerned about sepsis and gave the child IM antibiotics because no IV access has been obtained.

70. Case #9 What are the first things you should do? Airway & Breathing Bagging this child with 100% oxygen increased the heart rate to 180 bpm Circulation This child is in shock. An attempt at IV access should be made. If no access is obtained in 90 seconds or after 3 attempts, an IO needle should be placed. After this, the child should receive 20 cc/kg of crystalloid solution

71. Case #9 What should be done next? Disability This child is hypothermic and should be placed under warming lights or wrapped in a blanket

72. Case #9 What components of the history should be obtained? Birth history: Full term or premature? Discharged right after birth or was there a prolonged stay? GI: Has the child been taking good PO? Making good UOP? Diarrhea or vomiting?

73. Case #9 ID: Any fever? Any rash? Any sick contacts? Medical: Is the child on any medication? When was the last visit to the doctor? Are the vaccinations up to date?

74. Case #10 You arrive at your night shift on a community hospital inpatient floor. One of your patients is a 9 month old, former 25 week male premie who is respiratory distress. The nurse signing out to you states that the child has developmental delay and cerebral palsy. The child presented to your facility with fever and rhinorrhea for 3 days, with progressively increasing work of breathing. The child has been receiving albuterol nebs Q 2 hours around the clock for the last 2 days without relief. VS: 38.3�C, HR 195, RR 60, BP 100/57, SpO2 89% on 5L FM, and CR <2 sec

75. Case #10 Different parts of the respiratory tree may be contributing to this infant�s problems Nasal Passages: obstruction from rhinorrhea, adenoid hypertrophy Oropharynx: inability to clear secretions, pharyngeal hypotonia with obstruction, tonsillar hypertrophy Trachea: Stenosis, malacia, vocal cord paralysis, viral croup Small Conducting Airways: Reactive airway disease, bronchopulmonary dysplasia Alveoli: pneumonia, bronchopulmonary dysplasia

76. Case #10 Name different ways to overcome these airway problems Nasal Passages: suction, ?-agonists (i.e. Afrin) Oropharynx: suction, BVM to give CPAP with 100% oxygen, intubation Trachea: racemic epinephrine nebs, Heliox, BVM to give CPAP with 100% oxygen, intubation Small Conducting Airways: albuterol, ipratroprium, BVM to give CPAP with 100% oxygen, intubation Alveoli: BVM to give CPAP with 100% oxygen, intubation

77. Case #11 You are transporting a 14 year old male with bilateral frontal contusions after a MVC. The child has also sustained pulmonary contusions and a liver laceration. He was intubated for a GCS of 6. His pupils are 4mm and sluggish. VS: T 37.2�C, HR 108, BP 90/45 with SpO2 100%. Vent settings are VT 400 cc, PEEP 5, IMV 12, FiO2 1.0.

78. Case #11 During transport, the child develops a BP of 180/120 & pulse 65. What might be happening? The bradycardia and elevated BP suggest Cushing�s Triad (altered respirations is the third component) which suggests impending herniation. What is the next most appropriate step in management? Hyperventilation: decreases PCO2 causing cerebral vasoconstriction leading to decreased blood flow decreasing cerebral edema. Hyperosmotic agents: Mannitol or 3% NaCl: removes water from brain and can relieve edema Elevation of head.

79. Case #11 Now his sats are falling... You begin to manually bag him and notice that it is much more difficult to obtain chest rise than previously. What should you think of next? �DOPE� Displacement Obstruction Pneumothorax Equipment Failure

80. Case #11 You check for displacement by auscultation bilaterally No air exchange in the right lung fields with good air exchange in the left lung fields. Could the ETT have slipped and led to left main-stem intubation? This is unlikely as the right main-stem is straighter and the tube is still taped at the original position. You check for obstruction of the ETT by passing a suction catheter into the ETT Suction catheter passes without difficulty

81. Case #11 You check for a possible pneumothorax There is no air exchange on the right side There is no chest rise on the right side The trachea is deviated to the left These findings suggest a right sided pneumothorax You quickly access for equipment failure The BVM is connected to 100% oxygen The anesthesia bag inflates correctly You suspect a right sided PTX and perform a needle thoracotomy in the 2nd ICS at the mid-clavicular line and hear a whoosh of air

82. Case #12 You arrive at an ER to transport a 5 year old male who was intubated for respiratory failure secondary to shock. His VS are 39.2�C, P 140, RR 32, BP 90/30, SpO2 93% on 100% O2. The child received 40 cc/kg LR, vancomycin, & ceftriaxone prior to intubation. There is an IO in the left tibia (attempt at a right IO failed). There is an a-line in the right radial artery.

83. Case #12 En route, the becomes hypotensive to 55/20. While pushing volume, the IO displaces. What should you do next? Place an IO in either femur, just proximal to the knee. Placement of the IO in either of the tibias may result in extravisation of fluid out of the previous IO attempt sites

84. Case #12 The child remains hypotensive despite a 20 cc/kg bolus (60 cc/kg total given since presentation). What should you do next? Begin dopamine at 5 mcg/kg/min How do you make a drip using the rule of 6�s? Wt(kg) x 60, 6, or 0.6 = # mg/100 cc to make a drip that at 1 cc/hr = 10, 1, or 0.1 mcg/kg/min

85. Case #12 You obtain a arterial blood gas which demonstrates: pH 7.20, PaCO2 60, PaO2 75. What is happening and what should you do? The patient is suffering from a respiratory acidosis and you should increase the ventilation rate or tidal volume How can you estimate the change in pH from the change in PCO2? For every 10 change in PCO2, a change of 0.08 in pH will be seen

86. Case #12 You have attempted to titrate the dopamine to keep the MAP > 65. It is now at 18 mcg/kg/min but the hypotension persists. Which agent should you consider if the child has a CR < 2, peripheral pulses +3, and a hyperdynamic precordium? This child is in warm septic shock. Norepinephrine should be started. Which agent should you consider if the child has a CR ~ 4 and the peripheral pulses are thready? This child is in cold septic shock. Epinephrine should be started.

87. Case #13 You are transporting a 16 year old male from a peripheral ER who is suspected of taking PCP. He was combative and received IM haloperidol which controlled his temperament adequately. During transport, he develops muscle spasms, eye dancing, a stiff neck, and an inability to open his jaw. What is happening? Acute dystonic reaction from haloperidol

88. Case #13 What other drugs can commonly cause this reaction? Metoclopromide (Reglan) Prochlorperazine (Compazine) How is this reaction treated? Diphenhydramine (Benadryl) Benztropine (Cogentin)

89. Case #13 You arrive at the ER of a rural medical center to transport a 13 month old child who has respiratory distress for the last 3 days. He is now significantly worse. VS T 39.8�C, HR 198, RR 55, BP 65/30, SpO2 93% on 5L FM. The child appears physically exhausted. Physical examination demonstrates rales on auscultation bilaterally, distant heart sounds, and increased liver size. His pulses are thready and CR ~3 sec. The CXR is shown on the next slide.

91. Case #13 The diagnosis of acute myocarditis is made. While transporting the child, he develops the following rhythm:

92. Case #13 What should you do next? Check for a pulse If no pulse present, initiate CPR and PALS pulseless arrest algorithm If pulse present with poor perfusion: STAT defibrillation 2 J/kg. Consider alternative medications Amiodarone 5 mg/kg IV over 20 minutes or Lidocaine 1 mg/kg IV Intubation

93. Case #13 What should you do next? (Con�t) Check for a pulse If pulse present with adequate perfusion: Consider medications Amiodarone 5 mg/kg IV over 20 minutes or Lidocaine 1 mg/kg IV Cardioversion with 0.5 to 1.0 J/kg

94. Case #14 You arrive at a physician�s office to transport a 4 year old child with a suspected acute abdomen. The child has had bilious emesis for 2 days along with loss of appetite. VS: T 40.1�C, HR 140, RR 45, BP 80/40, SpO2 100% on room air, CR < 2 sec. The physician has given the child 4 doses of morphine (2 mg) with minimal pain relief.

95. Case #14 While en route, the child falls asleep and appears comfortable. The BP cycles and determines that the BP is now 60/20 with the heart rate elevated to 180. What should you do now? Consider a crystalloid bolus of 20 cc/kg

96. Case #14 The child�s SpO2 is beginning to fall (84%). Examination demonstrates shallow respirations. What should you do next? Place the child on 100% FM The SpO2 continues to fall after oxygen. Should you intubate this child? No. This child is probably suffering from a depressed respiratory drive, try naloxone (Narcan).