9/4/2018 1 Common Pediatric Emergencies Angie Kratochvil-Stava, M.D. September 7, 2018 [email protected]Objectives Evaluate and initiate treatment for critically ill infants Evaluate and initiate treatment for critically ill children NO DISCLOSURES
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
10-day-old full term infant presents with poor feeding and decreased alertness
9/4/2018
14
Critical Newborn – Other Causes
Inborn Errors of Metabolism Glucose, electrolytes, ammonia, ABG
Non-accidental trauma A shaken baby often presents with poor feeding
as the only sign of abuse
Critical Pediatric Patients
9/4/2018
15
Pediatric Emergency – Scenario 1
3-year-old male with known asthma presents with sudden onset cough and “wheezing.” He has received albuterol via nebulizer every 3 hours x 3 without improvement.
Pediatric Emergency – Scenario 1
Sitting, leaning forward, coughing
HR 170, RR 56, BP 92/66, Temp 98.8
Lungs: rare breath sounds on right, left normal
Circulation: normal
CXR: severe atelectasis of right lung
9/4/2018
16
Pediatric Emergency – Scenario 1Foreign Body
Most common in kids < 3 years
Most common objects: peanuts, grapes, coins, small toys, jewelry, latex balloons, hot dogs
Majority aspirated into right lung
Suspicious when acute respiratory distress and no prodromal illness
Pediatric Emergency – Scenario 1Foreign Body – CXR
About 10% of FBs are radioopaque May see radiolucent objects if severe
obstruction Most common findings in lower airway FBA
20 ml/kg crystalloid infused in < 20 minutes and reassess
Repeat 20 ml/kg fluid boluses
Use pulses, extremity temp, cap refill, level of alertness to guide therapy
Pediatric Emergency – Scenario 3
A 15-month-old infant presents with 2 days of rhinorrhea, cough, and low-grade fever. The child became acutely worse after going to bed and the parents now describe a “squeaking” noise and difficulty breathing.
9/4/2018
20
Pediatric Emergency – Scenario 3
Sitting on parents lap, suprasternal retractions, tachypnea, stridor
Nebulized racemic epinephrine 0.05 ml/kg of 2.25% solution in 3 ml NS
Risk of rebound edema 30-90 minutes after
Dexamethasone 0.6 mg/kg PO/IM/IV (max 10 mg)
Inhaled Budesonide?
Prednisolone?
Pediatric Emergency – Scenario 4
5-year-old child presents with dry cough and increasing shortness of breath over the last 24 hours. He has been taking cetirizine for allergic rhinitis for the last two weeks. No fever.
9/4/2018
22
Pediatric Emergency 4 – Asthma Epidemiology – National
20.3 million asthmatics in U.S.
Morbidity/Mortality 1.8 million ER visits annually
500,000 hospitalizations
5000 deaths
Pediatric Emergency 4 – Asthma Epidemiology – National (Peds)
#1 chronic childhood illness in U.S.
Almost 5 million children with asthma
3rd ranking cause of pediatric hospitalization
4th most common cause for pediatric visits
14 million lost school days annually
9/4/2018
23
Pediatric Emergency – Scenario 4Asthma
What is asthma? Bronchial muscle spasm
Mucosal edema
Inflammation
Mucus plugging
Severity of wheezing does not always correlate with severity of airway obstruction
1. Shake the inhaler at least 5 times and take cap off.2. Place the spacer on the end of the inhaler.3. Relax and breathe out. Hold your head looking straight ahead, not
looking down.4. Put the spacer in your mouth, on top of your tongue.
Close your lips around the spacer.5. Press down on the inhaler.
This will put 1 puff of medicine into the spacer.
6. Breathe in slowly and deeply until your lungs are full, five times.
7. Wait at least 1 minute. Then repeat the above steps.
9/4/2018
26
Pediatric Emergency – Scenario 4Asthma – Controller MedicationsUsed in persistent asthmaDo not stop an asthma episodeShould be taken every day, even when
children are feeling wellAct over a long period of time, taking weeks to
reach effectiveness
Tell families to think of them as vitamins protecting children from serious illnessNot addicitve, rare side effects
Terbutaline SC/IM 0.01 mg/kg dose (max 0.4 mg/dose) May repeat q 20 minutes x 3
Epinephrine SC/IM 0.01 mg/kg dose (max 0.4 mg/dose) May repeat q 20 minutes x 3, then every 2-6 hours
Terbutaline IV Bolus 10 mcg/kg over 10 min, then 0.3-0.5 mcg/kg/min,
inc. by 0.5 mcg/kg/min q 30 min (max 5 mcg/kg/min)
9/4/2018
28
Pediatric Emergency – Scenario 5
2-month-old former 35 week premature infant presents with few days of rhinorrhea and mild cough and now having difficulty breathing. Infant has felt warm and is not eating well.
Pediatric Emergency – Scenario 5
Anxious appearing infant in respiratory distress
HR 180, RR 85, BP 80/40, Temp 101.6
Chest: moderate retractions, occasional grunting
Lungs: scattered wheezes, fine crackles
Circulation: warm, well-perfused
9/4/2018
29
Pediatric Emergency – Scenario 5Bronchiolitis
Etiologies: RSV, human metapneumovirus
Causes small airway obstruction
Most severe in children < 2 years
Prodrome: cough, coryza, low-grade fever
Apnea in very young infants
CXR: hyperinflation w/patchy infiltrate and atelectasis
A 4-month-old infant who started coughing while sitting in an infant seat. She then had a large emesis, turned “white,” and had a long pause in her breathing.
Pediatric Emergency – Scenario 6
Well-appearing, alert infant, sitting on mom’s lap