MUSC Pediatric Emergency Medicine Handbook 2013

Handbook for the

MUSC Pediatric Emergency Department

2013-2014

Editors: Carrie Busch MD, Kate Hewett MD,

Dan Park MD, and Amanda Price MD

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Table of Contents Common Medical Complaints: PALS p4-6 Anaphylaxis p7-8 Asthma p9-10 Burns p11-12 Croup p13 Congenital Heart Disease p14-16 Febrile Neonate p17-18 Fever p18 Urinary Tract Infection p19

Ingestions p20 Seizures p21-22 Adolescent Medicine p23 STI Treatment p24

Endocrine Emergencies p25-26 DKA/HHS p27-29

Headaches/Migraines p30-31 Acute Scrotum p32

Hematology/Oncology in the PED: Fever and Neutropenia p33-34 Hyperleukocytosis p35 Tumor Lysis Syndrome p36 Anemia p37-38 Thrombocytopenia p39 ITP p40-41 DIC/Coagulopathy p41 Transfusion Guidelines p42-46 Hemophilia p47-49

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Table of Contents Continued vonWillenbrand’s Disease p50-51

SVC syndrome p52 Sickle Cell Disease

Fever/Sickle Cell Disease p53 Pain/Sickle Cell Disease p54-56 Acute Chest Syndrome p57

Sedation and Injuries: Wound closure p58

Mammalian Bites p59-61 Snake Bites p62-63 Puncture wounds p63 Sedation p64 Splinting p65-66 Psychiatric Considerations Organic vs. Functional Psychosis p67 Resuscitation Protocols: Trauma Guidelines p68-70

Rapid Sequence Intubation p71-72 Tube sizes, etc p73 Vasoactive and inotropic drugs p74-75 Shock p76-77 Radiology Helpful Hints p78 The online and paper ED resident manuals have lots more detailed information, references and articles, in addition to specific treatment guidelines developed in EBM fashion. Please consult them and use this handbook as a quick reference.

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PALS PROTOCOLS Start w/ checking for Pulse (circulation), then airway, breathing For infants to adults: Compression rate 100/min Compression:ventilation ratio Single rescuer: 30:2 2 rescuers: 15:2 Rescue breathing with advanced airway: 8- 10 breaths/min (1 breath every 6-8sec) Compression method (push hard and fast + allow full recoil):

• <1 yo: 2 thumb-encircling technique • 1-8 yo: 1 hand technique or 2 hand technique • >8 yo: 2 hand technique

AED:

• Infant pads: Up to 1 year or 10 kg • child pads <1-8 yrs • >8 years: use adult pads • Epi doses: 0.01mg/kg (1:10,000); IO/IV= 0.1ml/kg;

0.1mg/kg (1:1000) ETT= 0.1ml/kg

PEA/ASYSTOLE • Epi q3-5 min; CPR • Evaluate for reversible causes:

Hypothermia Tension Pneumo Hypoxia Toxins Hyper or Hypo K+ Thrombosis (MI) Hypovolemia Tamponade H+/acidosis Thromboembolism (PE)

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UNSTABLE BRADYCARDIA (CV compromise) • Chest compressions for hr <60 if under 8 years old • Epi, repeat every 3-5 min • Atropine 0.02 mg/kg IV/IO q5 min (min dose 0.1mg),

may repeat x1 (for increased vagal tone or primary AV block)

• Consider pacing SVT

• Consider ice to face if patient stable (no carotid massage)

• Adenosine 0.1 mg/kg IV/IO (max 6 mg), then 0.2 mg/kg (max 12 mg) if no response OR synchronized cardioversion 0.5-1 J/kg, may repeat at 2 J/kg

STABLE VT (wide QRS, >0.08sec)

• Lidocaine 1mg/kg over 2-3min; may repeat every 5min for total of 3mg/kg OR amiodarone 5mg/kg over 20-60 min IV/IO

• OR procainamide 15 mg/kg over 30-60 min IV/IO UNSTABLE VT (CV compromise)

• Cardioversion 0.5-1 J/kg • OR try drugs (amiodarone, procainamide bolus)

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V-FIB/PULSELESS VT • Shock: 2 J/kg • 5 cycles of CPR • Check rhythm: Shock 4 J/kg • Epi, repeat every 3-5 min • 5 cycles of CPR • Check rhythm: Shock 4 J/kg • Lidocaine 1mg/kg OR Amiodarone 5 mg/kg bolus

IV/IO • OR Mag 25-50 mg/kg IV/IO if torsades (max 2g)

HELPFUL FORMULAS

• ETT size: 4 + (age/4): subtract 0.5 for cuffed tube *Downsize tube 0.5 for inhalation injury and croup

• Insertion Depth: tube size x 3 • Weight (kg): 8+ 2 x (age)

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Anaphylaxis Definition: Acute, potentially life-threatening syndrome caused

by the release of inflammatory mediators involving 2 or more organ systems

Causes: Foods (Milk, eggs, wheat, soy, peanuts, fish) Preservatives Allergens Insect venom Blood products Radiocontrast dye Latex Drugs (antibiotics, local anesthetics, analgesics) Signs and Symptoms: Skin: Urticaria, angioedema Respiratory: Cough, chest pain, wheezing, stridor, hoarseness, or throat tightness Gastrointestinal: Nausea/vomiting, abdominal pain, diarrhea Cardiovascular: Tachycardia, hypotension, arrhythmias, Decreased peripheral perfusion Central Nervous System Dizziness, syncope or AMS *** Hymenoptera Caviat: If > 16 years of age and hives are the only symptom literature suggests IM Epinephrine, due to risk of progression to severe symptoms. If less than 16 years treat as below.

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Anaphylaxis Continued: Initial Management:

1) Establish ABC’s 2) Consider Epinephrine: 0.01mg/kg (1:1000)IM;

0.01ml/kg, max 0.5ml *Repeat every 15 min not to exceed 4 doses

3) Albuterol neb 4) H1-receptor antihistamine: diphenhydramine 1-2 mg/kg

IV/IM/PO (max dose 50 mg) 5) H2-receptor antagonists: ranitidine 1-2 mg/kg IV/IM

every 12 hours or 3-5mg/kg PO q 12(max dose 100mg) 6) Corticosteroids- may prevent late phase reactions

Methylprednisolone 2mg/kg IV bolus, then 2mg/kg/day OR Prednisone 2 mg/kg po, repeat daily for 2-3 days.

IF Hypotensive: *Establish IV or IO (if under age 8 years)

1) Bolus with normal saline 20ml/kg rapidly. Repeat bolus as necessary

2) Epinephrine 0.01mg/kg (1:10,000) IV/IO over 2-5 minutes (0.1ml/kg)

3) Epinephrine infusion: 0.1-1mcg/kg/min, titrate until normotensive

Disposition: Mild (urticaria only): Observe in ED for 2-4 hours Moderate or severe symptoms and/or sig. history of atopy: ADMIT Discharge Medications: * H1 and H2 blockers for 24-72 hours * May consider short course of oral steroids *Any patient with history of life-threatening symptoms should be discharged from hospital with Epi-pen (Epipen JR if <30kg)

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Asthma Asthma Score: for patients 1 year old and greater ; non-bronchiolitis

Parameters Score 0 Score 1 for each item

Score 2 for each item

Respiratory effort

Full sentences, babbles

Short phrases or cries

Max ability single words or grunts

Accessory muscle use

No retractions

Inter / subcostal retractions

Inter / subcostal, supraclavicular retractions +/- flaring

Auscultation Clear / minimal expiratory wheeze

Inspiratory and expiratory wheezes

Diminished or absent breath sounds

O2 sat on room air

> 95% 91-95% < 91%

Sensorium Normal Slightly decreased or agitated

Markedly depressed or non-responsive

Total Score

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Practice Guideline Considerations for patients 1 year and older: If Mild (asthma score 0-2), recommend:

• Albuterol HHN 2.5 or 5mg with ipratropium bromide 500 micrograms nebulized or albuterol 4-6 puffs MDI with spacer with ipratropium bromide 4-6 puffs MDI with spacer • Consider Prednisone/Prednisolone PO 2 mg/kg (max

60 mg) or dexamethasone 0.6mg/kg (max 15mg) If Moderate (asthma score 3-6), recommend:

• Albuterol HHN or CNB 10-20 mg/hour nebulized with ipratropium bromide 500 micrograms nebulized OR albuterol 6-10 puffs MDI with spacer with ipratropium bromide 4-8 puffs MDI with spacer

• Prednisone/Prednisolone PO 2 mg/kg (max 60-100 mg) or Methylprednisolone IV (same dose) or dexamethasone

If Severe (asthma score 7-10), recommend: • Albuterol CNB 10-20 mg/hour nebulized with

ipratropium bromide 500 micrograms nebulized OR albuterol 6-10 puffs MDI with spacer with ipratropium bromide 4-8 puffs MDI with spacer

• Prednisone/Prednisolone PO 2 mg/kg (max 60-100 mg) or Methylprednisolone IV (same dose) • Magnesium sulfate 50-75 mg/kg IV (max 2 grams)

over 20-30 minutes (max rate 150 mg/minute)

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Burns Remember MUSC is a pediatric (<16y) burn center!

1) Airway Stabilization: see trauma/RSI • 100% humidified 02 for all pts with possible inhalational

injury. • Measure carboxyhemoglobin and ABG. • Intubate for evidence of inhalational injury.

2) Aggressive fluid resuscitation: based on BSA burned

(see below) on infants with >10% BSA and children with >15% BSA.

• Parkland formula (updated 2013): 3cc/kg x wt (kg) x percent of body with second or third degree burns. Give half of total fluids in first 8 hours and the rest in the next 16 hours. Remember to always add maintenance fluids to total calculation for <5yo.

• Calculate body surface area (BSA) burned based on second and third degree burns only (see page 12).

o First degree/ superficial: Painful and erythematous; only epidermis

o Second degree/ partial thickness: Any blistering, painful,

may progress to third degree; epidermis and dermis involved

o Third degree/ full thickness: Leathery, white and

painless; involve all layers of epidermis and dermis; best treated with skin grafting

3) IV analgesia is necessary for pain for moderate to

severe burns. Give po pain meds for milder burns. 4) Remember tetanus prophylaxis.

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Source: UpToDate 2013

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Croup Croup Scoring System 0 1 2 3 Stridor none only with at rest severe agitation Retractions none mild moderate severe Air Entry nml mild decr mod decr severe Color nml nml nml cyanotic Mental Status nml restless v. restless lethargic Croup Severity/ Management Score Severity Management < or =4 mild steroids* 5-6 mild-mod steroids, racemic epi** 7-8 mod steroids, racemic epi, admit > or =9 severe steroids, r.epi, PICU

*0.6 mg/kg oral dexamathasone or 0.3-0.6mg/kg IM ** observe 2-3hrs after racemic epi Admission for hypoxia, poor po, underlying laryngeal dz, or moderate dz with parental anxiety or distance from ED

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Congenital Heart Disease *Cyanotic babies WITHOUT known cardiac disease:

1. Think SEPSIS

2. Give fluid gently and gradually (10ml/kg)

3. Check pulses and BP in ALL 4 extremities

4. Minimize positive-pressure ventilation and O2

5. Hyperoxia challenge (if SaO2 <85%= ductal dependent lesion)

6. Call for prostaglandin E1 (0.05mcg/kg/min) and call cardiology

7. Intubate or have airway equipment immediately available as prostaglandin E1 may cause apnea

*Differential Diagnosis for Cyanotic Heart Lesions:

1. Truncus Arteriosus

• single trunk supplying syst., pulm. and coronary beds

• CXR: cardiac enlargement, incr pulm vasc.

2. Transposition of Great Arteries

• Aorta from RV and Pulm Art from LV

• CXR: “Egg on string”

3. Pulmonary Atresia/Tricuspid Atresia

• Atretic valve with poorly formed RV

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• CXR: hyperlucent lungs (decr vasc.) absent PA

4. Tetralogy of Fallot (most common Cyanotic CHD)

• RVOT obstr, RVH, Overriding Aorta, and VSD

• CXR: RVH, up-tilting of apex

5. TAPVR

• Pulm veins do NOT return to LA

• CXR: Ground glass, incr. Pulm vasc.

*Cyanotic babies WITH known cardiac history--things to remember:

1) Tetrology: “Tet spells”

Goal: In cr SVR to reverse shunt

(IVF, knee to chest, morphine, O2 or ketamine)

TOF normal sat >80%

2) Tricuspid Atresia/Hypoplastic Left Heart Syndrome

• After BT shunt: avoid dehydration (shunt can clot); • May have sx of failure if shunt too big • After Glenn: SVC syndrome is sign of increased PVR

and pulm hypertension • After Fontan: sats should be in 90’s but can be in 80’s

if has a fenestration; watch for thromboemboli through fenestration

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3) Truncus Arteriosus: Arrhythmias, valvar insufficiency

4) TAPVR : Pulmonary edema, pulmonary hypertension if re-stenosed at the anastamosis

5) Transposition : May have cardiac ischemia

*Acyanotic Lesions complications s/p repair:

1. Coarctation: assess for re-coarctation

• Check 4 pulses and BP • Usually occurs w/in 1st year if going to occur

2. VSD:

• Failure to Thrive • Congestive Heart Failure • Pulmonary Hypertension • Arrhythmias

3. ASD: Arrhythmias

4. Heart Transplant: Bradycardia can be sign of rejection as pt will have no angina. Epi and atropine might not work in this situation as no innervations so consider pacing. Always consider rejection if presenting with viral symptoms (remember HR is UNRELIABLE)

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Febrile Neonate

IF Temp>100.4F or 38.0C AND Age < 8weeks, THEN:

= Septic Infant until proven otherwise

*If neonate/child is ill-appearing, evaluate fully for sepsis and consider admission regardless of results. Refer to Febrile Neonate Order Set!

Workup

• Accucheck glucose

• CBC, BCx, CMP, HSV PCR blood*

• UA, UCx

• CSF gluc/prot, cell count/gram stain &culture

• HSV PCR if ill or less than 4 weeks*

• CXR if tachypnea or hypoxemia

• Consider CRP and Procalcitonin *See HSV treatment guidelines in online manual which includes serum HSV PCR, LFT’s and appropriate skin and mucous membrane cultures as indicated.

Antimicrobials (Less than 4 weeks):

Ampicillin 50mg/kg/dose q8h <1wk, q6h >1 wk

AND Gentamicin (<7d) 2.5mg/kg/dose q12h

(>7d) 2.5mg/kg/dose q8h

OR Cefotaxime 50mg/kg/dose q8h <1wk, q6h >1wk

AND Acyclovir 20mg/kg/dose q8h*

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AFTER 4 weeks:

May use Ampicillin AND

Cefotaxime 50mg/kg/dose q8h

OR

Ceftriaxone 50mg/kg/dose q12h

* Goal is to have antibiotics given within 1 hour of arrival

Fever (T 102.2F or 39.0C) 61 days to 2 years: Well or mildly ill-appearing with no source of fever:

• Cath UA and urine cx on all females and circumcised males <6mos and uncirc <12mos

• CXR if tachypnea or hypoxemia • Stool studies if blood in stool or known contact

Ill-appearing:

• Stabilize ABC’s • Consider full septic evaluation and antibiotics

*With universal Prevnar immunization, occult bacteremia is very rare and does not cause sig. adverse outcomes to warrant CBC or blood culture in well-appearing children. *Please consult online or paper resident manuals for specific articles and references.

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UTI Recommendations *See the formal guidelines on the portal for more details and the MUSC antibiogram. We recommend a 3rd generation cephalosporin (ie. Cefdinir) as empiric therapy for the following patients:

1. Any child less than 2 with a suspected urinary tract infection 2. Those diagnosed with pyelonephritis at any age 3. Children at high risk of having underlying genitourinary

abnormalities (i.e. a patient with ear anomalies)

Empiric options for uncomplicated cystitis in an older child/adolescent:

1. Cephalexin - good choice for patients who can swallow pills and demonstrate ability for good compliance (do note it is bad tasting in liquid form and is q6 hour dosing)

2. Amoxicillin –inexpensive and good tasting; do note the listed resistance is very high but in discussion with our ID experts the concentration sustained in the urine is likely high enough to overwhelm this documented resistance

3. Cefprozil – another broader choice that is good tasting 4. Nitrofurantoin – good first line for the adolescent with no

systemic symptoms

*If history of recurrent/resistant UTI’s always check previous sensitivities to guide antibiotic choice! *Consider admission if <3 months, ill appearing, inability to take PO, severe pain, or immunocompromised.

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Ingestions/ Toxicology *Poison Control Center is staffed 24 hrs/ day: 1-800-222-1222

• Assess ABC’s and evaluate mental status/level of consciousness

• Detailed history re: substance(s), quantity, strength, time of ingestion, medical history, treatments prior to ED.

*Lab tests should be individualized but consider: • Glucose (ALWAYS with mental status changes) • CBC, CMP, ABG, serum osmolarity, UA, UDS • Serum acetaminophen, aspirin and ethanol levels • Urine pregnancy test • EKG/cardiac monitor • CXR/KUB

*GI decontamination options:

• NO IPECAC!! • NO Single-Dose activated charcoal; exception is within

one hour in acetaminophen ingestions; weigh risks/benefits

• MDAC (multi-dose activated charcoal) for potentially-lethal ingestions within one hour of presentation and for drugs specifically absorbed by charcoal including: ACT PDQ (aspirin, carbamazepine, theophylline, phenobarbital, dapsone and quinine).

• NO Gastric Lavage • Whole-bowel irrigation: theoretical benefit for heavy-

metal ingestions or packets of illicit-drugs or extended-release drugs.

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Seizures

Types: • febrile or afebrile • complex or simple • patient with known seizure or new seizure • focal or generalized • ongoing sz activity/ status epilepticus

RESUSCITATION:

• ABC's first--position airway, sniffing position establish IV access; glucose accucheck If hypoglycemic, give dextrose 0.5g/kg: D10 5ml/kg; D25 2ml/kg

MEDICATIONS

• 1st line: Ativan 0.1mg/kg IV, max dose 4mg at a time May repeat q5min for total of 3 doses

OR Versed 0.1m/kg IV/IM

• 2nd line: phenytoin 15-20mg/kg IV over 20-30min; max infusion rate 1mg/kg/min OR fosphenytoin 10-20PE/kg

• 3rd line: phenobarbital 20mg/kg IV load over 20min *Watch for resp. depression and BP OR Depakon (iv form of depakote) 15-20mg/kg OR Keppra 20-40mg/kg IV

• 4th line: pentobarb coma---must consult neurology at this point for continuous EEG

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Seizures: THINGS TO CONSIDER:

• Be prepared to bolus with IVF and provide ventilatory support

• Avoid paralytics in patients that seize--unable to assess ongoing seizure activity if paralyzed

• Further evaluation once ABC's intact o ct? lp? uds? o in young infants--metabolic reasons (nh4,

urine organic acids, plasma amino acids) o Consider hyponatremia/ hypocalcemia o Pregnancy—eclampsia (magnesium) o After each medication, re-check ABC’s and

glucose.

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Adolescent Medicine

• All physicians doing pelvic examinations must be accompanied by a female nurse or MD.

• Please do a urine pregnancy test on all females of

child-bearing age with trauma, abdominal pain, vaginal bleeding or discharge, UTI, when considering x-rays and before feto-toxic drugs.

• Please DO NOT trust your intuition as to who might or might not be sexually active.

• EVERY work-up for STD (including pubic lice) must

include GC and Chlamydia. *Consider evaluation for RPR, Hepatitis and HIV.

• Abdominal pain, cervical motion tenderness or adnexal

tenderness on exam equals PID and treatment is different. Consider ultrasound to rule out TOA.

• Encourage patient to tell partner so treatment can be

obtained if cultures positive. Encourage patient to discuss openly with parents.

• Arrange follow-up in STD clinic or Adolescent

Medicine

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STI TREATMENT Uncomplicated Cervicitis/ Urethritis Chlamydia: Azithromycin 1g po x1 or Doxy 100mg po bid x7d Gonorrhea: Ceftriaxone 250mg IM x1 or Cefixime 400mg pox1 BV: Metronidazole 500mg po bid x7 days Trichomonas: Metronidazole 2 g po x1 PID Ceftriaxone 250mg IM x1 (there is no non IM option) + Doxycycline 100mg po bid x10 days +/- Meronidazole 500mg po bid x14 days Epididymitis Ceftriaxone 250mg IM x1 + Doxycycline 100mg po bid x10 days ASA PPX Ceftriaxone 250mg IM x1 or Cefixime 400mg po x1 + Metronidazole 2 g po x1 + Azithromycin 1 g po x1

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Endocrine Emergencies

Hypoglycemia: 5-10 ml/kg D10 IV/IO if <6 months OR

2-4 ml/kg D25 IV/IO if >6 mos

*Dobson’s Rule: ___ cc/kg x D___W = 50 (0.5g/kg)

*If necessary, continuous infusion is 6-8mg/kg/min or 4 x wt(kg) = ml/hr D10.

*When blood sugar is <45-50, repeat test and if persistently <45-50, get the following per endocrinology recs: CMP, insulin, C-Peptide, proinsulin, cortisol, growth hormone, lactate,

pyruvate, ammonia, plasma and urine amino acids, urine organic acids,

serum beta-hydroxybutyrate, free fatty acids, plasma acyl carnitines,

urine for acylglycines and ketones and urine drug screen (ie, oral

hypoglycemia agents, send out to Mayo Clinic)

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Hyperglycemia: Check VBG to check for acidosis. *In known patient with IDDM, IVF and appropriate SQ insulin should correct hyperglycemia if no evidence of DKA or HHS (see below).

Hypocalcemia: 30mg/kg calcium gluconate over 30min or 20mg/kg of calcium chloride 10%

Hypercalcemia: Lasix, hydration, glucocorticoids

Adrenal Insufficiency: NS bolus and IVF, dextrose for hypoglycemia, hydrocortisone 2mg/kg IV STAT. As outpatient, stress dose steroids are 3-4x regular dose.

CAH: IVF and Hydrocortisone (Solu-cortef) as below:

*2mg/kg IV OR <2yrs: 25mg, 2-8yrs: 50mg or >8yrs: 100mg

Thyrotoxicosis: give

1) High dose PTU 200-400mg q6h

2) beta blocker (IV propranolol 0.5 to 1 mg over 10 min)

3) cooling blanket

4) IVF

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Diabetic Ketoacidosis: *See treatment guidelines in online and paper manual for complete references.

Labs: bedside glucose, VBG, BMP w/ Ca, Mg, Phos, UA EKG if K> 6

*If new onset, also get HbA1C, TFT, anti-GAD, ICA-512, anti-islet and anti-insulin cell antibodies

Management: Fluid bolus 20ml/kg NS over first hour then repeated as necessary for cardiovascular instability or evidence of moderate to severe dehydration.

NO insulin boluses.

If pH <7.24 and/or HCO3 <16 and urine ketones:

Start Insulin Drip at 0.1U/kg/hr and Normal Saline at 1.5-2 times MIVF for first 6-8hrs, then change to ½ NS

Labs: Q1h glucose at bedside

Q1-2h VBG and BMP

If K+ <5.5-6, add K+ as 20mEq/L KCl and 20mEq/L KPhos

If BG <300, add D5 to fluid to support glucose but continue insulin drip to correct acidosis. Add D10 with lower glucoses.

Cerebral Edema:

If patient shows alteration in mental status, give Mannitol 0.5mg/kg or 3%NS 2-4cc/kg then get Head CT. Decrease IVF to 2/3 MIVF.

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Hyperosmolar Hyperglycemia Syndrome: Often presents late with severe dehydration and associated morbidity.

Diagnosis: Glucose >600, pH >7.3, small to no ketones; Osmolality > 320

Watch for risk of thrombosis, rhabdomyolysis, renal failure, hyperthermia, cerebral edema, and arrhythmias

Treatment:

• NS boluses at a rate to restore perfusion (often enough to correct glucose)

• Change to 0.45% - 0.75% NS: to replace deficit (goal is drop Na by 0.5mEq/L/hr)

• Electrolyte abnormalities as in DKA (can be much worse)

• Insulin drip at 0.025-0.05U/kg/hr if fluid alone does not drop glucose >  50mg/dL/hr

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Headaches: Indications for imaging: progressively worsening headache; early morning headaches or pain that awakens children from sleep; abnormal neurologic exam; children < 3y with unexplained severe headache.

**Consider blood sugar/urinalysis for patient with new onset recurrent headaches

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Migraines: *See portal for additional information. Diagnosis: based almost exclusively on the history, supported by the absence of abnormalities on exam.

Treatment: Regimens address 3 major mechanisms in the pathogenesis of migraine:

• dopaminergic hypersensitivity • inflammation • 5-hydroxytryptamine (5-HT) metabolism

**Hydration with NS Analgesics:

• Acetaminophen 15mg/kg po, max 1000mg • Ibuprofen 10mg/kg po, max 600mg • Ketorolac 30-60mg IM or IV

Antiemetics:

• Prochlorperazine 0.1mg/kg PO/IV/IM, max10mg • Reglan 0.5-2mg/kg PO/IV, max 10mg • Phenergan 0.25-1mg/kg PO/ IV/IM, max 25mg

Antimigraine agents:

• Sumatriptan 10mg intra-nasal, 6 to 11 years of age; 20mg intra-nasal, 6mg SC or 100mg PO, 12 or greater years of age OR

• Dihydroergotamine 0.5-1mg/dose IV/IM Other options:

• Dexamethasone 10 to 20mg PO/IV/IM

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Acute Scrotum Pathway Patient presents to ED with complaint of scrotal pain concerning for testicular torsion •Acute onset < 6 hours, tenderness to palpation, swelling, abnormal testicular lie, loss of cremasteric reflex

•High suspicion for testicular torsion •Make NPO, obtain IV •Consult urology resident immediately • Obtain US* to confirm diagnosis but do not delay consult *notify radiology resident the need for urgent US looking for torsion

•Negative or indeterminate US •Exam and history less concerning for torsion and/or labs and exam consistent with epididymitis •Pain developing over several days, + Prehn's sign, dysuria, urethral discharge, point tenderness

•Treat epididymitis with antibiotics and ASAP to urology for follow-up in 1 week •STD/STI Suspected: Doxycycline 100mg PO BID for 10-14 days PLUS cetriaxone 250mg IM once or cefixime 400mg PO once •STD/STI Not Suspected: Ciprofloxacin 500mg PO BID for 10-14 days or Levofloxacin 750mg PO daily for 10-14 days for children >8 years. < 8 years TMP/SMX 8-12 mg/kg/day divided BID

•Exam or history concerning for intermittent torsion •Discuss with urology resident; arrange for patient to be seen within 24 hours in urology clinic

•Intermittent pain, pain > 6 hours, suspicion for infection, fever •Obtain US* and urine dip and culture *notify radiology resident the need for urgent US looking for torsion

•US positive for testicular torsion •Consult urology immediately

•US positive for torsion of the testicular appendix •Discuss with urology and advise family on pain control. D/C with specific instructions: loose-fitting underwear, testicular elevation, NSAIDS. ASAP to urology for follow-up in 1 week

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Hematology/Oncology: Neutropenia Defintion: Based on Absolute Neutrophil Count (ANC cells/cmm)

• Mild: 1000-1500 Moderate: 500-1000 • Severe: <500 Profound: <200

Etiology: -Viral infection (most common) -Drugs (2nd most common): Anticonvulsants, antibiotics, antipsychotics, anti-thryroid medication, -Malignancy and chemotherapy, -Autoimmune neutropenia including lupus, IBD -Congenital disorders: Kostman syndrome, Schwachman diamond syndrome etc, -Cyclic neutropenia -Storage diseases: GSD type1b.

Fever and Neutropenia (in oncology patients) Definition: ANC < 500/cmm and Fever >38.5ºC (orally) or >38ºC twice 4 hours apart

Examine fully and monitor VS closely

Special Considerations: No suppositories or rectal temperatures No IM injections If you believe you need a urine cx and patient is in diapers, Use a bag…NO CATH (can introduce bacteria).

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Risk of serious infection increased when ANC < 500/ mm3

• Bacteremia risk increases w/ decreased ANC • Fever can be the only sign of serious infection • Neutropenia often occurs 7-10d after chemo

Labs ASAP: (use neutropenia order set!) – CBC with diff and plt – Blood cx from each lumen of CVL, no peripheral cx – BMP – Hold type and screen – Coags (w/ fibrinogen and D-dimer) if ill-appearing – UA and urine cx in small infants but NO CATH (can

introduce bacteria) – Culture and PCR of any wound/lesion – CXR if respiratory symptoms

START ABX as soon as cxs obtained; do not delay! All Patients: Cefepime 50mg/ kg/dose q8h (max 2gm) OR Meropenem 40 mg/kg/dose (max 2gm) If Hypotensive with chills:

Cefepime OR Meropenem PLUS Tobramycin AND Vanc Bolus IVF

If Abdominal pain: Cefepime, Tobra AND Flagyl (7.5mg/kg) Consider CT or KUB to look for typhlitis Consider stool cx for C. diff

Presumed CVL and tunnel infections: Cefepime and Vancomycin (20mg/kg)

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Hyperleukocytosis: *Acute leukemia esp. T cell ALL often presents with hyperleukocytosis *Usually symptoms seen if WBC >100,000. The risk of hyperviscosity is greater with AML than with ALL (myeloid cells are “stickier” than lymphoid cells.) Clinical sequalae:

• Hyperviscosity and sludging leading to stroke, altered mental status, renal failure and hypoxia with increased pulmonary markings diffusely on chest x-ray

• DIC • Tumor lysis syndrome

Management:

• Hydration, alkalinization, allopurinol, monitoring renal function (see tumor lysis syndrome management)

• Correct coagulopathies (more prominent with AML) • Keep Hbg< 10mg/dL as PRBC’s will increase viscosity Leukopheresis: • Symptomatic patients regardless of WBC count • Asymptomatic patients with WBC >100,000 (Recent

evidence suggests that >300,000 esp. in ALL patients) • Avoid in AML type3 (acute promyelocytic) as it may

induce DIC due to granular blasts • Treatment of underlying malignancy

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Tumor Lysis Syndrome: • Secondary to spontaneous (Burkitt’s) or treatment-related tumor

necrosis

• Acute lysis of tumor cells results in rapid release of K, phosphates and nucleic acids which results in:

• Hyperkalemia: cardiac arrhythmias

• Hyperuricemia: renal failure

• Hyperphosphatemia, and resultant hypocalcemia: Tetany, seizures, cardiac arrhythmias

• Multi-organ system failure

Management:

• Vigorous hydration: IVF D5 1/2NS +40 meq/L NaHCO3 at 2x maintenance OR 3000 ml/m2 *NO K+ in IVF*

• Alkalanize urine, goal urine pH 7-7.5 (uric acid is more soluble in alkaline pH), don’t overshoot >7.5 as calcium stones may form

• To inhibit production of uric acid from xanthine, start Allopurinol (po): <20kg: 50mg tid, 20-40kg: 100mg tid, >40kg: 200mg tid

• Consider using Rasbiuricase for severe hyperuricemia (Recombinant urate oxidase converts already existing uric acid to water soluble inert Allantoin)

• Monitor lytes, Mag, Ca, Phos, uric acid and renal function; Q4-6 h labs for high risk pts and Q12h for lower risk

• Consider dialysis if symptomatic HyperK and Hyperphos/ HypoCa, worsening renal function and/or volume overload

37

Anemia

• Check vital signs, hypoxia and bleeding manifestations • See tables below and perform labs pertinent to your

clinical suspicion • Refer to PRBC transfusion guideline •

Low or Normal Reticulocytes High Reticulocytes

Hypochromic Microcytic (MCV < 78) iron deficiency

• thalassemia • lead poisoning • chronic disease • sideroblastic anemia

*Treated nutritional deficiency

Normochromic Normocytic (80 < MCV < 100)

• chronic disease • liver disease • uremia • endocrine disorders

(hypo/hyperthyroid, Addison’s) • connective tissue diseases • primary marrow abnormalities • myelodysplasia • infiltration (leukemia, metastates) • myelofibrosis • aplasia

*Hemolytic anemia *Post hemorrhagic anemia

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Macrocytic/Megaloblastic (MCV > 100)

• Megaloblastic o B12 / folate deficiency o drugs (MTX,

cyclophosphamide, o nitrous oxide, arsenic)

• Macrocytic o hypothyroidism o hypoplastic marrow, aplasia o liver disease o alcohol o smoking

Differentiation of common causes of microcytic anemia

Fe def Thal Trait Infectious

Hgb

MCV Normal

RDW Normal Normal

FEP Normal

TIBC Normal

Ferritin Normal Norm/

39

Thrombocytopenia

*Normal platelet count is 150,000-400,000/cmm (including premies and newborns)

Etiology:

1) Increased destruction (most common)

• Immune • Primary: Idiopathic thrombocytopenic purpura (ITP)

[most common & a diagnosis of exclusion] • Secondary: Drugs (heparin), SLE, Common Variable

immunodeficiency, Evans syndrome • Non-immune • TTP/HUS • DIC • Drugs: anticonvulsants (valproate)

2) Decreased production • Infection/sepsis • Malignancy/chemotherapy • Aplasia • Thrombocytopenia-absent radiai syndrome (TAR) • Congenital amegakaryocytic thrombocytopenia 3) Sequestration • Hypersplenism • Kasabach-Meritt syndrome (kaposiform

hemangioendothelioma with DIC)

40

Idiopathic Thrombocytopenic Purpura (ITP)

• Peak age 3-4 years

• Prodromal viral symptoms in 2/3 of cases

• Mainly mucocutaneous bleeding: Petechiae, epistaxis, ICH very rare

**RED FLAGS: presence of LAD, HSM and decrease in other cell lines

**Initial investigations: CBC with diff and platelets, Peripheral smear, DAT, Rh type, serum Ig G,A,M levels, ANA, C3&4.

Treatment:

• Symptomatic patients other than petechiae (regardless of platelet count)

• Asymptomatic patients with platelet count <20,000

Drugs: (premedication often necessary) • WinRho 75 microgram/kg IV (only for Rh+ patients

with normal Hb) OR • IVIG 1g/kg IV infusion • Prednisone 4mg/kg/day for 4 days (NEED BMA prior

to starting steroids) • Avoid NSAIDS (causes platelet dysfunction)

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• Platelets transfusions are used only in patients with intractable bleeding refractory to other treatments. (see transfusion guidlelines)

DIC/Coagulopathy: Etiology: Shock, Hemorrhage, Infection, Acidosis, Liver failure, Malignancy (esp APML), TTP/HUS etc Diagnosis:

– Plt count decreased – PTT/ PT prolonged – Fibrinogen decreased – Fibrin Split Products increased – Peripheral Smear microangiopathic changes

(helmet cells, schistiocytes) Supportive Care:

• FFP *Contains all clotting factors *Give 10ml/kg to keep PT/PTT < 1.5 x uln

• Platelets • Cryo

*Prepared from solid fraction of thawed FFP *Enriched in fibrinogen, vWF, Factor VIII *Give 5ml/kg (each unit contains 20ml) to keep fibrinogen >100mg/dL

42

Transfusion Guidelines: Red Cell Transfusions Product Parameters:

• hematocrit: 50-65% • volume: 250-300mL • shelf-life: 42 days

Indications: • patients with a symptomatic deficiency in oxygen-

carrying capacity • children/adolescents:

o Hgb any level with symptomatic anemia o Hgb < 8.0g/dL perioperative period o Hgb < 13.0g/dL with severe

cardiovascular disease o Acute blood loss > 25% blood volume

• infants: o Hgb any level with symptomatic anemia o Hgb < 10.0g/dL perioperative period o Acute blood loss > 25% blood volume

Compatibility; ABO selection: Red Cell Type Patient Type

1st Choice

2nd Choice

3rd Choice

4th Choice

AB AB A B O A A O B B O O O

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Dosing/Response:

• Dosage: 10-15mL/kg infused over 2-4 hours for anemia (STAT if acute blood loss)

• Expected response: Hgb ↑ 2-3 g/dL Clinical considerations:

• Leukoreduction: o all products are leukoreduced o reduces risk of febrile reactions o CMV-safe

• Irradiation (Graft versus Host Disease risk) o Must be requested o Immunocompromised patients including:

blood for intrauterine transfusion, premature neonates, congenital immunodeficiency, exchange transfusion for HDFN, bone marrow (stem cell) transplant patients, hematologic malignancy or solid tumor on ablative chemotherapy or radiotherapy, recipient of familial blood donation

• Washed: o Remove residual plasma o IgA deficient patients (anaphylaxis) o Intractable allergic reactions

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Transfusion Guidelines: Platelet Transfusions Product Parameters:

• Single donor (apheresis platelets): 3.0 x 1011 platelets/unit

• Volume: ~250mL • Shelf-life: 5 days

Indications: • bleeding due to thrombocytopenia • prophylaxis in thrombocytopenic patients

o < 50,000/µL with significant bleeding or planned invasive procedure

o < 50,000/µL neonates o < 20,000/µL with risk factor for bleeding

(sepsis, fever, etc.) o < 10,000/µ with no risk factor for

bleeding Dosing and Response:

• Dosing: 5-10mL/kg • Expected response: ↑~50,000/µL

Clinical considerations: • Leukoreduction:

o Same as red cell transfusion • Irradiation (Graft versus Host Disease risk):

o Same as red cell transfusion • Washed:

o Same as red cell o Washing procedures tend to cause

damage to platelets and should be avoided if possible (expect 20-40% reduction in post-transfusion platelet count)

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Transfusion Guidelines: Plasma and Cryoprecipitate Transfusion Product Parameters:

• Frozen plasma: stored -18°C for 1 year; volume ~250mL

• Cryoprecipitate: stored frozen -18°C for 1 year; each unit contains ~440mg fibrinogen in a volume of 10-30 mL

Indications: • Plasma: PT or aPTT > 1.5 times normal due to a

deficiency of clotting factors (do not use when coagulopathy due to a deficiency of factors VIII or IX alone)

• Cryoprecipitate: ↓fibrinogen Compatibility:

• Plasma and cryoprecipitate should ABO compatible with patient’s red cells

Dosing and Response: • Plasma: 10-15mL/kg; should ↑factor levels 15-

20% • Cryoprecipitate: 1 unit/10kg; should ↑fibrinogen

60-100mg/dL Clinical considerations:

• Irradiation (Graft versus Host Disease risk): o Need for irradiation controversial

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Transfusion Guidelines: Granulocyte Transfusion Product Parameters:

• 1.0 x 109 neutrophils/unit • Must be ordered 24-48 hours before need • Shelf-life 24 hours (transfuse as soon as possible) • Will be provided before infectious disease testing

completed Indications:

• Documented infection • Failed trial of antibiotics • Granulocyte count < 500/mm³ • Neonatal sepsis

Compatibility: • Must be ABO compatible (same as red cell

transfusion) Dosing and Response:

• 15 mL/kg; repeat daily • Daily until clinical improvement (5-7 days) • Most effective in bacterial infections; less effective

in fungal infections Clinical considerations:

• Irradiation (Graft versus Host Disease risk): o Same as for red cells

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Hemophilia A and B

Hemophilia A: Factor VIII deficiency and Hemophilia B: Factor IX deficiency (Christmas Disease)

Both are X-linked recessive disorder

Normal Factor activity is 50-150%

Severity of Hemophilia A and B (based on factor activity level) Mild: 5-25% - bleeding with surgery or trauma Moderate: 1-5% - bleeding with mild injury Severe: <1% (most common) – spontaneous bleeding

Clinical manifestations (hemophilia A & B are indistinguishable)

- Hemarthrosis (most common) - Soft tissue hematomas (e.g., muscle) - Other sites of bleeding: 1. Urinary tract

2.CNS, neck (may be life-threatening) - Prolonged bleeding after surgery or dental extractions

Laboratory diagnosis - Both will cause prolonged aPTT with normal pT - DO NOT OBTAIN BLEEDING TIME (NOT DONE ANYMORE) - Low Factor VIII (hemophilia A) and Factor IX (hemophilia B)

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- Factor VIII deficiency can be diagnosed at birth as newborns including premies have normal levels - Factor IX deficiency may be difficult to diagnose at birth as it is low up to 6 months of age (exception severe cases with positive family history)

Treatment guidelines Recombinant Factor products:

• Factor VIII (Helixate-FS), Factor IX (Benefix) • Dosing: One unit/kg of Factor VIII increases plasma

factor activity by 2%. Example: To obtain 50% factor activity in a 25kg child with hemophilia A, you need to give 625 Units of Helixate (FVIII dose (U) = body weight (kg) X desired FVIII increase (%) X 0.5 U/kg)

• Whereas, one unit/kg of Factor IX increases plasma factor activity by 1%. Example: To obtain 50% factor activity in a 25kg child with hemophilia B, you need to give 1250 Units of Benefix (FIX dose (U) = body weight (kg) X desired FIX increase (%) X 1U/kg)

• Mild bleeding Hemarthrosis, oropharyngeal or

dental, epistaxis, hematuria Target increase: 30-40% factor

activity; 1-2 days

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• Major bleed CNS trauma, hemorrhage, lumbar

puncture Surgery Retroperitoneal hemorrhage GI bleeding Target increase: 80-100% factor

activity; 7-14 days Adjunctive therapy

Amicar (epsilon aminocaproic acid) Anti-fibrinolytic agent useful in mucocutaneous bleeds Dose: 100mg/kg/dose q6hours PO for 4-5 days Contraindicated in patients with hematuria (it can cause clots in urogenital system)

DDAVP • Useful only in mild Hemophilia A patients (it releases

FVIII from endothelial cells) • Dose: 0.3 µg/kg q 12 hr IV for only maximum of 3

days Or Stimate nasal spray (150 mcg) (for children >5 years) one spray if < 50Kg or two sprays >50kg for only maximum of 3 days

• Dose and formula is different from treatment of enuresis

• Side effects: Flushing, hyponatremia –seizures, tachyplaxis.

• Need to have DDAVP challenge test to assess the patient’s response (done soon after diagnosis)

• Contraindicated in children <2 years (causes dilutional hyponatremia)

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vonWillebrand’s Disease

Most common inherited bleeding disorder worldwide von Willebrand factor is synthesized in endothelium and megakaryocytes and forms a large multimer to carry factor VIII and anchors platelets to subendothelium as bridge between platelets Inheritance - autosomal dominant Clinical features - mucocutaneous bleeding; epistaxis, menorrhagia etc.

Classification

- Type I: Partial quantitative deficiency of vWF (70% of cases, mild-moderate disease)

- Type II: Qualitative deficiency of vWF (25% of casese, mild to moderate disease)

- Type III: Total or near total deficiency of vWF (5% of cases, severe disease) Diagnosis

- Prolonged aPTT in 50% of cases (due to low factor VIII). Normal aPTT does not rule out vWD.

- Normal PT - Prolonged bleeding time; DO NOT PERFORM. This

is replaced by PFA-100 which is not available at MUSC (assess platelet function)

- Send vWF antigen level and activity, Factor VIII, Ristocetin cofactor assay, vWF multimeric analysis

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Treatment • DDAVP: Useful in mild cases (Type I),

contraindicated in Type IIB, not useful in Type III. See hemophilia section for dosing details

• vWF replacement therapy: Humate-P (recombinant

product): The dosage of Humate-P® required (IU VWF:RCo) = body wt. (kg) x desired % increase in VWF activity ÷ 1.5. As a rule, 40-80 IU VWF:RCo per kg body weight are given every 8-12 hours. The dose should be adjusted according to the type of VWD and the extent and location of the bleed.

• Adjunctive therapy with Amicar (see hemophilia section)

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Superior Mediastinal/Vena Cava Syndrome Usually seen in Hodgkin’s and Non-Hodgkin’s lymphoma, T cell ALL

Clinical features • Plethora, facial swelling • Engorged neck and facial veins • Orthopnea, hypoxia, dizziness • Dysphagia and drooling are late ominous signs (as

espophagus is posterior)

Management: • Airway control is very important • Supplemental Oxygen • CXR, CT or MRI to access the airway. Avoid sedation • Place IV in legs. DO NOT PLACE IV IN UPPER

EXTREMITIES (as it drains to SVC which is already obstructed)

• Emergency treatment includes Steroids, radiation which often precedes any diagnostic study

• Attempt to diagnose underlying malignancy if possible (eg. BMA and Bx under local anesthesia, pleural or pericardiocentesis)

53

Fever and Sickle Cell Disease Temperature ≥ 38.5C Presume bacteremia until proven otherwise Labs: -CBC with diff and reticulocyte count, BCx if <12yrs -CXR if any respiratory symptoms -Other cultures as indicated (or in neonate) Treatment: -Ceftriaxone 75 mg/kg IV or IM immediately; max 2G Disposition: -Once labs available, discuss all patients with H/O fellow or attending; Augmentin po for 3 days if discharged -Admit febrile patients with SCD if exclusion criteria for outpt not met (see manual for specific criteria). -Arrange follow-up for all patients in 24H for repeat dose of Ceftriaxone, to review blood culture, and for clinical evaluation. *Notes on Blood Transfusions for Sickle Cell Patients

1. Antigen-match blood when time allows 2. Goal Hgb <10 (>10 causes blood to be viscous)

*Note on Supplemental Oxygen for Sickle Cell Patients Avoid unnecessary O2 which may suppress reticulocyte count and exacerbate anemia

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Sickle Cell Pain Crisis

History - Nature, location, duration, and severity of pain - Character of pain similar to previous sickle pain - Analgesics already used for this episode - Associated symptoms- esp fever or dehydration - Consider etiologies other than sickling - Previous experience with analgesics (efficacy and

side effects). What does patient / family feel best alleviates pain? Physical Exam: complete with emphasis on:

a. Vital signs b. Hydration status c. Degree of pallor d. Evidence of infection e. Cardiopulmonary status f. Spleen size (compare with baseline exam) g. Penis (priapism) h. Neurological

Laboratory - CBC, diff, platelets, and reticulocyte count (compare

with patient’s baseline values) - Blood culture if febrile (T > 38.5oC) - Type and crossmatch if extreme pallor, respiratory or

neurological symptoms, or acute splenic enlargement present. - CXR and pulse ox if: chest pain, cough, tachypnea or

respiratory symptoms - Consider abdominal ultrasound and liver function

tests for RUQ, epigastric pain (R/O cholelithiasis/cholecystitis)

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Treatment: - IVF: D5 ½ NS at 1.5 times maintenance

If acute chest syndrome, D5 ½ NS at ¾ maint. - Medications

NSAIDs: Ketorolac (Toradol) 0.5 mg/kg (30 mg maximum dose) IV OR Ibuprofen 10 mg / kg PO (800 mg maximum dose) Antipruritic: Diphenhydramine 1 mg/kg PO prn itching (50 mg max dose) Opioids: < 50 kg: Morphine 0.1-0.15mg/kg IV OR Hydromorphone (Dilaudid) 0.015-0.02 mg/kg > 50 kg: Morphine 5-10 mg IV OR Hydromorphone (Dilaudid) 1.5 mg IV.

Titrate Opioid for 2 hours -Titrate with ¼ to ½ of the initial opioid dose q 30 minutes until patient experiences relief or is sedated (Opioid sedation scale >=3, see below) -Reassess pain and degree of relief q 15-30 min. Adequate pain control is defined as a 50-60% reduction in the pain score (see Wong-Baker Faces Pain Rating Scale below).

Disposition:

- Treat patient as outlined above for 2 hours. If pain is controlled, give dose of the patient’s prescribed oral opioid analgesic(s). - If pain relief is maintained for 1 hour following oral analgesic, discharge home with appropriate prescriptions and follow-up per Hematologist on-call. - If pain is not controlled, start scheduled opioid, notify Hematologist on-call and admit to hospital.

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Schedule opioid q 1-2 hours and calculate scheduled dose as in Section 4b. above. - Give “rescue doses” at ¼ to ½ scheduled dose at 30 minute intervals between scheduled doses. OR start PCA pump (consult Hematologist on call).

Opioid Sedation Scale S = Sleep, easy to arouse 1 = Awake and alert 2 = Slightly drowsy, easily aroused 3 = Frequently drowsy, arousable, drifts off to sleep during

conversation 4 = Somnolent, minimal or no response to physical stimulation McCaffery M, Pasero C: Pain: Clinical manual, p. 267. Coypright © 1999, Mosby, Inc.

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Sickle Cell And Acute Chest Syndrome -Any acute illness associated with lower respiratory symptoms, chest pain, hypoxia, or a new infiltrate on CXR Labs: -CBC with diff/plt and reticulocyte count -CXR -Blood culture if febrile -Consider renal function and liver function tests if severe pain -ABG if severe respiratory compromise -Type and cross match for PRBC (minor antigen matched, sickle negative) Treatment: -IVF at 0.75 x maintenance -Oxygen to maintain O2 sats ≥94% -Incentive Spirometry on all patients -Morphine or dilaudid boluses -Ketorolac 0.5mg/kg/dose IV Q6H (max 30mg/dose) -Ceftriaxone 75mg/kg/dose IV -Zithromycin -Consider bronchodilators if patient has a history of reactive airway disease -Consider RBC transfusion for severe illness or HgB>1g/dL below baseline Admit anyone with acute chest syndrome to the PICU

.

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Wound Closure/Suturing 1. LET (takes 20-30 min. to work) or injected lidocaine (1%)

-buffered lido (1mL Bicarb:9mL Lido) to reduce pain -lido with epi for hemostasis but avoid on digits, penis, tip of nose and ears -toxic dose of lido 5ml/kg; buffered or with epi max dose is 7ml/kg

2. Preparation: Irrigation; Betadine prep

Suture Types:

Skin: Face: 6-0 Ethilon/Nylon or Prolene Or 5.0 Fast absorbing gut

Hands: 5-0 Ethilon/Nylon or Prolene Extremities: 3-0 or 4-0 Ethilon/Nylon or Prolene Scalp: Consider staples, sutures, hair apposition technique Subcutaneous suture: Vicryl/ Absorbable suture;

usually same size as skin Oral cavity: Chromic gut 5-0 or 6-0 Other options: Steri strips and/or Dermabond

Time to suture removal (non-absorbable sutures): Scalp: 5-7 days for staples Face: 3-5 days Extremities: In general, re-check at 5-7 days, may take 8-10days for full healing, especially joints.

Don’t forget tetanus! <7years DTaP; 7-10y Td; >10y TdaP Give tetanus booster if risky wound (e.g. rusty nail) and >5 yrs since vaccine or if >10 yrs since vaccine and clean wound

59

Care of Animal and Human Bites History: Type of animal involved Behavior of animal: Provoked versus Unprovoked. Location and current owner of animal Animal’s rabies vaccination status Patient’s immunization status—last tetanus booster Physical Exam: Inspect wound Document tissue damage, tendon or bone exposure, foreign bodies, circulatory compromise, motor or sensory deficits. Imaging Studies: Radiographs generally not helpful in routine evaluation except:

1) To exclude the presence of a foreign body 2) In cases of deep scalp wounds. A large dog may be able to fracture a young child’s skull 3) Exam consistent with possible fracture—may see with bites to hands and fingers.

Consider Speciality Consultation: Plastic Surgery: if wound potentially disfiguring Hand Specialist: hand injuries involving tendons, joints, or

vasculature Orthopedics: joint, tendon, or bony injuries Neurosurgery: penetrating wounds to skull Pediatric Surgery: deep neck wounds

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Bites, con’t: - Irrigate with Normal Saline Use a minimum of 200mL/ bite, approx 100-200ml/inch - Suture: Wounds on the face Wounds less than 6 hours old.

Use minimal number of interrupted, nylon sutures. Avoid deep sutures.

- Discuss with ED attending before suturing the following bites: (prone to infection)

Puncture wounds Bite wounds of hands and lower extremities Cat and human bites Immunocompromised or asplenic hosts.

Wounds older than 6 hours old Inpatient Admissions: Severe soft-tissue injuries Penetrating skull injuries Consider admission if infection present Follow-up care: DHEC called for any dog bite Wound check: 24-48 hours Patient/ family Education:

Review signs and symptoms of wound infection. Advise family to promptly seek medical attention if signs of infection occur. Inform family of risk of infection despite proper wound care and antibiotics

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Antibiotics for Bites: Prophylactic antibiotics indicated in: Cat bites Human bites Puncture wounds Hand and foot wounds Wounds with care delayed beyond 12 hours Immunocompromised hosts Animals Organisms Antibiotics Rabies

Vaccine? Bat, Skunk, Raccoon

Unknown Augmentin or Doxycyline

YES

Cat Pasturella Multicida/ Staph

Augmentin or TMP/SMX PLUS Clinda

NO

Dog P. muticida, Staph, Bacteroides, Fusobacterium, EF-4, Capnocytophagia

Augmentin or TMP/SMX PLUS Clinda

YES

Human Viridans Strep, Staph, Corynebacterium, Eikenella, bacteroides, Peptostrep

Augmentin (Unasyn) or Clindamycin AND TMP/SMX

NO

Fish (oyster/ fish hook)

Vibrio Doxy (if >8) or Omnicef

NO

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Snake Bite Management Algorithm

63

Snake Bite Antivenom: CroFab * See portal for treatment algorithm (and help for management for Coral snake bite)!

• Works for Crotalid snakes only (not Coral snakes) • Give with signs of envenomation: Swelling, pain,

ecchymosis • Give with coagulation abnormalities • Monitor closely for hypersensitivity reaction during

administration (Benadryl and epi at bedside)

Puncture Wounds

Obtain history on time of injury, object causing injury, tetanus status and footwear worn if foot involved. Administer tetanus. Obtain xray to rule-out retained foreign body even if low suspicion for foreign body. Consider Ortho consult for deep punctures that could enter bone or joint space. Vigorous cleaning and debridement after local anesthesia or regional block. Dress wound with bacitracin and sterile gauze. Instruct family how to dress wound at home. Antibiotic therapy should be initiated to cover staph and strep with first-generation cephalosporin or Augmentin. Cover for Psuedomonas if rubber shoe sole involved in wound.

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Sedation and Analgesia Monitor patient during procedure and until fully awake.

Use End-tidal CO2 monitor with all sedations if available.

Have all airway equipment readily available.

Wall suction and BVM must be set-up and working.

Remember Time-Out Forms

For general procedures (anxiety, mild pain): Versed: po or intranasal: 0.5-0.7mg/kg

onset 15-30min; lasts 2hrs IV: 0.05- 0.1mg/kg, max 4mg Fentanyl: 1-3mcg/kg IV (max 100mcg/dose)

onset 5-10min; lasts 1hr 1.5-2mcg/kg intranasal (max 100mcg/dose)

For more painful procedures, including ortho: Versed (only small doses necessary to ease pt into sedation and

for amnesia) generally 0.5-1.0mg TOTAL Ketamine 1mg/kg IV or 2-4mg/kg IM; titrate to effect Onset 1 min; duration 5-10min Contraindicated in CHI or eye injuries as increases ICP/IOP Other options for sedation include Propofol and Etomidate. Must add analgesia for painful procedures.

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Splinting

Arm fractures: Sugar tong splint - ulnar and radial fx, Double sugar tong- fracture was reduced, manipulated, or very

proximal. Thumb spica - thumb fractures, scaphoid fx Ulnar gutter - fractures of 4 and 5th metacarpal or phalanges. Posterior long arm splint - supracondylar fractures

Distal Leg Fractures: Posterior splint with stirrup

Toddlers’ fractures (spiral distal tibial fractures) ultimately require Ortho to place long leg cast.

Salter Harris Classification:

66

Splinting continued.

67

Organic vs. Functional Psychosis

Remember that this is not an all exhaustive list and should be based on each individual case in conjunction with consulting services. Remember to consult Neurology early. Labs/ Studies:

CBC c diff, CMP, Mg, Phos TFTs, Heavy Metals UDS, EtOH, Salicylates, Acetaminophen VBG, UA, CXR, EKG, Head CT v MRI, LP

Learning Points:

New Onset Psychosis is Organic until proven otherwise IOP is not equipped to complete a medical evaluation New Onset Psychosis → plan for General Pediatric Admission Consult Psychiatry for help with -

Work up Inpatient management of symptoms

Mutual Respect – Willingness & Support

ORGANIC FUNCTIONAL

* Sudden Onset * Gradual Onset

* Pre-pubertal * Young Adulthood

Abnormal VS Normal VS

Psychomotor Retardation Ataxia

Repetitive Activity Rocking

* Visual Hallucinations * Auditory Hallucinations

Emotional Lability Flat Affect

Disoriented Oriented

Islands of Lucidity Continuous Scattered Thoughts

Impaired Consciousness Alert & Awake

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Trauma Resuscitation

Primary Survey and Resuscitation

*Intervene at each step as appropriate

A Airway Establish and maintain airway with C-spine precautions

B Evaluate Breathing Place on O2

Symmetric movement and sounds

C Circulation Check CENTRAL pulses, manual BP IV access x2 (large bore) – 20ml/kg NS Control hemorrhage

D Disability

Brief Neuro assessment (pupils, AVPU)

E Exposure Completely undress patient Obtain history from EMS

Avoid Hypothermia!! Always check GLUCOSE in setting of AMS.

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Trauma Resuscitation cont. Secondary Survey

AMPLE history (allergies, medications, PMHx, last meal, events)

Listen to EMS report! Thorough exam from head to toe:

“Finger in every orifice” - Studies:

Portable CXR +/- pelvis film if sx of LE trauma “Trauma labs:” CBC, CMP, Amylase, UA, VBG, T&S Additional imaging based on exam

Don’t forget Tetanus!

Assume spine precautions Leave C-collar on, but don’t forget to examine the neck while in in-line stabilization

Log-roll patients to examine spine Remove from spine board ASAP if no obvious abnormalities but keep flat if any spinal process pain on exam

Indications for Mass Transfusion Protocol

Trauma + Instability post 2 crystalloid bolus’ + evidence of on-going bleeding. Requires attending order for: Infuse emergent uncrossed blood and charge nurse to notify blood bank.

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Guidelines for Activation of Trauma Team Pediatric Trauma Alert Level Criteria (scene transport)

Age 15 and under Level A - Respiratory distress/intubated - Hypotension/shock* - Unconscious patient (GCS 9 or less) - Penetrating injury to head, neck, or torso - Open or depressed skull fx - Flail Chest - Limb-threatening injury □ Amputation proximal to wrist or ankle □ Crushed, degloved, or mangled extremity

□ Penetrating injury proximal to elbow or knee plus diminished or absent pulse, expanding hematoma, or ongoing bleeding

- Paralysis - Burns 2nd or 3rd degree > 40% BSA or if suspicion of smoke inhalation or hemodynamic compromise - Suspected pelvic fx with hemodynamic instability

Level B - Altered mental status (GCS 9-13)

- Burns 2nd or 3rd degree 20-40% BSA - Fall >20 feet (one story is approx 10 feet) - Ejection from vehicle; Death in same vehicle - Auto/ped or Auto/bicycle with pt thrown, run over, or with impact >20 MPH -Motorized off road vehicle or motorcycle crash >20MPH - MVC > 35mph - Attending Physician concern for serious injury

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8 P’s for Rapid Sequence Intubation 1. Preparation: O2 ECG Monitor

BVM Tracheal tube size and +/-0.5 tube size Stylet Suction

Drugs as below Consider NG tube 2. Pre-assessment Difficult to bag? Difficult to intubate? 3. Pre-oxygenate - Use NRB, have BVM available 4. Pretreatment (LOAD):

a. Lidocaine 1-1.5mg/kg if suspected head injury *most effective if given 4 min prior to intubation b. Opiod (Fentanyl) 2-3mcg/kg

c. Atropine 0.02mg/kg (0.1mg min -0.5mg max) *decreases vagal response and oral secretions, use when <1yo and always when using Succ d. Defasciculation: 1/10 nondepolarizing paralytic if using depolarizing paralytic such as succinylcholine 5. Paralysis after induction: a. Sedative/Hypnotic Versed 0.1-0.2 mg/kg Onset 1-5min, duration 30-60min Etomidate 0.3mg/kg Onset 15-30sec, duration 1-5min * Good for head trauma with stable hemodynamics, because can decrease bp Thiopental 2-5 mg/kg Onset 15-20sec, duration 5-10min * Can cause decreased bp and histamine release Ketamine 1-2mg/kg (see sedation) * Good for asthma, shock states

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Propofol 1-3mg/kg Onset 15-30sec, duration 10-15min * Can cause decrease in bp. * Avoid in soy or egg allergy patients b. Paralytic Agents Rocuronium 1mg/kg Onset 30 sec, Duration 30-45min Succinylcholine 1-2mg/kg (non-depolarizing) * Not preferred in increased ICP, crush injury, burns, hyperK, neuromuscular disorders, penetrating eye injuries Onset 45 sec, Duration 4-5min Vecuronium 0.1-0.2mg/kg Onset 30 sec, Duration 30-60min 6. Placement: shoulder roll, sniffing position, cricoid pressure 7. Placement with proof: (CO2 detector, auscultation) 8. Post-intubation care: Sedation and Paralysis; continuous ETCO2 monitoring

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Tube/Line sizes Uncuffed ETT= (age/4) + 4 ETT depth= 3 x internal diameter ETT CVL NGT Chest

tube Foley Catheter

Newborn

3.0-4.0

3F

5-8F

10-14F

5-8F

2-12mo

3.5-4.0

3F

8-10F

14-20F

8F

12-24mo

4.0-4.5

4F

8-10F

14-24F

8F

2-3 yrs

4.5

4F

8-10F

14-24F

8-10F

4-5 yrs

5.0-5.5

4-5.5F

10-12F

20-32F

10F

6-7yrs

5.5-6.0

5.5F

12F

20-32F

10F

8-11yrs

6.0 cuffed

5.5F

14F

28-38F

12F

12-15yo

6.5-7.0 cuffed

5.5-6F

14F

28-38F

12-16F

>15yo

7.0-8.0 cuffed

7-8.5F

16-18F

28-38F

14-16F

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Vasoactive and Inotropic Drugs

Rule of 6: mix 6mg/kg in 100ml D5W: 1ml/hr = 1ug/kg/min Drug Dosage Receptors Usual

Effect/Usage Dopamine 0.5-

3ug/kg/min 5-10 10-25

Dopaminergic β-adrenergic ∝-adrenergic

Dilation in renal, mesenteric, cerebral vasc. Mostly inotropic (↑cardiac output) ↑HR, vascular resistance, BP

Dobutamine 1-20ug/kg/min

β-adrenergic Inotropic, vasodilation

Epinephrine 0.02-0.1ug/kg/min 0.1-1

β-adrenergic ∝ and β-adrenergic

Inotropic ↑Vascular resistance and BP: for “cold shock”

Norepinephrine 0.05-0.5ug/kg/min

Mostly ∝-adrenergic, some β1

↑Vascular resistance: for “warm shock”

Phenylephrine (neosynephrine)

0.5-8ug/kg/min

∝-adrenergic only

↑Vascular resistance; maintain MAP and CPP

Milrinone (primacor)

Loading dose: 50ug/kg slowly Infusion: 0.25-0.75ug/kg/min

P-diesterase inhib: potentiate β receptor stimulation

Inotropic, vasodilation

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Nitroglycerin 1-5 ug/kg/min None Systemic and pulmonary vasodilation

Sodium Nitroprusside

0.5-10 ug/kg/min

None Systemic and pulmonary vasodilation

Labetolol Hypertensive emergency: intermittent dose @ 0.3-1mg/kg/dose Q 10min PRN; max 20mg/dose. Infusion: Harriet Ln

∝ and β-adrenergic antagonist

Patient should be supine. Refer to Harriet Lane and other sources for side effects, contraindications

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Goal-Directed Shock Guidelines *See Septic Shock Order Sheet and portal for Flowchart Identify Shock: Compensated - Tachycardia, tachypnea with

poor perfusion (cap refill >2s) and/or AMS

Decompensated- Above sx and systolic BP low for age ( < 70 + age x 2; newborn <60; 10y and above <90) 0-5 mins -Start O2 and airway management; consider ETCO2 monitor -IV access x 2 ; IO if unsuccessful -Labs: Accucheck, Blood culture, cbc, cmp,venous blood gas, cortisol, lactate, coags -Calculate baseline shock index (HR/SBP) -Bolus IVF: 60 ml/kg NS (Ringers lactate for burns) over 15 minutes -Pressure bag, Push/Pull method or Rapid Infuser – no IV pump -If any concern of sepsis, start antibiotics 15-20 -Reassess vitals, cap refill and mental status with each mins 20ml/kg Fluid-refractory shock: 1) Catecholamines: A) Dopamine: begin 10mcg/kg/min B) Next line: Epinephrine (0.05mcg/kg/min) if cold shock

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Norepi (0.01mcg/kg/min) if warm shock or spinal cord injury 2) If hypotension unresponsive to IVF:

A)Consider bedside US to rule out cardiac tamponade B) If rales/hepatomegaly, consider Dobutamine for cardiogenic shock

3) Consider sedation with ketamine for CVL placement, CVP monitor, foley catheter Caveats: 1) Trauma: Transfuse pRBCs 10-20ml/kg after 60ml/kg NS if no improvement 2) RSI: consider Atropine/Ketamine/Paralytic 3) Hydrocortisone: Shock dose 50 mg/kg for catecholamine resistant shock and/or suspected adrenal insufficiency Goals : Cap refill <3s; normal systolic BP for age; improving shock index (HR/SBP), normal mental status

78

Radiology Helpful Tips:

• CT: o Trauma head – WITHOUT contrast o Mass head – WITH contrast (consider CTA/ MRI

for vascular issues) o Soft tissue neck– WITH contrast o Abdominal (for appy)– WITH IV and PO contrast o Facial & Orbit fractures – “limited facial bones

non-contrast CT”

• Ultrasound: o Abd (for appy or intussusception)-empty bladder o Pelvic for ovaries/torsion – full bladder, WITH

Doppler (can use foley to fill bladder if necessary) o Testicular – WITH Doppler

• Xrays:

o All Extremity films-order as “***** Series” o Knees –always include sunrise view (for patella) o Hips – “bilateral AP with Frog-leg” o Cspine – adequate views must include top of T1 &

odontoid view (if able) o CXR AP = portable o CXR lateral can only be portable if <10kg o Skeletal Surveys: preferred in daytime for tech

skill