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TRANSCRIPT
10/11/2017
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SCARY INFANTS AND CHIDREN:
IT’S NOT THAT COMPLICATED
Richard M. Cantor, MD FAAP/FACEPProfessor of Pediatrics and Emergency Medicine
Director, Pediatric Emergency ServicesMedical Director, CNY Poison Control Center
Golisano Children’s HospitalSyracuse NY
Overview
Cases
CHF
Cyanosis
Pallor
Shock
Objectives
� Present the common critical scenarios
� Outline the most utilized traditional therapies
� Highlight the pitfalls in care
� Describe novel approaches
General Management Principles
Problem: Vascular Access
� Any interventions will necessitate vascular access
� What is available?
� The usual sites
� Hand
� Antecubitus
� Foot
� Saphenous
Problem: Vascular Access
� Alternative Access in Infancy: Scalp Veins
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Problem: Vascular Access
� Alternative Access in Infancy: Scalp Veins
Problem: Vascular Access
� Alternative Access in Infants
Less Than 14 days: Umbilical Vein Approach
Problem: Vascular Access
� Alternative Access in
Infants Less Than 14 days: Umbilical Vein
Approach
Problem: Vascular Access
� Alternative Access in Infants Less Than 14 days:
Umbilical Vein Approach
Problem: Vascular Access Problem: Vascular Access
� Intraosseous Approach
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Problem: Airway
� Intubation is indicated
� Regardless of age, RSI is indicated
� ALL drugs (except Etomidate) have been accepted for use in general practice
� Benzos alone are useless
Problem: Airway
Problem: Airway
ALWAYS get the air out!
Other Pitfalls in Infant Stabilization
� You must identify and correct hypoglycemia at the
bedside
� Normothermia must be maintained
� Something ALWAYS goes wrong with the airway!
Case:
An Abject Failure
Case: Shock To The System
� A 3 week old presents with a 1 day history of poor
feeding and apparent respiratory distress
� Birth history and HPI unremarkable
� Afebrile, HR 160, RR 40, BP 50/30, OSAT 90% in RA
� Cool extremities, capillary refill 5 seconds
� All peripheral and central pulses are weak
� Grunting with retractions, poor air entry
� No murmur
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Case Discussion
� This infant is in uncompensated shock
� Unclear etiology at this point
� Septic ?
� Hypovolemic?
� Cardiogenic?
� Accompanying respiratory failure
Case Progression: Circulation
� Could this be distributive or septic shock?
� There is no history of volume loss
� After blood cultures obtained, antibiotics are indicated
� Cefotaxime
� Ampicillin (Listeria)
Case Progression: Circulation
� Undifferentiated neonatal shock
� Volume is indicated
� 10 - 20 cc/kg NS push
� Repeat up to 60 cc/kg
� Obtain CXR to check heart size as a rough estimate
of vascular status
Case Progression: Circulation
� Given 60 cc/kg NS
� Respiratory distress increases
� Hepatomegaly
� CXR
Case Progression: Circulation
� Could this be congenital heart disease?
� NOT the cyanotic variety
� Present early (ie first few days)
� Would fail hyperoxia challenge
� Most likely a ductal dependent lesion
Congenital Heart Disease
Presenting as Failure in Infancy
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Left Sided Outflow Obstruction Case Resolution
� The child is in CHF
� Given Prostaglandin E1
� Perfusion normalizes
� Echocardiogram demonstrates Coarctation of the Aorta with ductal dependent perfusion
� Repaired surgically
Take Home Message
� Infants < 2 weeks presenting in shock deserve
consideration of:
� Volume loss
� Sepsis
� Ductal dependent lesions
� Prostaglandins should always be considered
SHOCK MADE
SIMPLEEasy Steps
Easy Steps
� Administer 20 cc/kg NS FAST
� If ABC’s worsen, immediate CXR (could be cardiogenic) or sono
� If cardiac silhouette is enlarged, consider Prostaglandin PGE1
� If cardiac silhouette is equivocal, room for more fluids
Easy Steps
� If vitals improve administer another 40 cc/kg NS
� If vitals stabilize, relax, consider volume loss or distributive causes
�Consider sepsis, draw blood cultures, administer antibiotics
IF CONSIDERING A HYPOVOLEMIC ETIOLOGY,
IT WOULD BE NICE TO HAVE A CONSISTENT HISTORY
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Easy Steps
� If vitals do not improve, begin pressors
�DON”T forget pallid shock – need RBC not crystalloid
� Volume loading would be harmful in anemic shock
Case:The Definition of Insanity
History
An ALS Radio call is received, in midwinter, announcing the transport of a 3 week old AA male in respiratory distress
He is described as in marked respiratory distress, mildly cyanotic, with good perfusion
Wheezing is heard and, as per protocol, a nebulizedalbuteroltreatment is administered during the 10-minute transport
History
History obtained from the mom on arrival reveals a normal prenatal and birth history
She thinks he has “Sickle Trouble”
He had been well, on proprietary formula, until earlier that day when he developed a cough and became more and more ill appearing
Physical Examination
Vital Signs
• T37.7C• HR 180
• RR 60
• BP 90/70
OSAT 50% in room air
General
• Crying, profoundly cyanotic infant with retractions
Physical Examination
Chest
• Scattered upper airway sounds
• Good air entry
• No murmur
Skin
• Blue
Pulses
• Normal
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Preliminary Results
WBC Normal/HgB 9.7
ABG: 7.30/ pCO2 28/ pO2 50/ BE -8 (in 100% O2)
EKG- Sinus Tachycardia
CXR cardiomegaly
Real Time Case Progression
� Interventions
� Albuterol
� 20 cc/kg NS
� Antibiotics
Reality Based Outcome
� OSAT still 50% (on 100%)
� Still screaming
� Room getting smaller
� More people watching the case
Hyperoxia Test
CXR Time to earn your money
� IV Morphine 0.1 mg/kg
� Calms, respiratory rate decreases
� OSAT jumps to 98% (your heart rate drops below 200)
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TetrologyCongenital Lesions Usually
Associated With Cyanosis
Common Cyanotic Cardiac Lesions
� Tetrology of Fallot
� Transposition of the great vessels
� Truncus arteriosus
� Tricuspid atresia
� TAPVR
Hypoxemic (“TET”) Spells
� Usually self limited (15-30 minutes)
� More common in the AM or after a nap
� May be self perpetuating
Stepwise Treatment of Tet Spells
� Comfort; knee chest position; 100% O2
� Morphine 0.1 mg/kg
� IV fluid resuscitation
� IV Bicarbonate
� IV phenylephrine (increases SVR)
� IV propranolol
Take Home Message
� The secret of mammalian oxygenation:
� You breathe it (pulmonary)
� You pump it (cardiac)
� You carry it (hemoglobin)
� Hints
� Use the hyperoxia test
� OSATs in the mid 80s are often methemoglobinemia
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CYANOSIS
MADE SIMPLEEasy Steps
Easy Steps
�Administer supplemental oxygen
� If OSAT rises, most likely pulmonarydisease
Easy Steps
�Administer supplemental oxygen
� If OSAT does not rise consider Cyanotic Heart Disease OR Methemoglobinemia
�On 100% O2 if pO2 is high and OSAT is low = Methemoglobinemia
� you can dissolve it but NOT carry it
Easy Steps
� Administer supplemental oxygen� If OSAT does not rise consider Cyanotic Heart
Disease OR Methemoglobinemia
� On 100% O2 if pO2 is low and OSAT is low, consider cyanotic heart disease
� The “5 T’s”� Tetralogy (only defect likely to present late)� Tricuspid atresia� Transposition� Truncus arteriosis� Total anomalous venous return
Hyperoxia Test
Am I White?:
Pallor in the Pediatric Patient
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Casper The Friendly Infant
Case
� A 7 month old presents with pallor
� Seen earlier at a PMD who sent the child to a lab for
blood work
� Fingerstick Hgb = 5.5
� Referred for evaluation
Case
� Normal birth history
� Initially formula fed, now on cow’s milk
� No recent change in feeding, activity, behavior
� Immunized
Case
� Vigorous “white as a sheet” infant
� T 37, HR 100, RR 16 BP 90/50 OSAT 98%
� Capillary refill brisk, 2 seconds
� Entire exam unremarkable
Case
� CBC
� H/H 5/15
� WBC, platelets normal
� MCV 55
� RBC LOW
� BMP unremarkable
� Next?
Case Concepts
� Profound anemia WITHOUT physiologic compromise
� Probably an insidious onset
� Further labs
� Reticulocyte count
� Coombs
� Hemoccult
LOW
NEGATIVE
POSITIVE
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Low Reticulocyte Count
USUALLY A LOW RBC COUNT
USUALLY A HIGH RBC COUNT
Most Likely?
� Cow’s milk protein enteropathy
� Insidious LGI bleeding (often not noticed)
� Treatment
� Dietary adjustment
� Iron supplementation
� DO NOT TRANSFUSE (this child is stable)!
What Does This Kid Eat?
Case
� A 7 year old presents with vomiting, irritability for 3
days
� His stools have turned red
� No significant PMH
� Emesis is clear
� No one ill at home
Case
� Tired irritable young child
� Profoundly pale
� Afebrile HR 100 RR 16 BP 90/70 OSAT normal
� Tender abdomen in all quadrants
� Stool red, hemoccult positive
Problem List
� Emesis with a tender abdomen
� LGI bleeding
� Borderline hypoperfusion
� Obvious pallor
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Workup
� H/H 5/15
� MCV normal
� All other cell lines normal
� BMP normal
� Next?
Workup
� Abdominal series normal
� Sonogram demonstrates ileocolic intussusception
� Reduced uneventfully
� BUT……..
� Isn’t this child a bit old?
� How frequent is massive LGI bleeding with
intussusception?
� Are we done?
Workup
� Abdominal CT
� Appendix NOT visualized
� Otherwise unremarkable
� Surgery signs off the case
� Next?
� Pediatric GI consulted
� They order?
MECKEL’S SCAN POSITIVE
Meckel’s
� 2% of the population
� Most common omphalomesenteric duct remnant
� Only 2% of persons with a Meckel's diverticulum manifest any clinical problems
� The most common complication of a Meckel's
diverticulum is a bleeding ulcer
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Omphalomesenteric Duct Meckel’s
Meckel’s
� Ectopic gastric mucosa in such patients is usually present in
the diverticulum
� Currant jelly stools or hemorrhage may be present
� Other modes of presentation include diverticulitis, perforation
with peritonitis, or intussusception as a result of the
diverticulum's serving as a lead point
Meckel’s
� Barium studies usually fail to outline a Meckel's diverticulum
� The imaging modality of choice for detection of ectopic gastric mucosa in a bleeding Meckel's diverticulum is nuclear
scintigraphy
� The accuracy of scintigraphy in detection of ectopic gastric
mucosa in Meckel's diverticula is approximately 95%
Just Another Virus?
Case Four
� A 5 year old girl awakens in the middle of the night
and while walking to her parents room suffers a brief syncopal episode
� Taken to a local ED
� Her parents think she has become ““““extremely pale for the last 3 days, like she has the flu””””
� No fever, medications, injury, PMH
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Case Four Presentation
� 5 year old lethargic, extremely pale child
� Mild Jaundice
� Afebrile
� HR = 150
� BP = 70/40
� No bruising
� Rectal negative for blood
Case Four Questions
� What is the clinical status of this child?
� She is in pallid shock with no history of blood
loss
� What Interventions are indicated?
� Immediate volume resuscitation
� What lab studies are indicated?
� CBC, platelets
� Coombs
� Bilirubin
� Reticulocyte Count
Case Four Progression
� Given 20cc/kg IV push X 2
� Remains pallid, slight improvement of vital signs
� Labs
� WBC and platelets normal
� H/H = 4/12 MCV normal
� Coombs positive
� Bilirubin = 6 (direct = 0.1)
� Reticulocyte Count elevated
� What is indicated at this time?
� Immediate PRBC transfusion
Elevated Reticulocytes
Case Four Progression
� Given 2 units PRBC
� Vitals normalize
� Hematology consult
� Smear demonstrates massive hemolysis
� Bone marrow aspirate WNL
� Final diagnosis
� Autoimmune hemolytic anemia
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States of Shock
Case
� A 12 month old is brought to the PED with a chief
complaint of fever and a rash
� He is unarousable and has petechiae and purpura on his extremities and trunk
� Temp 40C
� HR 180
� BP 60/20
� Capillary refill 4 seconds
The Rash Case Questions
� What is the probable diagnosis and what type of
shock would this be?
� Septic shock
� How would you treat this child?
� Repeated fluid boluses, 20cc/kg X3
� Immediate broad spectrum antibiotics
� If there is no initial response to fluid resuscitation, what are your alternatives?
� Pressors
Case Outcome
� After 3 fluid boluses
� BP 90/50
� HR 140
� Capillary refill 3 seconds
� Dopamine drip begun
� PICU course
� 2 day pressor therapy
� Blood cultures grew Meningococcus
� Recovered uneventfully
A Final Case
� A 10 year old is struck by a car while walking
� He arrives backboarded and crying
� BP 70/30
� HR 140
� Extremities cool
� Bruising on upper abdomen
� Obvious femur fracture
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Case Questions
� What type of shock does he have?
� Hemorrhagic
� What is the treatment?
� Crystalloids >>>>>blood products
� What signs of improvement would you look for?
� Normalization of VS
Case Progression
� Fluid resuscitation in ED (3 liters crystalloid)
� FAST exam noted splenic blood
� Given 4 units whole blood
� CT demonstrated splenic hematoma (encapsulated)
� Managed in PICU conservatively
� Discharged 7 days later
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