Pediatrics On-Call Michael Dale Warren, MD Pediatric Chief Resident Vanderbilt Children’s Hospital

Objectives Explain approach to two common pediatric on-call situations Review basic physiology as applied to these scenarios

Case #1 You are called to bedside by nurse because she doesn’t think the patient is doing well. Patient is 6 year old male History of vomiting and diarrhea for several days Low-grade fever (Tmax 101)

Case #1 You examine the child: P 180, R 45, BP 105/65, SpO2 100% T 101 Mildly ill-appearing child Eyes sunken, mucous membranes dry Normal S1/S2, no murmur, cap refill 3-4 seconds Clear breath sounds Soft, non-tender abdomen Extremities cool to touch

What else might you want to know?

What do you think is going on? Mild dehydration Moderate dehydration Severe dehydration Hypovolemic shock :10

Hypovolemic Shock Remember, shock is defined as inadequate tissue perfusion Clue from this exam: poor cap refill Blood pressure not a good early indicator of shock In children, blood pressure is preserved until significant volume depletion occurs

Hypovolemic Shock Risk factors Vomiting Diarrhea Poor PO intake Fever

What is your immediate next step? Bolus 10cc/kg with D5 ½ NS Bolus 20 cc/kg with NS Bolus 10 cc/kg with ½ NS Bolus 20 cc/kg with D5 ½ NS :10

Management Obtain IV access Fluid bolus Maintenance fluids If unable to obtain IV access, may place I/O catheter Fluid bolus Always bolus with isotonic fluids Use 20cc/kg bolus unless child has heart disease May repeat bolus as needed until clinical improvement occurs Maintenance fluids Add dextrose and electrolytes Remember the 4-2-1 rule for hourly maintenance IV rate 4 cc/hr for each kg (0-10kg) 2 cc/hr for each kg (11-20 kg) 1 cc/hr for each kg above 20 kg

Case #2 After successfully rehydrating the first child, you head to the call room to get some sleep. Just as you drift off to sleep, you get a page from the charge nurse on 7B, who wants you to come look at a baby who is “having trouble breathing.”

Case #2 6-month old male infant Previously healthy 3 days of cough, runny nose, low-grade fever Admitted earlier today for difficulty breathing

Case #2 You examine the child: P 180, R 80, BP 95/60, SpO2 88% T 101.5 Mildly ill-appearing child MMM No murmur, cap refill 2-3 seconds Coarse breath sounds bilaterally with diffuse end expiratory wheezing, nasal flaring, intercostal and suprasternal retractions Soft, non-tender abdomen Extremities warm

What else might you want to know?

What do you think is going on? Asthma Respiratory distress Croup Bronchiolitis :10

Respiratory Distress Respiratory problems are fairly common in pediatric patients Pediatric cardiac arrest usually preceded by respiratory distress and subsequent respiratory failure Goal is to prevent this progression

Respiratory Distress Back to physiology: R∞1/r4 This means that airway inflammation and edema is going to cause an increase in airway resistance to a greater extent in the child as compared to an adult

What is your immediate next step? Order tylenol to reduce fever Call for a chest radiograph Obtain an arterial blood gas Reposition baby to most comfortable position :10

Management Remember ABC’s First step should always be to protect/establish airway Positioning is important Head tilt or jaw thrust maneuvers For conscious patient, let them assume position of comfort Second step is to check breathing Do you need to provide breaths? Mouth-to-mouth breaths Bag-mask ventilation

Management Oxygen may not always be the right answer Adjunctive therapies can result in dramatic improvement Bronchodilators Racemic epinephrine Nasopharyngeal suctioning Fever can cause tachypnea and contribute to increased work of breathing

Management Be alert for signs of impending respiratory failure Slow or irregular respiratory rate Change in mental status Increased use of accessory muscles

Phrases that should get your attention “This patient doesn’t look right.” “I’m worried about this patient.” “She’s having trouble breathing.” “Mom thinks he isn’t acting like himself.” “I think she could be having a seizure.” “He is vomiting up blood”….“having bloody diarrhea”….(basically blood from any orifice needs your attention.)

Take Home Messages Children are not little adults For pediatric patients, fluid/medication dosing is weight-based Respiratory distress leading to arrest is more common in kids than primary cardiac arrest Listen to parents and nurses Reducing fever will often make kids look better