1. Case Conference: Pediatric Critical Care Mary King, MD, MPH Assistant Professor Pediatric Critical Care Medicine Harborview Medical Center and Seattle Children’s

2. Pediatric Critical Care Cases Case 1

3. HPI 7 day old female presents to nurse midwife with lethargy, decreased PO intake, no wet diapers today History reveals child has not seen a doctor yet as this was a home delivery, no U/S, routine delivery What should be on your differential diagnosis for this lethargic 7 day old neonate?

4. Differential Dx Differential diagnosis of a lethargic neonate: FEN/GI: Uremia, hypoglycemia, hypothyroid, adrenal insufficiency CV: Congenital heart disease, Myocarditis ID: Sepsis, Meningitis, UTI, necrotizing enterocolitis Neuro: NAT, IVH, Seizure, toxin What would you like to specifically know on PE?

5. Vitals HR 200, sinus BP 50/28 O2 sat 89% RR 70 T36.0

6. PE Lethargic baby not interacting Fast unlabored breathing with mild retractions No peripheral pulses, 1+ femoral pulses + systolic murmur at LUSB Abdomen soft No rashes, appears pale What would you like to do for this child? What is your most likely diagnosis?

7. Course What would you like to do for this child? –Call 911, immediate transfer to tertiary peds center –IV access, NS bolus 20 cc/kg, check blood glucose, administer PGE (prostaglandins) –Echocardiogram –Rule Out Sepsis (Bcx, Ucx, LP, cefotaxime, ampicillin)

8. Initial workup ABG: 6.9/20/22/5/-21 Glucose: 169 Na: 131 WBC: 14K

9. Diagnosis What is your most likely diagnosis? –Congenital Heart Disease Left ventricular Outflow Tract Obstruction –ie) Aortic Stenosis Cyanotic heart disease with incr pulmonary Q –ie) HLHS –Neonatal sepsis

10. Course ECHO: Aortic stenosis, PDA barely open, poor systolic LV function Continue prostaglandins Place a 4F/5cm femoral CVL Initiate Milrinone PDA opens fully Aortic valvuloplasty performed Acidosis, perfusion and LV function improve Goes home 3 weeks later

11. Pediatric Critical Care Cases Case 2

12. HPI 23 month old male with Trisomy 21 Given small piece of toffee candy by mom Mom tried to get it out of his mouth by sweeping mouth with her pinky finger Child immediately began choking, gagging, making poor respiratory effort Child turned blue and became unresponsive

13. Prehospital course 911 was called Family friends started bystander CPR Medics arrived and found a blue child with an undetectable O2 saturation with a HR = 40 A,B: Manually bagged and intubated the child C: CPR and placed an intraosseus needle HR and BP returned after 8 minutes of CPR Valium given for agitation Emesis at the scene

14. Vitals T 34.7 HR 126 BP 128/83 RR 30 SpO2 93% on FiO 2 85%

15. PE RESP: –no chest rise on right –absent breath sounds on the right –scattered rhonchi on the left CV: –sinus tachycardia, regular, no murmur –no hepatosplenomegaly –brisk capillary refill –2+ pulses

16. Labs Electrolytes: Na 137, K 4.5, Cl 105, CO2 23 BUN/Cr: 19/0.5 Glucose: 320 CBC: WBC 22, Hct 32, Plt 402 Lactate: 3.5 (0.5-1.6) ABG: 7.21 / 52 / 73 / 21 / -7

17. CXR

18. CXR after ETT reposition

19. Problem list?

20. Problem list Severe hypoxemic respiratory failure Foreign body aspiration Complete right mainstem obstruction and atelectasis Likely aspiration pneumonitis Status-post cardiopulmonary arrest Trisomy 21

21. Plan?

22. Plan Emergent rigid bronchoscopy for foreign body removal Supportive care via mechanical ventilator

23. Hospital day 1 OR with Otolaryngology for rigid bronchoscopy A very gooey piece of English Toffee is removed from the right main bronchus with a large amount of inflammatory material Child returns to the PICU

24. CXR-post bronchoscopy

25. Hospital day 2 The next morning: –improved chest movement on right –improved aeration on right –scattered rhonchi throughout right –SpO2 95% on FiO2 40% (from 85%)

26. CXR-hospital day 2

27. Hospital days 2-4 Weaned from the mechanical ventilator Extubated to mom’s arms ~ 24 hrs after bronch Weaned from nasal canula oxygen to room air No bed available on the floor for transfer Taking vigorous PO feeds Discharged from PICU to home with parents