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

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

3. 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)

4. 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

5. What else might you want to know?

6. What do you think is going on?
Mild dehydration
Moderate dehydration
Severe dehydration
Hypovolemic shock
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7. 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

8. Hypovolemic Shock
Risk factors
Vomiting
Diarrhea
Poor PO intake
Fever

9. 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
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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 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

11. 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.”

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

13. 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

14. What else might you want to know?

15. What do you think is going on?
Asthma
Respiratory distress
Croup
Bronchiolitis
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16. 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

17. 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

18. 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
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19. 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

20. 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

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

22. 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.)

23. 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