The Crashing Pediatric Patient: Stopping the Fall

Transcription

1 The Crashing Pediatric Patient: Stopping the Fall I can t breathe... 4 year old BIBA from school with sudden severe resp distress Hx of asthma, food allergies Judith Klein, MD FACEP Assistant Professor of Emergency Medicine UCSF-SFGH Emergency Medicine PE: RR 40, 95%; tripod posture, retractions, poor air move/few wheezes Objectives Respiratory Distress: Advance Preparation Advance preparation pearls Status asthmaticus: act early Infants in shock: not little adults Seizures: when to worry and what to do Tachycardia in kids Oxygen, suction, NP/ OP airway, monitors Intubation equipment/ IV/IO

2 Severe Asthma Pharma He s getting worse: Next steps... Start albuterol, ipratropium nebs Solumedrol 1-2 mg/kg IM/IV ASAP Reassess... IM epinephrine (1:1000): 0.1cc/kg? (IV or IM?) Magnesium? Heliox? When to intubate? Intubated...but still crashing a. ABG: elevated CO2 b. Worsening pulse oximetry c. AMS (agitation/somnolence) Pt intubated with ketamine... Hypoxic High peak pressures Hypotension

3 Neonatal nightmare... Differential? 7 day old with poor feeding, sweating tachypnea PE: RR 70, 85%, P 180, T 35.5, 50/p; FSBG 60 Cool, pale, sleepy, CRT 4 sec Overwhelming sepsis*** Congenital adrenal hyperplasia - Na, K, glucose -genitalia Duct dependent heart disease -murmur? -100% O2 test? -CXR? -failure of usual tx? CRT>2-3 seconds Cool skin Low UOP AMS Increased HR Shock: pitfall of hypotension Narrowed pulse pressure Lactate >3-4 A/B: intubate, O2 C: IV/IO -20cc/kg bolus x 2 -pressors Labs: -lytes/fsbg, BCx, UCx, CXR -LP Abx ASAP (GBS, E coli): -Amp/vanco plus cefotaxime Steroids? Management

4 Respiratory distress worsening... Cyanosis/Shock: cardiac etiologies Etiology: Bolus x 2-->persistent hypotension Lytes, fsbg normal CXR... On 100% NRB-->88% Hmmm... LVOT obstruction DA closure-->shock Suspect if: Murmur, 100% O 2 test CXR: large, odd shape heart Management: Prostaglandin E1 Echo, cardiologist He s really shaking... Advance preparation 2 year old GTC seizure x 10 min EMS: buccal versed 0.5 mg/kg Ongoing seizures... Airway: NRB, suction, NP/ OP airway Access: IM, IV...IO sooner rather than later 3 critical questions: -FSBG? -Rectal temp? -Head trauma?

5 Initial interventions A/B: jaw thrust/np airway, suction, O2 He s still seizing... >10 min: Fosphenytoin 30 mg/kg <2 yrs >20 min? >2 yrs C: IV attempt x 2 min -->IO -Lorazepam 0.1 mg/kg x 2 Phenobarbital 20 mg/kg Valproate 20 mg/kg or Kepra 30 mg/kg D: FSBG 80, no head trauma visible E: T 38.5 persistent seizures? Coma: midazolam 0.1-2mg/kg/hr Consider INH ingestion: pyridoxine 1-5gm Workup? How fast should my baby s heart go? Stabilize/seizure cessation first! Acute intracranial process? CT Otherwise MRI preferred Labs: sepsis workup? Abx? LP when stable? 10 mo old with resp distress, poor po RR 40, 97%, HR 260, BP 70/p, T 37 PE: alert, CRT 2 sec, mild tachypnea, no murmur

6 Tachycardia in children Management: Reasons for ST: -fever -anemia/hypovolemia -excitement\pain SVT vs ST? -rate>220 -no variability -up to 50% with p waves EKG pearls: speed up paper Unstable: Sync cardiovert J/kg BP stable/borderline: Fluids, anti pyretics Vagal maneuvers Adenosine mg/kg AVOID calcium or beta blockers Pearls... Rapid response to resp distress: IM epi! Pitfall of hypotension in shock: don t wait for it Early IO if IV not happening Seizures: remember fsbg? trauma? temp? Unique pediatric heart: PGE, no nodal blockers