10/11/2017. Overview. Objectives. General Management Principles. Problem: Vascular Access. Problem: Vascular Access

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Overview CHF SCARY INFANTS AND CHIDREN: IT S NOT THAT COMPLICATED

Cantor, MD FAAP/FACEP Professor of Pediatrics and Emergency Medicine

Control Center Golisano Children s Hospital Syracuse NY Shock Cases

Outline the most utilized traditional therapies Highlight the

Principles Problem: Vascular Access Problem: Vascular Access Any

1 Overview CHF SCARY INFANTS AND CHIDREN: IT S NOT THAT COMPLICATED Richard M. Cantor, MD FAAP/FACEP Professor of Pediatrics and Emergency Medicine Director, Pediatric Emergency Services Medical Director, CNY Poison Control Center Golisano Children s Hospital Syracuse NY Shock Cases Pallor Cyanosis 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 Problem: Vascular Access Any interventions will necessitate vascular access Alternative Access in Infancy: Scalp Veins What is available? The usual sites Hand Antecubitus Foot Saphenous 1

2 Problem: Vascular Access Problem: Vascular Access Alternative Access in Infancy: Scalp Veins Alternative Access in Infants Less Than 14 days: Umbilical Vein Approach Problem: Vascular Access Problem: Vascular Access Alternative Access in Infants Less Than 14 days: Umbilical Vein Approach Alternative Access in Infants Less Than 14 days: Umbilical Vein Approach Problem: Vascular Access Problem: Vascular Access Intraosseous Approach 2

Problem: Airway Problem: Airway Intubation is indicated Regardless of age, RSI is indicated ALL drugs (except Etomidate) have

must identify and correct hypoglycemia at the bedside ALWAYS get the air out!

Case: Shock To The System A 3 week old presents with a 1 day history of poor feeding and apparent respiratory distress Birth

3 Problem: Airway 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 Other Pitfalls in Infant Stabilization You must identify and correct hypoglycemia at the bedside ALWAYS get the air out! Normothermia must be maintained Something ALWAYS goes wrong with the airway! 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 Case: An Abject Failure Cool extremities, capillary refill 5 seconds All peripheral and central pulses are weak Grunting with retractions, poor air entry No murmur 3

Case Discussion Case Progression: Circulation This infant is in uncompensated shock Unclear etiology at this point Septic? Hypovolemic? Cardiogenic?

There is no history of volume loss After blood cultures obtained, antibiotics are indicated Cefotaxime Ampicillin (Listeria) Case Progression: Circulation Case Progression: Circulation

4 Case Discussion Case Progression: Circulation This infant is in uncompensated shock Unclear etiology at this point Septic? Hypovolemic? Cardiogenic? Accompanying respiratory failure 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 Case Progression: Circulation Undifferentiated neonatal shock Volume is indicated cc/kg NS push Repeat up to 60 cc/kg Given 60 cc/kg NS Respiratory distress increases Hepatomegaly CXR Obtain CXR to check heart size as a rough estimate of vascular status Case Progression: Circulation Congenital Heart Disease Presenting as Failure in Infancy 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 4

Left Sided Outflow Obstruction Case Resolution The child is in CHF Given Prostaglandin E1 Perfusion normalizes

Message Infants < 2 weeks presenting in shock deserve consideration of: Volume loss Sepsis Ductal dependent

20 cc/kg NS FAST If ABC s worsen, immediate CXR (could be cardiogenic) or sono If cardiac silhouette is enlarged,

another 40 cc/kg NS If vitals stabilize, relax, consider volume loss or distributive causes Consider sepsis, draw

5 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 SIMPLE Easy Steps Easy 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 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 5

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 History

6 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 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 nebulized albuterol treatment is administered during the 10- minute transport 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 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 Chest Scattered upper airway sounds Good air entry No murmur Skin Blue Pulses Normal 6

Preliminary Results Real Time Case Progression EKG- Sinus Tachycardia CXR

30/ pco2 28/ po2 50/ BE -8 (in 100% O2) WBC Normal/Hg B 9.

screaming Room getting smaller More people watching the case CXR Time to earn

7 Preliminary Results Real Time Case Progression EKG- Sinus Tachycardia CXR cardiomegaly Interventions Albuterol 20 cc/kg NS Antibiotics ABG: 7.30/ pco2 28/ po2 50/ BE -8 (in 100% O2) WBC Normal/Hg B 9.7 Reality Based Outcome Hyperoxia Test OSAT still 50% (on 100%) Still screaming Room getting smaller More people watching the case 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) 7

Tetrology Congenital Lesions Usually Associated With Cyanosis Common Cyanotic Cardiac Lesions Hypoxemic ( TET ) Spells Tetrology of Fallot Usually self limited (15-30 minutes) Transposition of the

8 Tetrology Congenital Lesions Usually Associated With Cyanosis Common Cyanotic Cardiac Lesions Hypoxemic ( TET ) Spells Tetrology of Fallot Usually self limited (15-30 minutes) Transposition of the great vessels More common in the AM or after a nap Truncus arteriosus May be self perpetuating Tricuspid atresia TAPVR Stepwise Treatment of Tet Spells Take Home Message Comfort; knee chest position; 100% O2 Morphine 0.1 mg/kg IV fluid resuscitation IV Bicarbonate IV phenylephrine (increases SVR) IV propranolol 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 8

Easy Steps Administer supplemental oxygen CYANOSIS MADE SIMPLE Easy Steps If OSAT rises, most likely pulmonary disease Easy Steps Easy Steps Administer supplemental oxygen If OSAT does not rise

9 Easy Steps Administer supplemental oxygen CYANOSIS MADE SIMPLE Easy Steps If OSAT rises, most likely pulmonary disease Easy Steps 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 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 9

10 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 Casper The Friendly Infant Referred for evaluation Case Case Normal birth history Initially formula fed, now on cow s milk No recent change in feeding, activity, behavior Immunized 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 Case Concepts CBC H/H 5/15 WBC, platelets normal MCV 55 RBC LOW BMP unremarkable Next? Profound anemia WITHOUT physiologic compromise Probably an insidious onset Further labs Reticulocyte count LOW Coombs NEGATIVE Hemoccult POSITIVE 10

11 Low Reticulocyte Count Most Likely? Cow s milk protein enteropathy Insidious LGI bleeding (often not noticed) USUALLY A LOW RBC COUNT USUALLY A HIGH RBC COUNT Treatment Dietary adjustment Iron supplementation DO NOT TRANSFUSE (this child is stable)! Case A 7 year old presents with vomiting, irritability for 3 days His stools have turned red No significant PMH What Does This Kid Eat? Emesis is clear No one ill at home Case Problem List Tired irritable young child Profoundly pale Afebrile HR 100 RR 16 BP 90/70 OSAT normal Tender abdomen in all quadrants Emesis with a tender abdomen LGI bleeding Borderline hypoperfusion Obvious pallor Stool red, hemoccult positive 11

How frequent is massive LGI bleeding with intussusception? Are we done? Abdominal CT Appendix NOT visualized Otherwise unremarkable Surgery signs off the case Next?

12 Workup H/H 5/15 MCV normal All other cell lines normal BMP normal Next? Workup 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? Abdominal CT Appendix NOT visualized Otherwise unremarkable Surgery signs off the case Next? Pediatric GI consulted They order? Meckel s MECKEL S SCAN POSITIVE 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 12

Omphalomesenteric Duct Meckel s Meckel s Meckel s Ectopic gastric mucosa in such patients is usually present in the diverticulum Barium studies usually fail

in a bleeding Meckel's diverticulum is nuclear scintigraphy Other modes of presentation include diverticulitis, perforation with peritonitis, or

diverticula is approximately 95% Case Four A 5 year old girl awakens in the middle of the night and while walking to her parents room suffers a brief

13 Omphalomesenteric Duct Meckel s Meckel s Meckel s Ectopic gastric mucosa in such patients is usually present in the diverticulum Barium studies usually fail to outline a Meckel's diverticulum Currant jelly stools or hemorrhage may be present The imaging modality of choice for detection of ectopic gastric mucosa in a bleeding Meckel's diverticulum is nuclear scintigraphy Other modes of presentation include diverticulitis, perforation with peritonitis, or intussusception as a result of the diverticulum's serving as a lead point The accuracy of scintigraphy in detection of ectopic gastric mucosa in Meckel's diverticula is approximately 95% 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 Just Another Virus? Her parents think she has become extremely pale for the last 3 days, like she has the flu No fever, medications, injury, PMH 13

14 Case Four Presentation Case Four Questions 5 year old lethargic, extremely pale child Mild Jaundice Afebrile HR = 150 BP = 70/40 No bruising Rectal negative for blood 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 Elevated Reticulocytes 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 Case Four Progression Given 2 units PRBC Vitals normalize Hematology consult Smear demonstrates massive hemolysis Bone marrow aspirate WNL Final diagnosis Autoimmune hemolytic anemia 14

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 States of Shock HR 180 BP

15 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 States of Shock 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 A Final Case 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 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 15

Case Questions Case Progression What type of shock does he have? Hemorrhagic What is the treatment? Crystalloids >>>>>blood products What signs of improvement would you look for?

16 Case Questions Case Progression 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 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 Thank You! Heme Products 16

Cardiovascular Pathophysiology: Right to Left Shunts aka Cyanotic Lesions

Cardiovascular Pathophysiology: Right to Left Shunts aka Cyanotic Lesions Ismee A. Williams, MD, MS iib6@columbia.edu Pediatric Cardiology Learning Objectives To discuss the hemodynamic significance of