Pediatric Emergency Cases

Melissa Joy, RNMichael Mojica, MDTodd P Chang, MD

CASE 3A…Peace puts her everywhere…

Case 3A - Briefing4-week-old male

Progressive non-bilious vomiting x 3 days

No urine output x 20 hours

Difficult to awaken

4wk listless vomiting

Temperature (Axillary)

Temperature (Rectal)

Glucose

Blood Gas Lytes Blood Gas

Radiography 2

Laboratory 2 Radiography 1Laboratory 1

go

4wk listless vomitingUS SI

Na 149 149K 2.1 2.1Cl 82 82HCO3 37 37BUN 19 6.8Cr 0.8 61.9Glucose 55 3.0

4wk listless vomitingUS SI

WBC 14.8 14.8Hgb 17.2 10.7Hct 50.1 0.5Plt 284 284

4wk listless vomiting

36.7 C = 98.1 F

4wk listless vomiting

37.4 C = 99.3 F

4wk listless vomitingUS SI

Glucose 55 3.0

4wk listless vomitingUS SI

pH 7.50 7.50pCO2 48 48pO2 (cap) 92 92HCO3 35 35%sat (cap) 82 82Na 151 151K 1.8 1.8Cl 86 86Hgb 17.2 10.7

4wk listless vomiting

4wk listless vomiting

PEDIATRIC SHOCK

Infant Shock

HRb/p

Infant Shock

HRb/p

Heart RatesAge Typical Heart

RatesNewborns 0 – 3 months 100 – 150

Infants 3 – 6 months 90 – 120Infants 6 – 12 months 80 – 120

Children 1 – 10 years 70 – 130Adolescents 10+ years 60 – 100

Blood PressureTotal Gestational

Age (weeks)

=

(Mean Arterial Pressure)

The pump

The vessels

The tissues

The model

fluid

!

The Pump

!

The Fluid

!

The Vessels

Hypovolemic Shock# Dose Time

LimitForm

1 Access #1 1 minute IV or IO2 0.9% Normal

Saline60 mL/kg 15 minutes IV push

Hypovolemic Shock# Dose Time

LimitForm

1 Access #1 1 minute IV or IO2 0.9% Normal

Saline60 mL/kg 15 minutes IV push

3 Access #2 15 minutes IV or IO4* Ceftriaxone 50 mg/kg 60 minutes IV

Hypovolemic Shock# Dose Time

LimitForm

1 Access #1 1 minute IV or IO2 0.9% Normal

Saline60 mL/kg 15 minutes IV push

3 Access #2 15 minutes IV or IO4* Ceftriaxone 50 mg/kg 60 minutes IV5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip5b Norepinephrine 0.1 mcg/kg/min to

260 minutes IV drip

6 0.9% Normal Saline

Ad lib - IV

Hypovolemic Shock# Dose Time

LimitForm

1 Access #1 1 minute IV or IO2 0.9% Normal

Saline60 mL/kg 15 minutes IV push

3 Access #2 15 minutes IV or IO4* Ceftriaxone 50 mg/kg 60 minutes IV5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip5b Norepinephrine 0.1 mcg/kg/min to

260 minutes IV drip

6 0.9% Normal Saline

Ad lib - IV

7 D5-0.45% NS orD10-0.25% NS

1.5x Maint IV drip

8 Hydrocortisone 50 mg/m2 60 minutes IVEstimates of body surface area:

Newborn (0.25m2) 8 years old (1m2)2 years old (0.5m2) non-obese adult (1.5m2)

Push-Pull

PYLORIC STENOSIS…Peace puts her olives everywhere…

Pyloric Stenosis

Pyloric Stenosis

Rule of 6’sIf you are ******** age, and you have a surgical abdomen, then you have…

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation

6 Weeks

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation

6 Weeks Pyloric Stenosis6 Months

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation

6 Weeks Pyloric Stenosis6 Months Intussusception6 Years

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation

6 Weeks Pyloric Stenosis6 Months Intussusception6 Years Appendicitis66 Years

Rule of 6’sAge Likely Surgical

Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation

6 Weeks Pyloric Stenosis6 Months Intussusception6 Years Appendicitis66 Years Diverticulitis?

Pyloric Stenosis• Peaks @ 6 weeks• M to F 4 to 1

• Non-bilious emesis• “Projectile” is rare• “Olive” is very rare• Look for vomiting with all feeds

Pyloric Stenosis• Hypochloremic alkalosis

• Single large stomach Abdominal Xray• Paucity of gas distal of stomach

Pyloric Stenosis• 3+mm thick

or• 15+mm long

Pyloric Stenosis

Pyloric StenosisManagement

Manage Dehydration

Dextrose too

Nasogastric Tube Intermittent low suction

NPO

Surgical consultation

Urgent, not Emergent

Maintenance FluidsAge Fluid

Infants < 10kg D10 – ¼ NS

All other Peds D5 – ½ NS

Maintenance FluidsWeight Rate

5kg 20 mL/hr10kg 40 mL/hr20kg 60 mL/hr30kg 70 mL/hr

Tubes• Endotracheal Tube Size:

4 + (Age (yr) / 4)

• Subtract ½ for the cuff

TubesETT Multiplier

Tube Corresponding Size (unit)

X 1 ETT Size diameter (mm)X 2 NG Tube size (Fr)X 3 ETT depth from gum/teeth

(mm)X 4 Chest Tube size (Fr)