1 / 23

Pediatrics On-Call

Pediatrics On-Call. Michael Dale Warren, MD Pediatric Chief Resident Vanderbilt Children’s Hospital. Objectives. Explain approach to two common pediatric on-call situations Review basic physiology as applied to these scenarios. Case #1.

emma-parks
Download Presentation

Pediatrics On-Call

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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. :10 What do you think is going on? • Mild dehydration • Moderate dehydration • Severe dehydration • Hypovolemic shock

  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. :10 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

  10. Management • Obtain IV access • 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 4-2-1 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. :10 What do you think is going on? • Asthma • Respiratory distress • Croup • Bronchiolitis

  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. :10 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

  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

More Related