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Pediatrics Review Emergency. Gina Neto, MD FRCPC Division of Emergency Medicine. Objectives. Review pediatric resuscitation guidelines Recognize pediatric conditions that present to the emergency Describe management of pediatric emergency cases. Pediatric Resuscitation. Pediatric Airway

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pediatrics review emergency

Pediatrics ReviewEmergency

Gina Neto, MD FRCPC

Division of Emergency Medicine

objectives
Objectives
  • Review pediatric resuscitation guidelines
  • Recognize pediatric conditions that present to the emergency
  • Describe management of pediatric emergency cases
pediatric resuscitation
Pediatric Resuscitation
  • Pediatric Airway
    • Larger head
    • Bigger tongue
    • Narrowest part is subglottic area
    • Epiglottis is more floppy
    • Larynx is more anterior and cephalad
    • Chest wall more compliant
pediatric resuscitation1
Pediatric Resuscitation
  • Airway Management
    • Position, suctioning
    • Nasal/Oral airway
    • Endotracheal intubation
      • Cuffed tube size: age/4 + 3 (+/- 0.5mm)
    • Medications
      • Atropine (consider if< 6 yrs)
      • Paralytic - Succinylcholine, Rocuronium
      • Ketamine, Midazolam/Fentanyl, Propofol
pediatric resuscitation2
Pediatric Resuscitation
  • Bradycardia
    • Non-Cardiac causes (6 H’s, 5 T’s)
      • Hypoxia (Most Common)
      • Hypovolemia, Hypo/Hyperkalemia, Hypoglycemia, Hypothermia
      • Toxins, Tamponade, Thrombosis, Trauma (ICP)
    • Cardiac causes - AV block, sick sinus
  • Epinephrine 0.01 mg/kg (repeat every 5 min)
  • Consider Atropine 0.02 mg/kg
pediatric resuscitation3
Pediatric Resuscitation
  • Tachycardia
    • Narrow
    • Wide
    • Stable or Unstable
  • Know what is normal for age
pediatric resuscitation4
Pediatric Resuscitation
  • Sinus Tachycardia
    • Rateusually < 220/min
    • Variable rate
    • Look for causes
      • Pain, fever, dehydration, resp distress, poor perfusion
  • SVT
    • Rate usually > 220/min infants, > 160 teens
    • Rate is fixed
pediatric resuscitation5
Pediatric Resuscitation
  • SVT
    • Vagal maneuvers
      • Ice to face, Valsalva
    • Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg
  • If Unstable:
    • Synchronized Cardioversion 0.5-1 J/kg
      • If not effective increase to 2 J/kg
pediatric resuscitation6
Pediatric Resuscitation
  • Tachycardia with Wide QRS
  • Stable
    • Consider Adenosine
    • Amiodarone 5 mg/kg
    • Consult Cardiology
  • Unstable with pulse
    • Cardioversion 0.5 - 1 J/kg 1st dose, then 2 J/kg
pediatric resuscitation7
Pediatric Resuscitation
  • Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation
    • CPR
      • Start at 16:2 compressions/breath
    • Defibrillation 2 J/kg
      • Then 4 J/kg
      • Increase subsequent shocks to max of 10 J/kg
    • Epinephrine 0.01 mg/kg every 3-5 min
    • Amiodarone 5 mg/kg
slide14
Case
  • 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days.
  • T 36.5, RR 40, HR 130, O2 Sat 89%.
  • Suprasternal and scalene retractions, decreased air entry, expiratory wheeze.
  • Describe your management.
asthma
Asthma
  • Mild Asthma:
    • Salbutamol MDI x 3 doses prn
  • Moderate Asthma:
    • Salbutamol MDI x 3 doses then prn
    • Steroids
      • Dexamethasone 0.15-0.3 mg/kg PO (max 12)
      • Prednisone 1-2 mg/kg PO (max 60 mg)
asthma1
Asthma
  • Severe Asthma:
    • Salbutamol via nebulization with
    • Ipratropium 250 mcg x 3 doses q20 min
    • Steroids
      • Dexamethasone 0.15-0.3 mg/kg PO (max 12)
      • Prednisone 1-2 mg/kg PO (max 60 mg)
asthma2
Asthma
  • If not improving within 60 min or signs of impending respiratory failure:
    • Magnesium Sulfate50 mg/kg/dose IV (max 2g)
        • Give over 20-30 min
        • May cause severe hypotension
          • IV NS 20 bolus ml/kg
    • Methylprednisolone 1-2 mg/kg IV
slide18
Case
  • 2 mo male with 2 day hx rhinorrhea, poor feeding and cough.Few hrs resp distress.
  • RR 60 HR 120 T 37C. Pink, well hydrated.
  • Chest - inspiratory crackles, exp wheezes.
  • Diagnosis?
  • Treatment?
bronchiolitis
Bronchiolitis
  • RSV - Respiratory Syncytial Virus most common
    • Parainfluenza, Influenza A, Adenovirus, Human metapneumovirus
  • Peak in winter
  • More serious illness
    • < 2 months
    • Hx of prematurity < 35 weeks
    • Congenital heart disease
bronchiolitis1
Bronchiolitis
  • Treatment
    • Nebulized Epinephrine – short term relief
    • ? Dexamethasone
      • 1 mg/kg on Day 1
      • 0.6 mg/kg for another 5 days
    • ? Nebulized Hypertonic Saline
slide21
Case
  • 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough.
  • HR 100 RR 28 T 37
  • Mild distress. Stridor at rest.
  • Diagnosis?
  • Treatment?
croup
Croup
  • Parainfluenza most common
  • Hoarse voice, barky cough, stridor
  • Peak fall and spring
  • Infants and toddlers
  • Treatment
    • Dexamethasone (0.6 mg/kg)
    • Nebulized Epinephrine if in respiratory distress
    • Consider Nebulized Budesonide
slide24
Case
  • 18 month female with fever x 2 days. Difficulty swallowing.
  • HR130 RR28 T39C
  • Exam normal except won’t move neck fully.
  • What diagnostic test should be performed?
retropharyngeal abscess
Retropharyngeal Abscess
  • < 6yrs
  • Complication of bacterial pharyngitis
    • Infection of posterior pharyngeal nodes – regress by school age
  • Grp A strep, oral anaerobes and S. aureus
  • Treatment
    • IV Clindamycin and Cefuroxime
    • Consult ENT
retropharyngeal soft tissues
Retropharyngeal Soft Tissues*

*

Retrotracheal Soft Tissues *

*

slide28
Case
  • 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling.
  • Not immunized.
  • HR 140 RR 20 T 39.5
  • Very quiet, doesn't move.
  • Slight noise on inspiration.
  • Chest clear, exam normal.
epiglottitis
Epiglottitis
  • Rarely seen
  • Strep pneumoniae
  • H. influenzae uncommon due to vaccine
  • Do not disturb patient
  • Consult Anesthesia, intubate
  • IV Ceftriaxone and Clindamycin
slide31
Case
  • 17 mo male with sudden onset noisy and abnormal breathing
  • Was playing on floor before developing difficulty breathing
  • VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
  • Mild wheezing with mild inspiratory stridor
foreign body aspiration
Foreign Body Aspiration
  • Highest risk between 1 -3 yrs old
      • Immature dentition, poor food control
      • More common with food than toys
        • peanuts, grapes, hard candies, sliced hot dogs
  • Acute respiratory distress (resolved or ongoing)
    • Witnessed choking
    • Cough, Stridor, Wheeze, Drooling
    • Uncommonly…. Cyanosis and resp arrest
slide37
Case
  • 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding.
  • Looks well, alert and interactive
  • T 38.9o HR 176 RR 42 BP 100/50
  • Font flat, neck supple, exam non remarkable
  • What is your approach to this case?
fever 1 month
Fever < 1 month
  • Etiology is organisms from birth canal
      • Group B Streptococcus , Escherichia coli (Gram neg), Listeria monocytogenes
  • Highest rate of bacterial infection of any age group
    • <2 weeks - 25%
    • 0-4 weeks - 13%
  • Septic Work Up
  • Admission, IV antibiotics
fever 1 3 months
Fever 1-3 months
  • May still see birth canal organisms, but also:
      • Streptococcus pneumoniae , Neisseria meningitidis, Haemophilus influenzae type b (uncommon)
  • Overall rate of bacterial infection is ~8%
      • Bacteremia 2%
      • Meningitis 0.8%
      • UTI 5%
  • “Low Risk Infant” rate of bacterial infection is 1%
      • Bacteremia 0.5%
low risk criteria rochester for febrile infants
Low Risk Criteria “Rochester” for Febrile Infants
  • Well appearing infants 1-3 mos are low risk for serious bacterial infection if:
      • Previously healthy
        • Born at term (> 37 weeks)
        • No hyperbilirubinemia
        • No hospitalizations
        • No chronic or underlying diseases
      • No evidence of focal bacterial infection
      • Laboratory parameters:
        • WBC count 5-15/mm3
        • Urinalysis WBC count < 5/hpf
        • Stool WBC count < 5/hpf (if infant has diarrhea)
fever 3 36 months
Fever 3-36 months
  • Viral infections cause of fever in >90%
    • 6% of children seen in the ED have a specific, recognizable viral syndrome
      • e.g. croup, bronchiolitis, roseola, varicella, coxsackie
  • UTI in ~5%
  • Bacteremia very low rates now (< 0.2%)
    • 5% in 1980’s, HIB vaccine 1987
    • 2% in 1990’s, Pneumococcal vaccine 2000
slide42
Case
  • 2 year old boy with generalized tonic clonic movements. Duration 5 min.
  • T 39.2o HR 110 RR 24 BP 110/60
  • Awake now, normal neurological exam.
  • Right TM bulging, neck supple, no rash.
  • Past med history unremarkable.
  • Approach?
febrile seizure
Febrile Seizure
  • Simple Febrile Seizure
    • T>38.5
    • 6 mo-5 yr
    • Generalized seizure, < 15 min
    • One seizure within 24 hours
    • Neurologically normal before and after
  • Occur in ~ 5% of children
  • Recurrence in 30%
febrile seizure1
Febrile Seizure
  • Risk of epilepsy is 1%
    • ~ same as general population
  • Higher risk (2.4%) if:
    • Multiple febrile seizures
    • < 12 mos at the time of first febrile seizure
    • Family history of epilepsy
seizure management
Seizure Management
  • ABC's
  • IV access
  • Seizure treatment
    • 1st Line - Benzodiazepines
        • Lorazepam or Diazepam (Rectal or IV)
        • Midazolam (Intranasal or Buccal)
    • 2nd Line
      • Phenytoin, Fosphenytoin
      • Phenobarbitol
seizure management1
Seizure Management
  • Seizure treatment
    • 3rd Line
      • Midazolam infusion
      • Thiopental
      • Propofol
      • Paraldehyde
  • Observe in the ED until child returns to normal
  • After simple febrile seizure no neurological investigations indicated (eg CT, EEG)
slide47
Case
  • 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea x 10 today. Voiding scant amounts.
  • HR 120 RR 36 BP 100/50 T 38.5
  • Cap refill 2 sec, pink, decreased skin turgor.
  • Font sunken, eyes sunken.
  • Abdo + GU normal.
slide48
Case
  • What is the degree of dehydration of this child?
  • Management?
gastroenteritis
Gastroenteritis
  • ORT with rehydration solution (eg Pedialyte)
    • 5 ml/kg/hr divided every 5 min, continue until appears hydrated
  • Consider Ondansetron (0.15 mg/kg)
  • Early refeeding (including milk) within 12 hrs
  • Rule out UTI
fluids and electrolytes
Fluids and Electrolytes
  • Maintenance (D5NS)
      • 4ml/kg/hr for first 10 kg
      • 2ml/kg/hr for second 10 kg
      • 1 ml/kg/hr for rest of weight in kg
  • Deficit (NS)
    • If severely dehydrated give NS bolus
      • 20 ml/kg over 15-60 min
    • Replace over 24 hours
      • First half over 8hrs, second half over 16 hrs
  • Ongoing Losses
    • Diarrhea, Vomiting, Insensible losses with fever
slide52
Case
  • 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus.
  • HR130 RR24 T37
  • Tender abdomen with fullness in RUQ
  • Diagnosis?
  • Investigations?
intussusception
Intussusception
  • 1-3 years
    • Boys 2:1
  • Classic Triad (10-30%)
    • Vomiting
    • Crampy abdominal pain
    • “Red currant jelly” stools
  • Lethargy is common
intussusception1
Intussusception
  • 75% are ileo-colic
  • Lead point
    • Peyer's Patches
      • preceding viral infection
    • Meckel diverticulum
    • Polyps
    • Hematoma (Henoch Schonlein Purpura)
    • Lymphoma
intussusception2
Intussusception
  • Plain AXR
    • May be normal
    • May have signs of bowel obstruction
    • Paucity of air in RLQ
    • No air in Cecum on Lateral Decubitus
intussusception3
Intussusception
  • Air Contrast Enema
  • Success rate >80%
  • Recurrence 10-15%
slide60
Case
  • 4 week old boy with vomiting for past week. Initially one emesis per day now emesis with every feed. Forceful. No bile.
  • No fever. No diarrhea.
  • Looks well. Mild dehydration.
  • Abdomen soft, non tender, BS present.
  • DDx?
slide61
Case
  • Na 140 K 3.0 Cl 90 BUN 24 CR 50
  • WBC 8.5 Hgb 120 Plts 360
  • Venous gas

pH 7.50, PCO2 44, HCO3 30

pyloric stenosis
Pyloric Stenosis
  • Most common surgical condition < 2 mos
  • 4-6 wks of age
  • Ratio male to female is 4:1
  • Increased in first born males
  • Occurs in 5% of siblings and 25% if mother was affected
pyloric stenosis1
Pyloric Stenosis
  • Nonbilious vomiting
  • Emesis increases in frequency and eventually becomes projectile
  • Classic findings:
    • Hypertrophied pylorus palpable “olive” in epigastric area
    • Peristaltic waves progressing from LUQ to the epigastrium
pyloric stenosis2
Pyloric Stenosis
  • Laboratory abnormalities:
    • Hypokalemia
    • Hypochloremia
    • Metabolic alkalosis
  • Ultrasound
    • Thickened pylorus
slide65
Case
  • 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability.
  • Looks unwell, irritable cry.
  • Abdomen distended.
  • Weak pulses, cap refill>5 sec.
  • DDx? Management?
volvulus
Volvulus
  • Twisting of a loop of bowel around its mesenteric attachment.
  • 80% present by the first month
      • 40% present in the first week
      • Rarely can be seen in older children.
volvulus1
Volvulus
  • Sudden onset of bilious vomiting in a neonate.
  • Acute abdomen with shock
  • May have more gradual course with episodic vomiting
volvulus2
Volvulus
  • Evidence of small bowel obstruction
    • Dilated loops
    • Air fluid levels
    • Paucity of distal air
volvulus3
Volvulus
  • Upper GI series
    • “corkscrew” appearance of the duodenum and jejunum
slide70
Case
  • 2 yr old boy with fever for 6 days.
  • Red eyes but no discharge.
  • Generalized rash.
  • Erythema of the palms of hands and soles of feet.
  • Red, swollen lips.
  • Enlarged cervical lymph nodes.
kawasaki disease
Kawasaki Disease
  • Usually < 4 yrs old, peak between 1-2 yrs
  • Fever for > 5 days and 4 of the following:
      • Bilateral non-purulent conjunctivitis
      • Polymorphous skin eruption
      • Changes of peripheral extremities
        • Initial stage: reddened palms and soles
        • Convalescent stage: desquamation of fingertips and toes
      • Changes of lips and oral cavity
      • Cervical lymphadenopathy ( >1.5 cm)
kawasaki disease1
Kawasaki Disease
  • Subacute phase - Days 11-21
    • Desquamation of extremities
    • Arthritis
  • Convalescent phase - > Day 21
    • 25% develop coronary artery aneurysms if untreated
  • Other manifestations:
    • Uveitis, Pericarditis, Hepatitis, Gallbladder hydrops
    • Sterile pyuria, Aseptic meningitis
kawasaki disease2
Kawasaki Disease
  • Treatment
  • IV Immunoglobulin
    • Reduces incidence of coronary aneurysms to 3% if given within 10 days of onset of illness
    • Defervescence with 48 hrs
  • ASA
    • High dose during acute phase then lower dose for 3 mos
slide74
Case
  • 3 yr old girl with rash starting today.
  • Recent URTI.
  • Swollen ankles and knees. Painful walking.
  • Diagnosis?
henoch schonlein purpura
Henoch-Schonlein Purpura
  • Systemic vasculitis – IGA mediated
  • 75% are 2-11 yrs
  • Clinical Features
      • Rash (non thrombocytopenic purpura) 100%
      • Arthritis (ankles, knees) - 68%
      • Abdominal pain - 53%
      • Nephritis - 38% (ESRD in ~1%)
  • Intussusception (2-3%)
slide76
Case
  • 1 yr old boy with mouth lesions for two days
  • What are the two most likely causes?
herpetic gingivostomatitis
Herpetic Gingivostomatitis
  • Herpes Simplex
    • Severe primary infection
    • HSV1 (80%), HSV2 (20%)
  • Fever, irritability, poor intake
  • Ulcers on mucous membranes
  • Treatment
    • Acyclovir
    • Pain control, IV hydration
hand foot and mouth disease
Hand, Foot and Mouth Disease
  • Coxsackievirus, usually A16
  • Summer
  • Ulcers on tonsilar pillars
    • can have generalized stomatitis
  • Vesicles on hands and feet
  • URTI, pharyngitis
  • Vomiting and diarrhea
  • Generalized maculopapular rash
slide79
Case
  • 5 yr old girl with itchy rash
  • Varicella Zoster
  • This child comes back to the ED three days later with worsening fever and pain...
diagnosis
Diagnosis?

Necrotizing Fasciitis

  • Invasive group A streptococcal infection
  • IV Penicillin and Clindamycin
  • Consult ID, surgery
  • MRI
slide81
Case
  • 3 yr old girl fever for 3 days, unwell
  • Rash spreading over entire body with skin peeling
staphylococcal scalded skin syndrome
Staphylococcal Scalded Skin Syndrome
  • Exotoxin causes separation of epidermis
  • < 2yr
  • Fever, toxic appearance, generalized erythema
    • Exfoliation of skin, accentuated in flexor surfaces
    • skin lifts to touch (Nikolsky’s sign)
  • Perioral crusting, “honey coloured” lesions
  • Fluid resuscitation
  • IV Cloxacillin, Cefazolin or Clindamycin
slide84
Case
  • 10 yr old boy with fever
  • Unwell today
  • Rapidly progressing rash since this morning
meningococcemia
Meningococcemia
  • Usually < 5 yrs, Adolescents outbreaks
  • Fever, toxic appearance
  • Petechiae, purpura
  • DIC, shock
  • High mortality (25-80%)
  • Resuscitation
  • IV Ceftriaxone
  • Treat household contacts
septic shock
Septic Shock
  • How are you going to resuscitate this child?
  • First intervention?
  • Next?
  • Next?
  • Next?
septic shock1
Septic Shock
  • Leading cause of death in infants and children
      • 6 million deaths per year worldwide
  • Etiology of sepsis
    • Streptococcus pneumonia
    • Escherichia coli
    • Neisseria meningitidis
    • Other: Group A strep, other Gram neg bacilli, Staph. aureus, Enterococcus
  • IV Antibiotics: Ceftriaxone and Vancomycin
septic shock2
Septic Shock
  • Sepsis if systemic inflammatory response signs (SIRS) and signs of infection
    • Fever,  or  HR,  RR,  or  WBC
  • Severe sepsis if signs of organ dysfunction or tissue hypoperfusion
  • Septic Shock if cardiovascular dysfunction
septic shock3
Septic Shock
  • Hypotension is DECOMPENSATED SHOCK
  • Most children have “cold shock”
      • Decreased cardiac output and increased systemic vascular resistance
      • Poor perfusion, cool extremities, delayed cap refill
  •  Adolescents more likely to have “warm shock”
      • Low systemic vascular resistance
      • Bounding pulses, wide pulse pressure
slide94
Case
  • 2 yr old at grandmother’s house
  • Took unknown amount of pills that he found in her purse 30 minutes ago
  • No symptoms
  • What is your approach?
poisoning in children
Poisoning in Children
  • Young children
      • Exploratory ingestion
      • Ingest small amount of a single substance
        • Can grasp single pill at 1 yr
        • Can’t hold handful of pills until > 15 mos
        • Child preparations have small opening – spills out
    • Adolescents
      • Ingest large amounts of one or more substances
      • Suicidal gesture
gi decontamination
GI Decontamination
  • Activated Charcoal
    • 1 g/kg
    • Greatest benefit is within 1 hr of ingestion
      • At 30 min 89% decrease
      • At 1 hr 37% decrease
    • Not useful for
      • Alcohols
      • Hydrocarbons
      • Anions or Cations (Iron, Lithium)
      • Acids or Alkali
gi decontamination1
GI Decontamination
  • Whole Bowel Irrigation
    • PegLyte
      • 0.5-2 L per hour via NG
    • For substances not adsorbed by charcoal and sustained release preparations
      • Iron
      • Lithium
      • EC ASA
poisoning in children1
Poisoning in Children
  • Common ingestions
    • Household products
    • Cough/cold, vitamins, antibiotics
    • Acetaminophen and Ibuprofen
    • Antidepressants
  • Pills that are harmful if single dose taken
    • Oral hypoglycemics, calcium channel blockers, tricyclic antidepressants
acetaminophen
Acetaminophen
  • Clinical Effects
    • 0-24 hrs
      • GI irritation, may be asymptomatic
    • 24-48 hrs
      • Signs of liver involvement begin
    • 72-96 hrs
      • Fulminant hepatic failure
      • Renal failure
acetaminophen2
Acetaminophen
  • > 4 hr Acetaminophen level
  • Plot on nomogram
  • N-Acetylcysteine
    • Precursor for glutathione
    • Increases sulfation metabolism
    • Directly reduces NAPQI to APAP
    • Directly conjugates NAPQI
salicylates
Salicylates
  • Clinical Effects
    • GI upset - N&V, Gastritis
    • Tinnitus – often the first symptom
    • CNS – Confusion, Lethargy, Cerebral edema
    • Hyperpnea– Early have respiratory alkalosis
    • Hyperthermia
    • Renal and Liver toxicity – rare
    • Impaired platelet function
salicylates1
Salicylates
  • Mechanism of Action
    • Uncoupling of oxidative phosphorylation
      • Hyperthermia
      • Glycogenolysis, Lipolysis
      • Hyperglycemia initially then hypoglycemia from impaired gluconeogenesis
    • Inhibits Kreb’s cycle
      • Anaerobic metabolism
      • Lactic acidosis
salicylates2
Salicylates
  • Urine alkalinization
    • Ion trapping – ASA is weak acid
  • Hemodialysis
    • If signs of multiorgan failure
ibuprofen
Ibuprofen
  • Low incidence of toxicity, most asymptomatic
  • Reversibly blocks cycloxygenase,  prostaglandins
  • Clinical Effects
    • GI upset, bleeding
    • Renal failure
    • Bronchospasm
    • Massive overdoses > 400 mg/kg
      • metabolic acidosis, seizures, coma, hypotension
tricyclic antidepressants
Tricyclic Antidepressants
  • Triad of clinical effects:
    • Cardiovascular
      • Prolonged QRS, QT, PR, Arrhythmias
      • Hypotension
    • CNS
      • Coma, Seizures
    • Anticholinergic symptoms
tricyclic antidepressants1
Mechanisms of toxicity

Blockade of fast Na+ channels

Type 1A “quinidine-like effects”

Membrane stabilizing effects

Inhibition of GABA reuptake

Blockade of alpha 1 receptors

Anticholinergic effects

Tricyclic Antidepressants
tricyclic antidepressants2
Tricyclic Antidepressants
  • NaHCO3
    • 1-2 meq/Kg then infusion
      • D5W + 150 meq NaHCO3/L at 1.5 x maintenance
  • Benzodiazepines
    • Sedation, seizures
  • Lipid therapy
    • May be helpful, case reports
ssri s
SSRI’s
  • Much safer than TCA’s
  • Clinical Effects:
    • N&V
    • Sedation
    • QT prolongation
    • Seizures
  • Serotonin Syndrome
ssri s1
SSRI’s
  • Serotonin Syndrome
      • Agitation, Hypervigilance
      • Myoclonus, Muscle rigidity
      • Seizures
      • Diaphoresis, shivering
      • Hyperthermia, Autonomic dysfunction – HR, BP
      • Diarrhea
  • Treatment
    • Benzodiazepines, Active cooling
summary
Summary
  • Review of pediatric emergency cases:
      • Resuscitation
      • Asthma, Bronchiolitis, Croup, Upper airway
      • Fever in infant, 3-36 months
      • Febrile seizures, Status epilepticus
      • Gastroenteritis, Pyloric stenosis, Intussusception
      • Rashes associated with serious illness
      • Sepsis
      • Poisoning