Pediatric Case Studies

1
Pediatric Case Studies

• Jana A. Stockwell, MD, FAAP
• Pediatric Critical Care Medicine
• Childrens Healthcare of Atlanta _at_Egleston
• Atlanta, Georgia
• jana.stockwell_at_CHOA.org

2
Case 1

• You receive a 4 month old male from another ER
  who is suffering from respiratory distress

• Vital signs T 39.2ºC, HR 220, RR 55, BP 75/40,
  SpO2 99 on 2L NC, CR 4 sec

• He is sleeping but arouses to stimulation.

• His CXR is read as no infiltrate

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4
Case 1

• Shortly after arriving on the ward, the child
  develops difficulty breathing and an elevated
  heart rate. The rhythm strip is shown below...

5
Case 1

• How fast is the heart beating?
• Use the 300-150-75 rule

So, a little less than 300 bpm!!!
6
Case 1
You suspect SVT...
SupraVentricular Tachycardia

• What should you do next?
• Determine if the child is clinically stable or
  unstable

HOW?
7
Case 1

• In SVT, if the child is clinically stable, try
• Inducing the Dive Reflex by applying an ice bag
  to the face
• Bearing down (i.e. Valsalva maneuver)
• Eyeball pressure carotid massage, may be
  harmful and are discouraged

8
Case 1

• You suspect SVT
  the child is clinically
  unstable
• Place an IV
• Give IV bolus of ADENOSINE
• Very short t? (10 sec) must be given rapidly
• Continuous rhythm strip during attempted
  conversion
• Potential side effects include hypotension,
  bronchospasm, and flushing
• Be prepared to see a flat line EKG!

9
Case 1

• You suspect SVT
  the child is very clinically unstable
• If an IV cannot be started quickly OR
• If the patient fails to convert with IV adenosine
  OR
• Patient becomes unconscious or unresponsive
• Then, cardiovert using 0.5 - 1 joule/kg

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Case 1 Summary

• Things are not always what they are advertised to
  be
• Be aware that multiple therapies may be available
  and choice depends upon clinical situation

11
Case 2

• You are admitting a 6 year old male with no
  significant past medical history who presented at
  an outlying physicians office with a decreased
  level of consciousness. He has been having
  massive amounts of emesis and diarrhea.

• VS T 38.2ºC, HR 150, RR 28, BP 70/30, SpO2 97
  on Room Air

• There is good air exchange in all lung fields,
  peripheral pulses are 1, central pulses are 1,
  the CR is 4 sec

12
Case 2

• What is wrong with this child?

This child is in uncompensated shock, most likely
from hypovolemia
What is the first logical step in management of
this child?
Crystalloid (NS, LR) at 20 cc/kg bolus
13
Case 2

• After giving 20 cc/kg of NS, what should be done?
• Re-assess the childs clinical status
• Check pulses and heart rate
• Check blood pressure
• Evaluate capillary refill time
• Evaluate mental status
• Auscultate chest to determine if heart can handle
  volume load -- rales, gallop

14
Case 2

• VS HR 150, RR 32, BP 70/50, SpO2 97 on RA
• There is good air exchange in all lung fields,
  peripheral pulses are 1, central pulses are 1,
  the CR is 4 sec
• Now that the BP has improved, is this child still
  in shock?

Yes, the child is in uncompensated shock!!
What should you do now?
Repeat the NS bolus at 20 cc/kg
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Case 2

• VS HR 140, RR 30, BP 90/60, SpO2 97 on RA.
  There is good air exchange in all lung fields,
  peripheral pulses are 2, central pulses are 2,
  the CR is 3 sec
• Now that the BP has improved, is this child still
  in shock?

Yes, it is now compensated shock
What should you do now?
Repeat the NS bolus at 10-20 cc/kg
16
Case 2

• The childs VS are HR 100, RR 22, BP 98/65, SpO2
  94 on RA. There is good air exchange in all lung
  fields, peripheral pulses are 2, central pulses
  are 2, the CR is lt 2 sec
• Now that the VS have improved, is this child
  still in shock?
• No. The fluid resuscitation has brought this
  child out of hypovolemic shock

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Case 2 Summary

• When the tank is low, it may take a lot of fluid
  to fill it back up!
• Remember, being 10 dehydrated means 10 of the
  body weight is lost due to fluid ouput/poor intake

18
Case 3

• You are transporting a 13 year old male who
  presented to an outlying ER with nausea and
  bilious vomiting. He has a past history of BMT
  for CML. He also has a history of recurrent
  bowel obstructions.
• In the ER, VS are T 35.7ºC, HR 110, RR 32, BP
  90/45, SpO2 98 on RA. His extremities are warm
  and well perfused.

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Case 3

• During transport, the child begins to speak in
  incomprehensible sentences.
• VS T36.8ºC, P 162, RR 38, BP 70/42, SpO2 95 on
  RA, he is having rigors.
• What should be done next?

This child is in uncompensated shock. He should
receive 20 cc/kg of crystalloid
20
Case 3

• After receiving a total of three 20 cc/kg boluses
  of crystalloid, the child remains hypotensive.
• What should be the next course of action?

Pharmacological support of his BP
21
Case 3

• Dopamine added
• What dose should you start?
• You titrate the dose to 12 mcg/kg/min and the
  child is still hypotensive...
• What exam findings are important in guiding
  therapy at this time?
• Capillary refill time
• Tactile temperature of the extremities
• Mental status
• Peripheral and central pulses

22
Case 3

• What are the clinical features of warm vs.
  cold septic shock?
• Warm Cold

CR time
Brisk Prolonged
Skin temp
Precordium
Pulses
Warm Cool
Nml/?activity Nml/?activity
Bounding Nml/Thready
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Case 3

• How do these findings guide the next phase of
  therapy?
• In warm septic shock, the underlying problem is
  decreased SVR, therefore an agent with mostly
  vasopressor activity should be started (i.e.
  norepinephrine)
• In cold septic shock, the underlying problem is
  decreased CO, therefore an agent with inotropic
  activity and/or afterload reduction should be
  started (i.e. epinephrine, milrinone, nipride)

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Case 3 Summary

• The stage of shock will determine which drugs are
  most appropriate for resuscitation -- the list of
  choices is long

norepinephrine
neosynephrine
dopamine
milrinone
dobutamine
nipride
epinephrine
25
Case 4

• You are transporting a 4 year old male who fell
  out of a 4th story window. His head CT reveals
  small contusions. He is in a C-collar.
• VS HR 65, RR 20, BP 60/30, SpO2 98 on RA, CR
  4 sec. His neck films are shown.

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Case 4
27
Case 4

• Recognizing the hypotension, a medic has already
  administered three boluses of NS at 20 cc/kg, but
  the child remains hypotensive.
• Repeat VS HR 55, RR 25, BP 65/30, SpO2 98 on
  RA, CR 4 sec.
• What is unique about these vital signs?
• There is no compensatory tachycardia for the
  hypotension
• What does this suggest?
• The child may have neurogenic shock

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Case 4

• What is neurogenic shock?
• It is a condition characterized by loss of
  sympathetic tone to the peripheral vascular bed
  and to the heart
• What is the hallmark of this type of shock?
• There is marked hypotension without compensatory
  tachycardia following a CNS injury

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Case 4
Now the brain cannot control the heart and the
heart functions independently from the rest of
the circulation

• How does this occur?

30
Case 4

• How is this treated?
• The use of pure ?-agonist (e.g. neosynepherine)
  agents is preferred

31
Case 4 Summary

• Not all shock secondary to trauma is due to blood
  loss!

32
Case 5

• You are working on Transport, when a 16 year old
  male, who was riding a motorcycle when he lost
  control, flipped, and smashed into a guard rail,
  is brought in to a referring ED. He was wearing
  a helmet.
• He was found to have a multiple rib fractures an
  and underlying hemothorax.
• His chest x-ray is as follows.

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Case 5

• Prior to transport, the child has been intubated
  for respiratory distress and altered mental
  status.
• A left chest tube has been placed. CTs of the
  head, chest, abdomen, and pelvis are negative for
  additional pathology.
• VS T 38.2ºC, HR 108, RR 20, BP 90/60, SpO2 98.
  
• He is currently intubated, sedated, and
  paralyzed. He is stable and he is loaded onto the
  ambulance for transport.

35
Case 5

• During transport, the child becomes progressively
  tachycardic. What do you do now?
• Check all vitals and perform quick, focused
  clinical exam accessing airway, breathing, and
  circulation
• You determine that there is no immediately
  life-threatening cause of the tachycardia and
  suspect pain and under sedation for which you
  administer fentanyl and lorazepam.

36
Case 5

• Now the teenagers pulse is 185 and he is
  becoming hypotensive to 50/20. You check the
  pupils because heart rate and BP changes are part
  of Cushings Triad. What is Cushings Triad?
• Bradycardia
• Hypertension
• Altered respirations

37
Case 5

• This is not Cushings Triad what else could it
  be? Your quick physical examination finds the
  following
• Neck vein distension
• Tachycardia with decreased heart sounds
• Hypotension
• Thready pulses

38
Case 5

• What is happening?
• Cardiac tamponade
• How is this treated?
• 20 cc/kg fluid push
• Emergent pericardiocentesis
• Removal of even a small volume of fluid is the
  definitive treatment can rapidly improve BP
  cardiac output -- may ultimately prove to be
  lifesaving

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Cardiac tamponade occurs when blood or other
fluid accumulates in the pericardial space. This
creates increased pressure around the heart and
interferes with heart function.
40
Case 5

• What are the signs of cardiac tamponade?

• Tachycardia
• Hypotension
• JVD
• Decreased cardiac output
• Pulsus paradoxus - gt10 mmHg change between
  inspiratory and expiratory systolic BP
• Narrow pulse pressure
• Muffled heart tones

41
Blind Pericardiocentesis - Technique

• Subxiphoid Approach
• Position the patient so the chest is at a
  30-degree angle
• Insert an 18-gauge spinal needle attached to a
  20-ml syringe into the left xiphocostal angle
  perpendicular to the skin and 3 to 4 mm below the
  left costal margin
• While aspirating constantly, advance the needle
  directly into the inner aspect of the rib cage

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Blind Pericardiocentesis - Technique

• Depress the needle so the needle points toward
  the left shoulder
• Using a slow, cautious, turning action of the
  fingers, advance the needle until fluid is
  aspirated
• Observe the cardiac monitor for arrhythmias
• Successful removal of fluid confirms the needle's
  position

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Blind Pericardiocentesis - Complications

• Laceration of a coronary artery
• Laceration or perforation of either ventricle
• Laceration or perforation of the right atrium
• Perforation of the stomach or colon
• Pneumothorax
• Arrhythmias
• Tamponade
• Hypotension (perhaps reflexogenic)

44
Case 6

• Your 3 y.o. patients mother calls out that
  something is wrong.
• You find the child lying on the bed with his
  right arm in extension with his hand twitching
  his eyes dancing horizontally. Mom states that
  she has been trying to arouse the child without
  success.
• VS T 39.2ºC, HR 180, BP 110/70, RR 38 and
  irregular, SpO2 82 on room air.

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Case 6

• What is your first impression of this situation?
• Child with
• Complex focal seizure
• Hypoxic respiratory distress
• Tachycardia
• Fever

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Case 6

• What are the first things you should assess?
• Airway
• Breathing
• Circulation

Appears patent
Ineffective, child is cyanotic
Child is tachycardic with good pulses brisk
capillary refill time
47
Case 6

• Does this child need intubation?
• Not at this time. While the child is hypoxic,
  repositioning and oxygen by face mask can improve
  oxygenation.
• Additionally, treatment of the childs seizures
  may restore regular respirations and improve the
  oxygenation status.

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Case 6

• What medications should be given and by which
  routes?
• Diazepam (Valium) onset in 2-10 minutes
• Rectal gel (Diastat)
• Infants lt6 months Not recommended
• Children lt2 years Not been studied
• Children 2-5 years 0.5 mg/kg
• Children 6-11 years 0.3 mg/kg
• Children 12 years and Adults 0.2 mg/kg
• Round doses to nearest 2.5, 5, 10, 15, and 20
  mg/dose

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Case 6

• What medications should be given and by which
  routes?
• Lorazepam (Ativan) onset in 2-5 minutes
• Neonates 0.05 mg/kg IV/IM
• Infants, Children, and Adolescents 0.1 mg/kg
  (max 4 mg) IV/IM
• May repeat up to 3 times before considering a
  non-benzodiazepine agent

50
Case 6

• What medications should you consider if the first
  line agents fail to control the seizures?
• Phenobarbital
• Phenytoin (Dilantin)
• Fosphenytoin if peripheral IV questionable

51
Case 6

• The child stops twitching after lorazepam is
  given. His respirations are shallow his SpO2 in
  100 on NRB FM at FiO2 1.0
• What reflexes should be evaluated to see if this
  child requires intubation?
• Gag to evaluate airway protection.

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Case 7

• You are working in the ER when a 13 year old
  unresponsive female is brought in.
• Her little brother states the girl has been sick
  all day. She was really thirsty having consumed
  four 2 liter bottles of Coke in the last 8 hours.
  
• VS T 36ºC, HR 165, BP 80/palp RR 25 and very
  deep, SpO2 99 on room air.

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Case 7
What is the differential diagnosis? "AEIOU -
TIPS

• A abuse or alcohol
• E encephalopathy or endocrine
• I insulin/ hypoglycemia/ metabolic
  disorder
• O opiates
• U uremia

• T trauma/ tumor
• I infection/ intussusception
• P poisoning
• S sepsis/ seizure/ shock

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Case 7
What is the differential diagnosis? DPT - OPV -
HIB - MMR

• D dehydration
• P poisoning
• T trauma
• O occult trauma
• P post-ictal or post- anxoia
• VVP shunt infection

• H hypoxia/ hyperthermia
• I intussusception
• B brain mass
• M meningitis
• M metabolic
• R Reyes syndrome

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Case 7

• The sibling states that she takes injections in
  her leg. What is the most likely diagnosis?

Diabetic ketoacidosis
56
Case 7

• You check a blood gas which demonstrates
• pH 6.91, PaCO2 23, PaO2 80, SaO2 98, base
  deficit -27
• Na 133, K 6.5, Glucose , iCa 4.5 mg/dL

57
Case 7

• Should you give NaHCO3 to correct the acidosis?
• No. NaHCO3 should only be given in the setting
  of cardiovascular dysfunction, i.e. arrhythmias.
  Its use has been associated with the development
  of cerebral edema in patients wth DKA.
  (N Engl J Med
  2001344264-9)

pH 6.91, PaCO2 23, PaO2 80, SaO2 98, base
deficit -27 Na 133, K 6.5, Glucose , iCa 4.5
mg/dL
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Case 7

• Why is the K elevated?
• Elevated serum hydrogen ion is counter-transported
  across the RBC membrane with potassium in an
  effort to buffer the acidosis

pH 6.91, PaCO2 23, PaO2 80, SaO2 98, base
deficit -27 Na 133, K 6.5, Glucose , iCa 4.5
mg/dL
59
Case 7

• Why is Na low?
• The hyperosmolality of diabetes attracts more
  water into the intravascular space. This causes
  a ficticious hyponatremia.

pH 6.91, PaCO2 23, PaO2 80, SaO2 98, base
deficit -27 Na 133, K 6.5, Glucose , iCa 4.5
mg/dL
60
Case 7

• What IVF should be given and how much?
• 0.9 NaCl at 20 cc/kg unless in uncompensated
  shock. Excess IVF has been associated with
  cerebral edema. (4 liters/M2)

pH 6.91, PaCO2 23, PaO2 80, SaO2 98, base
deficit -27 Na 133, K 6.5, Glucose , iCa 4.5
mg/dL
61
Case 8

• You are admitting a 6 year old male who is
  coughing uncontrollably.
• VS T 37.2ºC, HR 140, RR 40, SpO2 85 on room
  air.
• He has nasal flaring, supra-sternal, intercostal,
  and subcostal retractions.
• By auscultation, you hear expiratory wheezes
  bilaterally with a prolonged expiratory time.

62
Case 8

• What is this childs problem?

Acute exacerbation of asthma
Asthma is a chronic inflammatory pulmonary
disorder that is characterized by reversible
obstruction of the airways
63
Case 8

• What is the 1st step in treatment?
• Provide oxygen
• What is the next step?
• Provide nebulized bronchodilators

64
Case 8

• How would the diagnosis change if the child had a
  right-sided, wheeze heard best on inspiration,
  with decreased air exchange on the right side,
  and tracheal deviation to the left?
• This would suggest the presence of a foreign
  body.
• Remember, all that wheezes is not asthma!

65
Case 8

• Physical examination of the child reveals a
  palpable liver edge 5 cm below the right costal
  margin. Why is this?
• Hyperinflation related to obstructive airway
  disease in asthma has pushed the liver inferiorly
  into the abdomen.

66
Case 8

• What agents are used in the treatment of asthma
  and why?
• ?-agonist agents
• Increase cAMP which leads to decreased
  intracellular calcium and smooth muscle
  relaxation.
• Albuterol nebs or MDI, terbutaline nebs or SQ,
  epinephrine SQ

67
Case 8

• Agents
• Anticholinergic agents
• Inhibit the acetylcholine receptor thereby
  decreasing the intracellular cGMP which leads to
  decreased intracellular calcium and smooth muscle
  relaxation.
• Ipratroprium bromide nebs
• Steroids
• Acutely, they may lead to ?-receptor upregulation
  and sub-acutely/chronically have been shown to
  decrease the inflammatory response in asthma

68
Case 8

• Agents
• Magnesium sulfate
• Competitively inhibits intracellular calcium and
  leads to smooth muscle relaxation
• Ketamine
• Binds sigma opiate receptors to cause
  dissociative amnesia and relaxation.
• Causes secondary release of endogenous
  epinephrine which causes smooth muscle
  relaxation. Can cause excessive secretions.

69
Case 9

• A 7 week old female infant is being seen for
  unresponsiveness after being found face down in
  the bed by her parents.
• VS T 35.2ºC, HR 68 thready, RR 13, BP 65/40
  with SpO2 unable to trace, and CR 5 sec. She
  responsive to painful stimulation.
• The physician seeing the patient is concerned
  about sepsis and gave the child IM antibiotics
  because no IV access has been obtained.

70
Case 9

• What are the first things you should do?
• Airway Breathing
• Bagging this child with 100 oxygen increased the
  heart rate to 180 bpm
• Circulation
• This child is in shock. An attempt at IV access
  should be made. If no access is obtained in 90
  seconds or after 3 attempts, an IO needle should
  be placed.
• After this, the child should receive 20 cc/kg of
  crystalloid solution

71
Case 9

• What should be done next?
• Disability
• This child is hypothermic and should be placed
  under warming lights or wrapped in a blanket

72
Case 9

• What components of the history should be
  obtained?
• Birth history
• Full term or premature?
• Discharged right after birth or was there a
  prolonged stay?
• GI
• Has the child been taking good PO?
• Making good UOP?
• Diarrhea or vomiting?

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Case 9

• ID
• Any fever?
• Any rash?
• Any sick contacts?
• Medical
• Is the child on any medication?
• When was the last visit to the doctor?
• Are the vaccinations up to date?

74
Case 10

• You arrive at your night shift on a community
  hospital inpatient floor. One of your patients
  is a 9 month old, former 25 week male premie who
  is respiratory distress.
• The nurse signing out to you states that the
  child has developmental delay and cerebral palsy.
  
• The child presented to your facility with fever
  and rhinorrhea for 3 days, with progressively
  increasing work of breathing. The child has been
  receiving albuterol nebs Q 2 hours around the
  clock for the last 2 days without relief.
• VS 38.3ºC, HR 195, RR 60, BP 100/57, SpO2 89
  on 5L FM, and CR lt2 sec

75
Case 10

• Different parts of the respiratory tree may be
  contributing to this infants problems
• Nasal Passages obstruction from rhinorrhea,
  adenoid hypertrophy
• Oropharynx inability to clear secretions,
  pharyngeal hypotonia with obstruction, tonsillar
  hypertrophy
• Trachea Stenosis, malacia, vocal cord paralysis,
  viral croup
• Small Conducting Airways Reactive airway
  disease, bronchopulmonary dysplasia
• Alveoli pneumonia, bronchopulmonary dysplasia

76
Case 10

• Name different ways to overcome these airway
  problems
• Nasal Passages suction, ?-agonists (i.e. Afrin)
• Oropharynx suction, BVM to give CPAP with 100
  oxygen, intubation
• Trachea racemic epinephrine nebs, Heliox, BVM to
  give CPAP with 100 oxygen, intubation
• Small Conducting Airways albuterol,
  ipratroprium, BVM to give CPAP with 100 oxygen,
  intubation
• Alveoli BVM to give CPAP with 100 oxygen,
  intubation

77
Case 11

• You are transporting a 14 year old male with
  bilateral frontal contusions after a MVC.
• The child has also sustained pulmonary contusions
  and a liver laceration. He was intubated for a
  GCS of 6. His pupils are 4mm and sluggish.
• VS T 37.2ºC, HR 108, BP 90/45 with SpO2 100.
• Vent settings are VT 400 cc, PEEP 5, IMV 12, FiO2
  1.0.

78
Case 11

• During transport, the child develops a BP of
  180/120 pulse 65. What might be happening?
• The bradycardia and elevated BP suggest Cushings
  Triad (altered respirations is the third
  component) which suggests impending herniation.
• What is the next most appropriate step in
  management?
• Hyperventilation decreases PCO2 causing cerebral
  vasoconstriction leading to decreased blood flow
  decreasing cerebral edema.
• Hyperosmotic agents
• Mannitol or 3 NaCl removes water from brain and
  can relieve edema
• Elevation of head.

79
Case 11

• Now his sats are falling...
• You begin to manually bag him and notice that it
  is much more difficult to obtain chest rise than
  previously.
• What should you think of next?
• DOPE
• Displacement
• Obstruction
• Pneumothorax
• Equipment Failure

80
Case 11

• You check for displacement by auscultation
  bilaterally
• No air exchange in the right lung fields with
  good air exchange in the left lung fields.
• Could the ETT have slipped and led to left
  main-stem intubation? This is unlikely as the
  right main-stem is straighter and the tube is
  still taped at the original position.
• You check for obstruction of the ETT by passing a
  suction catheter into the ETT
• Suction catheter passes without difficulty

81
Case 11

• You check for a possible pneumothorax
• There is no air exchange on the right side
• There is no chest rise on the right side
• The trachea is deviated to the left
• These findings suggest a right sided pneumothorax
• You quickly access for equipment failure
• The BVM is connected to 100 oxygen
• The anesthesia bag inflates correctly
• You suspect a right sided PTX and perform a
  needle thoracotomy in the 2nd ICS at the
  mid-clavicular line and hear a whoosh of air

82
Case 12

• You arrive at an ER to transport a 5 year old
  male who was intubated for respiratory failure
  secondary to shock.
• His VS are 39.2ºC, P 140, RR 32, BP 90/30, SpO2
  93 on 100 O2.
• The child received 40 cc/kg LR, vancomycin,
  ceftriaxone prior to intubation.
• There is an IO in the left tibia (attempt at a
  right IO failed). There is an a-line in the
  right radial artery.

83
Case 12

• En route, the becomes hypotensive to 55/20.
  While pushing volume, the IO displaces. What
  should you do next?
• Place an IO in either femur, just proximal to the
  knee. Placement of the IO in either of the tibias
  may result in extravisation of fluid out of the
  previous IO attempt sites

84
Case 12

• The child remains hypotensive despite a 20 cc/kg
  bolus (60 cc/kg total given since presentation).
  What should you do next?
• Begin dopamine at 5 mcg/kg/min
• How do you make a drip using the rule of 6s?
• Wt(kg) x 60, 6, or 0.6 mg/100 cc to make a
  drip that at 1 cc/hr 10, 1, or 0.1 mcg/kg/min

85
Case 12

• You obtain a arterial blood gas which
  demonstrates pH 7.20, PaCO2 60, PaO2 75. What
  is happening and what should you do?
• The patient is suffering from a respiratory
  acidosis and you should increase the ventilation
  rate or tidal volume
• How can you estimate the change in pH from the
  change in PCO2?
• For every 10 change in PCO2, a change of 0.08 in
  pH will be seen

86
Case 12

• You have attempted to titrate the dopamine to
  keep the MAP gt 65. It is now at 18 mcg/kg/min
  but the hypotension persists.
• Which agent should you consider if the child has
  a CR lt 2, peripheral pulses 3, and a
  hyperdynamic precordium?
• This child is in warm septic shock.
  Norepinephrine should be started.
• Which agent should you consider if the child has
  a CR 4 and the peripheral pulses are thready?
• This child is in cold septic shock. Epinephrine
  should be started.

87
Case 13

• You are transporting a 16 year old male from a
  peripheral ER who is suspected of taking PCP. He
  was combative and received IM haloperidol which
  controlled his temperament adequately.
• During transport, he develops muscle spasms, eye
  dancing, a stiff neck, and an inability to open
  his jaw. What is happening?
• Acute dystonic reaction from haloperidol

88
Case 13

• What other drugs can commonly cause this
  reaction?
• Metoclopromide (Reglan)
• Prochlorperazine (Compazine)
• How is this reaction treated?
• Diphenhydramine (Benadryl)
• Benztropine (Cogentin)

89
Case 13

• You arrive at the ER of a rural medical center to
  transport a 13 month old child who has
  respiratory distress for the last 3 days.
• He is now significantly worse. VS T 39.8ºC, HR
  198, RR 55, BP 65/30, SpO2 93 on 5L FM.
• The child appears physically exhausted.
• Physical examination demonstrates rales on
  auscultation bilaterally, distant heart sounds,
  and increased liver size.
• His pulses are thready and CR 3 sec.
• The CXR is shown on the next slide.

90
Note the increased cardiac to thoracic ratio
91
Case 13

• The diagnosis of acute myocarditis is made.
  While transporting the child, he develops the
  following rhythm

• What is the diagnosis of this rhythm?
• Ventricular tachycardia

92
Case 13

• What should you do next?
• Check for a pulse
• If no pulse present, initiate CPR and PALS
  pulseless arrest algorithm
• If pulse present with poor perfusion
• STAT defibrillation 2 J/kg.
• Consider alternative medications
• Amiodarone 5 mg/kg IV over 20 minutes or
• Lidocaine 1 mg/kg IV
• Intubation

93
Case 13

• What should you do next? (Cont)
• Check for a pulse
• If pulse present with adequate perfusion
• Consider medications
• Amiodarone 5 mg/kg IV over 20 minutes or
• Lidocaine 1 mg/kg IV
• Cardioversion with 0.5 to 1.0 J/kg

94
Case 14

• You arrive at a physicians office to transport a
  4 year old child with a suspected acute abdomen.
  
• The child has had bilious emesis for 2 days along
  with loss of appetite.
• VS T 40.1ºC, HR 140, RR 45, BP 80/40, SpO2 100
  on room air, CR lt 2 sec.
• The physician has given the child 4 doses of
  morphine (2 mg) with minimal pain relief.

95
Case 14

• While en route, the child falls asleep and
  appears comfortable.
• The BP cycles and determines that the BP is now
  60/20 with the heart rate elevated to 180.
• What should you do now?
• Consider a crystalloid bolus of 20 cc/kg

96
Case 14

• The childs SpO2 is beginning to fall (84).
  Examination demonstrates shallow respirations.
  What should you do next?
• Place the child on 100 FM
• The SpO2 continues to fall after oxygen. Should
  you intubate this child?
• No. This child is probably suffering from a
  depressed respiratory drive, try naloxone
  (Narcan).

97
CASES