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Pediatric Emergency Cases
Melissa Joy, RNMichael Mojica, MDTodd P Chang, MD
CASE 3A…Peace puts her everywhere…
Case 3A - Briefing
4-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 vomiting
US SI
Na 149 149
K 2.1 2.1
Cl 82 82
HCO3 37 37
BUN 19 6.8
Cr 0.8 61.9
Glucose 55 3.0
4wk listless vomiting
US SI
WBC 14.8 14.8
Hgb 17.2 10.7
Hct 50.1 0.5
Plt 284 284
4wk listless vomiting
36.7 C = 98.1 F
4wk listless vomiting
37.4 C = 99.3 F
4wk listless vomiting
US SI
Glucose 55 3.0
4wk listless vomiting
US SI
pH 7.50 7.50
pCO2 48 48
pO2 (cap) 92 92
HCO3 35 35
%sat (cap) 82 82
Na 151 151
K 1.8 1.8
Cl 86 86
Hgb 17.2 10.7
4wk listless vomiting
4wk listless vomiting
PEDIATRIC SHOCK
Infant Shock
HRb/p
Infant Shock
HRb/p
Heart Rates
Age Typical Heart Rates
Newborns 0 – 3 months 100 – 150
Infants 3 – 6 months 90 – 120
Infants 6 – 12 months 80 – 120
Children 1 – 10 years 70 – 130
Adolescents 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 IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip
5b Norepinephrine 0.1 mcg/kg/min to 2
60 minutes IV drip
6 0.9% Normal Saline
Ad lib - IV
Hypovolemic Shock# Dose Time
LimitForm
1 Access #1 1 minute IV or IO
2 0.9% Normal Saline
60 mL/kg 15 minutes IV push
3 Access #2 15 minutes IV or IO
4* Ceftriaxone 50 mg/kg 60 minutes IV
5a Dopamine 5 mcg/kg/min to 20 60 minutes IV drip
5b Norepinephrine 0.1 mcg/kg/min to 2
60 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 IV
Estimates 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 Appendicitis
66 Years
Rule of 6’sAge Likely Surgical
Abdomen Diagnosis6 Hours Duodenal Atresia6 Days Volvulus / Malrotation
6 Weeks Pyloric Stenosis6 Months Intussusception6 Years Appendicitis
66 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/hr
10kg 40 mL/hr
20kg 60 mL/hr
30kg 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)