Pediatric Resuscitation

I don’t know who said this, otherwise I would give them credit. However, per The RAGE (The Resuscitationist’s Awesome Guide to Everything) podcast I was listening to today, this was the quote regarding IO access in pediatric resuscitation. From a peds EM doc in Australia, I believe…

(Doctor talking to nurse)

“I am going to have you hold this IO drill. We will do two IV attempts. If those fail and afterwards I don’t immediately grab the IO drill from you and place an IO, I’d like you to place an IO in my leg.”

Awesome.

Don’t forget to use the IO everyone. So easy, so great, so useful. Such a simple way to get everyone to start focusing on the resuscitation as a whole and not just everyone scrambling for access.

Todays learning point is a bit more than normal. This is a quite entertaining 19 minute long review of neonatal resuscitation that I saw online today. It is from Dr. Andrew Tagg, a pediatric EM doc from Melbourne Australia. Quite humorous as well as very informative regarding neonatal resus. Enjoy, and thanks Dr. Tagg.

Check out this amazing site with a great outline on how to diagnose and deal with dental trauma. Be sure to check out the full set of injury outlines for both primary and permanent teeth. Follow this link:

http://www.dentaltraumaguide.org/Primary_teeth.aspx

1. Spinal shock:

• Flaccid below level of spinal cord injury
• Absent reflexes
• Decreased sympathetic tone
• Autonomic dysfunction including hypotension
• Sensation may not be preserved. If absent, concern for total cord transection

2. Central Cord Syndrome

• Decreased or absent upper extremity function
• Lower extremity function preserved
• Associated with extension injuries

3. Brown-Sequard Syndrome

• Hemisection
• Ipsilateral loss of motor function and proprioception
• Contralateral loss of sensation – pain, temperature

4. Anterior Cord Syndrome

• Complete motor paralysis
• Loss of pain and temperature sensation
• Preservation of position and vibration sense
• Associated with severe flexion injuries

From Strange and Schafermeyer’s Textbook of Pediatric Emergency Medicine

Soft tissue lateral neck film

Guidelines for children less than 15yo

1. Prevertebral space <7mm anterior to C2

2. Prevertebral space <14mm anterior to C6

3. Prevertebral space <40% of anteroposterior diameter of C3 or C4 vertebral bodies.

4. Neck flexion can cause false positive results

5. CT w/ IV contrast very sensitive for RPA and will be better definition of airway impingement and involvement of local structures.

1. IV fluids – If severe dehydration bolus as you normally would to adequately resuscitate a child

2. Simultaneously start IV infusion of D10 at 1.5-2x maintenance rate. This delivers 10-15mg/kg/min of glucose with the goal of minimizing catabolism.

Review: Maintenance fluids in pediatrics: 1st 10kg, 4cc/kg/hr. 11-20kg 2cc/kg/hr. >20kg add an additional 1cc/kg/hr for each kilo above 20kg.

3. Only consider bicarb if severe acidosis with pH of <7.1

4. Be sure to be checking VBG and ammonia levels in addition to your standard metabolic panel. In all cases of known inborn errors of metabolism presenting with even minor illnesses and all cases of new hyperammonemia be sure to consult you metabolic or genetic specialist very early to tailor therapy.

5. In severe situations may need to progress to hemodialysis.

Tetralogy of Fallot – http://lifeinthefastlane.com/pediatric-perplexity-003/

I was thinking about doing a few pearls related to TET spells, as we had one the other day in our ED. Then I found this post on Life in the Fast Lane which “spelled” it out much better than I would have. Please click link to see an awesome rapid review of TET spells, the pathophysiology and the initial management. Kudos to the people at lifeinthefastlane.com for another fantastic post.

On an aside, I like the idea of ketamine (as mentioned in their post) instead of morphine for a severe TET spell. It will increase the systemic vascular resistance, calm the child and does it without the risk of apnea like with morphine would have in a neonate.

http://lifeinthefastlane.com/pediatric-perplexity-003/

True pediatric dermatologic emergencies:

1. Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson Syndrome

2. Staphylococcal Scalded Skin Syndrome

3. Toxic Shock Syndrome

4. Kawasaki Disease

5. Meningococcemia

6. Purpura fulminans

Obviously each diagnosis has their own subtleties but keep this list in mind….

For today’s post, just go have a read of this post about epiglottitis and a quick trick on how to diagnose at the bedside. Click link below to go over to the fantastic peds EM blog “Don’t forget the bubbles…”
http://dontforgetthebubbles.com/rule-out-epiglottitis/

High risk criteria for bacterial meningitis:

1. + CSF Gram Stain

2. CSF ANC >/= 1000

3. CSF Protein >/= 80

4. Peripheral blood ANC >/= 10000

5. Presence of seizure at or prior to presentation

Children with none of the above at very low risk of bacterial meningitis. Sensitivity 99.3%/Spec 62.1% w/ NPV 99.5%