Timing Matters 1. Single episode - concerning for impending airway compromise - get help! a. Febrile? - tonsills, abscess, mono, croup, tracheitis, epiglottitis, bronchiolitis b. Afebrile? - airway foreign body 2. Recurrent a. Inspiration - obstruction is above the level of the vocal cords; - Ex, laryngomalacia - from bith; worse with supine. eating or upset b. Expiration - below the vocal cords; - Ex, tracheomalacia in hypotonic kids; vascular anomalies c. Biphasic - at the level of the cords (or just below) - Ex, subglottic stenosis/ hemangioma (get bigger over the first year of life before they start to shrink); vocal cord dyfunction; esophageal foreign body
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Pediatric Tracheal Injury - Trach injuries- 15-50% mortality in 1st hour - Goals- control airway, ensure respiratory sufficiency - Anatomic differences- large mandible, head and short neck Indications for Intubation after Neck Trauma - stridor, dyspnea, hypoxia, expanding hematoma, - If pt is "stable," call anaesthesia, tube in OR with bronch - If more critical; try awake or minimally sedated intubation (Ketamine and no paralytic), prep surg airway, fiberoptic scope INTUBATION CAN GO BADLY... so be careful! You can disrupt tenuous attachment of trachea and it will retract back into chest (super bad). Immunodeficiency
- Primary: hereditary or genetic causes antibody related, B and T cell deficiency - Secondary- acquired - Red flags for primary immunodeficiency - family hx, FTT, IV abx and hospitalization to clear infection, recurrent candidiasis, recurrent abscesses, chronic diarrhea - >6 infections/yr, >2 serious sinus infxn or pneumonias, >2 sepsis/meninigitis in lifetime Dr. Stacey Reynolds - Pediatric Fever 0-28 days - don't overthink it! - full work up 29-90 days - to tap or not to tap? > If low risk - well appearing child full term with normal physical exam without evidence of focal bacteria infection - then blood cultures, UA (don't trust the dip) - if meets low risk criteria - can either choose to not tap & DC w/o antibiotics or tap, - if no pleocytosis, give dose of abx and DC home (if reliable parents) 3-36 months - does fever exceed 102.5? If not, no further testing is needed!! > Does patient have an obvious source of fever? if so treat. If not & febrile > 102.5 test > UTI - Test all with high risk (prior UTI, high grade VUR, renal abnl); uncircumcised male < 1,circumcised male < 6 months, females < 2 yrs > Bacteremia - If less then 2 prevnar (meaning 2 shots, then 2 weeks after 2nd set of shots) test - CBC, blood cultures - if WBC > 15K, ANC >10K, treat with ceftriaxone - If > 2 prevnar blood cultures at MD's discretion - If hyperpyrexia (temp of 106 or above) blood cultures at MD's discretion (based on small study that showed 10% bacteremia in hyperthermic kids - this was pre Prevnar) > PNA - CXR only needed if evidence of lower respiratory symptoms, hypoxemia, persistent fever, T over 103, WBC > 20K > Herpes - we overtest! (only 2% of what we send comes back positive > 60 day old febrile kid with + UA - to tap or not - data is still out Pneumococcal Meningitis with HUS Usually serotypes outside of 13-valent vaccine If you suspect, initial treatment with: - Cefotaxime 300 mg/kg/day IV (max 12g/day) in 3 doses OR - Ceftriaxone 100mg/kg/day IV (max 4g/day) in 2 doses PLUS - Vancomycin 60mg/kg/day IV (max 4g/day) in 4 doses Pneumococcal HUS Recognize classic triad: - Microangiopathic hemolytic anemia - Thrombocytopenia - Acute Kidney Injury Sources: - PNA - 70% - Meningitis - 20-30% - Others - Otitis, sinusitis, bacteremia - Not like STEC-HUS - Needs Tx with Abx - Pneumococcal leads to higher M&M Hemoptysis from 5-yr old retained GSW Delayed Pulmonary Hemorrhage from FB - Up to 30 yrs latency reported - Present with intermittent hemoptysis Complications: - Pulm Art or Aortic Pseudoaneurysm - AVMs with R -> L shunts - Embolization - arterial or venous Massive Hemoptysis No universal definition - "Is this life threatening?" Initial ED Management - ID bleeding lung and position dependently - A - Establish airway (8-0 ETT or bigger for bronchoscope) - B - Ensure good gas exchange on vent - C - Stop bleeding! Restore volume, give PRBCs, reverse coagulopathy,etc... Regular Wide Complex Tachycardia
- Consider VT until proven otherwise!!! - 80% is VT by numbers - Algorithms to differentiate SVT are difficult to remember - If you treat for VT, won't harm SVT - Nodal blockers for SVT can send VT into VF -- PLACE PADS with Adenosine! A great analysis of EP and Cardiologist failure in applying Brugada to electrophysiologically proven VT. Two fantastic talks from the ever-salient @amalmattu - VT vs SVT with Aberrancy - Adenosine Sensitive VT DDX of projectile vomiting
Imaging US - muscle length >17mm positive, width >3mm positive - tips: need true sag, need relaxed muscle UGI - If US not available - string sign Myth #1 - "Kids aren't little adults." - Less a myth and more a good idea gone awry. - We don't need to consider kids to be like aliens. - Just take into account the anatomic and physiologic differences, but don't let them frighten you. - They are a unique patient population (similar to all of your other unique patient populations). Myth #2 - "IVF are faster than ORT." --IVF are effective and often expected, but not always easy. --Painful, makes unhappy parents and unhappy patients. --ED LOS: ORT = 225 vs IVF = 358. Myth #3 - "Lidocaine makes LP worse." -- Neonates do feel pain, have greater sensitivity, and are more susceptible to long term effects. -- EMLA is safe, reduces pain during LP. -- Makes your job easier!! (keeps them from wiggling) Myth #4 - "To hold for LP, bend them into a donut." -- Don't do this. -- Hyperflexed neck leads to SUBOPTIMAL AIRWAY ALIGNMENT. -- Best airway position is sitting up with legs flexed and neck neutral. Myth #5 - You can adjust for RBCs in the "Bloody tap." -- Correct with 1:500 for WBC, etc etc -- these formulas don't work. -- When concerned for meningitis, be conservative WBCs. -- Do not adjust the WBC for the RBC in a traumatic LP. Use the total WBC. Myth #6 - "Nebulizers are better than MDI." -- Evidence shows that MDI are AT LEAST as good as nebs, if not better. -- MDI is faster and reinforces good MDI use, which can help prevent patients from needing to return to the ED. Intussusception:
-Paucity of gas due to loss of gas in ascending colon
-Age rage 5 mo - 3 yr but typically <1 yr
-Ideal U/S patient: sens 98-100%, spec 88-100% -Must prep patient well for US with good pain control and anxiolysis Bowel obstruction:
Appy: 2007 JAMA RCE - Does my patient have appendicitis
Chronic Abd Pain:
Case - 7 month old male - hx of complex congenital heart disease
- Be on the same team as the parent - you both want the kid to live - Be aware of the limitations of the members of your team and if things aren’t going well, rearrange things - Be empathetic - If you can’t make it, fake it!
Epiglottitis?
**Kids... look great until they plummet. Appear well until very close to decompensation. INTUBATION - DO IT BEFORE IT IS TOO LATE **Intubate early for children who are doing poorly, do not wait until they are becoming increasingly hypoxic and bradycardic! **40% of infant cardiac output goes to work of breathing - tremendous metabolic requirement. May need to intubate for non-respiratory reasons - use blood gases **Consider ketamine for sick neonate needing intubation/sedation INTUBATE THE STOMACH TOO!! **Decompress belly if needed: Infant diaphragm more horizontal, does not help with breathing as much. Distended gassy abdomen will severely inhibit breathing. Use NG TUBE RESUSCITATE!! GIVE FLUIDS FAST!! **FLUIDS: use up to 60cc/kg, one little bolus of 20cc/kg often gross under resuscitation. 60cc/kg is not the maximum... its the start DON'T FORGET THE SUGAR!! **Blood sugar: In infant it can drop from normal to low quickly. Can have wide range of symptoms or be asymptomatic. **sugar problems: infant brain uses 90% of glucose, head to body ratio MUCH higher in infant. Healthy infant uses 6-8 mg/kg/min sugar as opposed to 2mg/kg/min in adult **Sugar: High, keep checking. Normal, start basal rate. Low, give bolus! GET ACCESS NOW!! **IO: Difficult in infant, but it is DIFFICULT in the very young. We often wait too long to go to IO. Don't! |
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