Rosen & Barkin's 5-Minute Emergency Medicine Consult (614 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Skills may be enhanced with education and practice at a simulation center.
  
• Resuscitation, Pediatric
  

CODES

• 768.5 Severe birth asphyxia
  
• 768.6 Mild or moderate birth asphyxia
  
• 768.9 Unspecified severity of birth asphyxia in liveborn infant
  

BASICS

Emergent treatment of pediatric patients with imminent or ongoing respiratory or circulatory failure

• Respiratory failure
  
• Early shock (compensated)
  
• Late shock (uncompensated)
  
• Cardiopulmonary arrest
  
• Respiratory and/or circulatory failure leads to tissue hypoxia, acidosis, and cell death.
  
• Multisystem organ failure subsequently develops.
  

DIAGNOSIS

• History from caregivers/parents of onset, progression, inciting, contributing, or predisposing trauma/exposure/conditions, associated findings, past medical history, family history, medications, ingestions
  
• History of preceding events from pre-hospital personnel
  
• Respiratory failure:
  
  • Tachypnea
    
  • Slow, irregular breathing pattern prearrest
    
  • Decreased or absent breath sounds; inadequate ventilation
    
  • Retractions, accessory muscle use, expiratory grunting, nasal flaring
    
  • Mottled skin, cyanosis
    
  • Altered level of consciousness: Irritability, agitation, lethargy, weak or absent cry, decreased response to pain
    
  • Weak or absent cough or gag reflex
    
  • Most common presenting condition
    
• Early shock (compensated):
  
  • Vital signs initially compensated
    
  • Orthostatic changes or isolated tachycardia
    
  • Slightly delayed cap refill (>2 sec)
    
  • Warm, dry skin in early septic shock
    
• Late shock (uncompensated):
  
  • Tachycardia, tachypnea, prearrest bradycardia
    
  • Hypotension, weak peripheral pulses
    
  • Mottled, pale, cool extremities with markedly decreased capillary refill
    
  • Poor muscle tone
    
  • Decreased urine output progressing to anuria
    
  • Decreased LOC, seizures, coma
    
  • Fever or hypothermia in septic shock
    
• Cardiopulmonary arrest:
  
  • Final common pathway of progressive deterioration of respiratory and circulatory function
    

• Airway assessment:
  
  • Look, listen, feel for air movement, breath sounds, and chest movement. Observe for stridor or signs of obstruction.
    
• Breathing assessment:
  
  • Respiratory rate: Tachypnea or slow/irregular pattern (more ominous)
    
  • Respiratory effort: Note grunting, nasal flaring, head bobbing, retractions, stridor.
    
  • Pulse oximetry reflects hemoglobin oxygen saturation, not necessarily oxygen delivery.
    
  • Auscultation: Assess for wheezing, rales, diminished breath sounds.
    
• Circulatory assessment:
  
  • Pulse: Tachycardia or bradycardia (more ominous); orthostatic changes noted easily.
    
  • BP: Typical SBP in children is 90mm Hg plus twice the age (yrs). Hypotension is a late finding; widened pulse pressure in early septic shock.
    
  • Peripheral pulse presence and strength (correlates better than BP)
    
  • Capillary refill: Delayed >2 sec with poor perfusion
    
  • Skin: Mottled, pale, or cyanotic
    
• Mental status assessment:
  
  • Decreased responsiveness, irritability, confusion, agitation, poor muscle tone, sluggish pupillary response, posturing.
    
• Complete set of vital signs including rectal temperature, oximetry, and orthostatics when appropriate
  

• ABCDE evaluation:
  
  • Airway: Assess ability to speak/cry; assess for air movement. Assess for stridor or trauma.
    
  • Breathing: Observe for nasal flaring, grunting, head bobbing, retractions, tracheal deviation, chest injury or pneumothorax; auscultate, apply oxygen.
    
  • Circulation: Evaluate for pulses, capillary refill, mottling, cyanosis.
    
  • Disability: Determine mental status with alert/verbal/painful/unresponsive (AVPU) scale or Glasgow Coma Scale. Assess for neurologic deficits; check stat glucose.
    
  • Exposure/environment: Fully expose for skeletal survey. Prevent hypothermia.
    

• Workup directed by history, assessment of (ABCs), and differential diagnosis
  
• Arterial blood gas with oximetry to assess oxygenation, ventilation, acid–base status
  
• Glucose, electrolytes
  
• Other metabolic/toxicology tests as indicated
  
• Sepsis evaluation including lumbar puncture, urine and blood cultures as indicated
  

• CXR to evaluate pulmonary or cardiac sources
  
• Lateral decubitus, inspiratory/expiratory film, or laryngoscopy/bronchoscopy if foreign body (FB) suspected
  
• ECG
  
• Echocardiogram
  
• Cervical spine, other trauma films as indicated
  
• CT brain for trauma or abnormal neuro exam
  
• US as indicated
  

• Respiratory:
  
  • Upper airway obstruction: Croup, epiglottitis, peritonsillar or retropharyngeal abscess, FB, tracheitis, congenital abnormalities
    
  • Lower airway obstruction: Asthma, pneumonia, bronchiolitis, FB, cystic fibrosis
    
  • Thoracic trauma, near drowning
    
• Hypovolemia: Trauma/hemorrhage, diarrhea/vomiting, burns
  
• Cardiovascular: Congenital/acquired heart disease, myocarditis, pericarditis, CHF, dysrhythmias
  
• Infectious: Sepsis, meningitis, gastroenteritis, peritonitis, pyelonephritis
  
• CNS: Status epilepticus, epidural/subdural hematoma
  
• Metabolic: DKA, hypoglycemia, hypernatremia, hypo/hyperkalemia, acidosis
  
• Toxicologic: CO poisoning, cardiotoxic agents
  
• Near sudden infant death syndrome/apparent life-threatening event
  
• Consider child abuse when history is inconsistent with the illness or pattern of injury.
  

TREATMENT

• Stabilize ABCs; monitor.
  
• Avoid prolonged on-scene times
  
• Gather pertinent history from family/bystanders
  
• Recognize respiratory or circulatory failure; intervene early.
  
• Recognize impending arrest; support ABCs
  
• Automated external defibrillator for ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in children ≥1 yr.
  
• Early ED notification to allow preparation
  

• Early recognition and stabilization of shock
  
• Glucose, IV, oxygen, cardiac monitoring
  
• Diagnose and treat immediate life-threats
  
• Employ Broselow Pediatric Emergency Tape for appropriate drug doses and equipment.
  

• Airway:
  
  • Secure 1st in every resuscitation.
    
  • Employ head tilt/chin lift or modified jaw thrust (if trauma suspected).
    
  • Clear secretions and blood with suction.
    
  • Temporary stabilization with oral or nasal airway, bag-valve mask assistance
    
  • Intubation as necessary using appropriate tube size ([16 + age in years]/4) or size similar to patient’s little finger or nares
    
• Rapid-sequence intubation:
  
  • Preoxygenate
    
  • Pretreatment: Atropine to prevent bradycardia, lidocaine if head injury
    
  • Induction agents: Midazolam, thiopental, etomidate (avoid in septic shock), ketamine
    
  • Paralytics: Rocuronium, vecuronium, pancuronium, succinylcholine
    
  • Position of endotracheal tube (ETT) at lips (cm) = 3 times diameter of tube (mm)
    
  • Postintubation: Confirm placement with continuous end-tidal CO
    ₂
    monitoring
    
• Breathing:
  
  • Oxygenate with supplemental O
    ₂
    , nonrebreather mask; assist ventilation with bag-valve mask or control ventilation if intubation performed.
    
  • Treat conditions that limit ability to oxygenate/ventilate: Pneumothorax, hemothorax, cardiac tamponade, circumferential burns.
    
• Circulation:
  
  • Obtain IV, intraosseous (IO), or central access
    
  • Resuscitate with 0.9% NS or LR bolus at 20 mL/kg; repeat if necessary
    
  • Control obvious bleeding sources: Apply direct pressure; elevate.
    
  • Consider transfusion of packed RBCs after crystalloid replacement in trauma.
    
  • Use pressors early; peripheral use OK
    
  • Dopamine preferred 1st line; if refractory, norepinephrine (warm shock) or epinephrine (cold shock)
    
• Cardiopulmonary resuscitation:
  
  • Provide blood flow to vital organs while restoring spontaneous circulation
    
  • Infant <1 yr: Check brachial/femoral pulse
    
  • Child 1–8 yr: Check carotid pulse
    
• Cardiac dysrhythmias:
  
  • Often due to respiratory/metabolic process
    
  • Treat dysrhythmias per PALS algorithms.
    
  • Unstable tachydysrhythmias may require adenosine, amiodarone, procainamide, cardioversion, or defibrillation.
    
  • Unstable bradydysrhythmias may require atropine, epinephrine, or pacing.
    
  • Pulseless rhythms: VF, pulseless VT, pulseless electrical activity, asystole may require defibrillation, epinephrine, amiodarone, lidocaine.