1. Pediatric Emergency Cases Melissa Joy, RN Michael Mojica, MD Todd P Chang, MD

2. CASE 3A …Peace puts her everywhere…

3. Case 3A - Briefing 4-week-old male Progressive non-bilious vomiting x 3 days No urine output x 20 hours Difficult to awaken

4. 4wk listless vomiting Temperature (Axillary) Temperature (Rectal) Glucose Blood Gas LytesBlood Gas Radiography 2 Laboratory 2Radiography 1Laboratory 1 go

5. 4wk listless vomiting USSI Na149149 K2.12.1 Cl8282 HCO 3 3737 BUN196.8 Cr0.861.9 Glucose553.0

6. 4wk listless vomiting USSI WBC14.814.8 Hgb17.210.7 Hct50.10.5 Plt284284

7. 4wk listless vomiting 36.7 C = 98.1 F

8. 4wk listless vomiting 37.4 C = 99.3 F

9. 4wk listless vomiting USSI Glucose553.0

10. 4wk listless vomiting USSIpH7.507.50 pCO 2 4848 pO 2 (cap) 9292 HCO 3 3535 %sat (cap) 8282 Na151151 K1.81.8 Cl8686 Hgb17.210.7

11. 4wk listless vomiting

13. PEDIATRIC SHOCK

14. Infant Shock HR b/p

15. Infant Shock HR b/p

16. Heart Rates AgeTypical Heart Rates Newborns0 – 3 months100 – 150 Infants3 – 6 months90 – 120 Infants6 – 12 months80 – 120 Children1 – 10 years70 – 130 Adolescents10+ years60 – 100

17. Blood Pressure Total Gestational Age (weeks) = (Mean Arterial Pressure) (Mean Arterial Pressure)

18. The pump The vessels The tissues The model

19. fluid The Pump

20. The Fluid

21. The Vessels

22. Hypovolemic Shock #DoseTime LimitForm 1 Access #1 1 minuteIV or IO 2 0.9% Normal Saline 60 mL/kg15 minutes IV push

23. Hypovolemic Shock #DoseTime LimitForm 1 Access #1 1 minuteIV or IO 2 0.9% Normal Saline 60 mL/kg15 minutes IV push 3 Access #2 15 minutesIV or IO 4*Ceftriaxone50 mg/kg60 minutesIV

24. Hypovolemic Shock #DoseTime LimitForm 1 Access #1 1 minuteIV or IO 2 0.9% Normal Saline 60 mL/kg15 minutes IV push 3 Access #2 15 minutesIV or IO 4*Ceftriaxone50 mg/kg60 minutesIV 5aDopamine5 mcg/kg/min to 2060 minutesIV drip 5bNorepinephrine0.1 mcg/kg/min to 260 minutesIV drip 6 0.9% Normal Saline Ad lib-IV

25. Hypovolemic Shock #DoseTime LimitForm 1 Access #1 1 minuteIV or IO 2 0.9% Normal Saline 60 mL/kg15 minutes IV push 3 Access #2 15 minutesIV or IO 4*Ceftriaxone50 mg/kg60 minutesIV 5aDopamine5 mcg/kg/min to 2060 minutesIV drip 5bNorepinephrine0.1 mcg/kg/min to 260 minutesIV drip 6 0.9% Normal Saline Ad lib-IV 7 D5-0.45% NS or D10-0.25% NS 1.5x MaintIV drip 8Hydrocortisone50 mg/m 2 60 minutesIV Estimates of body surface area: Newborn (0.25m 2 )8 years old (1m 2 ) 2 years old (0.5m 2 )non-obese adult (1.5m 2 )

26. Push-Pull

27. PYLORIC STENOSIS …Peace puts her olives everywhere…

28. Pyloric Stenosis

30. Rule of 6’s If you are ******** age, and you have a surgical abdomen, then you have…

31. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours

32. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days

33. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days Volvulus / Malrotation 6 Weeks

34. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days Volvulus / Malrotation 6 Weeks Pyloric Stenosis 6 Months

35. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days Volvulus / Malrotation 6 Weeks Pyloric Stenosis 6 MonthsIntussusception 6 Years

36. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days Volvulus / Malrotation 6 Weeks Pyloric Stenosis 6 MonthsIntussusception 6 YearsAppendicitis 66 Years

37. Rule of 6’s AgeLikely Surgical Abdomen Diagnosis 6 Hours Duodenal Atresia 6 Days Volvulus / Malrotation 6 Weeks Pyloric Stenosis 6 MonthsIntussusception 6 YearsAppendicitis 66 YearsDiverticulitis?

38. Pyloric Stenosis Peaks @ 6 weeks M to F 4 to 1 Non-bilious emesis “Projectile” is rare “Olive” is very rare all Look for vomiting with all feeds

39. Pyloric Stenosis Hypochloremic alkalosis Single large stomach Abdominal Xray Paucity of gas distal of stomach

41. Pyloric Stenosis 3+mm thick or 15+mm long

42. Pyloric Stenosis

43. Management Manage Dehydration Dextrose too Nasogastric TubeIntermittent low suction NPO Surgical consultation Urgent, not Emergent

44. Maintenance Fluids AgeFluid Infants < 10kg D10 – ¼ NS All other Peds D5 – ½ NS

45. Maintenance Fluids WeightRate 5kg 20 mL/hr 10kg 40 mL/hr 20kg 60 mL/hr 30kg 70 mL/hr

46. Tubes Endotracheal Tube Size: 4 + (Age (yr) / 4) Subtract ½ for the cuff

47. Tubes ETT MultiplierTube Corresponding Size (unit) X 1ETT Size diameter (mm) X 2NG Tube size (Fr) X 3ETT depth from gum/teeth (mm) X 4Chest Tube size (Fr)