Old Ironsides NMCSD Handbook - The Uniformed Services at USU

Transcription

OLD IRONSIDES
NMCSD DEPARTMENT OF PEDIATRICS
NORMAL VITAL SIGNS
HR
Beats/min
RR Breaths/min
BP Systolic
BP Diastolic
Newborn
0-1 mo
100-180
30-60
73-92
52-65
Infant
1-12 mo
80-150
30-60
90-109
53-67
Toddler
1-3 yrs
75-130
25-35
95-105
56-68
Preschool
3-5 yrs
75-120
22-32
99-110
55-70
School
6-11 yrs
70-110
20-30
97-118
60-76
Pre-adolescent
11-13 yrs
70-110
18-22
105-124
60-80
Adolescent
13-18 yrs
65-105
16-22
110-133
63-83
Adult
18+ yrs
50-90
12-20
113-136
65-84
VITAL SIGN MONITORING GUIDELINES FOR COMMON ADMISSIONS:
• ROS: Q3 vitals with CRM/POX x24hrs, then Q6 w/o monitors (if stable)
• Hyperbilirubinemia: Q6 vitals with temps Q1 x3 then Q3
USERNAMES & PASSWORDS
Username
Essentris
CHCS/AHLTA
DEA
NPI
AAP
ACGME
Athens
Up to date
My Evals
Epic
2
Password
Table of Contents
Section 1: Nuts & Bolts........................................................................................... 4
Section 2: Radiology.............................................................................................10
Section 3: Cardiology........................................................................................... 14
Section 4: Emergency Medicine..........................................................................22
Section 5: Endocrinology.....................................................................................32
Section 6: FEN/Gastrointestinal...........................................................................38
Section 7: Hematology/Oncology....................................................................... 48
Section 8: Infectious Disease.............................................................................. 55
Section 9: Pediatric Neurology............................................................................ 72
Section 10: PICU.................................................................................................. 92
Section 11: Pulmonology.....................................................................................105
Section 12: Renal.................................................................................................. 117
Appendix.............................................................................................................. 136
3
SECTION 1
Nuts & Bolts
Contact numbers.................................................................................................... 5
Important codes................................................................................................. 5
Important pharmacy/EEG numbers.................................................................. 5
Important laboratory numbers.......................................................................... 5
Pediatric subspecialist — attendings/consultants............................................. 6
Other important contact numbers......................................................................7
Type and Duration of Precautions Recommended for Select Infections........... 8
4
N U TS & B O LTS
CONTACT NUMBERS
HOSPITALISTS
Dr. Andersen.................................... 619-218-5714
Dr. Ruff.............................................619-602-1483
Dr. Villarroel (Forensic Peds).........619-453-6081
IMPORTANT LABORATORY
NUMBERS
Laboratory Division
Phone number
Main Lab
2-9200
CDR Boamah..................................619-602-9240
Supervisor
2-8834
CHIEF RESIDENT
Blood Bank
2-9356/9357/9353
Chemistry
2-7090
Hematology
2-6311
Microbiology
2-9234
Differential
2-9283
Mail Out
2-9271
PROGRAM DIRECTOR
Ben Briggs....................................... 619-750-4528
NURSING DEPT. HEAD
Deb Norton......................................619-532-6253
IMPORTANT CODES
2East Door Code
2-5-1
Outside Lab numbers
Phone number
Intern Call Room
(4,5)-(1,2)
PICU Call Room
3-2-1
Newborn screens
866-463-6436
ER
9911*
HSV CSF PCR
858-966-5940
Resident’s Room
6-8-4-7
HSV Serum PCR
800-522-2787
Attending Office
25-31
UCSD Virology
619-543-5797
UCSD PCR
619-543-3798
CA Encephalitis
510-307-8608
Metabolic Clinic
619-543-7800
NHCP Lab
760-719-4088
IMPORTANT PHARMACY/
EEG NUMBERS
EEG
Phone number
NHCP Micro
760-725-3410
Office number
2-7278/9757
NHCP Rads
760-719-4641
EEG Tech
619-665-3467
RCHSD Lab
858-966-5940
Sleep Lab
2-5620
RCHSD Micro
858-966-7725
Quest
800-848-4225
Pharmacy Division
Phone number
Discharge Pharmacy
2-5794
Wards/PICU/NICU
2-6310/8596
Compound
2-8406
NUTS & B OLTS
5
PEDIATRIC SUBSPECIALIST – ATTENDINGS/CONSULTANTS
***If there are multiple providers, please check call schedules before paging the subspecialists
Specialty
Physician
Adolescent Medicine
Duty Pager
Office number
Pager number
619-804-4398
(after hours)
Allergy Clinic (NTC)
524-1519
Anesthesia
Floor Walker
Duty Pager
619-218-1692
Cardiology
CDR Mao
EKG fax (Mao)
LCDR Kendall
EKG fax (Kendall)
240-988-7742
888-415-7814
919-949-0909
Dental
Duty Pager
619-453-6570
Dermatology
Dr. Gibbs
619-218-4488
Dietitian
Charis Ross
Carly Hill
ENT
Duty Resident
Endocrine
Duty Pager
CDR Kunz
CDR Yates
2-6904
2-6920
619-804-4115
619-602-9454
619-804-4388
Gastroenterology
CDR Boamah
Dr. Yang
2-9720
619-602-9240
619-750-7895
2-9035
2-7540
2-8905
619-453-6955
General Surgery consult
619-453-7013
Genetics
Dr. Willis
Hematology/Oncology
CAPT McManaman
Dr. Pene
2-8861
619-218-9354
619-804-4328
Infectious Disease
LCDR Arnold
CDR Milder
2-7452
619-804-4807
619-453-7098
2-7745/5261
619-532-5261
Lactation
Nephrology
CAPT Ferrara
Neurology
Dr. Serena
Dr. Zeldin
Neurosurgery
Duty Pager
Dr. Klugh
Occupational Therapy
619-804-4111
858-229-4301
2-9575
619-602-1739
619-804-4507
619-379-2604
619-665-3029
2-7100/7135
Ophthalmology
Duty Resident
619-453-6302
Orthopedic Surgery
Bone Phone
Ortho Intern
619-954-6797
619-384-7173
Orthopedics (Hand)
Ortho Cast Room
6
2-8473
24hr on call
Cast Room
2-8454/8439
619-453-6883
N U TS & B O LTS
Pain Service
Duty Pager
619-677-7415
Physical Therapy
2-7100/7107
Plastics
2-6950
Psychiatry
Duty Resident
Pulmonary
CDR Cleary
CAPT Wojtczak
Pediatric Surgery
(call 2-North for Surg resident
schedule and phone number)
Margie Gabriel
Dr. Ignacio
Dr. Henry
619-384-7280
2-6883
519 532 6896
619-804-4757
619-453-6846 (Tues-Fri)
619-453-6956
502-938-5163
619-847-3541
202-257-6923
Peds Surg day pager
619-822-5495
Social Work
Heather Ducksworth
2-9329
619-804-4008
OTHER IMPORTANT CONTACT NUMBERS
Hospital/Area
Phone Number
Hospital/Area
Phone Number
2East
2-6250
Fax: 2-5237
Alberta Agyemang
2-5081
619-886-7102
2East Backroom
2-5294
Lisa Burns (Pulm RN)
2-8819
2North Clinic
2-5953
Adolescent Clinic
2-6930
PICU
2-8153
Fax: 2-8668
Subspecialty Clinic
(bldg 2)
2-6896 (parents)
2-5393 (staff)
PICU Call Room
2-8979
NICU
2-8910
Audiology
2-9602
NICU Backroom
2-8913
619-453-6939
ER
2-8274
Melanie Kilgore
(Peds audio)
Gen Peds appt line
(staff)
2-5767 or 2-5009
Med Photo
2-8051
619-279-0494 (ED)
Gold Team Cell:
619-665-3903
RCHSD Main number 858-576-1700
RCHSD ER
858-966-8005
NHCP Quarter Deck
760-725-1288
NHCP ER
760-725-3258/1093
Green Team Cell:
619-847-7138
NHCP Clinic
760-725-1578
NTC
619-524-4947
Continuity Cell:
619-453-6841
TOC Clairemont
619-645-0155
TOC Chula Vista
Gen Peds appt line
(parents)
619-744-5365
(Dr. Ogena)
2-8225
Poison Control
800-411-8080
After Hours Pager
800-453-0491
Wound Care Nurse
619-453-6309
(LT Allison Redden)
If you know the
patient’s team (PCM)
you can arrange f/u
with the team nurse.
NUTS & B OLTS
Blue Team Cell:
619-379-6613
7
TYPE AND DURATION OF PRECAUTIONS
RECOMMENDED FOR SELECT INFECTIONS
Infection
Type of Precautions
Duration
Abscess
Contact
Duration of illness
Cellulitis
Standard
C. Diff
Contact
Until negative repeat x2
Enteroviral infections
(i.e. Group A and B Coxsackie
viruses)
Standard
EXCEPT use contact for diapered or incontinent children
Duration of illness (if implementing contact precations)
Gastroenteritis
Standard
EXCEPT use contact for diapered or incontinent children
Duration of illness (if implementing contact precations)
HSV
- Encephalitis
- Mucocutaneous, disseminated or primary, severe
- Mucocutaneous, recurrent
(skin, oral, genital)
- Neonatal
Standard
Contact
Until lesions dry & crusted
Standard
Contact
Until lesions dry & crusted
Influenza
Droplet
5 days except immunocomp=duration of illness
Measles (rubeola)
Airborne
4 days after onset of rash;
duration of illness in immunocompromised persons
Meningitis
- Asceptic
- Bacterial, gram-neg enteric,
in neonates
- Hib, Neisseria, meningococcal disease (sepsis, PNA, meningitis) (known or suspected)
Standard
Standard
Droplet
Until 24hrs after initiation of
treatment
MDROs
Contact
Duration of illness
Pertussis
Droplet
5 days
RSV
Contact with mask
Duration of illness
Varicella
Airborne, contact
Until lesions dry and crusted
* For infections not listed above, please refer to the Infection Control Manual
under “references” on the intranet homepage
Standard = Hand washing
Contact = Gown and gloves
Droplet = Mask and gloves
Airborne = N95 respirator and gloves
8
N U TS & B O LTS
NOTES
NUTS & B OLTS
9
SECTION 2
Radiology
Radiology phone directory...................................................................................10
Radiology (ordering studies).................................................................................11
Ordering additional studies.................................................................................. 12
NPO parameters.................................................................................................... 12
Arranging pediatric follow up from ER................................................................ 12
Drug levels............................................................................................................. 12
RADIOLOGY PHONE DIRECTORY
Radiology Department
Phone Number
Front Desk
2-8666
Pediatric Reading Room
2-7382/6137
ER Reading Room
2-8684 (not available between 8am-noon)
Fluoroscopy (UGI, VCUG, IVP, BE)/Nuc Med
2-8686/8775
CT Front Desk and Tech
2-8377 (Desk); 2-8731 (Tech)
CT Scanner 1 & 2/ ER CT
1: 2-8771 2: 2-8772 ER: 2-8245
MRI Front Desk
2-7865
MRI Residents
2-7382/6137
US Desk/Techs/Duty Pager
2-8725 (Desk) 2-8746 (Techs)
619-453-6351 (Duty Phone)
US Reading Room
2-5780/7820/5458
Interventional Radiology (IR)
2-8742
10
RA DI O LO G Y
RADIOLOGY (ORDERING STUDIES)
MRI
CT scan
Ultrasounds
Fluoroscopy
(UGI, VCUG,
IVP, BE)
Not sedated?
Place STAT CHCS order
Place order in Essentris (so nurses are aware of the study)
Call Radiology (pediatric reading room) to inform them of the order and the
indication for it – 2-6137 / 2-7382
Plain films
(CXR, KUB,
AAS)
Place order in
essentris only &
include reason
for study (i.e.
r/o infiltrate) –
clerk will fill out
a chit and make
the phone call
to radiology
*Do not need to
call radiology
Sedated?
Follow guidelines for ordering nonsedated MRI/CT scan →
Notify Anesthesia Floor Walker of
need for sedation – (619) 218-1692
Coordinate study/sedation time
between Anesthesia Floor Walker &
Radiology
*Routine Peds Anesthesia day is
Tuesdays
R ADIOLOGY
11
ORDERING ADDITIONAL STUDIES
ECHOs: coordinated directly with the Pediatric Cardiologist
EEG: order in CHCS stat, coordinated with EEG techs (2-7278; 619-665-3467) in conjunction with
Pediatric Neurology
Modified barium swallow studies: coordinate with June Carter, Speech Pathologist 2-5874
NPO PARAMETERS
Clears: 2 hours
Breast Milk: 4 hours
Cow’s Milk: 6 hours
Full Meal: 8 hours
ARRANGING PEDIATRIC FOLLOW UP FROM ER
1. Open AHLTA
2. Select “ Telephone Consults” in Left-hand folder list column
3. Select “Actions” from top bar
4. Select “New Telcon”
5. Enter patient information and select “Find”
6. Select correct patient and press “Ok”
7. Select “Pediatrics General” . Verify phone number.
8. Select “Reyes, Edna” for Assigned Owner
9. Enter information and requested follow-up time frame and press ok
DRUG LEVELS
Vancomycin
Trough only – 5th dose
Peak if concern for gram + (ex. Staph aureus)
after 4th dose
Gentamicin
Trough AND peak 3rd dose
12
RA DI O LO G Y
NOTES
R ADIOLOGY
13
SECTION 3
Cardiology
EKG (mini).............................................................................................................. 14
EKG norms............................................................................................................. 16
Murmurs................................................................................................................ 17
Congenital heart defects....................................................................................... 17
SVT......................................................................................................................... 17
SVT management.................................................................................................. 18
Chest pain.............................................................................................................. 18
Syncope................................................................................................................. 19
Kawasaki Disease................................................................................................. 20
EKG (MINI)
**Below are mini-EKGs – so boxes represent lead 1-V6, strip at bottom is II or V1
Where to Look
What to Look For
1) Rate
Paper speed- 25 mm/sec
1 small square= 1 mm = 0.04 sec
1 large square= 5 mm= 0.2 sec
2) Rhythm
Sinus: P wave before every QRS; P wave for every
QRS; normal PR interval, normal P-wave axis (up in
lead 1 and aVF)
14
CA RDI O LO G Y
3) Axis
up/up = normal
down/up = RAD
up/down = LAD
4) P wave
Long width, biphasic V1 =
LAE Tall height = RAE
Height >2 small squares
Width > 2.5 small squares
5) PR interval
Long PR = 1st degree AVB
Short PR w/ delta wave = WPW
6) QRS duration
QRS > 120msec, > 3 small squares
Rabbit ears in V1 = RBBB
Rabbit ears in V6 = LBBB
7) QRS voltage
Big R in V1 = RVH
(Other criteria for RVH =
upright T in V1; QR in V3R)
Big R in V6 = LVH
(R+S)(I) + (R+S)(II) + (R+S)(III)
8) ST segment
Horizontal depress. or elev.
> 1mm (use TP baseline)
Downward sloping
T wave axis:
9) T wave
10) QTc= QT/
square root(RR)
Age
V1, V2
AFV
V5, V6
<1 day
+/-
+
+/-
1-4 days
+/-
+
+
4 days- adolesc
-
+
+
Adolesc- adult
+
+
+
Prolonged QTc: Female adol. >450
Male adol. >440
*Can calculate in any lead that
the QTc is well visualized.
If long QT, consider obtaining EKGs on primary
family members.
*If sinus arrhythmiacalculate range
C AR DIOLOGY
15
EKG NORMS
QRS
Duration
(sec)±
RV1 amp
(mm)±
SV1 amp
(mm)±
RV6 amp
(mm)±
SV6 amp
(mm)±
+30 to 180 0.08-0.12
(+110)
(0.10)
0.05
(0.07)
13.3
(25.5)
7.7
(18.8)
4.8
(11.8)
3.2
(9.6)
105-180
(145)
+30 to 180 0.08-0.12
(+110)
(0.10)
0.05
(0.07)
10.6
(20.8)
4.2
(10.8)
7.6
(16.4)
3.4
(9.8)
1-6 mos
110 - 180
(145)
+10 to 125
(+70)
0.08-0.13
(0.11)
0.05
(0.07)
9.7
(19)
5.4
(15)
12.4
(22)
2.8
(8.3)
6-12 mos
110-170
(135)
+10 to 125
(+60)
0.10-0.14
(0.12)
0.05
(0.07)
9.4
(20.3)
6.4
(18.1)
12.6
(22.7)
2.1
(7.2)
1-3 yrs
90-150
(120)
+10 to 125
(+60)
0.10-0.14
(0.12)
0.06
(0.07)
8.5
(18)
9
(21)
14
(23.3)
1.7
(6)
4-5 yrs
65-135
(110)
0 to +110
(+60)
0.11-0.15
(0.13)
0.07
(0.08)
7.6
(16)
11
(22.5)
15.6
(25)
1.4
(4.7)
6-8 yrs
60-130
(100)
-15 to +110 0.12-0.16
(+60)
(0.14)
0.07
(0.08)
6
(13)
12
(24.5)
16.3
(26)
1.1
(3.9)
9-11 yrs
60-110
(85)
-15 to +110 0.12-0.17
(+60)
(0.14)
0.07
(0.09)
5.4
(12.1)
11.9
(25.4)
16.3
(25.4)
1.0
(3.9)
12-16 yrs
60-110
(85)
-15 to +110 0.12-0.17
(+60)
(0.15)
0.07
(0.10)
4.1
(9.9)
10.8
(21.2)
14.3
(23)
0.8
(3.7)
>16 yrs
60-110
(80)
-15 to +110 0.12-0.20
(+60)
(0.15)
0.08
(0.10)
3
(9)
10
(20)
10
(20)
Age
Heart
Rate*
QRS
axis*
0-7 days
95-160
(125)
1-3 wks
PR
interval
(sec)*
0.8
(3.7)
* Normal range and (mean)
± Mean and (98th percentile)
16
CA RDI O LO G Y
MURMURS
Benign heart murmurs: soft, systolic, ejection-type, vary with position
•Still’s murmur- LLSB-LMSB, low- freq vibratory
•Peripheral pulmonary stenosis of newborn- LUSB-transmits to back
•Venous Hum-clavicular areas, inaudible in supine position
Likely pathologic murmur: cyanosis, systolic murmur grade 3 or above, harsh, holosystolic,
diastolic murmur, abnormal heart sounds, abnormally strong or weak pulses, family history of
structural heart disease or sudden death
•Holosystolic- VSD, MR, TR, PDA
•Diastolic- AR, PR, mitral stenosis, tricuspid stenosis
•Ejection-aortic stenosis, pulmonic stenosis, HOCM
CONGENITAL HEART DEFECTS
Occurs in 0.5-0.8% of live births.
Acyanotic heart defects: volume vs. pressure overload
•Volume overload: ↑ pulmonary to systemic blood flow (Qp :Qs). Eventually leads to left heart
failure and resultant pulmonary edema (high-output failure). Examples: left-to-right shunts
such as VSD or regurgitant lesions.
•Pressure overload: obstruction to flow. Sx depend on location of obstruction (right vs. left
heart failure). Examples: aortic valve stenosis or coarctation of the aorta.
Cyanotic heart defects: ↑ or ↓ pulmonary blood flow
•↑ Qp: no obstruction to pulmonary flow; involves abnormal flow patterns/connections (e.g.
transposition of the great arteries) or mixing of venous and arterial blood (e.g. TAPVR or
truncus arteriosus).
•↓ Qp: obstruction to pulmonary flow with right-to-left shunt.
•Examples: Tetralogy of Fallot or tricuspid atresia
SVT
SVT includes atrial tach, AV nodal tach, and reentrant tach (ex WPW)
•No P waves or abnormal P wave axis or P after QRS
•Regular, rapid – usually > 220 in infants, >180 in older
C AR DIOLOGY
17
SVT MANAGEMENT
Unstable patient (hypotensive, infant w severe CHF): IMMEDIATE CARDIOVERSION
Stable: Vagal maneuvers
•Infant: bag of ice to face for up to 10 seconds, PROTECT EYES
•Older child: bearing down, blow through straw, headstand; avoid carotid massage
If vagal maneuvers fail and still stable: Set up EKG and call PICU or cards
• Adenosine: 100mcg/kg x1, if no effect rpt at 100mcg/kg, can go up to 200mcg/kg- Always admin
with defib pads on
•note: frequent sinus pause! scary for patients!
•complicated to give – needs 3-way stopcock; set up prior to pushing adenosine
•first stop-cock w/adenosine attached, second w/ saline flush
•need to push adenosine FAST- adenosine has 10 sec half life → then immediately push
5-10 mls NS
CHEST PAIN
Rarely cardiac origin in kids.
DDx:
•Cardiac – hypertrophic CM, myo/pericarditis, arrhthymia, coronary artery anomaly,
dissection (Marfan’s)
•Chest wall – costochondritis, precordial catch (better w/ deep breath);
•Pulm – PNA, asthma, PTX, acute chest in SS;
•GI - GERD, esophageal spasms;
•Psych – hyperventilation
Dx: if positive family hx or past medical hx → EKG. If positive HPI or exam → EKG, monitors,
consider card consult.
Tx: mostly reassurance; NSAIDs for chest wall pain, etc
Go to www.chop.edu/pathways/emergency-department/chest-pain/ for helpful chest pain pathway,
specific questions to ask
18
CA RDI O LO G Y
SYNCOPE
Brief loss of consciousness due to lack of blood flow to brain.
Note: syncope pts often have hypoxic jerks until the blood flow to the brain improves – this is not
a seizure!
Workup:
•Good history, exam including neuro (and pupils), orthostatics and EKG.
•CT head is NOT needed unless focal neuro signs or significant head injury from fall.
Vasovagal Syncope
Vasovagal syncope (most common): sympathetic burst followed by parasympathetic activation
leading to profound bradycardia, hypotension.
Dx: History – can have premonitory symptoms. Ex: feeling hot, sweating, lightheadedness, nausea,
vision going black
•Associated with emotional states, prolonged standing, dehydration, hair brushing, going to
the bathroom
•Post-syncope pallor, re-syncope on standing too quickly afterward, hypoxic jerks
occasionally occur
•pt wakes up rapidly upon lying down, can feel dizzy and “not usual self” for several hours
following
Tx: hydration, lie down when feeling lightheaded, nml dietary salt intake, avoidance of stimulants
Cardiac Syncope
Cardiac syncope: due to hypertrophic CM, tachy or bradycardia, aortic stenosis, CHF, etc
•Few preceding sx; usually abrupt onset/offset; occ w/ palpitations but not always!
•May occur during exercise – always worrisome!
Dx: hx, exam, EKG, Holter, echo
Tx: depends on cause; beta blocker for HCM and SVT, etc
SEIZURES
Seizures: urine incontinence (can happen w/vasovagal as well), Postictal confusion, tongue biting, etc
Dx: hx, exam, EEG if convincing hx
Tx: see neuro section
C AR DIOLOGY
19
KAWASAKI DISEASE
Dx: Fever lasting 5 days, plus 4 of the following
criteria:
•Bilateral conjunctival injection without
exudate
Incomplete Kawasaki: Fever x 5 days plus 2-3
above criteria, plus supplemental lab criteria
•Labs:
•Elevated inflammatory markers:
CRP, ESR
•Red mouth and pharynx, strawberry
tongue, or red, cracked lips
•Leukocytosis (WBC> 15)
•Rash (may be morbiliform,
maculopapular, or scarlatiniform)
•Thrombocytosis (plts >500K)
•Albumin < 3
•Swelling of hands and feet, redness of
palms and soles
•Elevated AST, ALT
•U/A: sterile pyuria
•Cervical lymphadenopathy- usually
single and unilateral
•LP: aseptic meningitis
Tx:
•IVIG- within first 10 days of illness, 2 g/kg
over 10-12 hours
•Aspirin: 80-100 mg/kg/day div over 4
doses
•Echo (r/o coronary involvement
Evaluation of Suspected incomplete Kawasaki Disease (KD)
20
CA RDI O LO G Y
NOTES
C AR DIOLOGY
21
SECTION 4
Emergency
Medicine
Wound management............................................................................................23
Acetaminophen toxicity........................................................................................23
Chemical exposures..............................................................................................24
Toxidromes............................................................................................................25
Antidotes............................................................................................................... 26
Burns......................................................................................................................27
Bite Management..................................................................................................28
Sutures...................................................................................................................28
Suturing................................................................................................................. 29
Fractures............................................................................................................... 30
22
E M E RGE N CY M E D IC IN E
WOUND MANAGEMENT
Clean and Minor Wounds
All Other Wounds (1)
Tetanus toxoid
TIG (2)
Tetanus toxoid
TIG (3)
<3 or unknown
Yes
No
Yes
Yes
≥3
Only if last
dose given ≥ 10
years ago
No
Only if last
dose given ≥ 5
years ago
No
Previous
Doses of
Tetanus toxoid
(1) Such as wounds contaminated with dirt, feces, soil, and saliva; puncture wounds, avulsions and wounds resulting from missles,
crushing, burns, and frostbite.
(2) The preferred vaccine preparation depends upon the age of the child or adolescent:
< 7 years: DTaP
> 7 years: Tdap
(3) Intravenous immune globulin should be administered if TIG is not available.
ACETAMINOPHEN TOXICITY
E ME R GE NCY MEDICINE
23
CHEMICAL EXPOSURES
Table 1. Features of Selected Major Chemical Exposures
Feature
Asphyxiants
Cholinesterase
Inhibitors
Respiratory Tract
Irritants
Most likely agent in
accidental release
Carbon monoxide
Organic phosphorus
pesticides
Chlorine and its deriv———
atives, ammonia
Most likely agent in
act of terrorism
Cyanide
Sarin and VX
Chlorine, phosgene
Sulfur mustard
Hallmark
Tissue hypoxia in
cardiovascular system
and central nervous
system; usually,
absence of respiratory tract irritation; no
increase in secretions
Cholinergic syndrom
with pupil constriction
(miosis) and increased
exocrine secretions,
with or without fasciculations; increasing
effects on central
nervous system with
increasing exposure
Respiratory tract irritation and symptoms,
usually more prominent than irritation of
eyes and skin
Eye injuries and skin
burns with vesicle formation, followed by
respiratory irritation
and, in the case of
exposure to high concentrations, systemic
effects
Headache, fatigue,
anxiety, irritability,
dizziness, nausea
Miosis, dim vision,
eye pain, rhinorrhea,
irritability, headache,
chest tightness,
sweating
Nose and throat
irritation, sore throat,
cough, chest tightness, eye irritation
Conjunctivitis, limited
erythema, epistaxis,
sore throat, cough
Moderate to severe
symptoms
Dyspnea, altered
mental status, cardiac
ischemia, syncope,
coma, seizure
Silivation, lacrimation,
urination, defectation, gastrointestinal
cramping, and emesis
(SLUDGE); wheezing,
muscle weakness, fasciculations, cognitive
impairment, incontinence, coma, seizure
Corneal damage,
Laryngitis, wheezing,
visicles and bullae,
stridor, laryngeal ede- nausea, wheezing,
ma, acute lung injury
stridor, laryngeal edema, acute lung injury
Hyperacute onset —
sudden collapse
High concentrations
of cyanide or hydrogen sulfide and oxygen deficiency within
a confined space
Exposure to VX or
high-vapor concen———
trations of other nerve
agents
Acute onset —
typically within
minutes to hours
after exposure
Most exposures to
asphyxiant gases
(carbon monoxide,
cyanide) or oxygen
deficiency
Vapor exposure, ingestion of liquid form,
or moderate-to-large
dermal exposure
Riot-control agents,
irritants highly and
intermediately water
soluble (ammonia,
hydrochloric acid,
chlorine)
Lewisite, phosgene
oxime, high concentrations of sulfur
mustard
Delayed onset —
typically 4 to 6 hr
after exposure
Low to moderate
concentrations of
substances that metabolize to primary
asphyxiant — methylene chloride (carbon
monoxide), acrylonitrile, and propionitrile
(cyanide)
Limited exposure of
skin to droplets but
not vapor
Poorly soluble gases
(phosgene, nitrogen
dioxide)
Sulfur mustard
Vesicants
Typical presentations
Mild symptoms
24
———
TOXIDROMES
25
ANTIDOTES
Drug
Antidote
Acetaminophen
N-acetylcysteine
(NAC, Mucomyst)
Alcohols
Calcium gluconate
Alcohols
(ethylene glycol, methanol)
Ethanol 10% or Fomepizole
(4— methylpyrazole, Antizol)
Anticholinesterase
Atropine
Antihistamines
Other anticholinergic agents
Physostigmine [Antilirium)
Benzodiazepines
Flumazenil (Romazicon)
ß-Blockers
Glucagon
Calcium-channel blockers
Calcium or Glucagon
Carbon monoxide
Hyperbaric oxygen
Cyanide
Cyanide antidote kit
Digitalis
Digoxin—specific Fab antibodies
(Digibind)
Iron
Desferoxamine (Desferal)
Methemoglobinemia
Methylene blue
Opioids
Naloxone (Narcan): serum half—life
is 1 hr. Duration of action is 1-4 hr.
Pesticides (carbamate,
organophosphate)
Atropine or Pralidoxime (2—PAM,
Protopam)
Phenothiazines
Diphenhydramine (Benadryl)
Phenothiazines — acute dystonic
reaction
Benztrapine (Cogentin)
Warfarin
Vitamin K
26
BURNS
BURN CENTER TRANSFER CRITERIA: TBSA >10%, involvement of face, hands feet, genitalia,
perineum or major joints. Chemical or electrical burns, inhalation injury, or 3rd Degree burns.
27
BITE MANAGEMENT
• Irrigate!!! Leave open: bites > 24 hours old or deep puncture wounds of hand/foot — esp. human
or cat bites.
• Steri-strips OK.
• Never close an infected wound.
• Antibiotics: (augmentin, cefuroxime, or doxycycline) for 5 days with HIGH RISK wounds (hand/
foot bites, puncture wounds, deep or extensive wounds, immunosuppressed or diabetic patients).
• Re-examine within 24-48 hours.
SUTURES
SUTURE TYPES
Absorbable (time)
Non-absorbable
Chromic (3-4 weeks)
Nylon
Vicryl (2-3 weeks)
Ethilon
Fast gut (3-5 days)
Prolene
• Removal: face in 3-5 days,
extremities in 10-14 days
• Use 5-0 or 6-0 for faces
• Use 3-0 or 4-0 for ext/chest/
abd
SUTURE MATERIAL, SIZE AND REMOVAL
Body Region
Monofilament *
Absorbable †
(Superficial Lacerations) (Deep Lacerations)
Days
Scalp
5-0 or 4-0
4-0
5-7
Face
6-0
5-0
3-5
Eylid
7-0 or 6-0
———
3-5
Eyebrow
6-0 or 5-0
5-0
3-5
Trunk
5-0 or 4-0
3-0
5-7
Extremities
5-0 or 4-0
4-0
7
Joint Surface
4-0
———
10-14
Hand
5-0
5-0
7
Foot/Sole
4-0 or 3-0
4-0
7-10
* Examples of monofilament nonabsorbable sutures: nylon, polypropylene.
† Examples of absorbable sutures: polyglycolic acid and polyglactin 910 (Vicryl).
28
SUTURING
Irrigation
• NS >250cc + 60 cc syringe + 16g angiocath.
• Look for and document any foreign bodies.
• Avoid betadine — may cause tissue necrosis.
Numbing
• Topical LET (lidocaine, epinephrine, tetracaine): Max LET 0.5 ml/10 kg.
• Do not use on distal extremities, nose, or penis!
• Onset: 15 min.
• Duration: 20 min.
Buffered Lidocaine
• Use at room temp.
• Mix: lidocaine w/or without epinephrine (5cc of 2%) + sterile H20/NS (4 cc) + Sodium bicarb (1cc
of 8.4%)
• Onset: Rapid
• Duration: 20 min.
• The max dose of this 1% lidocaine is 4 mg/kg or 0.4cc/kg.
• No epinephrine on digits, nose, or penis!
Needle and Suture Selection
• Consider using steri-strips, Dermabond, or staples.
• Do buried stitches with Dexon (absorbable — takes two weeks to dissolve).
• Use Ethilon (nonabsorbable monofilament) on a cutting needle for most superﬁcial suturing: 4-0
to 5-0 for most lacs.
• Plain gut is absorbable and lasts 7 days max, so it is usually only used on face and scalp.
• Do not use chromic gut on the face — it scars!
• Consider 6-0 absorbable plain gut on little kids’ faces; it won’t need to be removed.
• May staple scalp lacerations under hair.
Discharge Advice
• Keep wound clean and dry, covered with antibiotic ointment to prevent scab formation.
• OK to shower, but do not comb hair if scalp laceration.
• Return to MD if signs of infection.
• Later: sunscreen to avoid hyperpigmentation.
29
FRACTURES
30
NOTES
31
SECTION 5
Endocrinology
Diabetes.................................................................................................................33
Hypoglycemia.......................................................................................................33
Adrenal Insufficiency.............................................................................................33
Short Stature.........................................................................................................34
Endocrine Disorders.............................................................................................34
Hyperparathyroidism............................................................................................35
Tanner Stages....................................................................................................... 36
Puberty................................................................................................................. 36
32
E N DOCRI N O LO G Y
DIABETES
Must meet 1 of 4 criteria.
• Symptoms of diabetes (polydipsia, polyuria, weight loss) AND random BG>200
• Fasting BG >126
• 2 hour post prandial (OGTT) >200
• HbA1C >6.5%
New onset labs: chem panel, HbA1C, islet cell antibodies, insulin antibodies, thyroid antibodies,
TFTs, endomesial antibody, TTG, IgA, b-hydroxybutyrate, serum insulin and C peptide,
Call ENDO ON CALL for recommendations for starting subcutaneous insulin
Record carbs, insulin, and BG on blank diabetes chart found on the ward
HYPOGLYCEMIA
BG<40-50mg/dl
Draw critical labs at the time of hypoglycemia: BG, insulin, GH, cortisol, beta hydroxybutyrate,
UA, AST, ALT, electrolytes, VBG
Treatment:
• If patient is conscious and can take food by mouth, administer 40% Glucose Gel. Single dose
equal to 0.5g/kg to max of 15 grams (1 tube) .
• If patient is NPO, administer 5ml/kg of D10% to max of 100 ml. Dose is given IV push and can
be repeated in severe cases.
• Check finger stick glucose every 15 minutes and repeat treatment until blood glucose is >80
mg/dl.
ADRENAL INSUFFICIENCY
• Stress Dose for Illness: 25-50 mg/m2/day of hydrocortisone IV/IM as a continuous drip or
divided q3-6hr
• Stress Dose for Surgery or Severe illness: hydrocortisone 50-125 mg/m2/day IV
Use a med calc to get BSA (mg/m2)
E NDOC R INOLOGY
33
SHORT STATURE
Midparental Height Bone Age
Growth Velocity
Idiopathic
Normal
Normal
Normal
Familial
↓
Normal
Normal
Constitutional Delay
Normal
↓
Normal
Endocrine*
Normal
↓
↓
Chronic illness malnutrition
Normal
↓
↓
* e.g. hypothyroidism, Cushings, GH deficiency
ENDOCRINE DISORDERS
Disorder
Diagnostic Studies and Lab Findings
Diabetes Insipidus
CMP, UA, serum and urine osm, possible H2O deprivation test
(consult: endo)
• Urine SG <1.005
• UR Osm 50-200
• Urine output > 4 ml/kg/hr
CMP, UA, serum and urine osm, urine Na
• Hyponatremia
• Low serum osm
SIADH
• High urine osm
• High urine Na > 40
Hypoparathyroidism
↓ serum Ca2+
↑ serum phos
Normal or ↓ alk phos
↓ 1,25-hydroxy-vit. D3
↓ PTH (nl or ↑ in pseudohypoparathyroidism)
Hyperparathyroidism
↑ serum Ca2+
↓ serum phos
Normal or ↓ alk phos
↑ 1,25-hydroxy-vit. D3
↑ PTH (nl or ↑ in pseudohypoparathyroidism)
CAH (21-hydroxylase
deficiency)
↓
↑
↑
↓
↑
↓
34
serum Na+ & Clserum K+
renin
cortisol
androgen/cortisol precursors
glucose
HYPERPARATHYROIDISM
Serum
Primary
Secondary
Tertiary
Calcium
↑
←→ or ↓
↑
Phosphorous
↓
↑
↑
Alkaline
Phosphatase
↑ or ←→
↑ or ←→
↑ or ←→
Calcium
↑
↓
Phosphorous
↑
↓
Urine
E NDOC R INOLOGY
35
TANNER STAGES
Female
Male
Pubic Hair
1
Pre-pubertal. No
breast tissue
Pre-pubertal
Pre-pubertal
2
Areolar enlargement,
breast bud
Testes enlarge (4ml);
scrotum larger, skin
reddened and coarser
Sparse, downy hair
3
Enlargement of breast
and areola as single
mound
Penis elongates, continued growth of testes Sparse, coarse hair
and scrotum
4
Projection of areola
above breast as double mound
Growth of testes, penis length & breadth.
Adult type hair, not on thighs
Scrotum has increased
pigmentation
5
Adult. Areola is a part
Testes, scrotum, penis
of breast contour, only
adult size
nipple projects
Adult type hair,
spread to medial thighs
PUBERTY
Thelarche
Precocious
Delayed
Work up
< 8 yr
>13 yr
LH, FSH, estradiol,
testosterone, bone
age, growth chart
Testicular enlargement < 9 yr
36
> 14 yr
NOTES
E NDOC R INOLOGY
37
SECTION 6
Gastroenterology
Diarrhea/stool replacement (for short gut or age)..............................................39
Oral rehydration therapy......................................................................................39
Elevated AST/ALT..................................................................................................39
H. Pylori.................................................................................................................39
Metabolic workup.................................................................................................39
Infant nutrition...................................................................................................... 40
Failure to thrive...................................................................................................... 41
TPN guidelines...................................................................................................... 41
TPN and re-feeding...............................................................................................42
TPN advancements...............................................................................................43
TPN monitoring.....................................................................................................43
Re-feeding syndrome...........................................................................................43
Inflammatory bowel disease/bloody diarrhea (initial workup)...........................43
Constipation......................................................................................................... 44
GI bleed.................................................................................................................45
Hyperbilirubenemia............................................................................................. 46
38
GA ST ROE NT E RO LO G Y
DIARRHEA/STOOL REPLACEMENT
(FOR SHORT GUT OR AGE)
• Initial Mgmt: bowel rest initially, then restart with eliminating excessive sugar from diet(juice,
fruit, soda) and add yogurt to reg. diet. Milk is okay.
• Report stool output in mL/kg/day. If > 30 mL/kg/d, consider replacing,
• For stool output > 5gm/kg/4 hours, replace 1ml fluid : 1gm stool with ½ NS + 20 meq/L K Acetate
(Or NaCO3 if K elevation). Send stool studies, stool electrolytes, osm
•*Do not exceed maintenance fluids or risk hyperK (max dose of K = 0.15 meq/kg/hr). Calculate
and write a max dose/rate with your order!
ORAL REHYDRATION THERAPY
• 1 Liter Water + 6 tsp sugar + ½ tsp salt
• Add ½ cup OJ or 1 mashed banana for added potassium
• Or Pedialyte
ELEVATED AST/ALT
• DDX: idiopathic, trauma, structural anomalies, infectious, inflammatory, autoimmune, medication
related, and familial or genetic disorders, toxic ingestion
• Labs:
• Initial: CMP, Dbili, GGT, Coags, EBV and CMV titers, acute viral hepatitis panel, urine tox,
acetaminophen level
• Extended: ferritin (hemochromatosis), ANA, total IgG, anti-smooth muscle Ab, Anti-LKM1
Ab (autoimmune hepatitis), celiac panel, serum copper, ceruloplasmin (Wilson’s), alpha-1
antitrypsin phenotype.
• Imaging: Abdominal ultrasound with Doppler (NPO x 8 hrs) Consider liver biopsy
H. PYLORI
• Lab: stool H.pylori antigen (NOT the serum antibody); falsely negative if on PPI or bismuth
• Treatment: PPI up to 20 mg BID, Clarithromycin 15 mg/kg/day up to 500 mg BID plus amox 50
mg/kg/day up to1g BID OR metronidazole 20 mg/kg/day up to 500 mg BID.
• Refer for EGD/Breath urea test if necessary (depending on symptoms, regardless of Lab results)
GA ST R O E NTEROLOGY
39
METABOLIC WORKUP
• Initial Labs: VBG, CBC, Chem18, NH4, Serum amino acids, UA, Urine organic acids, acylcarnitine
profile lactate, ESR, CRP, CK, Coags
• Check Newborn screen (If not in military call see http://www.babysfirsttest.org/newborn-screening/
states) and call appropriate stated. Give them mothers last name, birth hospital and date of birth
INFANT NUTRITION
WEIGHT GAIN EXPECTATIONS
Small Premie
15 gm/day
0-3 months
15-30 gm/day
3-6 months
15-20 gm/day
6-12 months
5-8 gm/day
1-6 years
5-8 gm/day
7-10 years
5-11 gm/day
MIXING INFANT FORMULAS
20 cal/oz
1 scoop
2 oz
24 cal/oz
3 scoops
5 oz
26 cal/oz
2 scoops
3 oz
28 cal/oz
7 scoops
10 oz
30 cal/oz
3 scoops
4 oz
CALORIC REQUIREMENTS BY AGE
Age
Calories/kg
Protein
1-6 months
108 kcal/kg/day
2.2 gm/kg/day
6-12 months
98 kcal/kg/day
2.0 gm/kg/day
1-3 years
102 kcal/kg/day
1.2 gm/kg/day
4-6 years
90 kcal/kg/day
1.1 gm/kg/day
7-10 years
70 kcal/kg/day
1.0 gm/kg/day
40
FAILURE TO THRIVE
• Definition: Wt < 2%tile for correct gest. age and sex more than once, crossing more than 2 major
weight %tiles, etc
• Etiology: Insufficient caloric intake (GERD, underfeeding, improper formula mixing, oral/motor
discoordination/aspiration, etc); increased metabolic demand (cardiac dz, metabolic/genetic,
RTA, other chronic illness), increased output (malabsorption, milk protein allergy, chronic
diarrhea, CF, etc)
• Labs: CMP, CBCD, UA , TFTs (>1 yo), Celiac panel (>1 yo), IGF-1 (After failure of dietary counseling
with increased calories)
• Extended, pre-albumin, zinc, selenium, celiac panel; consider metabolic/genetic
• Stool studies: stool fecal fat, reducing substance, alpha-fetal protein, fecal elastase.
• Imaging: KUB, UGI if persistent emesis to r/o malro, CT Head for possible increased ICP
• Daily weights, strict I/O, Nutrition (calorie count), possible NG placement, monitor for re-feeding,
follow up newborn screen
TPN GUIDELINES
Neonates
Per 24 hours
Preterms
less than
3 kg
Infants & Children
Full term
10 kg
10-20
kg
greater
than 20 kg
1000 mL - Add 50
mL/kg for each extra
kg greater than 10 kg
Adolescents
1500 mL - Add 2025 mL/kg for each
extra kg greater
than 20 kg
Fluids (mL/kg)
100-200
100-150
100125
Calories (Kcal/kg)
70-120
greater
than 100
75-90
75-90
greater
than 40
30-50
Protein (g/kg)
Max Perip: 2 g/kg/day
Max Central: 3.5 g/kg/
day
2.5-3.5
2-2.5
2-2.5
1.5-2.5
1.5-2.5
1-2
Dextrose (%)
Max Periph: 12.5%
Max Central (30%)
5-25
5-25
5-30
5-30
5-30
5-30
Fat: (g/kg/day)
0.5-3
1-3
1-3
1-3
1-3
1-3
Neonates
Vitamins (mL/day)
MVI - Peds
(Contains Vitamin K =
0.2 mg/5 mL)
Infants/Children
less than
1 kg
1-2.5 kg
greater than 2.5 kg & less
than 11 years
1.5 mL
3.25 mL/
day
5 mL/day
Children/Adult
greater than or
equal to 11 years
41
TPN AND RE-FEEDING
Pediatrics
Standard Adult Solution (3L)
*Sodium
2-5 mEq/kg/day
100 mEq/day
Potassium
2-5 mEq/kg/day
100 mEq/day
Chloride
2-5 mEq/kg/day
100 mEq/day
Phosphate (as K+)
1-4 mEq/kg/day
45 mEq/day
Calcium Gluconate
(Maximum peripheral conc = 2 mg/mL)
100-500 mg/kg/day
3000 mg/day
Magnesium
0.25-0.5 mEq/kg/day
24 mEq/day
* by Definition NS = 154 mEq/L; 1/4 NS = 38.5 mEq/L
Trace Elements
Infants greater than 3 months
and children
Neonates
Preterm
Peds Multi-Trace
0.2 mL/kg
Additional Zinc (mcg/kg)
*300
0-3 months
Average
0.2 mL/kg (max 10 mL/day)
150
* (Premature infants weighing less than or equal to 3 kg require an additional 300 mcg/kg/day of zinc for total of 400 mcg/kg/day)
PEDIATRIC MULTI-TRACE ELEMENTS — 0.2 ML/KG/DAY PROVIDES:
Element
Dose
Normal Range
Zinc
100 mcg/kg/day
100-300 mcg/kg/day
Copper
20 mcg/kg/day
15-30 mcg/kg/day
Chromium
0.17 mcg/kg/day
0.14-0.2 mcg/kg/day
Manganese
42
5 mcg/kg/day
2-10 mcg/kg/day
TPN ADVANCEMENT
• TPN should be calculate based on IBW not admit weight
• Increase dextrose 2.5 - 5% per 24 hours.
• Increase protein and fats 0.5 - 1g / kg / day, over 3 - 4 days. GOAL: Maximum of 60% total
calories from fat.
• If pt losing wt on TPN needs more calories even if at goal
TPN MONITORING
• Initiation/unstable: daily Chem10, TG; Twice/week: LFTs, Daily weights
• Monitor TG as the dose increases and keep below 100 - 250 mg / dL
• Check TG after lipids are off for 4 hours
• Stable: Twice/week BMP; weekly Mg, Phos, TG, LFTs
RE-FEEDING SYNDROME
• Severe fluid/electrolyte shifts in malnourished patients undergoing oral, enteral, or parenteral refeeding after prolonged fasting/poor feeding
• HypoPhos, hypoK, hypoMg, hyperglycemia
• Monitor lytes BID x 3d when initiating nutrition
• Correct electrolyte abnormalities and progress diet slowly until goal protein/energy intakes
achieved
INFLAMMATORY BOWEL DISEASE/BLOODY
DIARRHEA (INITIAL WORKUP)
• Initial workup: CXR, KUB, CBCD, ESR, CRP, CMP, DBili, GGT; consider type/cross with retic
count if significant hematochezia
• Stool labs: FOBT, CDiff, culture w/Yersinia, WBC
• Other: PPD, CXR, Quantiferon
• Initial management: NPO + IVF; may need clean out for endoscopy (see constipation section
43
CONSTIPATION
Mild:
Functional
constipation without
impaction
1. Increase fluids (consider prune /pear juice, 2-4 oz/d)
2. Regular toilet time (BID x 5-10 min after meals)
3. Benefiber:
- 6 – 11 yrs 1 t s p TID ( 4.5 gm/day)
OR
½ - 1½ chewable tabs 3-5 times/day
> 12 yrs 2 tsp TID (9 gm/day)
OR
1 -3 chewable tabs 3 -5 times/day
Moderate
1. Miralax (polyethylene glycol): Most ages ½ - 1 cap, 1-3 times/day
– titrate for effect
2. Milk of Magnesia: teens- 1 mL/kg/ day (conc. 400mg/5mL)
- maximum dose = 30 mL/day
OR 0.5 mL/kg /day (conc. 800mg/5mL)
- maximum dose = 15 mL/day
3. Senokot: - 2-6 yrs: 2.5-7.5 mL/day
- 6-12 yrs: 5-15 mL/day (syrup 8.8 mg/5 ml)
4. Dulcolax: 3-12 yrs: 5-10 mg or 0.3 mg/kg/day PO
>12yrs: 5-15 mg/day single dose PO; 39 mg max
5. Mineral Oil: over 1 yr: 5-30 mL/day BID
*DO NOT USE with children with neurological impairments or seizure
disorder due to risk of aspiration pneumonia
6. Lactulose: Infants-1ml/kg/day in divided doses
Severe:
Need for
Disimpaction
or clean out
1. Miralax Clean-out:
- Mix 238 g in 64 oz non-red fluid
- Give 8 oz every 20-30 min until complete
- Follow with 5-10 mg Dulcolax po x 1
2. Golytely Clean-out:
- Place NG, get KUB to confirm placement
- Start 50ml/hr x1 hr then advance to 100ml/hr x1 hr then to max rate of
200ml/hr as tolerated. Stop after max volume given. May consider additional dose if lytes stable and stools not yet clear.
- Max Doses: 10-20kg 1.5L; 20-30kg 2L; 30-40kg 3L;
40-50kg 3.5L; >50 kg 4L
- Check BMP, Mg, Phos qday while getting GoLytely
- Clears ad lib + MIVF during clean out
- Continue until clear effluent
1. Soap suds enema: 100ml/year of life up to 1 liter
44
GI BLEED
History and Physical Exam
Essential History: History of Bleeding/Coagulopathy/Gastroenteropathy/Ulcer/Liver Disease,
Frequency of Melena/Hematemesis
Current Medications
Physical Exam: Vital Signs (Orthostatics), Pallor, Jaundice, Hepatosplenomegaly
Labs: CBC Including including platelet counts, PT/PTT, Type and Screen, Liver Function Tests
NG/Gastric Aspiration to determine site of bleed (verify upper location) & lavage
STABLE
UNSTABLE
Discuss with Attending
Consider EGD Admt for observation?
Admit to ICU CArdiopulmonary
Monitor
NPO/IV access x 2
Fluid/blood product resuscitation
Octreotide bolus and drip
IV pantoprazole
Frequent Hemoglobin/Hct monitoring
q4
Unstable: If requiring > 85 cc/kg of
transfusion, CONSULT SURGEON.
Set up for EGD with surgery present
Stable: EGD
45
HYPERBILIRUBENEMIA
Guidelines for phototherapy in hospitalized infants
of 35 or more weeks gestation.
Guidelines for exchange transfusion in hospitalized infants
of 35 or more weeks gestation.
46
NOTES
47
SECTION 7
Heme/Onc
Anemia.................................................................................................................. 49
Pancytopenia work-up........................................................................................ 49
Transfusion guidelines......................................................................................... 50
Sickle cell care...................................................................................................... 51
Fever and Neutropenia.........................................................................................52
Tumor lysis syndrome..........................................................................................53
48
HE M E/ O N C
ANEMIA
Corrected reticulocyte index = % retics x (patient Hct / normal Hct) >1.5 suggests increased RBC
production from hemolysis or blood loss
CLASSIFICATION OF ANEMIA
Retic count
microcytic
normocytic
macrocytic
low
Iron deficiency, lead
poisoning, anemia of
chronic disease,
aluminum toxicity,
copper deficiency,
protein malnutrition,
inflammation
Chronic disease, RBC
aplasia(TEC, infection,
drug induced),
Malignancy, juvenile
rheumatoid arthritis,
endocrinopathies,
renal failure,
splenomegaly
Folate deficiency,
vitamin B12
deficiency, aplastic
anemia, congenital
bone marrow
dysfunction, drug
induced, trisomy 21,
hypothyroidism
normal
Thalassemia trait,
sideroblastic anemia
Thalassemia trait,
sideroblastic anemia,
acute bleed
Normal newborn,
trisomy 21, drug
induced
Thalassemia
syndromes,
hemoglobin C
disorders
Anti-body mediated
hemolysis,
hypersplenism,
microangiopathy
(HUS,TTP, DIC,
Kasabch-Merrit),
membranopathies
(spherocytosis,
elliptocytosis),
enzyme disorders
(G6PD,
pyruvate kinase)
hemoglobinopathies
Dyserythropoietic
anemia I,III; active
hemolysis
high
PANCYTOPENIA WORK-UP
1. CBC W/ manual diff, retic panel, chem 18 (CMP, LFT), LDH, DIC panel, CXR, other labs as
clinically indicated.
2. CALL HONC ATTENDING.
HE ME /O NC
49
TRANSFUSION GUIDELINES
Cryoprecipitate
•Dose: 1 unit: approx.. 250 mg fibrinogen.
Rate: As fast as tolerated
•Indications: raise fibrinogen when a small
volume is needed.
3.To achieve desired HCT: volume of
pRBC’s (ml) = EBV (ml) X (desired
HCT- actual HCT)/HCT of pRBC’s
EBV- estimated blood volume ( see
harriet lane for values)
Fresh Frozen Plasma
Ordering Packed Red Blood Cells:
•Dose: 10-30 mL/kg
•Leukoreduced
•Contains all factors and albumin, but no
platelets
•Rate: as indicated by clinical situation
•Indications: see sharepoint
Single Donor Platelet Pheresis (SDPP)
•Dose: 5-10 mL/kg, raises platelet count by
40,000 – 60,000 (for 10ml/kg)
•Rate: as fast as tolerated (30 minutes to 1
hour)
•Transfusion goals:
1. Placing lines > 20, 000
2.Lumbar puncture > 50,000
3.DIC > 20, 000
4.Normal maintenance > 10,000
5.Brain lesion or major surgery >
100,000
6.ITP- NEVER GIVE PLATELETS
WITHOUT DISCUSSING CASE
WITH ATTENDING
Packed Red Blood Cells
•Dose: 10 mL/kg ( if hgb is less than 6, use
numerical Hgb value as starting dose. Ex. If
hgb is 4, first transfusion dose should be 4ml/
kg); 10 mL/kg raises Hgb by 3 g/dl
•Rate: 2-5 mL/kg/hr, or mainly 10 mg/kg over
2-4 hours
•Indications: see sharepoint
1. If hGb < 4.0 call HONC attending
and transfer to PICU
2.Goal of transfusion > 7.0 or as
clinically indicated
50
•All blood products need to be
leukoreduced and CMV safe.
•Irradiated
•All neonates < 4 months
•Severe known or suspected
immunodeficiency or
immunosuppression(chemo, radiation,
stem cell transplant)
•Donor-directed blood products
•CMV Seronegative
•Infants < 1000gm
•CMV negative/pending patient:
•receiving stem cells from CMV
negative donor
•AML or aplastic anemia
•high-risk neuroblastoma
•congenital or acquired
immunodeficiency syndrome
•CMV+ patient with low or undetectable
viral load receiving stem cells from a
CMV neg donor
•Phenotype Matched
•Sickle cell, Thalassemia, other chronic
anemias (dicuss with heme/onc first)
•Washed RBCs
•Cardiac patients < 4 kg (non-pump
surgery or “push” transfusion)
•GI surgery patients < 5kg
•History of serious febrile or allergic
transfusion reaction
•IgA deficiency
•Kidney failure, Liver failure
HE M E/ O N C
SICKLE CELL CARE
ACUTE PAIN CRISIS
•Labs on admission: CBC w/ manual diff, retic panel, chem 18, blood culture, consider ordering
type and cross for 2-4 units and possible post-transfusion electrophoresis
•Orders on admission:
•Ketorolac q6h or other NSAID
•Oral opioid, consider PCA pump if pain is not well controlled
•1.5 X IVMF
•CXR
•Heating pad
•Incentive spirometry
•Miralax if pt will be receiving heavy opioids
•Antihistamine for pruritis
•ALWAYS CHECK FOR PRIAPISM: SURGICAL EMERGENCY IF PRESENT FOR > 4 HOURS
ACUTE CHEST SYNDROME
Most common cause of death in SCD. The development of a new pulmonary infiltrate associated
with fever, chest pain, hypoxia, tachypnea, and cough. Generally caused by infection, infarction, or
fat embolization.
•Acute Chest Syndrome Orders:
•STAT CXR- repeat CXR with any with any respiratory status changes
•Ketorolac Q6H or other NSAID; also consider opioid if pain is not well controlled
•1.5 X IVMF
•Transfuse- 10-20 ml/kg of pRBC’s (see transfusion guidelines) and recheck Hgb 2-4 hours
post-transfusion. Post transfusion should not exceed Hgb > 12 (see formula in transfusion
guidelines)
•Start broad spectrum (cefepime) and a macrolide (azithromycin)
•Give bronchodilators if wheezing
•Incentive spirometry
•Miralax if giving lots of opiates
•Antihistamine for pruritis
•Consider steroids
•ALWAYS CHECK FOR PRIAPISM: SURGICAL EMERGENCY IF PRESENT FOR > 4 HOURS
HE ME /O NC
51
FEVER AND NEUTROPENIA
Fever and neutropenia is the most common admission for heme/onc that you will get overnight. Be
aware that a neutropenic patient may not have a normal inflammatory response and could become
septic without signs of fever or other classical signs of infection. PE should include dental, nail
beds, perirectal examination, line site visualization. No rectal exams or temperatures. Generally
things that you should do:
•CXR
•Urine culture, blood culture (from port- each lumen)
•Cefepime unless there is a specific indication for another antibiotic- add vancomycin for
cellulitis, PNA, or ill-appearing upon presentation
•Chem10, LFT’s, and CRP
•Tylenol for fever/pain- No motrin until platelets return to greater than 150,000
•IVMF
•Consider LP if any signs of mental status changes (not routine)
•Q24H Bcx for continued fever relapse
52
HE M E/ O N C
TUMOR LYSIS SYNDROME
Etiology: Lysis of tumor cells before or during early stages of chemotherapy. Most commonly seen
in lymphomas and leukemias. Worry about renal failure. Check chem 10, LDH and uric acid q6h.
Labs abnormalities
Start treatment
Management
hyperurecemia
≥ 8.0
Or
Any 25% increase from
baseline
- Alkalinization: D5 ½NS +
40mEq/L NaHCO3 at 1.5- 2.0
xMIVF
- Allopurinol 200mg/m2/day
divided Q8 IV
- If Uric Acid still rising:
Rasburicase
0.2mg/kg/day IV infusion
over 30 mins (no alkalinization
required) – Call attending
before starting!
hypocalcemia
<8.0
Or
Any 25% decrease from
baseline
1. Correct for albumin
2. Check ionized calcium
3. Calcium Carbonate (Tums)
2-3 tabs QID (max 15 tabs/day)
4. If emergent: Calcium
Gluconate 100mg/kg IV
hyperkalemia
>7.0
Or
baseline
1. Stop K in fluids
2. EKG – if no changes, go to
Kayexalate; if changes or K
>7.0:
3. Calcium Gluconate (heart
protection) 100mg/kg IV
4. Insulin (0.1U/kg IV) +
Glucose
(D25W 2ml/kg) over 30 min
5. Beta-agonist: Albuterol nebs
6. Kayexalate 1g/kg/dose PO
Q6
hyperphosphatemia
>6.0
Consider NS bolus and
mannitol
>8.0
Or
baseline
If not responding to fluidsRenagel 120mg/kg/day
HE ME /O NC
53
NOTES
54
HE M E/ O N C
SECTION 8
Infectious Disease
Croup pathway..................................................................................................... 55
Admission for croup.............................................................................................57
Rule out serious bacterial infection.................................................................... 58
Community acquired pneumonia pathway........................................................ 59
Influenza................................................................................................................ 60
Endocarditis.......................................................................................................... 61
Urinary tract infection........................................................................................... 61
Meningitis............................................................................................................. 63
Intrauterine & perinatal infections (TORCH)........................................................67
Zoonotic exposure............................................................................................... 68
Septic joint............................................................................................................ 69
Acute otitis media treatment algorithm for children
6 months-12 years of age.................................................................................. 70
CROUP PATHWAY
Croup occurs most commonly in children 6 months to 3 years of age but may occur in children as
young as 3 months and as old as 12 to 15 years of age.
Inclusion criteria
•Age 3 months to 6 years old
•Able to control secretions
INF E C T IO U S DISEASE
55
•Moderate stridor with mild to moderate respiratory symptoms and upper respiratory symptoms
compatible with croup
•Alternate diagnosis not suspected (FB, anatomical abnormaility, etc.)
Croup Symptoms
•Barky cough
•Inspiratory stridor
•Hoarseness
•No to moderately high fever
•Symptoms usually improve during the day, exacerbate at night
•Majority of children resolve croup symptoms within 48 hours
•May or may not have antecedent cough, rhinorrhea or fever
Impending respiratory failure suggested by
•Changes in mental status such as lethargy, fatigue or listlessness
•Pallor, dusky appearance, or cyanosis
•Decreasing retractions or decreasing breath sounds with decreased stridor
Radiologic Pearls
•Croup - “steepling” of the subglottic area instead of normal square shoulder appearance on AP
neck radiograph
•Bacterial tracheitis – ragged edge or membrane spanning the trachea
•Epiglottitis - thickening of epiglottis and aryepiglottic folds “thumbprint” appearance
•Retropharyngeal abscess – bulging of the posterior pharynx soft tissues
Differential diagnosis
•Epiglottitis
•Foreign body
•Retropharyngeal abscess (before 3 to 4 years old) or peritonsillar abscess
•Hereditary angioedema
•Subglottic stenosis
•Infectious mononucleosis
•Diphtheria
•Extrinisic (hematoma) or intrinsic (tumor or cyst) obstruction of airway
•Trauma
56
I N F E CT I OU S DI S E AS E
ADMISSION FOR CROUP
57
RULE OUT SERIOUS BACTERIAL INFECTION
58
COMMUNITY ACQUIRED PNEUMONIA PATHWAY
Diagnostic Studies:
•Order studies only as anticipated to contribute to therapeutic decisions
•For outpatient, no need for CXR or BCx
•CXR (PA/Lat) for In-Pt management to document the presence, size, and character of
parenchymal infiltrates and identify complications of pneumonia
•A chest radiograph interpretation cannot be relied upon to distinguish between viral and bacterial
etiologies
•Blood cultures should be obtained in children requiring hospitalization for presumed bacterial
CAP that is moderate to severe, particularly those with complicated pneumonia
•CBC, CRP or ESR not necessary to empirically treat, nor to differentiate viral vs bacterial
•In selected older children, sputum Gram stain and culture might be helpful
•Nasopharyngeal bacterial cultures are not usually helpful
•If you are considering pertussis, obtain a nasopharyngeal swab or aspirate of the posterior
nasopharynx
•Laboratory confirmation of a viral etiology (e.g., RSV) can occasionally be helpful
•The incidence of bacterial co-infection with RSV pneumonia is low, so when the RSV test is
positive, generally antibiotics are not indicated
•Remember to consider TB and the intradermal TB skin test, or interferon gamma release assay
(Quantiferon) if >4y old
•PCR, serologies and acute phase reactant studies are not usually helpful
Admission Factors:
•Age < 6 months
•SpO2 <92% or marked respiratory distress
•Dehydration with inability to take PO fluids/antibiotics
•Toxic appearance
•complications (empyema/effusions)
•Failed oral antibiotics (48-72hrs)
•Comorbid conditions/ immumocompromised
•Unstable social situation; non-adherence
Outpatient Antibiotic Therapy for suspected Bacterial PNA (Community
Acquired)
•3 mo - 5 years: Amoxicillin 90mg/kg/day BID x 7-10 days
•≥ 5 years: Azithromycin 10mg/kg/day (Day 1), then 5mg/kg/day (Day 2-5)
•+/- Amoxicillin as above
59
Parenteral empiric antibiotics for inpatient treatment of pediatric pneumonia
•Bacterial and fully immunized-Ampicillin (150-200mg/kg/day div q6hr)
•Bacterial and partially immunized-Ceftriaxone (50-100mg/kg/day div q12-24hr)
•If atypical is suspected- Azithromycin (10mg/kg/day, then 5mg/kg/day )
•If complicated or suspect abscess- Clindamycin (30-40mg/kg/day div q6-8hr) , or Vancomycin
(60mg/kg/day div q6hr) if severe disease
INFLUENZA
60
ENDOCARDITIS
Diagnostic criteria
2 major criteria, or
1 major criteria and 3 minor criteria, or
5 minor criteria
Major criteria
•2 separate positive blood cultures positive for endocarditis organisms. Cultures must be drawn
>12 hours apart: Staph aureus,Viridans strep, Strep bovid, HACEK group, enterococci in absence
of primary focus
•Single positive blood culture for Coxiella burnetti
•Echocardiogram evidence of vegetations on valves or implanted devices
Minor criteria
•Predisposing heart condition
•Fever
•Vascular phenomena: arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial
hemorrhage, conjunctival hemorrhage, Janeway’s lesions
•Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor
•Micro evidence: positive blood culture for organism not associated with endocarditis
URINARY TRACT INFECTION
Clinical scenario: Consider UTI in any child < 2 years with fever; symptoms non-specific include
abdominal or flank pain, strong-smelling urine, new urinary incontinence, dysuria, urgency,
nausea/vomiting, diarrhea
Additional History: stooling pattern, prenatal ultrasound, potty-training and wiping, sexual
intercourse/abuse, circumcision, recent antibiotics; FHx VUR, recurrent UTI, CKD
Diagnosis: requires positive pure culture; pyelonephritis vs cystitis is clinical (fever, systemic
symptoms, CVA tenderness); febrile infants assumed to have pyelonephritis
UA: positive LE suggestive of WBCs; positive nitrite consistent with urease producing gramnegative bacteria (E. Coli, Klebsiella, Proteus), but poor sensitivity in infants who empty bladder
frequently
61
Collection Method
Colony Count
Probability of Infection
Suprapubic
Gram-negative:
any number
>99%
Aspiration
Gram-positive:
>1,000
Transurethral
>100,000
95%
Catheterization
10,000-100,000
Infection likely
1,000-10,000
Suspicious, repeat
<1,000
Infection unlikely
Clean-voided (boy)
>10,000
Infection likely
Clean-voided (girl)
> 100,000
80-95%
50,000100,000
Suspicious, repeat
10,000-50,000
Infection unlikely if no
symptoms
<10,000
Infection unlikely
Common Pathogens
E. coli (75-90%)
Klebsiella
Proteus
Staph saprophyticus
Staph aureus
*Consider enterococcus
and pseudomonas in
abnormal host.
*Consider GBS or other
blood-borne pathogens
in neonates
Admission criteria: Require IV fluids, Those who require Iv antibiotic due to severe illness or
failure of po antibiotics, <30 days, 31-60 days and high risk
62
Treatment:
* Prophylaxis may not prevent recurrent febrile UTI; no specific recommendation in current AAP
guideline, RCT (Randomized Intervention for Children with Vesicoureteral Reflux) in progress.
Consider prophylaxis for VUR Grade 3 or higher: < 2mo: Amoxicillin 20mg/kg daily, > 2mo: TMP/
SMX 2mg/kg daily or Nitrofurantoin 2mg/kg daily (depending on allergies)
* VCUG should not be performed routinely after first febrile UTI; VCUG indicated if RBUS reveals
hydronephrosis, scarring, or other findings suggestive of high-grade VUR or obstructive uropathy
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children
2 to 24 Months (Pediatrics 2011)
MENINGITIS
Hx & Sx
•Infants: change in temp, irritability, lethargy, poor feeding, high-pitched cry, vomiting, bulging
fontanelles, seizure
•Children: neck pain, HA, N/V, photophobia
Risk Factors
•Assess recent sinusitis, AOM, antibiotic use, sick contacts, recent trauma, h/o neurosurg or VP
shunt.
•Functional asplenia, sickle cell disease, nephrotic syndrome, IgG
•Deficiency: INC risk of encapsulated S. pneumo, Hib, N. meningitidis
•Complement deficiency - N. meningitidis risk
•CSF leak / head trauma- risk of strep or staph
•VP shunt: increased risk of Staph. epidermidis (coag neg) or P. acnes
63
PE findings
•Check fontanelle, FOC, papilledema, CN palsy, signs of head trauma, e/o otitis media, sinus
infection, neck pain/stiffness
•Petechial / purpuric rash assoc with meningococcus.
•Kernig sign: inability to straighten the knee with hip flexed due to pain
•Brudzinski sign: passive neck flexion that leads to hip flexion due to pain
Treatment
•Based on clinical suspicion and patient age
•If HSV is possible, give Acyclovir until HSV PCR is neg
•Prophylaxis needed for N. meningitidis or Hib with rifampin, Cipro or CTX
Complications
•Hypovolemia or hyponatremia 2/2 SIADH, sepsis, DIC, seizures, cerebral edema, herniation,
stroke, subdural effusions
•Sensorineural hearing lost is most common
COMMON ORGANISMS
Viral: Enterovirus (90%), HSV, EBV, CMV, VZV, arbovirus (EEE, West Nile), Influenza A/B
Bacterial: by age
Neonate
1-3mo
3mo-12yr
>12yr
GBS
GBS
S. pneumonia
N. meningitidis
E. coli
S. pneumonia
N. meningitidis
S. pneumonia
GNR
Listeria
Listeria
N. meningitidis
Salmonella
Tuberculous: Often indolent HA, low grade fever, may have CN palsy.
*In unvaccinated children, think of uncommon organisms as well*
64
RECOMMENDATIONS FOR ANTIMICROBIAL THERAPY
IN ADULT PATIENTS WITH PRESUMPTIVE PATHOGEN
IDENTIFICATION BY POSITIVE GRAM STAIN
Organism
Recommended Treatment
Alternative
S. pneumoniae
Vanco+ CTX or Cefotax
Mero, Fluoroquinolone
N. meningitidis
CTX or Cefotax
PCN G, Amp
Listeria
Amp
TMP-SMX, Mero
S. agalactiae
Amp
CTX or Cefotax
H. influenza
CTX or Cefotax
Cefepime, Mero
E. coli
CTX or Cefotax
Cefepime, Mero, TMP-SMX
In children, ampicillin is added to the standard therapeutic regimen of cefotaxime or
ceftriaxone plus vancomycin when Listeria is considered, and to an aminoglycoside if a
gram-negative enteric pathogen is of concern
EVALUATION OF CEREBROSPINAL FLUID
Age
WBC count (median)
95%ile
0-28 d
0-12 (3)
19
29-56 d
0-6 (2)
9
Child
0-7
n/a
Glucose
mg/dl
mmol/L
Preterm
24-63
1.3-3.5
Term
34-119
1.9-6.6
Child
40-80
2.2-404
Protein
mg/dL
g/L
Preterm
65-150
0.65-1.5
0-14d
56-102
0.56-1.02
15-28d
49-89
0.49-0.89
29-42d
41-75
0.41-0.75
43-56d
36-70
0.36-0.70
Child
5-40
0.05-0.4
Opening Pressure
Newborn
8-11 cm H2O
1-18yrs
11.5-28 cm H2O
65
HSV DISEASE IN NEONATES
Disseminated Disease
•25 percent of neonatal disase
•CNS involvement in 60-75% disseminated cases
•Sepsis-like state around day 7 to 14 of life
•Hepatitis and pneumonitis are common findings
•Death from severe coagulopathy, liver dysfunction, and pulmonary involvement
CNS Disease
•One-third of all neonates with HSV infection
•Seizures (both focal and generalized), lethargy, irritability, tremors, poor feeding, temperature
instability, and bulging fontanelle
•Presentation is usually around day 14 to 21 of life
•Can be indistinguishable from other viral and bacterial meningitis
•Should be considered in young infants evaluated for sepsis when bacterial cultures are negative
at 48 to 72 hours and the infant has experienced a worsening or lack of improvement clinically
•Mortality usually is the product of devastating brain destruction neonatal HSV can involve any
and often multiple parts of the brain
SEM Disease
•Infection localized to the skin, eye, and/or mouth
•20-45% of all cases of neonatal HSV disease
•Presentation usually around day 7 to 14 of life
•By definition, limited infection
•80-85% have vesicular lesions on physical examination
Risk Factors
•Type of maternal infection (primary > recurrent)
•Maternal antibody status (pos Hx = Abs)
•Duration of rupture of membranes
•Integrity of mucocutaneous barriers (fetal scalp electrodes)
•Mode of delivery (vaginal > cesarean)
Work Up & Treatment
•Surface cultures & PCR
•Single swab (Eyes, Nares, Mouth, Lesions, Rectum)
•General Viral Culture-red top, pink media (Mailout)
•Serum labs
•LFTs (in house) and Serum HSV PCR (Mailout)
66
•Alternative is Plasma HSV PCR (Local mailout, ~24hr turnaround time)
•CSF Labs
•CSF HSV PCR (Mailout)
•Acyclovir 60mg/kg/day div q8hr, 21days for disseminated and CNS disease (CSF PCR negative
prior to stopping), 14 days for SEM.
•Oral acyclovir suppression for 6 months after IV therapy completed
INTRAUTERINE & PERINATAL INFECTIONS (TORCH)
Organism
Characteristics
Prenatal Dx
Postnatal Dx
Treatment
CMV
IUGR, jaundice, HSmegaly, microcephaly,
TCP, intracranial
calcifications, deafness
n/a
Ucx/CSF Cx
within 2-4wks
Gancyclovir
Enterovirus
hepatitis, myocarditis,
encephalitis,
NEC, DIC
n/a
RNA PCR
IVIG
Hep B
jaundice, HS-megaly,
Chronic HBV
Maternal HBsAg
HBsAg &
anti-HBs @
9-18mo
HBIG + HepB
Vacc; IFN-a
Hep C
asymptomatic
Maternal Abs
IgG @ 18mo
IFN-a-2b +
ribarvirn
HIV
goal maternal viral load
<1000; elective C/S
at 38wks; avoid
breastfeeding
HIV screening
rapid HIV-Ab;
HIV DNA PCR
Zidovudine;
HSV
CNS, Disseminated or
SEM disease
Maternal screening
Culture; PCR
after 24hrs
Acyclovir
Parvo B19
hydrops, IUGR, pleural/
pericardial
effusions
n/a
Serum IgM;
PCR
Supportive, IU
transfusion
Rubella
IUGR, cataracts, cardiac
anomalies,
blueberry muffin rash
Maternal Abs
infant IgM or
nasal culture
Supportive
Syphilis
HS-megaly, abnml bone,
rash, LAD
VDRL or RPR;
FTA-Abs
VDRL or RPR
PCN G
Toxoplasmosis
chorioretinitis, meningitis,
cerebral calcifications
Parasite DNA
Baby & Maternal Abs; PCR
Pyrimethamine
+ sulfadiazine
VZV
rash, pneominitis,
encephalitis, purpura
fulinans, hypotension
n/a
DFA; PCR
Acyclovir;
VariZIG
67
ZOONOTIC EXPOSURE
COMMON AND UNCOMMON ZOONOTIC ORGANISMS
Host
Common
Uncommon
Humans
GAS, MSSA, Fusobacterium,
Peptostreptococcus
Eikenella, Prevotella, Porphyromonas
Dog
Rabies, Pasteurella
Campylobacter, Eccinococcus
Cat
Bartonella, Pasteurella
Giardia, Toxoplasma
Horse
Salmonella, Campylobacter,
Cryptosporidium
Giardia, Brucella, Coxiella
Rabbit
Tularemia, Babesia, Pasteurella,
Ringworm
Salmonella, Yersinia, Cryptosporidium
Cattle/Sheep
Brucella, Coxiella , M. bovis
Parapoxyvirus
Rodents
Streptobacillus moniliformis,
Spirillum minus, Leptospira
Salmonella, Tularemia, Hantavirus, Yersinia
Birds
C. psittaci, M. avium, Salmonella,
Avian Flu
Cryptococcus, Histoplasma, West Nile
Fish
M. marinum, Aeromonas
Erysipelothrix
Reptiles
Yersinia
Aeromonas, Pentastomiasis
Exotic animals
Cryptosporidium
Giardia, M. microti, Toxoplasma
68
SEPTIC JOINT
Evaluation/Treatment of the Child with Suspected Septic Arthritis
*used for children, with no known trauma, who have one or more of the following
•Significant joint pain with or without swelling
•Significant limp or refusal to bear weight
•Fever (absence of fever does not rule out septic arthritis or osteomyelitis)
69
ACUTE OTITIS MEDIA TREATMENT ALGORITHM
FOR CHILDREN 6 MONTHS-12 YEARS OF AGE
Based on the 2013 AAP Treatment Guidelines
•Do not diagnose AOM if there is no middle ear effusion
•Mgmt of AOM should include assessment for pain and treatment if pain is present
First line treatment of choice is Amoxicillin (80-90 mg/kg/day divided BID).
•Use Amox/Clav first line if:
•Antibiotics within 30 days or history of recurrent AOM unresponsive to Amox
•Child has AOM with conjunctivitis (likely to be H.influenzae)
Treatment failures (48-72 hours after appropriate treatment): Amox/Clav (if amox used) or
Ceftriaxone (3 doses 50mg/kg). Could consider Clinda with or without 3rd generation cephalosporin.
Tympanocentesis for multiple treatment failures (including Ceftriaxone x 3)
Alternatives for penicillin allergy include Cefdinir and Ceftriaxone. There are no official
recommendations for Type I PCN allergy (could consider Clindamycin with or without Septra).
Azithromycin is not recommended for any scenario in the guidelines
70
NOTES
71
SECTION 9
Neurology
Before Calling the Pediatric Neurologists............................................................ 73
Altered Mental Status........................................................................................... 73
Ataxia..................................................................................................................... 74
Concussion and RTP (Return to Play) Guidelines ..............................................76
Headaches and Headache medications.............................................................. 77
Seizure and AEDs................................................................................................. 80
Weakness/Peripheral neuropathy........................................................................83
Pain....................................................................................................................... 84
Head abnormalities.............................................................................................. 85
Developmental Milestones.................................................................................. 86
Neuro-imaging......................................................................................................87
Cranial Nerves...................................................................................................... 88
Reflexes................................................................................................................. 89
Motor.................................................................................................................... 90
Sensation/Dermatomes....................................................................................... 90
72
P E DI AT RI C N E U RO LO G Y
BEFORE CALLING THE PEDIATRIC NEUROLOGISTS
As a part of your excellent H&P, don’t forget to obtain
•Birth history
•Family history (seizure and use of medication and duration of treatment, early wheelchair,
family hx of developmental delays, neuro-genetic syndromes etc)
•Developmental history (when did they meet their milestones, regression)
•Head circumference in children <2yo
EEG’s
Consult Peds Neuro if you think you need an EEG. Order the EEG in CHCS (and Essentris). EEGs
will be approved and scheduled by Peds Neuro (or EEG tech). Read within 24-48 business hours of
the test, and the report documented as an encounter in AHLTA. See phone list for EEG Tech.
You do not need to consult neuro in the case of first time afebrile unprovoked sz. However, let
neurology know about any inpatient EEG so that they can look out for it.
ALTERED MENTAL STATUS
Definitions/Clinical Findings:
•Normal: awake, easy to arouse and maintain alertness
•Lethargic: difficult to maintain alertness
•Obtunded: decreased alertness, responsive to pain, other stimuli
•Stuporous: decreased alertness, responsive to pain only
•Comatose: unresponsive even to pain
PE DIAT R IC NEUROLOGY
73
DIFFERENTIAL DIAGNOSIS OF ALTERED MENTAL STATUS
T
Trauma
Tumor
Infection Increased ICP
I
Intussusception
- concussion, contusion, hemorrhage
- meningitis, encephalitis, CNS abscess
- space-occupying lesion, obstructed VP shunt, cerebral edema,
subarachnoid, subdural, intracerebral hemorrhage
P
Poisons
- CO, cyanide, acetaminophen, benzodiazepines, barbituates
S
Sepsis
Shock
Seizure
- nonconvulsive seizures or post-ictal state
A
Abuse
Alcohol
Encephalopathy
E
Endocrine
Electrolytes
I
Insulin/
Hypoglycemia
Inborn error of metabolism
O
Opiates
U
Uremia
- thyroid dysfunction, adrenal insufficiency
- low or high Na+, or Ca2+, low Mg2+, hyperammonemia, hypoxia,
hypercarbia
- Low or high glucose
Diagnostics:
•Consider: CMP, ammonia, ABG, CBC, TFT, tox screen, BCx, UCx, LP (strongly consider CT prior
to LP)
•Head CT, EKG, EEG
Management:
•Treat reversible causes (electrolytes/acid-base/glucose disturbances, maintain normal body
temp), abx (consider acyclovir), anticonvulsants, consider naloxone or specific antidotes
ATAXIA
•Dysmetria: disturbance of metric/rhythmic aspect of movement, incoordination of voluntary
movement
•Dysdiadochokinesia: dysfunction of rapid alternating movements
•Cerebellar ataxia: wide-based swerving gait, unchanged with eyes opened/closed, pendular
DTRs, dysmetria, dysdiadochokinesia, over/undershoot FTN test, scanning speech, intention
tremor
74
•Sensory ataxia: broad-based/high-step gait, worse with eyes closed, +Romberg
DIFFERENTIAL DIAGNOSIS OF ACUTE ATAXIA
Postinfectious
cerebellitis
Most common cause of acute ataxia in children, typically 1-3yo, often
1-3wks after illness or immunizations: Varicella (up to 26%), influenza,
mycoplasma, coxsackie etc. Maximum symptoms at onset, trunk>extremity,
head titubation, truncal ataxia, dysmetria, nystagmus, intention tremor,
opsoclonus and horizontal ocular flutter, no fever, typically no altered
mental status
Infectious
Usually viral, meningitis, labrynthitis
Drug ingestion
Alcohol, phenytoin, carbamazepine, sedatives, hypnotics, PCP, thallium,
antihistamine, mercury, lead, ethylene glycol, TCAs, insecticides
Other
Head trauma, cerebellar hemorrhage, neuroblastoma (opsoclonusmyoclonus-ataxia), ADEM, hydrocephalus, Miller-Fisher variant of GuillainBarré, seizure, post-ictal, basilar migraine, posterior circulation stroke,
conversion, mass
DIFFERENTIAL DIAGNOSIS OF INTERMITTENT ATAXIA
Metabolic disorder (eg. pyruvate dehydrogenase deficiency),
acute paroxysmal vertigo, basilar migraine, non-convulsive seizure,
genetic episodic ataxia
Other
DIFFERENTIAL DIAGNOSIS OF SUBACUTE, CHRONIC,
OR PROGRESSIVE ATAXIA
Other
tumor, congenital anomaly, degenerative spinocerebellar disease
(Friedreich ataxia, Ataxia-telangectasia), A-beta-lipoproteinemia
Diagnostics:
•Consider: CBC, P2, tox screen, LP, urine VMA/HVA, metabolic/genetics evaluation (VBG, Chem18,
NH4, Serum amino acids, UA, Urine organic acids, acylcarnitine profile lactate, ESR, CRP, CK,
CBC, Coags),
•Head CT or MRI, body CT/scintigraphy (mIBG) if suspect neuroblastoma, EEG (positive in postinfectious cases and non-convulsive seizures)
Management:
•Treat underlying etiology.
•Post-infectious cerebellitis is self-limited (begins to resolve in 1-4wks), steroids not indicated,
limited case studies show IVIG and/or plasma exchange to be effective, PT/OT.
•ADEM high-dose steroids/IVIG
75
CONCUSSION/HEAD TRAUMA
Clinical Findings:
Acute: LOC, headache, dizziness, emesis, incoordination, impaired physical skills, amnesia, slurred
speech, seizure, confusion, unsteady gait
Late: persistent headache, depression, disorganization, poor concentration, frustration,
emotionality, personality & behavior changes, memory problems
Diagnostics:
Pecarn Criteria
. <2 yo
. ≥ 2 yo
76
Severe mech of injury: MVC with patient ejection, death of another passenger, rollover, pedestrian
or bicyclist w/o helmet in MVC, falls more than 3ft (<2yrs) or 5 feet (>2yrs), or injury from high
impact object
Return to Play:
Each stage should last no less than 24 hours with a minimum of 5 days required to full return. If
symptoms recur, the athlete should stop immediately. Once asymptomatic after at least another 24
hours, resume at the previous asymptomatic level and try to progress again. Multiple concussions
or prolonged symptoms may require a longer rehabilitation.
RETURN TO PLAY GUIDELINES
Rehabilitation Stage
Functional Exercise
1. No activity
Complete physical and cognitive rest.
2. Light aerobic activity
Raise heart rate. Walking, swimming, stationary cycling at 70%
maximum heart rate, no resistance exercises, 5 to 10 minutes.
Absolutely no weightlifting, jumping or hard running.
3. Sport-specific exercise
Specific sport-related drills but no head impact. Moderate jogging,
brief running, moderate-intensity stationary biking, and moderateintensity weightlifting.
4. Non-contact training
drills
More complex drills. Running, high-intensity stationary biking, the
player’s regular weightlifting routine, and non-contact sport-specific
drills. This stage may add some cognitive component to practice
in addition to the aerobic and movement components introduced
above.
5. Full-contact practice
After medical clearance, participate in normal training.
6. Return to play
Normal game play.
HEADACHES
HA Red Flags
(consider non-con head
CT or MRI)
•Papilledema, worse supine, with valsalva or cough, awakes at
night or early in the morning, a/w N/V
•Abnormal neuro exam, vision change (not aura a/w migraine),
AMS or behavior change or LOC
•Sudden or recent onset of severe headache
•Progressive pattern
•Specific associated symptoms, including FTT or weight loss
•Headache a/w high risk condition
•<3yo
77
DIFFERENTIAL DIAGNOSIS
Types of Acute Headache:
Migraine without
aura
> or = 5 attacks, lasts 1-72 hrs, at least 2 of: frontal/temporal,
unilateral/bilateral (non-occipital), pulsating/throbbing, moderate – severe
pain, increases with activity, light, noise, at least 1 of:
photophobia/phonophobia, N/V
Migraine with
aura
Kids may present with irritability, malaise, anorexia, pallor, sensory, motor,
or visual change (scotoma, visual field defect), lasts minutes to hours,
includes basilar and hemiplegic
Tension
Bitemporal, tightening/pressure, worse with stress, noise, afternoon, lasts
min – days, no pulsating/throbbing
Cluster
Intense unilat periorbital/temporal, wks- mo, typically adult
Exertional
Occurs with exertion/exercise, migraine variant
Acute Localized
Sinusitis, myopia/eye strain, TMJ, trauma
Acute Generalized
Systemic infection or disease (SLE), CNS infection, CO toxicity, lead
poisoning, HTN, LP, hypoglycemia, trauma, CVA, venous sinus thrombosis,
substance use or withdrawal, infection
Types of Chronic Headache:
Chronic,
non-progressive
<6mo post-concussion, stress, chronic daily HA (>5/wk), medication
overuse, obesity, chronic illness, mental health disorder, facial pain,
vascular disorder, disorder of head/neck
Chronic
progressive
Brain tumor, pseudotumor cerebri, abscess, hydrocephalus, subdural
hematoma, SAH/ICH, arachnoid cysts, HTN, vasculitis, vasospasm,
refractive vision error, PRES
Diagnostics:
•BP, head circumference, fundoscopic exam
•Consider P2 and UA if elevated BP, CBC and BCX, LP (get opening pressure)
•Non-con head CT or MRI for Red Flags above
Management:
HEADACHE MEDICATIONS
ED Migraine Treatment Orders: NS bolus 20mg/kg x1-2; Benadryl 1mg/kg IV (max 50mg);
Ketorolac 0.5mg/kg IV (max 15mg); Reglan (see dosing below); if needed, Morphine 0.05-0.1mg/kg
(max 15mg). Reglan Dosing: <6 yo: 0.1mg/kg IV x1, 6-14 yo: 2.5-5mg IV x1, >14yo: 10mg IV x1.
78
Drug name
mg/kg/dose
Max dose
HA types
Side effects
Acetaminophen
15 PO/PR Q4-6
1g/dose,
4g/day
T
Hepatotoxicity,
nausea
Ibuprofen
10 PO Q6-8
40mg/kg/day
T, MA
Bleeding, renal
insufficiency
Naproxen
5-7 PO Q8-12
400mg dose,
1250mg/day
T, MA
Black Box: fatal
CV thrombotic
event
Ketorolac
0.5 IM/IV Q6
30mg/dose or
120 mg/day
MA
GI bleed,
nephritis
Sumatriptan
(Imitrex)
<12 yo: 0.06 SQ
Max 6mg
200mg/day PO
12mg/day SQ
MA Cluster
Vasospasm
Ergotamine
1mg/dose
Q30min SL/PO
3mg/HA child.
6mg/HA adult.
Cluster
GI, rebound HA
Propranolol
<35kg 10-20mg
PO TID
>35kg 20-40mg
PO TID
NA
MP, PTC
Asthma attacks,
depression,
exacerbates DM,
hypotension
Amitriptyline
0.1-0.25 QHS
2mg/kg/day or
75mg/day
MP
Minimal to mild
sedation,
anticholinergic
MP
Sedation,
increased
appetite,
anticholinergic.
Contraindicated
in asthma.
Cyproheptadine
(Periactin)
0.25-0.4 BID
2-6yr: 12mg/day
7-14yr: 16mg/day
Promethazine
(Phenergan)
0.25-1 PO Q4-6
25mg dose
Antiemetic
Black box:
respiratory
depression
Metoclopramide
(Reglan)
1-2 Q2-6
IV/IM/PO
10mg dose
Antiemetic
EPS, tardive
dyskinesia
Prochlorperazine
(Compazine)
0.1-0.15 IM Q8
10-14kg: 2.5mg
QD-BID
15-39 kg: 2.5mg
BID-TID
10-14kg: 7.5mg/
day
15-39kg:
10-15mg/day
Adult: 40mg/day
Antiemetic
EPS, orthostatic
hypotension
T=tension; MA = Migraine, abortive; MP= Migraine
Consider topiramate: Children 6 to <12 years; weight: ≥ 20 kg: Initial: 15 mg/day for one week; then
increase to 15 mg twice daily for 1 week; then increase to 25 mg twice daily for 7 days; continue to
gradually titrate to effect up to target dose of 2-3 mg/kg/day divided twice daily; maximum daily
dose: 200 mg/day for migraine prophylaxis
79
FEBRILE SEIZURE
>6mo of age with febrile illness not associated with previous seizures and not meeting criteria for
other acute symptomatic seizure. 50% of children who present with febrile seizures will not have
any identified risk factors (history of fever is first-degree relative, neurodevelopmental delays, HHV6, MMRV or DTaP or influenza vaccines)
TYPES OF FEBRILE SEIZURES
Simple febrile
seizure (75%)
<15min, generalized, 1 episode within 24hr period
Complex febrile
seizure (25%)
>15min, focal component, and/or >1 episode within 24hr period
Diagnostics:
•First simple febrile seizure: no work up unless otherwise clinically indicated.
•Complex febrile seizure: CBC w/ diff, P2, may consider EEG, LP if suspect meningitis/intracranial
infection, neuroimaging if focal
•Routine EEG and neuroimaging are not indicated for first simple febrile seizures. Neuroimaging is
recommended for neurologic deficits, prolonged post-ictal state, and increased ICP.
Management:
•Benzodiazepines/rectal diazepam for prolonged seizure >5min.
•Parent Education: Febrile seizures are the most common seizure disorder in children, affecting
2-5%, between 6-60mo. Recurrence usually occurs within the initial 1-2yrs after initial seizure.
Recurrence risk ~30% if >12mo and ~50% if <12mo at time of initial febrile seizure. Epilepsy
risk ~1% if >12mo and ~2.4% if <12mo after initial febrile seizure. Antipyretics have not shown to
decreased risk of recurrence of simple febrile seizures.
80
FIRST AFEBRILE SEIZURE
DIFFERENTIAL DIAGNOSIS OF FIRST AFEBRILE SEIZURE
Seizure
•Partial
paroxysmal change in motor or behavior caused
by abnormal electrical discharges in the brain
one cerebral hemisphere involved
motor signs, sensory, autonomic or psychic experience
•Simple partial - awareness preserved
•Complex partial - awareness impaired, often staring
•Generalized
both cerebral hemispheres involved
•Tonic-clonic, tonic, clonic, atonic, myoclonic, or absence
Epilepsy
2 or more unprovoked seizures >24hrs apart, usually stereotyped
Status epilepticus
single prolonged >30min or series of seizures >30min without full recovery
between events, see PICU section
Neonatal seizure
seizure in first 30DOL, most common cause in first 24HOL is HIE
Infantile spasm
90% present <1yo, hypsarrhythmia on EEG, developmental regression
Seizure-like
breath-holding, syncope, GERD/Sandifer syndrome, pseudoseizure, panic
attacks, TIA, vestibular disorder, paroxysmal choreoathetosis, atypical
migraine, tic, benign myoclonus of infancy, cardiac dysrhythmia with
collapse, syncope, behavioral event (eg. staring), conversion disorder, acute
dystonic reaction, medication withdrawal, night terrors, hypoxia, ischemia,
hyperammonemia, toxin, electrolyte disturbance
Diagnostics:
•consider: POC glucose, P2, VBG, CBC, UA, ammonia, lactate, tox screen, LP. Routine labs in
>6mo who returns to baseline and whose history is non-suggestive is generally not necessary.
•EEG on all first afebrile seizure (most sensitive within 24hrs of seizure). Urgent neuroimaging if
prolonged focal postictal deficit or not back to baseline within few hours.
•Strongly consider non-urgent imaging if cognitive or motor impairment of unknown etiology,
abnormal neuro exam, focal seizure, abnormal/non-benign EEG, or <1yo.
Management:
•AEDs not generally indicated after a first non-febrile seizure. AEDs are recommended after 2 or
more recurrent afebrile seizures.
•Parent Education: Majority of children with first unprovoked afebrile seizure have no or few
recurrences. Recurrence risk ~24% in 1yr, and ~45% over 14yrs.
81
SEIZURE
Min
Intervention
• Stabilize the patient
• Assess airway, breathing, circulation
0-5
• Check vitals. Administer oxygen. Pulse ox. IV or IO access. CR monitors. Check
Accucheck and electrolytes. (If hypoglycemic: check critical labs prior to
correction—glucose, insulin, cortisol, growth hormone, IGFPB1, C-peptide, lactate,
pyruvate, beta hydroxybutyrate)
• Correct Hypoglycemia: dextrose 25% 2–4 mL/kg. In adolescents, give thiamine
(100 mg) first.
• Labs: lytes, Ca, Mg, Phos, BUN, Cr, glucose, LFTs, CBC, ammonia, toxicology
(serum + urine), anticonvulsant levels, BCx, UCx, ABG if
arterial access.
Begin pharmacotherapy
•Lorazepam (Ativan) 0.1mg/kg IV or IM (max 4 mg). Rate of 2mg/min. Repeated Q
2-5 minutes x3. Watch for ↓BP, respiratory depression, ↓HR.
5-15
OR
• PR Diazepam (Valium)
- Dosing by age: 2-5yo: 0.5mg/kg, 6-11 yo 0.3mg/kg,
≥ 11 yo 0.2mg/kg. Max 20 mg.
OR
• Midazolam IM, IN or buccal if no IV access
AND
If infectious cause suspected: Ceftriaxone 100mg/kg once / Acyclovir
20mg/kg Q8 if <12 yo, 10mg/kg if >12yo
15
Fosphenytoin 20 mg/kg IV at 3mg/kg/min (max dose 1250mg, max rate 150 mg/
min). Watch for arrhythmias & hypotension. IM okay if no IV access. (ALWAYS
CHECK FOR PHENYTOIN ALLERGY)
CALL PICU after fosphenytoin administration if seizure continues.
20
Phenobarbitol 20mg/kg IV slow push (1mg/kg/min), max 300mg.
Watch for hypotension & respiratory depression. May take 10 minutes
for effect.
Fosphenytoin 20 mg/kg IV at 3mg/kg/min over 8 minutes.
ICU Management may include: continuous EEG
Midazolam 0.3mg/kg bolus with drip 10 μg/kg/min. Watch for hypotension &
apnea. Possible coma induction using penbarbital, propofol, or thiopental.
PICU
AFTER INITIAL IMAGING COMPLETED
•Continuous EEG if patient has prolonged altered mental status or was paralyzed
during resuscitation ef- forts to monitor for nonconvulsive status epilepticus.
•Head CT: Indications: new onset unexplained status epilepticus, or if no prior
imaging for patient with h/o status epilepticus, focal deficits, or suspected ↑ICP.
•LP: Concern for infection or SAH. Head CT first if concerned about ↑ICP.
82
WEAKNESS
DIFFERENTIAL DIAGNOSIS OF ACUTE WEAKNESS
CNS
Unilateral or bilateral stroke
CNS-spinal cord
Cord infarction, cord compression, trauma, contusion, ingestion, transverse
myelitis, spinal epidural abscess, syringomyelia
Peripheral nerve
spinal root
Guillain Barré
Peripheral nerve
ICU neuropathy, HIV or zidovudine therapy, hereditary tyrinosemia,
acute intermittent porphyria, medication-related (phenytoin, vincristine,
nitrofurantoin, INH), toxins (heavy metals, glue), metabolic (uremia),
autoimmune, chronic JRA, demyelinating diseases (CIS, ADEM, NMO, MS)
NMJ
Myasthenia gravis, botulism, tic paralysis, pharmacologic blockade,
aminoglycoside toxicity
Muscle
Myositis (infectious, dermatomyositis, polymyositis), metabolic
(hypocalcemia, hypokalemia, hypothyroid), medication- related, ICU
myopathy, familial periodic paralysis (hypo/hyperkalemia), Duchenne/
Becker Muscular Dystrophy
Diagnostics:
•Consider: CK, LP, lyme titers, amino-levulinic acid, muscle bx
•CT head, MRI brain if suspect stroke, MRI brain and spinal cord, EMG and nerve conduction
studies if after 1wk of symptoms
Central
Anterior
horn
Peripheral
nerve
NMJ
Muscle
Distribution
Distal
Proximal
Distal
Proximal, symmetric, wax/wane
Proximal,
symmetric
DTR
↑
↓,
Absent
Absent
WNL in MG, ↓ in
LE botulism
↓
Fasciculation
Absent
Yes
Variable
No
No
Atrophy
Not
acutely
Yes
Severe
No
Variable,
Pseudohypertrophy
Sensation
Often
impaired
WNL
Impaired
WNL
WNL
Nerve
conduction
WNL
↓30-50%
Decreased
velocity
Abnl repetitive
stimulation
WNL
CK
WNL
WNL /
mild ↑
WNL
↑
83
PAIN MANAGEMENT
NON-OPIOID ANALGESICS
Drug
Route
Dose
Comments
Acetaminophen
PO/IV
15 mg/kg q6h
Weak analgesic, excellent
antipyretic, no antiinflammatory properties
Ibuprofen
PO
10 mg/kg q6-8h
For age > 6 mo.
Contraindicated in IBD pts
and thrombocytopenia
Ketorolac
IV/IM/PO
0.5 mg/kg q6 to max
20 doses (72 hours)
1 mg/kg comparable to 0.1
mg/kg
morphine. Only IV NSAID.
Contraindicated in pts with
thrombocytopenia
or risk of bleeding.
Naproxen
PO
5-7mg/kg/dose q12h
Long acting NSAID
COMMON OPIATES
Drug
Starting Dose (IV)
Fentanyl
Infants: 3 mcg/kg/dose
q2-4 prn
Child: 1-2 mcg/kg/dose;
may
repeat 30-60 min
intervals
Hydromorphone
(Dilaudid)
0.015mg/kg/dose q3-6h
Hydrocodone w/
Tylenol (Lortab)
0.1-0.2mg/kg q4 PO
Meperidine (Demerol)
1 – 1.5 mg/kg/dose q3-4
prn (max 100 mg/ dose)
Morphine
0.05-0.1 mg/kg/dose Q21 mg IV = 3mg PO
4prn (max 15 mg/dose)
Oxycodone (oxycotin)
PO: 0.05–0.15 mg/kg/
dose q4-6 (max 5mg/
dose)
Methadone
0.1 mg/kg/dose q6-8 prn
(max 10 mg/dose)
84
Equianalgesic
Comments
Chest wall rigidity
with doses >5 mcg/kg. Tx
naloxone or
Neuromuscular
blockade.
1 mg IV = 5 mg PO
Decreased sedation,
nausea, pruritus than
morphine.
1 mg IV = 1.5 mg PO
More euphoria than
morphine. Not recommended for PCA.
Less nausea than
codeine
1 mg IV = 1 mg PO
RELATIVE POTENCY ( IV)
STARTING A PCA
Children ≥5 years and Adolescents, weighing
<50 kg:
•Meperidine 0.1
•Methadone 1
Usual concentration: 1 mg/mL
Demand dose: Usual initial: 0.02 mg/kg/dose;
usual range: 0.01-0.03 mg/kg/dose
Lockout: Usual initial: 5 doses/hour
Lockout interval: Range: 6-8 minutes
Usual basal rate: 0-0.03 mg/kg/hour
•Morphine 1
•Dilaudid 7
•Fentanyl 100
NAMES
•Percocet = oxycodone + acetaminophen
•Vicodin = hydrocodone + acetaminophen
•Lortab = hydrocodone + acetaminophen
•Norco = hydrocodone + acetaminophen
Children and Adolescents, weighing ≥50 kg:
Usual concentration: 1 mg/mL
Demand dose: Usual initial: 1 mg; usual range:
0.5-2.5 mg
Lockout interval: Usual initial: 6 minutes; usual
range: 5-10 minutes
Usual basal rate: 0-0.03 mg/kg/hour
HEAD ABNORMALITIES
Craniosynostosis
Abnormal head shape secondary to premature fusion of sutures. X-ray shows increased density
on closed suture. Head CT is indicated if ≥ 2 sutures involved or ↑ICP is suspected. NSG manages
these patients. In the non- syndromic subtype abnormal head shape is the only feature.
Definitions
•Acrocephaly: high, tower-like head with vertical forehead, premature coronal + sagittal +
lambdoid closure
•Brachycephaly: wide head, premature coronal suture closure
•Trigonocephaly: narrow triangle shaped forehead, premature fusion of metopic suture
•Plagiocephaly: flattened on one side, premature fusion of one coronal or one lambdoid suture
•Scaphocephaly/Dolichocephaly: long and narrow, premature sagittal suture closure
Normocephaly
Dolichocephaly
Triganocephaly
Plagiocephaly
Plagiocephaly
Brachycephaly
85
DEVELOPMENTAL MILESTONES
Age
Gross Motor
Fine Motor
Language
Social
1 mo
Raises head
when prone
Tight grasp,
tracks to midline
Alerts to sounds
Regards face
2 mo
Holds head up,
lifts chest when
prone
Tracks past
midline
Social smile
Recognizes
parent
3 mo
On forearms
when prone
Hands open at
rest
Laughs,
orients to voice
Reaches
for people,
objects
6 mo
Sits unsupported,
Raking grasp,
held horizontal w/
transfers objects
head above plane
Babbles
Recognizes
strangers
9 mo
Pulls to stand,
cruises
Immature pincer,
throws
Dada/mama
indiscriminant
Understands no,
plays pat-a-cake
12 mo
Walks
Mature pincer
grip
1-2 words, follows Imitates, comes
commands w/
when name is
gesture
called
15 mo
Creeps up stairs,
walks backwards
Scribbles, stacks
2 blocks
4-6 words, one
step commands
18 mo
Runs, throws
Scribbles, 3
7-10 words,
blocks, turn book
knows 5 body
pages. Hand prefparts
erence develops.
24 mo
Walks up/down
stairs
Takes off clothes
50 words, 2 word
phases, 2 step
commands
Parallel play
3 yr
Tricycle,
alternates steps
on stairs
Copies circle
250 words, 3
Word phrases,
uses pronouns/
plural
Knows name,
age, sex. Group
play
4 yr
Hop, skips
Copies square,
catches ball
Asks questions,
knows colors /
songs
Imaginative play,
tells stories
5 yr
Jumps over
things
Copies triangle,
ties shoes
Prints first name,
asks what words
mean
Plays games
86
Uses spoon &
cup
Copies tasks
NEURO-IMAGING
Type
DWI
Uses
Bright
Find dead (aka
ischemic) tissue
Dead tissue (aka
where there is no
H20) note airbrain and bonebrain interfaces
will be bright
ADC
Acute ischemia
SWI
Look for bleed
T1
Anatomy – like
the “real” brain
would be
Edema, gliosis,
CSF
Dark
Comments
CSF
To check if
artifact, look at
ADC – if bright
on MRI and dark
on ADC = REAL.
If bright both =
artifact
Acute ischemia
Use to distinguish
acute ischemia
on DWI from T2
shine through
artifact
Bleed! Will be
circular
White matter
> gray matter,
cancer, subacute
bleed
CSF, bone, acute
bleed
Look for open
space below
midbrain to r/o
herniation. T1 w/
gad good to eval
highly perfused
lesions – gad is
bright
T2
Infarcts,
inflammation,
tumors
CSF, fluid, bone,
Gray matter >
edema – opposite
white matter
T1
Good if white
matter lesions
present. Can also
look at CNs 7-8
as will be bright
at CPA
FLAIR
Edema, gliosis,
small white
matter lesions
Edema, gliosis,
old strokes,
subacute bleed
Hyperacute
bleed, CSF
Same as T2 but
with dark CSF
MR spect
Tumors,
metabolic
disorder
NA
NA
R → L: lipid,
lactate, NAA,
creatinine,
choline,
myoinositol
CT
Acute
hemorrhagic
stroke, skull fx,
hydrocephalus,
trauma
New blood, mets,
Tumor, old blood, posterior fossa
meningioma,
edema, air
poorly visualized
cancer, bone
87
CRANIAL NERVES
Function/ Region CN
Test/Observation
Olfactory
I
Smell (e.g., coffee, vanilla, peppermint)
Vision
II
Acuity, fields, fundus
Pupils
II, III
Pupil size, reaction to light and accommodation
Range and quality of eye movements, saccades, pursuits,
nystagmus, ptosis.
Eye movements
and eyelids
III, IV, VI
Frontal eye field cortical lesion causes deviation toward
lesion with intact doll’s eye. Cortical sz causes deviation
away from foci. Brainstem lesion causes ipsilateral deviation away from lesion side with impaired doll’s eye.
Sensation
V
Corneal reflexes, facial sensation
Muscles of
mastication
V
Clench teeth
Facial strength
VII
Observe degree of expression of emotions, eye closure
strength, smile, puff out cheeks, asymmetry forehead and
lower face
Hearing
VIII
Localize sound, audiologic testing: finger rub, Rhinne,
Weber
Mouth, pharynx
VII, IX, X, XII
Swallowing, speech quality (labial, lingual, or palatal
articulation deficits), symmetrical palatal elevation,
tongue protrusion
Head control
XI
Lateral head movement, shoulder shrug
Tongue
XII
Tongue protrusion, push out cheeks with tongue.
Deviation to side of lesion.
Test
CN tested
Cover eyes: baby opens eyes,
direct gaze to you
II, III, IV, VI
Facial symmetry
VII
Check rooting reflex on both sides
V (sensory), XI
Suck on finger, extend finger back to gag
V (motor), IX, X, XII
88
REFLEXES
Primitive reflexes
Appears by
Gone by
Gag
32 wk GA
Persists in 90%
Suck
34 wk GA
4 mo
Palmar grasp
34 wk GA
6 mo
Plantar grasp
34 wk GA
10 mo
Tonic neck - fencer’s
2-3 wks
7 mo
Moro
34 wk
3 mo (rarely 4-5 mo)
Stepping
35 wk
2 mo
Crossed adductor
35 wk
7 mo
Babinski- extensor
birth
9-12 mo
Grasp
32 wk
2 mo
Reflex
Site
Biceps
C5, C6
Brachioradialis
C5, C6
Triceps
C7, C8
Knee
L2-L4
Achilles
S1–S2
Grade 5
Normal power
Grade 4
Active movement against gravity with resistance
Grade 3
Active movement against gravity without resistance
Grade 2
Active movement with gravity eliminated
Grade 1
Only a trace or flicker of movement
Grade 0
No movement
89
UPPER AND LOWER MOTOR NEURON
General: brisk reflexes and weakness often suggests CNS problem, absent reflexes may suggest
lesion distal to CNS (nerve, NMJ, muscle). Asymmetries are always abnormal.
On Exam
UMN
LMN
Power
Decreased
Decreased
Reflexes
Increased
Decreased
Tone
Increased
Normal or decreased
Babinski
Toes up-going
Toes down-going
Exception: Acute upper motor neuron and spinal cord injury
produces decreased tone and absent/depressed reflexes.
DERMATOMES
90
NOTES
91
SECTION 10
PICU
PALS algorithms....................................................................................................93
Common medications and drips........................................................................ 96
Code meds........................................................................................................ 96
Vasoactive meds................................................................................................97
Sedation............................................................................................................ 98
Intubation.............................................................................................................. 99
Ventilator basics................................................................................................. 100
Status asthmaticus.............................................................................................. 101
DKA......................................................................................................................102
Status epilepticus................................................................................................ 103
92
P IC U
PIC U
93
94
P IC U
PIC U
95
CODE MEDS
Adenosine
SVT
0.1mg/kg (max 6mg) IV/IO rapid push
Second dose 0.2mg/kg (max 12mg) IV/IO
Amiodarone
Pulseless arrest
5mg/kg (max 300mg) IV/IO bolus
May repeat x2 up to 15mg/kg (max 2.2g/day)
Atropine
Severe bradycardia
0.02mg/kg (min 0.1mg, max 1mg) IV/IO
May repeat dose x1
Calcium chloride
10%
20mg/kg (max 2g) IV/IO slowly, CVL strongly preferred
Dextrose (D10W)
5-10 mL/kg
Epinephrine
Pulseless arrest/severe bradycardia
IV/IO: 0.01mg/kg (0.1mL/kg of 1:10,000) Q3-5 min (max 1mg)
ET: 0.1mg/kg (0.1mL/kg of 1:1,000) Q3-5 min (max 10mg)
Lidocaine
VF/pulseless VT/wide-complex tachycardia with pulse
1mg/kg (max 100mg) IV/IO bolus, 2-3mg/kg ET
Magnesium sulfate
Torsades de pointes
25-50mg/kg (max 2g) IV/IO
Procainamide
SVT, atrial flutter, VT with pulse
15mg/kg (max 500mg) IV/IO over 30 min
ProstaglandinE1
Ductal dependent congenital heart lesion
0.05-0.1mcg/kg/min IV/IO
Sodium
bicarbonate
1mEq/kg IV/IO, give slowly
96
P IC U
VASOACTIVE MEDS
Med
Infusion Rate
Inotropy
Chronotropy
Pressor Effects
Dopamine
1-10mcg/kg/min
10-20mcg/kg/min
↑↑↑↑
↑↑↑↑
↑↑
↑↑
↑↑
Epinephrine
0.1-0.5mcg/kg/
min
0.5-1mcg/kg/min
↑↑↑↑
↑↑↑↑
↑↑
↑↑
↑↑
Norepinephrine
0.05-2mcg/kg/
min
↑↑
↑
↑↑↑↑
Phenylephrine
0.1-0.5mcg/kg/
min
↑↑↑
Vasopressin
0.2-10mUnits/kg/
min
↑↑↑
Dobutamine
2-20mcg/kg/min
↑↑↑↑
Milrinone
0.25-0.75mcg/kg/
min
↑↑↑↑
Isoproterenol
0.05-2mcg/kg/
min
↑↑
Nitroprusside
0.3-10mcg/kg/min ↓*
PIC U
↑
↓↓*
↓↓*
↑↑↑↑
↓↓↓*
↓↓↓↓*
97
SEDATION
Adjuncts
Atropine
Bolus: 0.02mg/kg (min 0.1mg,
Prevents bradycardia
max 1mg)
Miscellaneous
Dexmedetomidine
Bolus: 1mcg/kg
Drip: 0.5-1mcg/kg/hr
Causes bradycardia
Etomidate
Bolus: 0.2-0.6mg/kg (max
20mg)
Drip: 5-20mcg/kg/min
Lowers ICP, few CV effects. Can cause adrenal
suppression (caution use with sepsis)
Ketamine
Bolus: 1-2mg/kg
Raises BP, ICP, and HR. Mild bronchodilator.
Thiopental
Bolus: 2-5mg/kg
Lowers BP, ICP, and CPP. Anticonvulsant.
Propofol
Bolus: 1mg/kg
Lowers BP
Benzodiazepines (Sedatives)
Midazolam
Bolus: 0.05-0.1mg/kg
Drip: 20-200mcg/kg/hr
Lowers BP and HR
Lorazepam
Lowers BP and HR
Opiates (Analgesics)
Fentanyl
Bolus: 1-5mcg/kg
Drip: 1-5mcg/kg/hr
Lowers BP. Can cause chest wall
rigidity if pushed rapidly.
Morphine
Lowers BP
Cisatracurium
Bolus: 0.15mg/kg
Drip: 1-4mcg/kg/min
Good choice for patients w/ hepatic
or renal dysfunction
Rocuronium
Bolus: 0.6-1mg/kg
Lasts 15-20min
Paralytics
Succinylcholine Bolus: 2mg/kg
Vecuronium
Bolus: 0.1mg/kg
Can cause muscle fasciculation
(depolarizing agent).
Contraindicated in many patients. May cause
hyperkalemic cardiac arrest. Do not use without
discussing with PICU Attending.
Defasciculation dose prior to succinylcholine:
0.01mg/kg
Reversal
Naloxone
Partial reversal: 5mcg/kg
Full reversal: 0.1mg/kg
Flumazenil
0.01mg/kg (max 0.2mg)
Neostigmine
0.07mg/kg (max 5mg)
Glycopyrrolate
0.2mg for each 1mg of
Neostigmine
98
***Pre-medicate first with glycopyrrolate
P IC U
INTUBATION
Age
Preterm
Newborn Infant
1yr
3yr
6yr
10yr
Adolescent
Adult
Weight
1.5kg
3kg
5kg
10kg
15kg
20kg
30kg
50kg
10kg
ETT
size
(uncuffed)
2.5-3.0
3.0-3.5
3.5-4.0
4.04.5
4.55.0
5.0-5.5
6.06.5
6.5-7.0
7.0
Blade
size
0
1
1
1-2
2
2
2-3
3>3
>3
1
1-1.5
1.5-2
2
2.5
3
3
4
Newborn
NewbornInfant
Infant
Child
Child
Adult
Adult
Adult
LMA
size
Mask
Newborn
INTUBATION ESTIMATES
Blade size:
•Preemie/newborn = Size 0
•Older newborn – 6 months = Size 1
•>6 months – 2 years = Size 1-2
•>2 years – 8 years = Size 2
ETT size:
•Uncuffed ETT size = (age/4) + 4 [max 7.0]
•*Chose ½ size smaller for cuffed ETTs
•*<1kg: 2.5, 1-2kg: 3.0, 2-3kg: 3.5, >3kg: 4.0
ETT depth:
• = age in years + 10 –OR- 3x ETT size
• *Max depth = 23cm for males or 20cm for females
PIC U
99
VENTILATOR BASICS
Non-Invasive Ventilation (via Mask or Nasal Cannula)
•BiPAP (Bi-level Positive Airway Pressure) – set rate and/or augment spontaneous breaths;
provides inspiratory pressure support and PEEP
•CPAP (Continuous Positive Airway Pressure) – provides PEEP
Liter Flow
% O2 Delivered
Nasal Cannula
1-4 L/min
21-50%
Simple Mask
5-10 L/min
21-50%
Partial-rebreather
6-10 L/min
Up to 80%
Non-rebreather
>10 L/min
Up to 80-100%
Vapotherm
8-40 L/min
Up to 100%
INVASIVE VENTILATION
Control of rate:
•AC (Assist Control) – minimum rate synchronized to patient triggered breaths; patient triggered
breaths above minimum rate delivers a breath identical to set breaths (see control of volume/
pressure below)
•SIMV (Synchronous Intermittent Mandatory Ventilation) – minimum rate synchronized to patient
triggered breaths; patient triggered breaths above min rate are supported with Pressure Support
•CPAP/PS (Continuous Positive Pressure with Pressure Support Ventilation) – no set rate, all
breaths patient triggered and pressure supported
Control of Volume/Pressure:
•Volume Control (may be AC or SIMV): Breaths supported to provide a pre-determined volume per
breath.
•Pressure Control (may be AC or SIMV): Breaths supported at a pre-determined pressure above
PEEP.
•PRVC (Pressure-Regulated Volume Control; may be AC or SIMV): Provider pre-determined a
volume per breath. Computer adjusts the pressure control to obtain volumes at the target volume.
Basic ventilator settings
Basic ventilator changes
Infant
Child
Goal
Rate
Rate
30-40
15-25
↑ CO2
↓
Tidal Volume
5-7cc/kg
5-7cc/kg
↓ CO2
↑
PEEP
4-5
3-5
↑ O2
I-time
0.4-0.6s
0.8-1s
↓ O2
10 0
PEEP
FiO2
↑
↑
↓
P IC U
STATUS ASTHMATICUS
Step 1: Immediately upon arrival in ED
or PICU
•Oxygen
•Steroids: SoluMedrol 2 mg/kg IV (max dose
150 mg) then 1 mg/kg IV q6hr
•Ranitidine 1 mg/kg IV q12hr
•Albuterol: Continuous Albuterol 1 mg/kg/hr
neb; max dose 40 mg/hr
•Do not wean Albuterol unless severe
tachycardia defined as:
•Sustained HR > 220 for children
under 2 years of age
aged 2 – 10 years
aged 10 – 20 years
•If patient develops sustained tachycardia,
wean Albuterol by 20% q1hr until HR <
maximum rates listed above. No role for
Levalbuterol.
•Atrovent 1 unit dose (500 mcg) neb q6hr only
for children > 6 years of age
•IV fluids: NPO. NS 20 ml/kg IV x 1-3 if signs
of depressed cardiac output then D5 ½NS +
20 mEq/kg KCl at 1-1.5x maintenance.
•Labs: Consider chest X-ray to rule-out
pneumonia or pneumothorax. Blood gas,
chemistry studies, CBC, and other labs are
generally not indicated. May consider EKG
prior to starting Terbutaline.
Step 2: If insufficient response to
step 1 (consider one of more of the
following)
•Terbutaline IV drip
•Start at 1 mcg/kg/min
•MgSO4 40 mg/kg (max 2 g) IV push over 20
minutes
•HeliOx
•Start with 80:20 (80% Helium: 20%
Oxygen)
•Use regulator to increase FiO2 as needed
to maintain SaO2 > 88%
•Use the least amount of O2 required to
maximize Helium concentration
•Ensure mask is tight fitting with high gas
flow rate to ensure pt is not entraining
Nitrogen from the room air
•Ensure that the continuous Albuterol
is running off of HeliOx to maximize
FiHelium.
Step 3: BiPAP via face mask: PEEP
10, PS 15, no rate; adjust setting as
needed
Step 4: Ketamine 1-2 mg/kg IV push
followed by 1-2.5 mg/kg/hr drip
Step 5: Endotracheal intubation with
mechanical ventilation
•Use rate similar to patient’s spontaneous
breathing rate, and attempt to mimic the
patient’s spontaneous inspiratory and
expiratory times. Rapidly transition patient to
Pressure Support mode (i.e., no set rate, no
set inspiratory time) as soon as paralysis is
resolved.
Step 6: Inhaled anesthetics
Step 7: Extra-Corporeal Membrane
Oxygenation (ECMO)
•Double dose q30min to desired effect or
severe tachycardia
•Maximum dose 10 mcg/kg/min
•Check Troponin I levels q6hr
PIC U
1 01
DKA
DKA = Hyperglycemia, presence of ketones (serum or urine), acidosis pH < 7.30 or HCO3 < 15 mM
Orders under “PICU Diabetic Ketoacidosis” order set
1. Initial laboratory studies:
•EG7, CBC w/diff, Chem 10, Urinalysis, HgbA1c, Anti-insulin antibody, Anti-GAD
antibody, Islet cell 512 antibody, Beta hydroxybutyrate, Serum insulin, C-peptide,
Thyroid panel, Anti-thyroid antibodies, Anti-tissue transglutaminase (tTG), total IgA,
Vitamin D 25-hydroxy
2. NPO status
3. Initial fluid resuscitation:
•0.9% normal saline 10-20 cc/kg over 1 hour or faster if in shock
4. Insulin drip: Do not give a bolus.
•Begin with a continuous insulin infusion of 0.1 unit/kg/hr. Do not adjust insulin rate
without discussing with PICU Attending.
5. Fluid therapy:
•Order both standard PICU DKA fluids:
•Bag #1: NS + 20mEq/L of KPhos + 20mEq/L of KAcetate.
•Bag #2: D12.5-NS + 20mEq/L of KPhos + 20mEq/L of KAcetate.
•Total IVF Rate: 1.5 x maintenance
•If glucose is >300, run Bag #1 at 1.5 x maintenance
•Once glucose falls below 300, adjust rate of Bag #1 and Bag #2 to keep glucose 150 –
250. Maintain total rate (Bag #1 + Bag #2) at 1.5 x maintenance
6. Laboratory studies: Order labs per DKA order set
•Glucose every hour
•Chem 10 q 2 hrs for first 6 hours. If stable after 6 hours then q4 hours.
•*Must correct Na for Glc
•EG7 with lytes until HCO3 > 10mM
•Calculate effective osmolality
•OSMeff = 2(sodium + potassium) + glucose/18 (normal range = 280-295 mosm)
•Phosphate and ionized calcium at 6 and 12 hour lab draw.
7. Monitor for complications:
•Cerebral edema, hypophosphatemia, hyponatremia, hypoglycemia, hypokalemia,
hypocalcemia
8. Switch to subcutaneous insulin when pH> 7.30 or HCO3 > 15 and patient is able to tolerate PO.
•Immediately after giving the first subcutaneous insulin injection, discontinue IV fluids
and continuous insulin infusion and allow the patient to eat their meal.
10 2
P IC U
STATUS EPILEPTICUS
Min
Intervention
•Stabilize the patient
•Assess ABCs
•Check vitals: give O2, pulse ox, IV or IO access, monitor
0-5
•Check Accucheck and electrolytes
•Correct hypoglycemia if present: D10W 5-10cc/kg
•Other labs: Gas, chem 10, LFTs, CBC w/diff, ammonia, toxicology (serum + urine), AED
levels, BCx, UCx
•Begin pharmacotherapy:
•Lorazepam (Ativan) 0.1mg/kg (max 4mg) IV/IO/IM
Repeat Q 2-5 min x3
5-15
•Rectal Diazepam (Valium) – for patient in ED when no IV access available
2-5yo: 0.5mg/kg
6-11yo: 0.3mg/kg
>11yo: 0.2mg/kg (max 20mg)
•If infectious cause suspected: Ceftriaxone 100mg/kg +/- Acyclovir 10mg/kg
•If not responsive to benzodiazepines:
•Levetiracetam (Keppra) 30mg/kg IV load
Maintenance of 10-20mg/kg IV Q12 hours
15-45
•Phenobarbital 20mg/kg IV over 20min
May repeat additional 10mg/kg x 2 or more. May require doses above 60mg/kg
•Fosphenytoin 20mg/kg IV over 10min
May repeat additional 10mg/kg
•If still not responsive to pharmacotherapy:
•Pentobarbital coma
5mg/kg IV over 20min, then 0.5-1mg/kg/hr titrated for burst suppression
•Midazolam coma
150-200mcg/kg IV, then 1-10mcg/kg/min
•Consider:
>60
•Continuous EEG
•Head CT
•Lumbar puncture
•Patients in induced coma will likely require intubation and mechanical ventilation.
Intubation is not a treatment for status epilepticus and should only be performed if
necessary. Paralytics used for intubation will mask physical signs of seizures,
however the seizures will continue throughout paralysis and lead to ongoing
neurological damage.
PIC U
103
NOTES
10 4
P IC U
SECTION 11
Pulmonology
ALTE.....................................................................................................................106
NMCSD ALTE Pathway....................................................................................... 107
Asthma.................................................................................................................108
Bronchiolitis.........................................................................................................112
PULMO NO LOGY
1 05
ALTE
Relationship to gastroesophageal reflux (GER)
•GER is normal event in infants.
•Possible to have evidence of GER and another disorder.
•Reflux induced apnea may be central or related to laryngospasm from local acid effect
Relationship to SIDS
•ALTE may be risk factor for SIDS, especially if required resuscitation
•ALTE peak 1 to 3 months of age
•SIDS peak 3 to 5 months of age
•Apnea of prematurity not a risk factor for SIDS
Conditions not requiring ALTE workup
•Normal child (overreaction to simple choking, gagging, vomiting episodeeyes open and
“bulging”, increased tone) if not sure, consider admission and workup
•Periodic breathing: respiratory pauses 320 seconds. Normal in preterm, may persist in term
infants.
Clues to diagnosis
•Nasal congestion/cough consider bronchiolitis
•Stridor/hoarsenss consider airway evaluation
•Recurrent ALTEconsider NAT
•History involving foreign bodyconsider FB aspiration
•Snoring/stridor at baseline consider obstructive sleep apnea/ airway eval
•Pallor consider anemia/intracranial hemorrhage
•Blood in infant’s mouth or nose consider NAT
•Visible hemangioma, especially on face/neckconsider airway eval
•History of altered consciousness during or following eventconsider seizure
•Low tone, constipationconsider infant botulism
10 6
P U LMON O LO G Y
NMCSD ALTE PATHWAY
PULMO NO LOGY
107
ASTHMA
SEVERITY OF ASTHMA EXACERBATION
Mild
Moderate
Severe
Respiratory
Arrest Imminent
Activity Level:
Walks briskly
Walks slowly
Walks with
assistance
Unable to walk
Feeding (infant):
Normal
Difficulty feeding
Unable to feed
Unable to suck
Talks in:
Sentences
Phrases
Words
Too dyspneic to
speak; perspiring
Sounds (infant):
Normal cry,
cooing
Short, clipped cry
Faint cry, grunting
Alertness:
May be agitated
Usually agitated
Usually agitated
Respiratory rate:
Increased
Increased
Often > 30/min
SIGNS / SYMPTOMS
Drowsy or
confused
Retractions &
accessory
muscle use:
Usually not
Usually
Usually
Paradoxical
thoraco-abdominal
movement (see-saw
breathing)
Wheeze:
Moderate, often
only end expiratory
Loud expiratory
Usually loud, may
be biphasic
Absence of wheeze
SaO2% (on RA)
> 95%
91-95%
< 90%
PEF after initial
bronchodilator
treatment
Over 80%
Approx. 60-80%
< 60% predicted
PaO2 (on RA)
Normal
Test not usually
necessary
> 60 mm Hg
< 60 mm Hg
Possible cyanosis
Cyanosis
PaCO2
< 45 mm Hg
< 45 mm Hg
> 45 mm Hg
>50 mm Hg
Partial relief
after multiple treatments.
Requires continuous inhaled SABA
Minimal or no
relief from
inhaled SABA.
Requires systemic
bronchodilator
(subcutaneous epinephrine,
terbutaline)
Emergency department; possible
hospitalization
Hospitalization
following stabilization in emergency
department
TESTS
INTERVENTION
Response to
inhaled Short-Acting
Bronchodilator
(SABA)
Prompt relief
Complete relief
after multiple
treatments
Location of care
Home
Management
Office or emergency department
10 8
P U LMON O LO G Y
DIFFERENTIAL DIAGNOSES
Diagnosis
Symptoms
Test
• Trial of antihistamines
Allergic Rhinitis
• Seasonal or chronic
rhinorrhea/nasal
obstruction
• Daytime and/or
morning cough
• Nasal steroids
• Heartburn
• Irritable after feeding
Gastro-esophageal Reflux
[children]
(GERD)
• Commonly
asymptomatic
• Allergy testing
• Trial of H2-blocker or
proton pump inhibitors
• Consider GI referral for
pH probe: reflux
Radiographic
Findings (CT, CXR)
N/A
N/A
• Poor response to
asthma Rx
Vocal cord
dysfunction (VCD)
• Inspiratory wheeze/
stridor
• Episodic dyspnea
• Laryngoscopy:
inspiratory vocal cord
closure
• Normal
• Rapid onset/relief
• Emotional trigger
Allergic
bronchopulmonary
aspergillosis (ABPA)
• Brownish sputum,
wheezing, SOB, fever,
malaise
• Blood: eosinophilia
• Serum precipitins to
aspergillus
• Very elevated IgE
• Recurrent fleeting
• infiltrates,
bronchiectasis
• Stage 0 — None
Sarcoidosis – Multisystem inflammatory
disorder; granulomatous
changes primarily found
in lung
• Asymptomatic, SOB,
• wheezing, cough
• ACE level: Elevated
hypercalcemia
• Stage 1 —
Hilaradenopathy
• Non-caseating
granulomas on biopsy
• Stage II — Adenopathy
+ infiltrates
• Stage III — Infiltrates
Bronchiectasis –
Airway enlargement due
to previous infections
• Chronic productive
cough, wheezing, SOB
None
• Unresponsive to
bronchodilator
Pulmonary embolus
(PE)
• High Resolution CT:
Localized infiltrates,
airway enlargement
• CT: chest PE protocol
• Hemodynamic
compromise
• D-dimer: elevated
• Sudden chest pain
• ABG: hypoxemia
• Presence of risk factors
• Ventilation/
• Perfusion (V/Q)
mismatch
• CXR normal
• Tachycardia
CHART CONTINUES ON NEXT PAGE
PULMO NO LOGY
1 09
Cystic Fibrosis
• Recurrent productive
cough
• Sweat chloride test:
abnormal
• Unilateral wheeze
Foreign Body
• Sudden onset
• Choking history
• Bronchoscopy
• Age: 6 months-6 years
• Hyperinflation, cystic
changes
• CXR – Unilateral
hyperinflation or
atelectasis
• Failure to deflate on
expiratory or decubitus
CXR
• Premature birth:
Bronchopulmonary
dysplasia (BPD)
• Hx prolonged
mechanical ventilation/
oxygen requirement
in neonatal period.
If responsive to
bronchodilators and
steroids, treat as
asthma
N/A
• CXR: May appear
identical to asthma
patients
• Laryngoscopy
N/A
• Bronchoscopy
N/A
• Inspiratory or
expiratory monophonic
wheeze
• Bronchoscopy
• No bronchodilator
response
N/A
• Inspiratory wheeze
Laryngomalacia
• Onset prior to 6 weeks
of age
• Improves when prone
response
• Hx of intubation
Subglottic stenosis
• Biphasic wheeze,
loudest in neck
response
Tracheo/
bronchomalacia
Bronchiolitis (asthma
exacerbation caused by
viruses)
Recurrent upper
respiratory infection
110
• No response to beta-2
agonist
• Diffused wheeze and/or
bronchi
• Respiratory Syncytial
N/A
• Virus testing
• Common cold
symptoms
• Reduction of respiratory
symptoms after bulb
N/A
suction or decongestion
P U LMON O LO G Y
PULMO NO LOGY
Minor
limitation
Minor
limitation
Some
limitations
Extremely
limited
Extremely
limited
> 2 days/
week,
not daily
Not
more
than
once a
day
Daily
Several
times a
day
Several
times a
day
Step 2
Mild
Step 3
Moderate
Step 4
Severe
Step 5
Severe
Step 6
Severe
Several
times a
day [a]
Throughout the
day [a]
Daily [a]
> 2 days/
week, not
daily [a]
> 2 days/
week, not
daily [a]
< 2 days/
week
Day
FEV1
Nightly
Nightly
Nightly
< 60%
< 60%
< 60%
> 1x/week, 60not nightly 80%
> 2x/month > 80%
< 2x/month > 80%
Night
Symptoms
Age ≥ 5 to Adult: High-dose ICS +
LABA + oral corticosteroids
SABA: Short acting beta agonist
ICS: Inhaled corticosteroid
LTRA: Leukotriene receptor antagonist
LABA: Long acting beta agonist
High-dose ICS +
LABA + LTRA
Refer to specialist
Refer to specialist
Refer to specialist
Age 0-4: Medium-dose ICS +
LABA + LTRA
Age 0-4: High-dose ICS + LABA +
LTRA
(Consider 5-10 day course of
oral corticosteroids)
Medium-dose ICS +
LTRA
Age ≥ 5 to Adult: Medium-dose
ICS + LABA
Medium-dose ICS +
LABA + LTRA
Consider referral to
specialist
Consider referral to
specialist
Age 0-4: Medium-dose ICS +
LTRA
Age ≥ 5 to Adult: High-dose ICS +
LABA
Consider oral corticosteroids
Low-dose ICS +
LTRA
--
Age 0-4: Medium-dose ICS or
Low-dose ICS +LTRA
Alternative
Age ≥ 5 to Adult: Low-dose ICS +
LABA or Medium-dose ICS
--
--
Low-dose ICS
SABA PRN
Preferred
Daily Medication
[a] More than 2 exacerbations per year (requiring oral systemic steroids) should prompt step up in therapy
NONE
< 2 days/
week
Step 1
Intermittent
Activity
limits
Use of
Quick
relief
Initial Severity
LONG TERM CONTROL STEP-WISE APPROACH
111
BRONCHIOLITIS
Mild
Moderate
Severe
Wheeze
None or end
expiratory
Entire expiration
Inspiratory & Expiratory
Feeding
Normal
Less than usual.
Frequently stops
feeding.
More than ½ normal
feed volumes.
Not interested.
Gasping / coughing.
Less than ½ normal feeds.
Oxygen
No oxygen requirement
May require oxygen
Requires oxygen
Indrawing
No / mild
indrawing
Intercostal and / or
tracheosternal
Severe with nasal flaring
Behaviour
Normal
Some / intermittent
irritability
Irritability and / or lethargy
Prevention
Hand Washing
Respiratory-Isolation Contact Precautions
Assessment/Diagnosis
Clinical history and PE
Influenza is endemic – test for flu when
considering anti-viral therapy
Monitoring
Repeated clinical assessment
Cardiac & Respiratory rate monitoring – acute
stage: risk of apnea &/or bradycardia
O2/Medication
O2 when <92% (awake
Consider wean when>95%
Single trial inhalation racemic epi or albuterol
(FHx: allergy,asthma,atopy)
Continuous pulse Ox – initial assessment and to
determine stability
Stable: spot check pulse ox with vitals
Education
care of child with bronchiolitis
Prevention
http://patiented.aap.org/content.aspx?aid=6347
Admission Criteria
Individual assessment
Indications for inpatient monitoring and
assessments.
Inhalations
Scheduled or serial inhalation therapies not to
be used routinely
Do not repeat if no improvement after trial
112
P U LMON O LO G Y
Hypertonic Saline Inhalations
Studies have not been able to universally
validate this therapy
Clinical Decision to use therapy
3% hypertonic
Used with bronchodilator therapy
Hypertonic saline continue to be used for
duration of nebulization therapies.
Corticosteroids
NOT RECOMMENDED
Antibiotics
Not be used in ABSENCE of identified bacterial
focus.
Other medications
Do NOT use
IVIG
Montelukast
rhDNAase
inhaled furosemide
OTC remedies
DO NOT USE antihistamines, oral
decongestants, & nasal vasoconstrictors.
Other Therapies
Not be used routinely
aerosol with saline
chest PT (unless used with neb therapies)
Diagnostic Testing
Do NOT perform routinely
CXR
Cultures
CBG, ABG
RSV/Influenza testing will not influence
management but may be useful for COHORT,
or ascertain need for antiviral
PULMO NO LOGY
113
114
P U LMON O LO G Y
Pancrelipase (Creon, Pancreaze)
Pancreatic Enzyme Replacement
Therapy (PERT) – can cause
fibrosing colonopathy, diaper
dermatitis, oral lesions (if
chewed)
Vitamins A, D, E, K (AquaDEKs)
Fat-soluble vitamin replacement
Dornase alfa (Pulmozyme)
Mucolytic (nebulized)
Hypertonic (7%) saline
Mucolytic (nebulized) – can
cause bronchospasm
N-acetylcysteine (Mucomyst)
Azithromycin
Ibuprofen
PULMO NO LOGY
Mucolytic (nebulized)
Anti-inflammatory
Anti-inflammatory
115
NOTES
116
P U LMON O LO G Y
SECTION 12
Renal
Calculations: GFR and FeNa............................................................................... 117
Urinalysis Interpretation.......................................................................................118
Hematuria............................................................................................................120
Proteinuria............................................................................................................121
Acute Kidney Injury..............................................................................................121
Indications for Acute Dialysis............................................................................. 123
Hyperkalemia, Hypernatremia, Hyponatremia................................................. 123
Hypertension....................................................................................................... 124
Nephrotic Syndrome.......................................................................................... 127
Glomerulonephritis............................................................................................. 128
Renal Tubular Acidosis (RTA).............................................................................. 129
Hemolytic Uremic Syndrome (HUS) vs Henoch-Schonlein Purpura (HSP).... 130
Chronic Kidney Disease...................................................................................... 131
Prenatal hydronephrosis algorithm................................................................... 132
Electrolytes.......................................................................................................... 134
GFR CALCULATION
Modified Schwartz:
GFR = 0.413 x height (cm)
Plasma creatinine
If Creatinine is doubling
daily → GFR is 0
*Patients with CrCl < 50 may need dose adjustments on medications
RE NA L
117
FRACTIONAL EXCRETION CALCULATION
* Only useful in oliguria or hypo/hypernatremia, unreliable if recent Lasix administration
Fractional Excretion of Sodium (FENa) = (PCr*UNa)/PNA x UCr) %
Prerenal
Intrinsic Renal
Postrenal
FENa
<1%
>1%
>4%
UNa (mmol/L)
<20
>40
>40
Prerenal: Anything that causes decreased effective renal perfusion: Hypovolema, CHF, Renal Artery
Stenosis, Sepsis, etc. Remember, contrast-induced nephropathy will often look pre-renal.
Intrinsic Renal: ATN, AIN, Glomerulonephritides, etc.
Postrenal: Obtrusion (BPH, bladder stone, bilateral ureter obstruction)
URINALYSIS INTERPRETATION
Dipstick
•Color: pink, green, white urine likely secondary to medications (green = propofol), consider UTI
or metabolic errors.
Grossly red urine = hematuria only if microscopy reports RBC too numerous to count
(otherwise think rhabdomyolysis or hemolytic anemic)
118
RE N AL
•Glucose: positive suggests systemic glucose > 180 or proximal tubule defect
•Glucose in the urine does not always mean diabetes (steroids given?)
•Isolated glycosuria with normal serum glucose is commonly due to a different set point for
glucose reabsorption in the proximal tubule, but requires Fanconi’s eval.
•Fanconi syndrome: spill glucose, phosphate, uric acid, bicarb, and amino acids (work up: chem
10 and VBG checked simultaneously with urine phosphate and urine creatine; urine amino acids
any time)
•Bilirubin: reflects elevated serum conjugated bili levels, consider liver or gallbladder disease
•Unconjugated bilirubin is not water soluble, so not excreted in urine
•Ketones: suggests ketosis (using fat instead of glucose for fuel)
•consider serum beta-hydroxybuterate levels
•anorexia, prolonged vomiting, high protein low carb diet, burns, fever, severe illness,
hyperthyroidism, diabetes
•Specific Gravity: depends on number and size of particles, varies with osmolality
• Normal findings: 1.003-1.030
• 1.008: isotonic with plasma (280 mOsm/kg)
•< 1.003: maximally dilute
•After IV contrast given, urine spec grav will go way up for 24-48 hours
•Blood: hematuria, free hemoglobin, or free myoglobin (ie rhabdomyolysis)
•See flowsheet above, hematuria section below
•False positive: semen present in urine
•pH: 4.5-8, reflects systemic acid-base status
•In metabolic acidosis, urine pH should be < 5. If not, consider distal RTA (with proximal RTA,
you can still bring your urine pH < 5)
•pH > 7.5, consider UTI (urease producing, ex: proteus mirabilis) or hypokalemia
•Protein: negative to trace is normal. Trace proteinuria does not need aggressive work up.
•Urobilinogen: formed in intestines by bacteria acting on bilirubin
•High: hemolytic anemia, liver disease
•Low: obstructive jaundice, broad-spectrum antibiotics (loss of intestinal flora)
•Interpret with urine bilirubin (high bilirubin with low urobilinogen suggests obstructive
gallbladder disease, because bili didn’t go into intestines)
•Nitrite: suggests bacteriuria; positive when bacteria able to convert urinary nitrate to nitrite
•False negative: bacteria with minimal nitrate reductase (ex: enterococcus), or minimal dwell time
in the bladder
•Leuko Est: released by WBC and macrophages; dilute urine favors cell lysis and may cause falsepositives (compare to WBC count on microscopy)
•Sterile pyuria (culture negative): consider interstitial nephriits, renal tuberculosis, nephrolithiasis,
Kawasaki, urethritis, non-cath sample
•Clinitest: presence of reducing substance (glucose, lactose, fructose, galactose, pentose)
•If no glucose, consider galactosemia or other inborn error of metabolism
•May be secondary to beta-lactam antibiotics
•Confirm normal newborn screen
RE NA L
119
HEMATURIA
Definition
>5 RBC per high power field in 3 consecutive fresh, centrifuged specimens obtained over the span
of several weeks or gross hematuria on single urine specimen
Red Flags:
•Elevated or rising creatinine
•Hypertension
•Proteinuria
Causes:
Renal (glomerular)
Extrarenal / Urologic
Color
Tea, Cola, Smoky
Red, Pink
RBC Morphology
Dysmorphic
Normal
Casts
RBC
---
Clots
----
+/-
Proteinuria
>2+
Usually <2+
Stream
Throughout
Partial
Extrarenal / Urologic:
Renal:
Urinary tract infection, irritation of meatus/
perineum, trauma (catheterized sample?),
nephrolithiasis, coagulaopathy, renal vessel
thrombosis, nutrcracker syndrome, neoplasm
glomerulonephritis
Work-up:
*Carefully weigh risk of IV contrast for CT if concerned for poor renal perfusion or obstruction
>5 RBC per high power field
Yes
- Abd/Pelvis
Imaging (CT, US,
KUB)
- Consider
cystoscopy
12 0
No
Trauma? (Clots?)
Yes
- Urine Ca/Cr
- Consider UTI (+ nitrite,
LE, WBC?)
- Image for stones (US if
possible intrarenal vs CT
stone protocol)
- US with Doppler r/o RVT
Pain?
No
- PMHx (sickle? Coagulopathy?)
- Meds (ASA, NSAIDs, PCN, Lasix?)
- Family history? / family UAs
- Serum Cr, Urine Ca/Cr, Urine Protein /Cr
- Renal US +/- dopplers, consider CT
- Work up glomerulonephritis: ASO, ANA,
C3/C4, dsDNA, IgA, electrolytes, albumin
- Consider biopsy (rarely needed)
RE N AL
PROTEINURIA
Definition:
Protein : Creatinine
24 hour sample
m2/hr
Abnormal
> 0.2
(>0.5 if <2yo)
> 150mg
(varies by age/BSA)
>4mg
Nephrotic Range*
>2
> 3.5g
>40mg
*Nephrotic Syndrome: proteinuria, hypoalbuminemia, hyperlipidemia, +/- edema
Causes
To determine glomerular vs tubular proteinuria: microalbumin vs beta-2-microglobulin
1.Glomerular (increased filtration): nephrotic syndrome, glomerulonephritis
•non-pathological: secondary to fever, exercise, seizure, orthostasis
2.Tubular (decreased proximal tubular reabsorption): low molecular weight proteins, Fanconi
syndrome
3.Overflow: very rare in children (multiple myeloma in adults)
Work-up:
•To rule out transient/orthostatic proteinuria, compare first morning sample to QHS sample
•Assess for other findings supportive of renal disease: change in urine volume or color, edema,
hypertension, recent streptococcal infection (pharyngitis in past 2 weeks/dermatitis in past 3
weeks), recent URI/AGE in past 24 hours with new onset gross hematuria (suggests IgAN), family
history of high frequency sensorineural hearing loss or anterior lenticonus (suggests Alport
disease)
•Chem 10, cholesterol, albumin; consider C3/C4, ANA, ASO, Hep B, Hep C, HIV
•Consider renal ultrasound, referral for possible renal biopsy
•See Nephrotic Syndome for more information
ACUTE KIDNEY INJURY
Definition:
•Declining GFR, decreased UOP  retention of nitrogenous waste, volume & electrolyte
dysregulation
•No single pediatric definition, especially difficult if baseline creatinine unknown
Calculate eCCl by Schwartz equation
RE NA L
121
Pediatric RIFLE Classification of acute kidney injury
pRIFLE stage
Estimated creatinine
clearance (eCCl)
Urine output
R = Risk for renal dysfunction
eCCl decreased by 25%
<0.5 mL/kg per hour for 8 hours
I = Injury to the kidney
eCCl decreased by 50%
<0.5 mL/kg per hour for 16 hours
F = Failure of kidney function
eCCl decreased by 75% or
eCCl <35 mL/min per 1.73m2
<0.3 mL/kg per hour for 24
hours or anuria for 12 hours
L = Loss of kidney function
Persistent failure > 4 weeks
E = End-stage renal disease
Persistent failure > 3 months
Causes:
Mechanism
Etiology
Decreased Intravasacular Volume
Dehydration, hemorrhage,
diuretics, burns, shock,
hypoalbuminemia
Decreased cardiac function
Heart failure, arrhythmia
Peripheral vasodilation
Sepsis, anaphylaxis,
antihypertensive meds
Renal vasoconstriction
Sepsis, NSAIDS, ACE-inhibitor
Tubular injury (ATN)
Prolonged ischemia, nephrotoxins,
hypotension, sepsis
Renal vascular disease
Hemolytic uremic syndrome,
vasculitidies, thrombosis
Interstitial disease
Interstitial nephritis, infection,
malignant infiltration
Glomerulonephritides
Post-infectious glomerulonephritis,
rapidly progressive
glomerulonephritis, HenochSchonlein purpura
Obstruction: bilateral urinary tract
obstruction, or obstruction of
urinary tract of solitary kidney
Renal calculi, clots, urinary
retention secondary to neurogenic
bladder or medications
Pre-Renal
BUN: CR
FeNa
> 20:1
< 1%
Intrinsic Renal
BUN: CR
FeNa
< 20:1
> 1%
Post-Renal
BUN: CR
FeNa
12 2
< 20:1
> 4%
RE N AL
INDICATIONS FOR ACUTE DIALYSIS
•Needed when metabolic/fluid derangements are not controlled by aggressive medical
management, or for some toxic ingestions
•Requires transfer to Rady Children’s Hospital (pediatric dialysis not currently available at
NMCSD)
Indications
*Creatinine level alone is not an indication for dialysis
Mnemonic: A – E – I – O – U
Acidosis – Electrolytes – Intoxications – Overload – Uremia
(see list on following page for details)
•Volume overload with pulmonary edema or hypertension refractory to diuretics
•Hyperkalemia > 6 (if hypercatabolic) or > 6.5
•Metabolic acidosis (pH < 7.2, HCO3 < 10)
•BUN > 150 or rising rapidly
•Neurological symptoms secondary to uremia and/or electrolyte imbalances
•Dialyzable toxin or poison (lactate, ammonia, ethanol, barbiturate, ethylene glycol, isopropanolol,
methanol, salicylates, theophylline)
•Tumor lysis syndrome with hyperuricemia not controlled medically (rasburicase, urinary
alkalinization, induction of high UOP).
HYPERKALEMIA
•Recheck K; hemolysis unlikely to have K > 6.5
•d/c K in IVFs and check EKG, place on CRM
•If K 6 - 7 and no EKG changes- Kayexelate 1g/kg/dose PO Q6h
•If K >7 or EKG changes
•Calcium gluconate 100 mg/kg/dose over 3-5 mins (may repeat in 10 mins)
•Sodium bicarb 1-2 meq/kg IV over 5-10 mins
•Insulin ( 0.1-0.3 U/kg) + glucose (1 g/kg) over 2h
•Furosemide
RE NA L
1 23
HYPERNATREMIA
Symptoms
neurologic (lethargy, weakness, altered mental status, irritability, seizure, decreased DTRs); muscle
cramps, respiratory failure
Treat
Replace free water losses, treat cause, consider natriuretic
Free Water Deficit (mL) = 4mL/kg x weight (kg) x [serum Na concentration – 140]
HYPONATREMIA
Symptoms
nausea, headache, lethargy, seizure, coma
Secondary causes
Na decreased by predictable amount in:
•Hyperlipidemia: 0.002 x lipid (mg/dL)
•Hyperproteinemia: 0.25 x [protein (g/dL) – 8]
•Hyperglycemia: 1.6mEq/L for each 100-mg/dL rise in glucose
Treat
Replace Na losses or restrict fluids, pending etiology
ACUTE HYPERTENSION
Definition
Normal BP depends on age, sex, and height; see Harriet Lane pg 156-163 for data
•Mean Arterial Pressure (MAP): 1/3 systolic + 2/3 diastolic BP
CONTINUES ON NEXT PAGE WITH CHART
124
RE N AL
Hypertensive Urgency
Hypertensive Emergency
Definition
Significant elevation in BP without
end-organ damage
Elevation of systolic and diastolic BP with endorgan damage
Symptoms
headache, blurry vision, nausea
cerebral infarction or hemorrhage, pulmonary
edema, renal failure, encephalopathy, seizure
Etiology
increased ICP (must be ruled out before lowering BP), cardiovascular, renovascular,
renal parenchymal, endocrine, CNS dysautonomia, medications, ingestions
Physical
Exam
Simultaneous RUE and RLE BP, fundoscopy (papilledema, hemorrhage, exudate), visual
acuity, thyroid exam, congestive heart failure signs (tachycardia, gallop, hepatomegaly,
edema, JVD), abdominal mass, bruit, detailed neuro exam, virilization, cushingoid
Labs
Chem 10, TSH/FT4, renin,
aldosterone, UA, tox screen
Add if pheochromocytoma suspected:
Urine catecholamines, plasma fractionated
metanephrines
Imaging
EKG, CXR, Renal ultrasound
Abdominal ultrasound r/o mass
Echocardiogram
CT Head
Treatment
Goal
Lower MAP by 20% over 1 hour
then return to baseline over
24-48 hours
Lower BP promptly but gradually to preserve
cerebral autoregulation; lower MAP by 1/3 of goal
over first 6 hours, next 1/3 over 24-3 hours, then
final 1/3 over next 48 hours
Transfer to PICU for continous BP monitoring
Drug
Mechanism
Onset
Duration
Increase
Dose
Comments
Diazoxide
Arteriole
vasodilator
1-5min (IV)
2-12h
15-30min
May cause edema,
hyperglycemia
Hydralazine
Arteriole
vasodilator
5-20min
(IV)
2-6h
4-6h
May cause reflex
tachycardia, prolonged low
BP, nausea
Nitroprusside
(drip)
Arteriole Venous
vasodilator
< 30sec (IV)
Very
short
30-60min
ICU, follow thiocyanate
levels
Labetalol
(drip)
Alpha-, betablocker
1-5min (IV)
~6h
10min
ICU
Nicardipine
(drip)
Ca channel
blocker
1min (IV)
3h
15min
May cause edema,
headache, nausea, vomiting
Enalapril
ACE-inhibitor
15min (IV)
12-24h
8-24h
May cause hyperkalemia,
hypoglycemia,
contraindicated in renal
artery stenosis
Minoxidil
Arteriole
vasodilator
30min (PO)
2-5 days
4-8h
Contraindicated in
pheochromocytoma
RE NA L
125
CHRONIC HYPERTENSION
Definition
Normal BP depends on age, sex, and height; see Harriet Lane pg 156-163 for data
Etiologies
•Factitious: improper cuff size or measurement technique (ask for manual)
•- Appropriate cuff size: 2/3 upper arm length with bladder cuff 80-100% of arm circumference
•Non-pathologic: fever, pain, anxiety, muscle spasm
•Iatrogenic: medication side effect, excessive fluid resuscitation
Age
Most common
Less Common
Neonate/Infant
- Renal artery thrombosis after
umbilical artery catheterization
- Coarctation
- Renal artery stenosis
-
Bronchopulmonary dysplasia
Medications
PDA (patent ductus arteriosus)
grade 4 IVH (intraventricular hemorrhage)
1-10y
- Renal parenchymal disease
(VURN)
- Coarctation
-
Renal artery stenosis
Hypercalcemia
Neurofibromatosis
Neurogenic tumor, pheochromocytoma
Mineralcorticoid increase
Hyper/hypothyroid
Obstructive sleep apnea
Essential hypertension
Medications
11-21y
- Renal parenchymal disease
- Essential hypertension
All diagnoses above
Evaluation:
•See acute hypertension for physical exam, labs, and imaging recommendations
•Consider assessing co-morbidities: polysomnography, fasting lipids, fasting glucose
Treatment:
•Non-pharmacologic: aerobic exercise, salt restriction, smoking cessation, weight loss x 6 months
•Pharmacologic: for BP >95-99%ile, secondary hypertension (if operative management not
recommended), end-organ damage (echocardiogram, retinal exam), comorbid diabetes mellitus,
or failed life-style modification after 6 months
•See Harriet Lane for options
12 6
RE N AL
NEPHROTIC SYNDROME
Definition
•renal diseases that increase the permeability across the glomerular filtration barrier
•Nephrotic range proteinuria (>3.5g/day, protein:cr ratio > 2), hypoalbumenia (serum < 3),
hyperlipidemia, +/- edema
Etiologies
determine if active urine sediment (red cell casts), which would suggest glomerular inflamation and
be more consistent with nephritic syndrome.
Primary Nephrotic Syndrome (no identifiable systemic disease)
Minimal change disease (MCD)
77%
2-6yo, no HTN when normovolemic, normal
complement, normal renal function; steroid trial
before biopsy
Membranoproliferative
glomerulonephritis (MPGN)
8%
Immune complex (low C4) vs complement mediated
(low C3)
Focal segmental glomerulosclerosis
(FSGS)
7%
Membranous nephropathy
2%
(most common cause in non-DM adults)
Secondary Nephrotic Syndrome
Systemic
lupus, HSP, vasculitides, HUS
Infectious
Hep B, Hep C, HIV
Drugs
NSAID, Lithium, Pamidronate
Malignancies
lymphoma, leukemia
Inherited Genetic Disorders
Sickle cell disease
Associated with secondary FSGS
Alport syndrome
abnormal type IV-alpha 5 collagen, hearing loss , x-linked,
anterior lenticonus (pathognomonic for Alport’s in
absence of penetrating eye trauma)
Rare genetic disorders
85% of all nephrotic syndrome in infants < 3mo of age,
poor outcomes (ex: Finnish CNS or Denys-Drash)
Evaluation
•urine protein:creatinine ratio, lipid panel, chem 10; renal ultrasound
•Evaluate for trigger of nephrotic flare: infection, medication/toxin
•Evaluate for secondary causes: ANA, dsDNA, ANCA, Hep B, Hep C, C3, C4
Treatment:
•Fluid overload: albumin/diuretic therapy: 25% albumin 1gram/kg (max 25g) IV over 1 hour if not
hypertensive or 2 hours if hypertensive with lasix 1-2mg/kg IV given immediately after albumin
infusion
RE NA L
127
•- Salt restrict (1.5-2g/day) and fluid restrict (variable, approximately 400 mls/m2 + 750 mls/day)
•- Place PPD in anticipation of steroids for immunosuppression; 2 mg/kg/day divided BID for 4
weeks followed by taper; consider solumedrol 60mg/m2 IV only if concerned that gut edema is
preventing oral steroid absorption
•- Only 10% of kids < 10yo fail steroids; if non-responsive, needs renal biopsy
GLOMERULONEPHRITIS
Definition
glomerular injury due to inflammation, produces active urine sediment
•Hematuria (microscopic or macroscopic, dysmorphic RBC and RBC casts pathognomonic),
proteinuria (may be up to nephrotic range), hypertension, acute kidney injury
Etiologies
narrow differential based on low or normal complement
Primary Glomerulonephritis
Low
complement
levels
Normal
complement
levels
Membranoproliferative
Glomerulonephritis (MPGN)
Type 1 vs Type 2 (dense deposit disease)
Berger’s disease
IgA nephropathy
Goodpasture’s disease
Anti-glomerular basement membrane
disease
Idiopathic crescentic
glomerulonephritis
Secondary Glomerulonephritis
Low
complement
levels
Post-streptococal GN
Skin or throat, Group A strep
Other post-infectious GN
Endocarditis, visceral abscess, shunt
nephritis, pneumococcal infection, typhoid,
EBV, parvo B19, CMV, coxsackie, rubella,
mumps, Hep B, malaria, toxo, filaria,
schistosoma
Lupus
Median age onset 12y, about 50% with renal
disease at time of diagnosis
Henoch-Schonlein Purpura
Normal
complement
levels
ANCA+ glomerulonephritis
(granulomatosis with
polyangiitis, microscopic
polyangiitis)
Evaluation
serology for recent strep infection (ASO titers), ANA, dsDNA, C3, C4, IgA level; consider CH50,
12 8
RE N AL
ANCA; consider serologic testing for EBV, Hep B, and Hep C, anti-GBM (if pulmonary symptoms)
Rapidly Progressive Glomerulonephritis (RPGN)
rare in children; may be caused by any immune mediated process, though anti-GBM, ANCA, and
HSP most common
•Elevated creatinine which continues to climb
•50% of glomeruli affected by crescents on renal biopsy histology
•Treat with steroids
RENAL TUBULAR ACIDOSIS (RTA)
Definition
renal abnormality causing loss of bicarb in urine; consider in differential of non-anion gap
hyperchloremic metabolic acidosis
Evaluation
blood gas, urinalysis, urine electrolytes (to calculate urine anion gap), chem panel
Type One (distal)
Type Two (proximal)
Primary defect
Impaired distal
acidification; can not
secret H+
Reduced proximal bicarb
absorption; also spills
Decreased aldosterone
phos, glucose, other
secretion or effect
electrolytes
Plasma HCO3
Variable, possible < 10
Usually 12-20mEq/L
Greater than 17mEq/L
Urinary pH
Greater than 5.3
Variable, above 5.3 if
above bicarb resorption
threshold
Usually less than 5.3
Plasma K
Usually low, may correct
with bicarb rx
Usually low, worsens
with bicarb rx
Increased
Causes
Familial (AD or AR),
hypercalciuria, SLE,
obstructive uropathy,
amphotericin B,
hyperglobulinemia,
sickle cell, lithium, renal
transplant
Cystinosis, tyrosinemia,
hereditary fructose
intolerance,
galactosemia, glucogen
storage disease type
1, Vit D deficiency,
renal transplant,
paroxysmal nocturnal
hemoglobinuria, heavy
metals, Fanconi’s
syndrome
Primary adrenal
insufficiency, CAH (esp
21-OH), heparin, ACEinhibitors, NSAIDS,
aldosterone resistence
(aldactone, triamterene,
amiloride, trimethoprim),
tubulointerstitial disease
Treatment
1-2mEq/kg/day bicarb,
decrease Na intake to
decrease Ca exchange at
distal tubule
10-15mEq/kg/day bicarb
(bicarb ingestion often
leads to bicarb diuresis
and excess K losses)
1-5mEq/kg/day bicarb;
consider diuretics and
fludrocortisone; restrict
dietary K
Nephrocalcinosis?
Common
Not common
Absent
RE NA L
Type 4 (hypo-aldo)
129
HUS & HSP
Features
Differential
Causes
Prodrome
Evaluation
Hemolytic Uremic Syndrome
Henoch-Schonlein Purpura = IgA
vasculitis
1. Microangiopathic hemolytic anemia
2. Thrombocytopenia
3. Acute Kidney Injury
1. Palpable purpura (normal plt &
coag)
2. Arthritis/Arthralgia
3. Abdominal pain / Intussusception
4. Renal disease
DIC, TTP, systemic vasculitis
Varies pending initial complaint
(purpura, joint pain, abdominal pain;
renal disease late)
Typical (diarrhea): Shiga toxin- producing E. coli
(STEC) or Shigella
Atypical (no diarrhea): strep pneumoniae, HIV,
H1N1 influenza; genetic disorders of complement
or cobalamin C, chemotherapy, post-transplant
immunosuppression
Immune-mediated vasculitis
associated with IgA deposition;
variety of infectious and chemical
triggers; undetermined pathogenesis
with immune, genetic, and
environmental factors
Typical HUS (>90%): abdominal pain, vomiting, bloody
diarrhea
May follow bacterial or viral
infection
Pneumococcal: 70% complicated pneumonia, 20-30%
meningitis; consider bactermia, sinusitis, otitis
CBC with peripheral smear (anemia ,
thrombocytopenia, schistocytes, helmet cells), renal
function panel, urinalysis; coag panel (to differentiate
from DIC); infectious studies (stool and blood
culture, CXR, HIV); for atypical, C3, C4, ANA, factor H
mutations
Clinical diagnosis (classic: purpura
on legs and buttocks); consider
skin biopsy if needed (diagnostic if
leukocytoclastic vasculitis with IgA
predominance), serum IgA elevated
in 50-70%
Urinalysis; confirm normal plt and
coag; consider serum creatinine if
abnormal UA
Supportive: PRBC for Hgb < 6, platelets for clinical
bleeding or invasive procedures, fluid/electrolyte
monitoring and management; watch for indications for
acute dialysis
Treatment
Consider Eclulizumab (C5 antibody) for familial HUS,
consider plasmapheresis or plasma infusions
Avoid abx if HUS thought to be due to shiga toxin
Pneumococcal: broad double coverage (cefotaxime,
vancomycin)
Supportive: hospitalization if
inability to orally hydrate, severe
abdominal pain, GI bleeding, altered
mental status, unable to ambulate
due to joint pain; elevated creatinine,
hypertension, or proteinuria
Monitor: blood pressure, urine
output, abdominal exam, stool
guaiac
Consider: NSAIDs, steroids,
abdominal imaging, surgical consult
13 0
RE N AL
Outcome
Follow-up
Typical: <5% mortality; hematologic lines recover in
1-2 weeks, followed by renal function recovery; 5-25%
permanent renal disease
Short- and long-term prognosis
excellent, resolves within 1 month;
recurrence in 1/3 (usually less severe
episode), usually within first 4
months
Pneumococcal: more severe initial disease, longer
duration oliguria, requires more transfusions; 12%
mortality, 10% ESRD, 16% CKD
Short-term morbidity from surgical
GI complications (intussception,
usually ileoileal so best diagnosed
by US not by barium enema); longterm from renal disease (20-54%
with renal disease, 90% within first 2
months, more likely if >8yo)
Annual: blood pressure, urinalysis, renal function
panel
Weekly or bi-weekly UA and BP for
4 months, then at subsequent well
checks
CHRONIC KIDNEY DISEASE
Classification
guides management by stratifying the risk of progression and complications
GFR Category
GFR (mL/min/1.73 m2)
Terms
G1
>90
Normal or high
G2
60-89
Mild decrease
G3a
45-59
Mild to moderate decrease
G3b
30-44
Moderate to severe decrease
G4
15-29
Severe decrease
G5
<15
Kidney failure
Selected Associated Problems
Cause
Diagnosis
Intervention
Fluid and Electrolyte
shifts, Edema
Oliguria, anuria, or
high urine output
History, urine output
Diuretic therapy, fluid
restriction, dialysis
Anemia
Poor EPO production,
low iron
CBC, retic, ferritin,
TIBC, serum Fe
Epogen, iron
supplement
Osteodystrophy
Failure to convert
Vit D to active
form, acidosis,
nutritional deficiency,
hyperparathyroid
Ca, Phos, iPTH, Vit D
25-OH Vit D
(cholecalciferol); if
Vit D deficient usually
need 1,25-OH Vit D
(calcitriol = Rocaltrol or
paricalcitol = Zemplar)
RE NA L
1 31
Phos
Phosphate binders
(PhosLo = CaAcetate,
TUMS = CaCarbonate,
Sevelamer with meals,
low phos diet
Growth curve
Improve electrolytes
and nutritional intake,
consider growth
hormone
Hyperphosphatemia
Poor excretion
Poor nutrition and
growth
Acidosis, anorexia,
growth hormone
binding protein
irregularities
Hypertension
Fluid status, vasoactive
Blood pressures, LVH
substances from
on echo
kidney
Low Na diet, antihypertensives
* Hemodialysis patients often get their Epopoetin and 1,25-OH Vit D as part of dialysis prescription
PRENATAL HYDRONEPHROSIS ALGORITHM
13 2
RE N AL
RE NA L
133
ELECTROLYTES
13 4
RE N AL
NOTES
RE NA L
135
SECTION 13
Appendix
Crawford’s AED Table......................................................................................... 125
Cystic Fibrosis Pathway..................................................................................... 128
Spirometry Interpretations in Adults.................................................................. 129
Evaluate spirometry and response to bronchodilator...................................... 130
Sickle Cell Disease and Pulmonary Complications........................................... 131
Urinary Casts....................................................................................................... 132
13 6
A P P E N D IX
APPE NDIX
137
13 8
A P P E N D IX
APPE NDIX
1 39
CYSTIC FIBROSIS PATHWAY
140
A P P E N D IX
APPE NDIX
1 41
142
A P P E N D IX
SICKLE CELL DISEASE AND PULMONARY
COMPLICATIONS
Test or Therapy
Frequency
Rationale
Review of Systems for atopy
and asthma. (All children with
SCD)
Annually, starting at one year
of age.
If history is positive, refer to
allergy or asthma specialist.
Atopy is a risk factor for
asthma. Children with asthma
and SCD are at increased risk
of vaso-occlusive episodes
(VOE) and ACS.
Assessment of lung function
by spirometry (All children
with SCD)
Annually in all children with
SCD starting at 6 years of age.
With every visit for children
with SCD and asthma, max 4
times per year.
Bronchodilator challenge
should be done in children
with obstruction (FEV1/FVC
less than 95% CI).
Children with SCD may have
obstructive and restrictive
defects.
Starting at 6 years of age:
Every 5 years in children with
no asthma or ACS episodes.
Every 2-3 years in children
with asthma or ACS episodes.
Children with SCD may have
obstructive and restrictive
defects.
Assessment of defects in lung
function by lung volumes with
plethysmography (All children
with SCD)
Treatment of children with
SCD and asthma per NHLBI
guidelines (All children with
SCD)
Review of Systems for Sleep
Disturbed Breathing (Sleep
Apnea) (All children with SCD
and asthma)
Indefinitely. Once diagnosed
with asthma, children should
be assessed at least every
6 months for persistent
symptoms.
Treatment of persistent asthma
in children without SCD with
daily inhaled corticosteroids
is effective in reducing asthma
hospitalizations and symptom
days.
Annually by history.
If history is positive, refer to
pulmonologist for evaluation.
Children with nocturnal
hypoxemia have higher rates
of pain (VOE).
At least annually for children
Appointment with
with SCD and mild asthma.
Pulmonologist, Allergist or
At least every 6 months
Asthma Specialist (All children
for children with SCD and
with SCD and asthma)
moderate to severe asthma.
Children with asthma and SCD
are at increased risk of vasoocclusive episodes (VOE) and
ACS.
Assessment for elevated TR
Jet velocity and pulmonary
hypertension by 2-D
Echocardiography (All
children with SCD)
A tricuspid jet velocity greater
than 2.5 m/s is associated with
an increased risk of death in
adults.
Effective intervention not well
defined.
APPE NDIX
At least once between ages
16-18 years.
143
URINARY CASTS
•Formed in tubular lumen (ie diagnostic of intrarenal origin); matrix = Tamm-Horsfall mucoprotein
Red Blood Cell
Glomerulonephritis
Interstitial Nephritis
White Blood Cell
Pyelonephritis
Proliferative Glomerulonephritis
Renal Tubular
Epithelial Cells
Acute Tubular Necrosis (ATN)
Proliferative Glomerulonephritis
Granular
Acute Tubular Necrosis (ATN)
Broad
Formed in large dilated tubules
with little flow = advanced CKD
* Waxy casts: nonspecific, seen in chronic and acute kidney disease
* Hyaline casts: nonspecific, seen in small volumes of concentrated urine or with diuretic use
144
A P P E N D IX
NOTES
OLD IRONSIDES
NMCSD Pediatric Ward Handbook
Last updated 08/2014

Old Ironsides NMCSD Handbook - The Uniformed Services at USU

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