Pearls for Pancreatitis in Kids
0 Comments
1. Papilledema is very specifically optic disk swelling in the presence of ICP. 2. Vomiting and abdominal distention should always worry you. 3. Bilious vomiting is a surgical emergency 40-60% of the time 4. Think non-typable haemophilus when you see conjunctivitis and otitis in tandem. - See Conjunctivitis-Otitis Morsel Common causes for acute ataxia in children are as follows:
They include:
Ataxia management follows a stepwise algorithm. ALCAPA
Pediatric Sinusitis
1. Leukostasis is a medical emergency and requires emergent intervention. - High mortality rate (up to 40%)! - Can cause end organ damage - may present with neuro symptoms (like ischemia). - Start IV Fluids to dilute the WBC. - Hydroxyurea can also help decrease WBC. 2. Always consider tumor lysis syndrome in any child who recently started chemotherapy. - Seen with conditions with large tumor burden (ex, large solid tumor, leukemia). - Look for High Potassium, High Phosphorous, and LOW Calcium! - Start IV Fluids - Check ECG. Treat Hyperkalemia! - Rasburicase for elevated uric acid. 3. It's okay to wait for the results of a CBC with diff in stable appearing patient on chemotherapy with a fever. - Neutropenic Fever untreated has a high mortality (80%), but treated appropriately it is 1-3%. 4. Involve oncology early whenever one of their patients arrive in the CED. Hemophilia
ITP
Case 1: Pediatric Airway Remember differences in pediatric airways vs adults: • Large Tongue, Large Head, Floppy Epiglottis • Cricoid is narrowest (vocal cords in adult) – Correct tube size is essential ( Age/4 + 3.5 ) – Newborn (<1 kg) - 2.5; 28-34 wks (1-2 kg) - 3.0; 34-38 wks ( 2-3 kg) - 3.5; >38 wks (3.5) - 4; 6 mo - 1 year - 3.5-4; 1 -2 yo - 4-5; >2 yo - 4.0-5 – BROSELOW TAPE!!! • Cuffed tube for all children >3 kg now • Glottis (Expect a high anterior airway) – C-1 in infancy – C-3-4 by age 7 – C-5 at adulthood • Nasal tracheal intubation more difficult due to anatomy - Gum Elastic Bougie for nasal intubation • Potential technique if fiber optic equipment unavailable - Load ET tube into nares and then advance to pharynx - Tip of GEB to protrude about 4-5 cm beyond tip of tube - Utilize angle of GEB to access airway or utilize Magill forceps • Potential technique if fiber optic equipment unavailable - Load ET tube into nares and then advance to pharynx - Tip of GEB to protrude about 4-5 cm beyond tip of tube - Can guide with Magill forceps through cords TRANSTRACHEAL JET INSUFFLATION (See Morsel and Video and another Video) Pros: – Quick (assuming you have your supplies available) – Simple and Effective – Less bleeding (than surgical cricothyroidotomy) – No age limit Cons: – Barotrauma (Cannot use if complete obstruction. Passive exhale) – No airway protection – Cannot suction • Every department will have different equipment. Know what equipment you have available and WHERE it is! If you take a job somewhere and there isn’t a kit ready, make one. • Jet insufflation is effective at oxygenation. All patients become hypercapnic of unclear significance, but jet insufflation has effectively oxygenated patients for hours. Do not forget this important tool in your bag! Pearl: Keep OP and NP airways in place to facilitate passive exhalation. CRICOTHYROIDOTOMY • Remember Mnemonic for difficult procedure: SMART – Surgery, Mass, Access/anatomy, Radiation, Tumor • Cricothyroid membrane: Essentially nonexistent <4 years old, relative contraindicated in children <10 years old • Percutaneous vs Open vs Modified Percutaneous – Open should be your choice with difficult anatomy. Percutaneous is effective but leads to more airway misplacement although less bleeding and less trauma to surrounding structures. Modified is a technique with an incision first followed by percutaneous approach and has been demonstrated to be effective and faster in model studies. Case 2: Esophageal Food Impaction • Take a good history upfront in order to save yourself headache later – It is not “Admit vs. Street” – Take a diagnostic pause to think about what you are forgetting. Okay to do this at bedside. • Food impaction: – “Steakhouse Syndrome” – Usually meats – Acute dysphagia (92%) to the point refuse to swallow spit, chest pain, neck pain (60%), regurgitation – Inability to swallow spit- Indicates Total Obstruction and emergent need for endoscopy. – 90% with baseline esophageal pathology, 60% with history of food bolus obstruction – Can trial glucagon 0.5- 1 mg IV x1. Time of action ~15 min. ~30% will resolve with this treatment (however, no different than placebo). The rest will need GI consultation for endoscopy. – Time to endoscopy directly related to complications
Heart Lesions 1. Left to right - VSD, ASD, cushion defect, PDA 2. Cyanotic - truncus, transposition, total anomalous, tricuspid atresia, tetralogy a. Cyanosis - decrease of deoxygenated hgb by 3-5 mg/dl 1. Shunting from lung 2. Mixing blue and red blood 3. Single ventricle Break the left side of the heart (Hypoplastic left, aortic stenosis, coarct) --> hepatomegaly, gray, pulmonary edema, etc Break the right side of the heart (hypoplastic right heart, tricupsid atresia, pulmonary atresia, tetrology of fallot) --> Blue, poor perfusion, acidosis Not all ductal dependent lesions are cyanotic - AS, coarct Not all cyanotic lesions are ductal dependent - truncus arteriosis, TAPR Cyanotic Lesions a. Truncus Arteriosus - Blue because they're mixing - mixing happens before duct, therefore not ductal dependent - Pulmonary exam will vary; You can give them O2 - won't worsen cyanosis but won't help b. Transposition of Great Arteries - Cyanotic because you have mixing blood; If you find these later (ie, in the ED and not immediately after birth) these kids will all have VSD; Ductal dependent O2 wont help but wont hurt c. Tricuspid Atresia - Blue because not perfusing lungs; Right ventricle doesn't develop (Hypoplastic right heart) Ductal dependent; only pulmonary artery flow will come through ductus from aorta ECG will show LVH but only because right side isn't balancing it out O2 will prob not help, but won't kill d. Tetrology of Fallot - Cyanotic because of decreased pulmonary perfusion and mixing - O2 can help e. Totally Anomalous Pulmonary Venous Return - Cyanotic because of mixing Hyperoxia Test - 10 minutes of 100% O2 and see response > may help differentiate between pulmonary and cardiac etiology * For cyanotic lesions oxygen is not going to kill - it just may not help* * O2 can hurt you on left to right shunts* Left to right shunts are usually dyspneic/hypoxic because they are over-perfusing the lungs and they get fluid overload. Oxygen will cause vasodilitation of the pulmonary vessels and increase left to right shunting worsening the problem. Prostaglandins - 0.05-0.1 mcg/kg/min > will cause apnea - tube the kid Kids are Different - Larger heads, tongues, smaller nostrils - Cricoid ring determines size of ET tube - Bradycardia is a BAD SIGN. Signs of Increased Respiratory Effort - Assumed position - Bobbing head - If kids are pulling off their mask, they might need to be intubated. Positioning - sniffing position, sometimes achieved without any padding - jaw thrust is preferred to chin tilt - always use an oral airway, measure from angle of mouth to angle of jaw DOPE for ETT problems - Check ETCO2 waveform - Dislodged - Occluded - PTX - Equipment Pitfalls Not recognizing compromise early! Not thinking to clean out the nose! Not thinking in terms of axis alignment! |
Archives
August 2018
Categories
All
|