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Pediatric Nightmares: Scenarios you better be ready for!! Jason P. Stopyra, MD FACEP Jason P. Stopyra, MD • Prior NYS AEMT-III • Residency Trained Emergency Physician • Private Community Hospital • City/County SWAT Medical Director • Local Aeromedical Medical Director • County Medical Examiner • NC State Paramedic Competition Medical Advisor ****Warning**** Talk about some tough stuff Real Cases My Nightmares! Case #1 Trauma Not a tree!! Pediatric Trauma ABCs Transport to Nearest Facility Transport to Pediatric ICU Tough Part Intraosseus Access Interaction with Family Dealing with loss of child What could I have done differently? Case #2 Yearly Reality RSV Bronchiolitis Under 6wks!! Hopefully they’re MAD!! Pediatric Resp Failure Spectrum of illness What are you gonna see? What ya gonna do? Oxygen - How? Bronchodilators? Steroids? Status Epilepticus Case #3 Seizure Management Positioning Fever Control ABCs Aspiration of sputum Apnea? Duration Seizure Management Benzodiazepines Valium - IV, IM, PR Versed Ativan Seizure Management Antileptics Phenobarb Dilantin Pentobarb Paralytics Hypovolemic Shock Case #4 Intraosseous Put it in!! Fluid Bolus 20cc/kg Vomiting Fix it? Monitor Urine Output Case #5 Long QT Interval Background Abnormal repolarization of heart Lead to differences in the “refractoriness” of the myocytes Lead to re-entrant ventricular arrhythmias Drug Induced Cardiac Arrest Torsades de Pointes Symptoms Fainting Palpitations Seizures Sudden Death Diagnosis The diagnosis of LQTS is not easy since 2.5% of the healthy population have prolonged QT interval, and 10–15% of LQTS patients have a normal QT interval.[4] A commonly used criterion to diagnose LQTS is the LQTS "diagnostic score" [5]. The score is calculated by assigning different points to various criteria (listed below). With 4 or more points the probability is high for LQTS, and with 1 point or less the probability is low. Two or 3 points indicates intermediate probability. ■ QTc (Defined as QT interval / square root of RR interval) ■ >= 480 msec - 3 points ■ 460-470 msec - 2 points ■ 450 msec and male gender - 1 point ■ Torsades de Pointes ventricular tachycardia - 2 points ■ T wave alternans - 1 point ■ Notched T wave in at least 3 leads - 1 point ■ Low heart rate for age (children) - 0.5 points ■ Syncope (one cannot receive points both for syncope and Torsades de pointes) ■ With stress - 2 points ■ Without stress - 1 point ■ Congenital deafness - 0.5 points ■ Family history (the same family member cannot be counted for LQTS and sudden death) ■ Other family members with definite LQTS - 1 point ■ Sudden death in immediate family (members before the age 30) - 0.5 points Treatment Restrict sports/strenuous activity/ stress Arrhythmia Prevention B-Blockers Arrhythmia Termination ICD Tough Stuff Young heart - prolonged VF/VT 2 hour code Where is the family? Case #6 What is your nightmare? Thanks!! Questions??
