Download Effects of Inhaled Nitric Oxide In Children with AHRF

Pediatric Case Studies
Jana A. Stockwell, MD, FAAP
Pediatric Critical Care Medicine
Children’s Healthcare of Atlanta @Egleston
Atlanta, Georgia
[email protected]
Case #1
• You receive a 4 month old male from
another ER who is suffering from
respiratory distress
• Vital signs: T 39.2ºC, HR 220, RR 55, BP
75/40, SpO2 99% on 2L NC, CR ~4 sec
• He is sleeping but arouses to stimulation.
• His CXR is read as “no infiltrate”
Case #1
Shortly after arriving on the ward, the
child develops difficulty breathing and
an elevated heart rate. The rhythm
strip is shown below...
Case #1
How fast is the heart beating?
Use the 300-150-75 rule
So, a little less
than 300 bpm!!!
300
Start here
and count
boxes
150
Case #1
You suspect SVT...
SupraVentricular Tachycardia
• What should you do next?
• Determine if the child is clinically stable
or unstable
HOW?
Case #1
• In SVT, if the child is clinically stable,
try:
 Inducing the Dive Reflex by applying an ice
bag to the face
 Bearing down (i.e. Valsalva maneuver)
 Eyeball pressure & carotid massage, may be
harmful and are discouraged
Case #1
• You suspect SVT
& the child is clinically unstable…
 Place an IV
 Give IV bolus of ADENOSINE
 Very short t (10 sec) & must be given rapidly
 Continuous rhythm strip during attempted conversion
 Potential side effects include hypotension, bronchospasm,
and flushing
 Be prepared to see a flat line EKG!
Case #1
• You suspect SVT…
& the child is very clinically unstable…
 If an IV cannot be started quickly OR
 If the patient fails to convert with IV
adenosine OR
 Patient becomes unconscious or unresponsive
 Then, cardiovert using 0.5 - 1 joule/kg
Case #1 Summary
• Things are not always what they are
advertised to be
• Be aware that multiple therapies may be
available and choice depends upon clinical
situation
Case #2
• You are admitting a 6 year old male with no
significant past medical history who presented
at an outlying physician’s office with a
decreased level of consciousness. He has been
having massive amounts of emesis and
diarrhea.
• VS: T 38.2ºC, HR 150, RR 28, BP 70/30, SpO2
97% on Room Air
• There is good air exchange in all lung fields,
peripheral pulses are 1+, central pulses are 1+,
the CR is ~4 sec
Case #2
What is wrong with this child?
This child is in uncompensated shock, most
likely from hypovolemia
What is the first logical step in management
of this child?
Crystalloid (NS, LR) at 20 cc/kg bolus
Case #2
• After giving 20 cc/kg of NS, what
should be done?
 Re-assess the child’s clinical status
Check pulses and heart rate
Check blood pressure
Evaluate capillary refill time
Evaluate mental status
Auscultate chest to determine if heart can
handle volume load -- rales, gallop
Case #2
• VS: HR 150, RR 32, BP 70/50, SpO2 97% on
RA
• There is good air exchange in all lung fields,
peripheral pulses are 1+, central pulses are 1+,
the CR is ~ 4 sec
• Now that the BP has improved, is this child
still in shock?
Yes, the child is in uncompensated shock!!
What should you do now?
Repeat the NS bolus at 20 cc/kg
Case #2
• VS: HR 140, RR 30, BP 90/60, SpO2
97% on RA. There is good air exchange
in all lung fields, peripheral pulses are
2+, central pulses are 2+, the CR is ~3
sec
• Now that the BP has improved, is this
child still in shock?
Yes, it is now compensated shock
What should you do now?
Repeat the NS bolus at 10-20 cc/kg
Case #2
• The child’s VS are HR 100, RR 22, BP
98/65, SpO2 94% on RA. There is good
air exchange in all lung fields, peripheral
pulses are 2+, central pulses are 2+, the
CR is < 2 sec
• Now that the VS have improved, is this
child still in shock?
 No. The fluid resuscitation has brought this child
out of hypovolemic shock
Case #2 Summary
• When the tank is low, it may take a lot
of fluid to fill it back up!
• Remember, being 10% dehydrated means
10% of the body weight is lost due to
fluid ouput/poor intake
Case #3
• You are transporting a 13 year old male
who presented to an outlying ER with
nausea and bilious vomiting. He has a
past history of BMT for CML. He also
has a history of recurrent bowel
obstructions.
• In the ER, VS are T 35.7ºC, HR 110, RR
32, BP 90/45, SpO2 98% on RA. His
extremities are warm and well perfused.
Case #3
• During transport, the child begins to
speak in incomprehensible sentences.
• VS: T36.8ºC, P 162, RR 38, BP 70/42,
SpO2 95% on RA, he is having rigors.
• What should be done next?
This child is in uncompensated shock. He
should receive 20 cc/kg of crystalloid
Case #3
• After receiving a total of three 20
cc/kg boluses of crystalloid, the child
remains hypotensive.
• What should be the next course of
action?
Pharmacological support of his BP
Case #3
• Dopamine added
 What dose should you start?
 You titrate the dose to 12 mcg/kg/min and the
child is still hypotensive...
• What exam findings are important in guiding
therapy at this time?




Capillary refill time
Tactile temperature of the extremities
Mental status
Peripheral and central pulses
Case #3
• What are the clinical features of “warm” vs.
“cold” septic shock?
Warm
Cold
CR time
Brisk
Prolonged
Skin temp
Warm
Cool
Precordium
Nml/activity
Nml/activity
Pulses
Bounding
Nml/Thready
Case #3
• How do these findings guide the next
phase of therapy?
 In warm septic shock, the underlying
problem is decreased SVR, therefore an
agent with mostly vasopressor activity
should be started (i.e. norepinephrine)
 In cold septic shock, the underlying problem
is decreased CO, therefore an agent with
inotropic activity and/or afterload
reduction should be started (i.e.
epinephrine, milrinone, nipride)
Case #3 Summary
• The stage of shock will determine which
drugs are most appropriate for
resuscitation -- the list of choices is
long
dobutamine
Case #4
• You are transporting a 4 year old male
who fell out of a 4th story window. His
head CT reveals small contusions. He is
in a C-collar.
• VS: HR 65, RR 20, BP 60/30, SpO2 98%
on RA, CR ~4 sec. His neck films are
shown.
Case #4
Case #4
• Recognizing the hypotension, a medic has
already administered three boluses of NS
at 20 cc/kg, but the child remains
hypotensive.
• Repeat VS: HR 55, RR 25, BP 65/30, SpO2
98% on RA, CR ~4 sec.
• What is unique about these vital signs?
 There is no compensatory tachycardia for the
hypotension
• What does this suggest?
 The child may have neurogenic shock
Case #4
• What is neurogenic shock?
 It is a condition characterized by loss of
sympathetic tone to the peripheral vascular
bed and to the heart
• What is the hallmark of this type of
shock?
 There is marked hypotension without
compensatory tachycardia following a CNS
injury
Case #4
How does this occur?
A lesion occurs in the cervical
region of the spinal cord
This cuts off the connection
between the heart and the brain
Now the brain cannot
control the heart and the
heart functions
independently from the
rest of the circulation
Case #4
• How is this treated?
 The use of pure -agonist (e.g.
neosynepherine) agents is preferred
Case #4 Summary
• Not all shock secondary to trauma is due
to blood loss!
Case #5
• You are working on Transport, when a 16
year old male, who was riding a
motorcycle when he lost control, flipped,
and smashed into a guard rail, is brought
in to a referring ED. He was wearing a
helmet.
• He was found to have a multiple rib
fractures an and underlying hemothorax.
• His chest x-ray is as follows.
Case #5
• Prior to transport, the child has been
intubated for respiratory distress and altered
mental status.
• A left chest tube has been placed. CT’s of the
head, chest, abdomen, and pelvis are negative
for additional pathology.
• VS: T 38.2ºC, HR 108, RR 20, BP 90/60, SpO2
98%.
• He is currently intubated, sedated, and
paralyzed. He is stable and he is loaded onto
the ambulance for transport.
Case #5
• During transport, the child becomes
progressively tachycardic. What do you do
now?
 Check all vitals and perform quick, focused clinical
exam accessing airway, breathing, and circulation
 You determine that there is no immediately lifethreatening cause of the tachycardia and suspect
pain and under sedation for which you administer
fentanyl and lorazepam.
Case #5
• Now the teenager’s pulse is 185 and he is
becoming hypotensive to 50/20. You
check the pupils because heart rate and
BP changes are part of Cushing’s Triad.
What is Cushing’s Triad?
 Bradycardia
 Hypertension
 Altered respirations
Case #5
• This is not Cushing’s Triad what else
could it be? Your quick physical
examination finds the following:
 Neck vein distension
 Tachycardia with decreased heart sounds
 Hypotension
 Thready pulses
Case #5
• What is happening?
Cardiac tamponade
• How is this treated?
 20 cc/kg fluid push
 Emergent pericardiocentesis
Removal of even a small volume of fluid is the
definitive treatment & can rapidly improve BP &
cardiac output -- may ultimately prove to be
lifesaving
Cardiac tamponade
occurs when blood
or other fluid
accumulates in the
pericardial space.
This creates
increased pressure
around the heart
and interferes with
heart function.
Case #5
• What are the signs of cardiac tamponade?
 Tachycardia
 Hypotension
 JVD
 Decreased cardiac output
 Pulsus paradoxus - >10 mmHg change between
inspiratory and expiratory systolic BP
 Narrow pulse pressure
 Muffled heart tones
“Blind” Pericardiocentesis - Technique
• Subxiphoid Approach
• Position the patient so the chest is
at a 30-degree angle
• Insert an 18-gauge spinal needle
attached to a 20-ml syringe into
the left xiphocostal angle
perpendicular to the skin and 3 to
4 mm below the left costal margin
• While aspirating constantly,
advance the needle directly into
the inner aspect of the rib cage
“Blind” Pericardiocentesis - Technique
• Depress the needle so the
needle points toward the left
shoulder
• Using a slow, cautious, turning
action of the fingers, advance
the needle until fluid is
aspirated
• Observe the cardiac monitor
for arrhythmias
• Successful removal of fluid
confirms the needle's
position
“Blind” Pericardiocentesis - Complications
• Laceration of a coronary artery
• Laceration or perforation of either ventricle
• Laceration or perforation of the right atrium
• Perforation of the stomach or colon
• Pneumothorax
• Arrhythmias
• Tamponade
• Hypotension (perhaps reflexogenic)
Case #6
• Your 3 y.o. patient’s mother calls out
that something is wrong.
• You find the child lying on the bed with
his right arm in extension with his hand
twitching & his eyes dancing horizontally.
Mom states that she has been trying to
arouse the child without success.
• VS: T 39.2ºC, HR 180, BP 110/70, RR 38
and irregular, SpO2 82% on room air.
Case #6
• What is your first impression of this
situation?
 Child with …
Complex focal seizure
Hypoxic respiratory distress
Tachycardia
Fever
Case #6
• What are the first things you should
assess?
 Airway
Appears patent
 Breathing
Ineffective, child is cyanotic
 Circulation
Child is tachycardic with good pulses & brisk
capillary refill time
Case #6
• Does this child need intubation?
 Not at this time. While the child is hypoxic,
repositioning and oxygen by face mask can
improve oxygenation.
 Additionally, treatment of the child’s
seizures may restore regular respirations
and improve the oxygenation status.
Case #6
• What medications should be given and by
which routes?
 Diazepam (Valium): onset in 2-10 minutes
Rectal gel (Diastat)
– Infants <6 months: Not recommended
– Children <2 years: Not been studied
– Children 2-5 years: 0.5 mg/kg
– Children 6-11 years: 0.3 mg/kg
– Children 12 years and Adults: 0.2 mg/kg
– Round doses to nearest 2.5, 5, 10, 15, and 20 mg/dose
Case #6
• What medications should be given and by
which routes?
 Lorazepam (Ativan): onset in 2-5 minutes
Neonates: 0.05 mg/kg IV/IM
Infants, Children, and Adolescents: 0.1 mg/kg
(max 4 mg) IV/IM
May repeat up to 3 times before considering a
non-benzodiazepine agent
Case #6
• What medications should you consider if
the first line agents fail to control the
seizures?
 Phenobarbital
 Phenytoin (Dilantin)
Fosphenytoin if peripheral IV questionable
Case #6
• The child stops twitching after
lorazepam is given. His respirations are
shallow & his SpO2 in 100% on NRB FM
at FiO2 1.0
• What reflexes should be evaluated to
see if this child requires intubation?
 Gag to evaluate airway protection.
Case #7
• You are working in the ER when a 13 year
old unresponsive female is brought in.
• Her little brother states the girl has
been sick all day. She was really thirsty
having consumed four 2 liter bottles of
Coke in the last 8 hours.
• VS: T 36ºC, HR 165, BP 80/palp RR 25
and very deep, SpO2 99% on room air.
Case #7
What is the differential diagnosis?
"AEIOU - TIPS”
• A: abuse or alcohol
• T: trauma/ tumor
• E: encephalopathy or
endocrine
• I: infection/
intussusception
• I: insulin/
• P: poisoning
hypoglycemia/
• S: sepsis/ seizure/
metabolic disorder
shock
• O: opiates
• U: uremia
Case #7
What is the differential diagnosis?
“DPT - OPV - HIB - MMR”
• D: dehydration
• P: poisoning
• T: trauma
• O: occult trauma
• H: hypoxia/
hyperthermia
• I: intussusception
• B: brain mass
• P: post-ictal or postanxoia
• M: meningitis
• V:VP shunt infection
• R: Reye’s syndrome
• M: metabolic
Case #7
• The sibling states that she takes
injections in her leg. What is the most
likely diagnosis?
Diabetic ketoacidosis
Case #7
• You check a blood gas which
demonstrates …
 pH 6.91, PaCO2 23, PaO2 80, SaO2 98%,
base deficit -27
 Na+ 133, K+ 6.5, Glucose ***, iCa++ 4.5 mg/dL
Case #7
• Should you give NaHCO3 to correct the
acidosis?
 No. NaHCO3 should only be given in the setting of
cardiovascular dysfunction, i.e. arrhythmias. Its
use has been associated with the development of
cerebral edema in patients wth DKA.
(N Engl J Med 2001;344:264-9)
pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27
Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
Case #7
• Why is the K+ elevated?
 Elevated serum hydrogen ion is countertransported across the RBC membrane with
potassium in an effort to buffer the acidosis
pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27
Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
Case #7
• Why is Na+ low?
 The hyperosmolality of diabetes attracts
more water into the intravascular space.
This causes a “ficticious hyponatremia”.
pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27
Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
Case #7
• What IVF should be given and how
much?
 0.9% NaCl at 20 cc/kg unless in
uncompensated shock. Excess IVF has been
associated with cerebral edema. (4
liters/M2)
pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27
Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL
Case #8
• You are admitting a 6 year old male who is
coughing uncontrollably.
• VS: T 37.2ºC, HR 140, RR 40, SpO2 85% on
room air.
• He has nasal flaring, supra-sternal,
intercostal, and subcostal retractions.
• By auscultation, you hear expiratory wheezes
bilaterally with a prolonged expiratory time.
Case #8
• What is this child’s problem?
Acute exacerbation of asthma
Asthma is a chronic inflammatory
pulmonary disorder that is characterized
by reversible obstruction of the airways
Case #8
• What is the 1st step in treatment?
 Provide oxygen
• What is the next step?
 Provide nebulized bronchodilators
Case #8
• How would the diagnosis change if the
child had a right-sided, wheeze heard
best on inspiration, with decreased air
exchange on the right side, and tracheal
deviation to the left?
 This would suggest the presence of a
foreign body.
 Remember, all that wheezes is not asthma!
Case #8
• Physical examination of the child reveals
a palpable liver edge 5 cm below the
right costal margin. Why is this?
 Hyperinflation related to obstructive airway
disease in asthma has pushed the liver
inferiorly into the abdomen.
Case #8
• What agents are used in the treatment
of asthma and why?
 -agonist agents
Increase cAMP which leads to decreased
intracellular calcium and smooth muscle
relaxation.
Albuterol nebs or MDI, terbutaline nebs or SQ,
epinephrine SQ
Case #8
 Agents…
 Anticholinergic agents
 Inhibit the acetylcholine receptor thereby decreasing the
intracellular cGMP which leads to decreased intracellular
calcium and smooth muscle relaxation.
 Ipratroprium bromide nebs
 Steroids
 Acutely, they may lead to -receptor upregulation
and sub-acutely/chronically have been shown to
decrease the inflammatory response in asthma
Case #8
• Agents…
 Magnesium sulfate:
Competitively inhibits intracellular calcium and
leads to smooth muscle relaxation
 Ketamine:
Binds sigma opiate receptors to cause
dissociative amnesia and relaxation.
Causes secondary release of endogenous
epinephrine which causes smooth muscle
relaxation. Can cause excessive secretions.
Case #9
• A 7 week old female infant is being seen for
unresponsiveness after being found face down
in the bed by her parents.
• VS: T 35.2ºC, HR 68 & thready, RR 13, BP
65/40 with SpO2 unable to trace, and CR ~5
sec. She responsive to painful stimulation.
• The physician seeing the patient is concerned
about sepsis and gave the child IM antibiotics
because no IV access has been obtained.
Case #9
• What are the first things you should do?
 Airway & Breathing
 Bagging this child with 100% oxygen increased the heart
rate to 180 bpm
 Circulation
This child is in shock. An attempt at IV access
should be made. If no access is obtained in 90
seconds or after 3 attempts, an IO needle
should be placed.
After this, the child should receive 20 cc/kg of
crystalloid solution
Case #9
• What should be done next?
 Disability
This child is hypothermic and should be placed
under warming lights or wrapped in a blanket
Case #9
• What components of the history should
be obtained?
 Birth history:
Full term or premature?
Discharged right after birth or was there a
prolonged stay?
 GI:
Has the child been taking good PO?
Making good UOP?
Diarrhea or vomiting?
Case #9
 ID:
Any fever?
Any rash?
Any sick contacts?
 Medical:
Is the child on any medication?
When was the last visit to the doctor?
Are the vaccinations up to date?
Case #10
• You arrive at your night shift on a community hospital
inpatient floor. One of your patients is a 9 month old,
former 25 week male premie who is respiratory
distress.
• The nurse signing out to you states that the child has
developmental delay and cerebral palsy.
• The child presented to your facility with fever and
rhinorrhea for 3 days, with progressively increasing
work of breathing. The child has been receiving
albuterol nebs Q 2 hours around the clock for the last 2
days without relief.
• VS: 38.3ºC, HR 195, RR 60, BP 100/57, SpO2 89% on
5L FM, and CR <2 sec
Case #10
• Different parts of the respiratory tree may be
contributing to this infant’s problems
 Nasal Passages: obstruction from rhinorrhea, adenoid
hypertrophy
 Oropharynx: inability to clear secretions, pharyngeal
hypotonia with obstruction, tonsillar hypertrophy
 Trachea: Stenosis, malacia, vocal cord paralysis, viral croup
 Small Conducting Airways: Reactive airway disease,
bronchopulmonary dysplasia
 Alveoli: pneumonia, bronchopulmonary dysplasia
Case #10
• Name different ways to overcome these airway
problems
 Nasal Passages: suction, -agonists (i.e. Afrin)
 Oropharynx: suction, BVM to give CPAP with 100% oxygen,
intubation
 Trachea: racemic epinephrine nebs, Heliox, BVM to give CPAP
with 100% oxygen, intubation
 Small Conducting Airways: albuterol, ipratroprium, BVM to
give CPAP with 100% oxygen, intubation
 Alveoli: BVM to give CPAP with 100% oxygen, intubation
Case #11
• You are transporting a 14 year old male with
bilateral frontal contusions after a MVC.
• The child has also sustained pulmonary
contusions and a liver laceration. He was
intubated for a GCS of 6. His pupils are 4mm
and sluggish.
• VS: T 37.2ºC, HR 108, BP 90/45 with SpO2
100%.
• Vent settings are VT 400 cc, PEEP 5, IMV 12,
FiO2 1.0.
Case #11
• During transport, the child develops a BP of 180/120 &
pulse 65. What might be happening?
 The bradycardia and elevated BP suggest Cushing’s Triad
(altered respirations is the third component) which suggests
impending herniation.
• What is the next most appropriate step in
management?
 Hyperventilation: decreases PCO2 causing cerebral
vasoconstriction leading to decreased blood flow decreasing
cerebral edema.
 Hyperosmotic agents:
 Mannitol or 3% NaCl: removes water from brain and can relieve
edema
 Elevation of head.
Case #11
• Now his sats are falling...
• You begin to manually bag him and notice
that it is much more difficult to obtain
chest rise than previously.
• What should you think of next?
 “DOPE”
Displacement
Obstruction
Pneumothorax
Equipment Failure
Case #11
• You check for displacement by auscultation
bilaterally
 No air exchange in the right lung fields with good
air exchange in the left lung fields.
 Could the ETT have slipped and led to left mainstem intubation? This is unlikely as the right mainstem is straighter and the tube is still taped at the
original position.
• You check for obstruction of the ETT by
passing a suction catheter into the ETT
 Suction catheter passes without difficulty
Case #11
• You check for a possible pneumothorax




There is no air exchange on the right side
There is no chest rise on the right side
The trachea is deviated to the left
These findings suggest a right sided pneumothorax
• You quickly access for equipment failure
 The BVM is connected to 100% oxygen
 The anesthesia bag inflates correctly
• You suspect a right sided PTX and perform a
needle thoracotomy in the 2nd ICS at the midclavicular line and hear a whoosh of air
Case #12
• You arrive at an ER to transport a 5 year old
male who was intubated for respiratory failure
secondary to shock.
• His VS are 39.2ºC, P 140, RR 32, BP 90/30,
SpO2 93% on 100% O2.
• The child received 40 cc/kg LR, vancomycin, &
ceftriaxone prior to intubation.
• There is an IO in the left tibia (attempt at a
right IO failed). There is an a-line in the right
radial artery.
Case #12
• En route, the becomes hypotensive to
55/20. While pushing volume, the IO
displaces. What should you do next?
 Place an IO in either femur, just proximal to
the knee. Placement of the IO in either of
the tibias may result in extravisation of
fluid out of the previous IO attempt sites
Case #12
• The child remains hypotensive despite a
20 cc/kg bolus (60 cc/kg total given
since presentation). What should you do
next?
 Begin dopamine at 5 mcg/kg/min
• How do you make a drip using the rule of
6’s?
 Wt(kg) x 60, 6, or 0.6 = # mg/100 cc to
make a drip that at 1 cc/hr = 10, 1, or 0.1
mcg/kg/min
Case #12
• You obtain a arterial blood gas which
demonstrates: pH 7.20, PaCO2 60, PaO2
75. What is happening and what should
you do?
 The patient is suffering from a respiratory
acidosis and you should increase the
ventilation rate or tidal volume
• How can you estimate the change in pH
from the change in PCO2?
 For every 10 change in PCO2, a change of
0.08 in pH will be seen
Case #12
• You have attempted to titrate the dopamine to
keep the MAP > 65. It is now at 18 mcg/kg/min
but the hypotension persists.
 Which agent should you consider if the child has a CR <
2, peripheral pulses +3, and a hyperdynamic
precordium?
 This child is in warm septic shock. Norepinephrine should be
started.
 Which agent should you consider if the child has a CR
~ 4 and the peripheral pulses are thready?
 This child is in cold septic shock. Epinephrine should be
started.
Case #13
• You are transporting a 16 year old male from a
peripheral ER who is suspected of taking PCP.
He was combative and received IM haloperidol
which controlled his temperament adequately.
• During transport, he develops muscle spasms,
eye dancing, a stiff neck, and an inability to
open his jaw. What is happening?
 Acute dystonic reaction from haloperidol
Case #13
• What other drugs can commonly cause
this reaction?
 Metoclopromide (Reglan)
 Prochlorperazine (Compazine)
• How is this reaction treated?
 Diphenhydramine (Benadryl)
 Benztropine (Cogentin)
Case #13
• You arrive at the ER of a rural medical center
to transport a 13 month old child who has
respiratory distress for the last 3 days.
• He is now significantly worse. VS T 39.8ºC, HR
198, RR 55, BP 65/30, SpO2 93% on 5L FM.
• The child appears physically exhausted.
• Physical examination demonstrates rales on
auscultation bilaterally, distant heart sounds,
and increased liver size.
• His pulses are thready and CR ~3 sec.
• The CXR is shown on the next slide.
Note the
increased
cardiac to
thoracic ratio
Case #13
• The diagnosis of acute myocarditis is
made. While transporting the child, he
develops the following rhythm:
• What is the diagnosis of this rhythm?
 Ventricular tachycardia
Case #13
• What should you do next?
 Check for a pulse
If no pulse present, initiate CPR and PALS
pulseless arrest algorithm
If pulse present with poor perfusion:
– STAT defibrillation 2 J/kg.
– Consider alternative medications
» Amiodarone 5 mg/kg IV over 20 minutes or
» Lidocaine 1 mg/kg IV
– Intubation
Case #13
• What should you do next? (Con’t)
 Check for a pulse
If pulse present with adequate perfusion:
– Consider medications
» Amiodarone 5 mg/kg IV over 20 minutes or
» Lidocaine 1 mg/kg IV
» Cardioversion with 0.5 to 1.0 J/kg
Case #14
• You arrive at a physician’s office to transport
a 4 year old child with a suspected acute
abdomen.
• The child has had bilious emesis for 2 days
along with loss of appetite.
• VS: T 40.1ºC, HR 140, RR 45, BP 80/40, SpO2
100% on room air, CR < 2 sec.
• The physician has given the child 4 doses of
morphine (2 mg) with minimal pain relief.
Case #14
• While en route, the child falls asleep and
appears comfortable.
• The BP cycles and determines that the
BP is now 60/20 with the heart rate
elevated to 180.
• What should you do now?
 Consider a crystalloid bolus of 20 cc/kg
Case #14
• The child’s SpO2 is beginning to fall
(84%). Examination demonstrates
shallow respirations. What should you
do next?
 Place the child on 100% FM
• The SpO2 continues to fall after oxygen.
Should you intubate this child?
 No. This child is probably suffering from a
depressed respiratory drive, try naloxone
(Narcan).
CASES