Pediatrics Whats New Introduction SME video of the

Pediatrics What’s New? ?

Introduction • SME video of the month- Dr. Mark Cichon • Review of pediatric SOP’s • Scenarios

SME Video • https: //youtu. be/mod. U 0 kzo. PF 0

Pediatric LVADS • Heart failure afflicts thousands of children and adolescents every year • It can occur unexpectedly and often undetected until its progression is very advanced

Pediatric Heart Failure • Cause of heart failure in children can include: o Defect of blood vessels in the head or other parts of the body (AV malformation) causing similar mixing arterial and venous blood but outside the heart o Abnormal heart valves o Infection o Pump Failure o Drugs especially those necessary to treat to other conditions o Abnormalities in the heart’s electrical system o Severe chest trauma o Muscular dystrophy can also cause problems with the heart muscle

Pediatric Heart Failure • Clinical History o Neonates and Infants • Poor feeding • Tachypnea worsening during feeding • Poor weight gain o Older Children • Fatigue • Exercise Intolerance • Dyspnea/Pedal Edema • Growth Failure

Pediatric LVADs • VAD support for children lags behind support options for adults • Limited number of devices suitable for children for both short and long term • Pediatric devices differ significantly from adult because they must support a wide range of sizes from newborn to adolescent. • They must allow for increased circulatory demand due to growth of child

Pediatric LVADs • Currently, the Berlin Heart EXCOR VAD is the only device approved by the United States FDA for the pediatric patient • Once medical devices are approved for use in adults, they can be considered for use in pediatrics depending on how the device is “labeled” • Currently approved LVADs in adults have no restriction specifically outlined for age or size, hence they can be used in children

Pediatric LVAD’s

Pediatric LVADs • Options for LVAD support continue to increase for larger children and adolescents, infants and small children remain restricted to the Berlin Heart EXCOR • Studies have shown that small children on the pediatric heart transplant wait list have the highest mortality rate because of the fewest VAD options.

Pediatric LVAD

Pediatric CPAP • Valued therapy in the adult patient • Rapidly gaining acceptance in the pediatric population • Allows for struggling child to convert rapid little “fish puffs” into fuller breaths with improved gas exchange • Sleep apnea and snoring are quite common in children for which CPAP is the indicated therapy

Pediatric CPAP • Other Applications Include: o Bronchiolitis: Studies have indicated the success of CPAP compared to intubation in treating respiratory failure associated with bronchiolitis o Pneumonia: CPAP helps increase lower airway resistance and relieves fatigued respiratory muscles to restore tidal volume o Asthma: Forces small bronchioles open and allows for trapped air to be released from the alveoli. They also allow for continuous administration of nebulized bronchodilators o Pulmonary Edema: Usually rare in the pediatric patient and non cardiac in nature. Complications from toxic inhalation and carbon monoxide inhalation can result in a non cardiac pulmonary edema. CPAP may help in fully oxygenating hemoglobin improving hypoxemia

CPAP • Applications cont: o Drowning: The use of CPAP may be considered in submersion injuries. • Freshwater drownings have pulmonary injuries that are associated with atelectasis and hypoxia • Saltwater near drowning are more likely to develop pulmonary edema from aspirated hypertonic solutions o CPAP improves oxygenation in both fresh and saltwater drowning patients who are awake and spontaneous breathing

Pediatric CPAP • Pediatric CPAP monitoring should include o Continuous cardiac monitoring o End tidal CO 2 and pulse oximetry o Frequent assessment of lung sounds, worsening gastric distention and temperature monitoring • Signs of Improvement are indicated by o o o Improving skin color, mental status Improvement in respiratory tidal volume, lung sounds Decrease in respiratory rate, accessory muscle use and retractions Decrease in anxiety or agitation Normalizing of heart rate

Pediatric CPAP • When utilizing CPAP on a pediatric patient, start with low pressures (5 cm H 2 O). • Increase in increments of 1 cm of H 2 O as tolerated • Recommended maximum CPAP should be 15 cm H 2 O for patients less than 12 years of age • 12 years of age and up, the maximum should be 20 cm H 2 O • Valued therapy for treating common causes of pediatric respiratory distress caused by bronchiolitis, asthma and pneumonia

ALTE • Originated in 1986 from the National Institute Conference on Infantile Apnea • Intended to replace the term “near miss sudden infant death syndrome” (SIDS) • “SIDS” is now Sudden Infant Unexplained Death and is only determined after autopsy has ruled out other causes • A broad range of disorders can present as an ALTE • For majority of well appearing infants the risk of a recurrent event or serious underlying disorder is low

ALTE • By definition, an ALTE refers to a sudden event, often characterized by apnea or other abrupt changes in the child’s behavior. Symptoms include one or more of the following: apnea, change in color or muscle tone, coughing or gagging. • These episodes may necessitate stimulation or resuscitation to arouse the child and initiate regular breathing.

BRUE • Replacing the Term ALTE • Brief Resolved Unexplained Event (BRUE) • Used to describe an event occurring in an infant younger than 1 year • Observer reports a sudden, brief and now resolved episode of one of the following o o Cyanosis or pallor Absent, decreased, or irregular breathing Marked change in muscle tone Altered level of responsiveness • Should diagnosis only when no explanation for event after a complete assessment

ALTE • Because not all children are brought in for evaluation the true incidence of ALTE is unknown • Most ALTE occurs in children younger than one year • Peak incidence occurred between one week and two months of age, with most events occurring in infants younger than 10 weeks • Uncovering the cause of the ALTE most important

ALTE • Those who are at increased risk include: o o o Premature infants with RSV infections Premature infants who undergo general anesthesia Children who feed rapidly, cough frequently or choke during feeding Occurs more often in boys than girls • Studies indicate that infants older than two months who had an ALTE and those with recurrent episodes of ALTE’s were more likely to be diagnosed with a significant disorder

ALTE • The child exhibits symptoms alone or in combination including : o o Apnea Change in color Change in muscle tone Coughing or gagging • Approximately 50% of these children are diagnosed with an underlying condition that explains the ALTE

ALTE • Commonly the etiology found is o o o o Digestive (GI) most common up to 50% Neurologic 30% Respiratory 20% Cardiac 5% Endocrine and metabolic less than 5 % Child abuse (less than 5%) Other 2% • Once etiology is found potential interventions can eliminate further events • 50% are idiopathic meaning a specific diagnosis is never made

Diagnosis made in Children with ALTE • Idiopathic approximately 50% • Gastro Intestinal (50%) o o Gastroesophageal reflux Intussusception Swallowing abnormalities Gastric Volvulus • Neurological (30%) o o o o Seizure disorder Febrile seizure CNS bleeding Vasovagal reflexes Hydrocephalus CNS Infection/Malignancy VP shunt malfunction • Respiratory (20%) Infection Obstructive sleep apnea Breath holding Vocal cord abnormalities Conditions affecting respiratory control (prematurity) o Foreign body aspiration o o o • Cardiac (up to 5%) o o Arrhythmia: long QT syndrome, WPW Congenital heart disease Myocarditis Cardiomyopathy

Diagnosis made in Children with ALTE • Metabolic Abnormalities 5% o o o Inborn errors of metabolism Endocrine, electrolyte disorders Other infections Urinary tract infection Sepsis • Other o Food allergy o Anaphylaxis • Child Abuse (<5%) o Munchausen syndrome by proxy • Suffocation • Intentional salt poisoning • Mediation overdose • Physical abuse • Head injury

ALTE • Description of the event (chief complaint) o Condition of child: awake, asleep, position of child • Activity at time of the event o Feeding, coughing, gagging, choking, vomiting • Breathing efforts o None, shallow, gasping, increased effort • Color o Pallor, red, purple, blue, peripheral cyanosis, circumoral cyanosis • Movement and Tone o Rigid, tonic-clonic, decreased, floppy

ALTE • Observations of productive cough, vomiting o Mucus, blood, or noise (silent, cough, gag, wheeze, stridor, crying) • Duration of the event o Length of time required to resume breathing and normal behavior or tone • Interventions o None, gentle stimulation, blowing in face, vigorous stimulation, mouth to mouth breathing, CPR by medically trained personnel • History o Illness, fever, poor feeding, irritability, lethargy, contact with someone who is ill • Medical History

ALTE

Munchausen by Proxy • Is characterized by feigning or intentionally producing physical and emotional symptoms in another person to place that person in a sick role. It is considered a mental illness and a form of child abuse

Munchausen by Proxy • Occurrence is very underestimated and can be completely missed • Males are victims as often as females • Caregivers are primarily women • Caregiver is vulnerable and may suffer from anxiety, depression and personality disorders • Caregiver may have history of losing a parent or being abused and neglected as a child • Caretaker may have trouble forming healthy attachment to their children

Munchausen by Proxy • This form of abuse claims the life of 9% of the children that fall victim to it • Extremely difficult to diagnosis which is why many children die before doctors realize what is actually happening • Children often require extensive emergency medical care and undergo several unnecessary procedures or surgeries

Munchausen by Proxy • Warning signs in a child include: o History of repeated injuries, illnesses , hospitalizations or surgeries o Symptoms that don’t quite fit any specific disease o Symptoms that don’t match test results o Symptoms that improve under medical care but get worse at home o Drugs or chemicals are found in the child’s urine, blood or stool • Warning signs in the caretaker include: o Attention seeking behavior o Striving to appear self sacrificing and devoted o Becoming overly involved with doctors and medical staff o Refusing to leave the child’s side o Exaggerating the child’s symptoms o Appearing to enjoy the hospital environment and the attention the child receives

Munchausen by Proxy • Extremely difficult to diagnose • Often goes undetected • Increased awareness and education for physicians, nurses and EMS • “Virtually all of the caregivers have personality disorders that lead them to behave in odd and destructive ways, especially when they feel under stress” • Treatment is psychotherapy

Measles • Leading cause of death in Children worldwide • Discovered in the 9 th century by a Persian physician • In 1912 it became a notifiable public health disease in the United States • 1963 vaccine became available • Prior to 1963 nearly all children got the measles by age 15 and 3 -4 million were infected every year. • Prior to 1963: 400 -500 people died, 48, 000 were hospitalized and 4, 000 suffered encephalitis from contracting measles

Measles • 1978 the CDC set a goal to eliminate measles from the U. S. • The measles vaccine drastically reduced the disease rate and by 1981 numbers were down by 80% • 1989 due to measles outbreaks in schools the American Academy of Pediatrics recommended a second dose of the MMR vaccine for all children • Measles was declared eliminated from the United States in 2000.

Measles • 2015: Large multi state outbreak linked to an amusement park in California • 2014: The U. S. experienced 23 measles outbreaks including one of 383 cases occurring primarily among the unvaccinated Amish community • 2013: U. S. experienced 11 outbreaks with over 120 cases • 2011: More than 30 countries worldwide reported and increase in measles with France experiencing a large outbreak. Most of the cases that were brought to the Unites States came from France

Measles • Caused by an infection with the rubeola virus • Acute and highly contagious • The virus lives in the mucus of the nose and throat of an infected child or adult • The infected person is contagious for 4 days before the rash appears, and continues for about 4 -5 days afterwards • Virus can live for up to 2 hours in the airspace where the infected person coughed or sneezed • So contagious that 90% of the people close to the person who are not immune will become infected

Measles

Measles

Pertussis • Highly contagious caused by the bacteria Bordetella pertussis • Bacteria attach to the cilia • Bacteria releases toxins which damage cilia and cause airways to swell • Transmitted person to person by coughing or sneezing • Infected people are contagious for 2 weeks after cough begins

Pertussis • Known for uncontrollable violent coughing • After fits of coughing when the person tries to take a deep breath it may result in a whooping sound • Can affect all ages but can be deadly in babies less than one year. • Disease starts with cold-like symptoms • In babies the only symptom may be apnea • Symptoms usually start 5 -10 days after exposure • Generally treated with antibiotics

Pertussis

Pertussis

Pertussis • Worldwide estimated 48, 500, 000 million cases per year with about 195, 000 deaths • 2012: there were 48, 277 cases in the United States. This was the largest number of cases in the U. S. since 1955.

Nicotine Poisoning • E cigarettes utilize nicotine and flavoring dissolved in a solution of propylene glycol, polyethylene glycol and/or vegetable glycerin • A small quantity of the liquid is passed over an interior heating element producing a dense vapor that simulates the smoke of burning tobacco • Most E cigarettes have a self contained cartridge with a refillable reservoir • Reservoir holds 0. 3 to 1. 6 ml of nicotine liquid • The nicotine concentration ranges from 0 -36 mg/ml but can be as high as 72 mg/ml

Nicotine Poisoning • The liquid is called “e-liquid” or “smoke juice” • It may be flavored to smell or taste like mint, chocolate, coffee or various fruits • Very concentrated • Even a small taste can cause nicotine poisoning in a child • Middle school students are using e-Cigs at double the rate from 2 years ago • 10% of high school students smoke e-Cigs

Nicotine Poisoning • In 2014 one half of reported exposures to liquid nicotine occurred in young children under the age of 6 • Year Number of Cases • 2011 271 • 2012 460 • 2013 1, 543 • 2014 3, 783 • 2015 3, 073 • 2016 • Through May 31, 2016 770

Nicotine Poisoning • Number of children under 6 poisoned by nicotine from ecigarettes rose 1500% between 2013 -2015 • More than 90% swallowed the nicotine laced liquid • Children attracted by colorful bottles and flavors

Nicotine Poisoning

Nicotine Poisoning • • • Nicotine is highly toxic Contents of liquid nicotine are unregulated As little as 1 mg can cause symptoms in an infant Nicotine acts on the brain Mild nicotine poisoning causes o o o Nausea and vomiting Dizziness Tremors Sweating Elevated blood pressure • Severe poisoning is life threatening and can lead to seizures. Onset in as little as 20 -30 minutes

Nicotine Poisoning • Symptoms of Acute Nicotine Toxicity o Gastrointestinal: • Sharp burning in the mouth and throat on contact. • Gagging, nausea, vomiting profuse salivation, abdominal pain and cramping o Central Nervous System • Headache • Dizziness • Lethargy • Agitation • Confusion • Delirium • Seizures and coma

Nicotine Poisoning • Cardiovascular o Transient vasospasm-induced hypertension and tachycardia followed in high doses by hypotension and bradycardia o Arrhythmias and coronary ischemia • Neuromuscular o o Muscle fasciculation Hypotonic muscles Muscle weakness Respiratory failure • Nicotine Poisoning is known as nature’s muscle relaxer • Very few states require childproof packaging!

Nicotine Poisoning • There is no specific antidote for nicotine • Care is symptomatic and supportive o o Fluids and vasopressors for hypotension Atropine for bradycardia and excessive secretions Benzodiazepines for seizures Ventilator support for patients with muscle weakness or respiratory failure • • Half life of nicotine is an hour or less • Mild toxicity rapidly resolves in 1 to 4 hours • Severe toxicity may last 18 -24 hours

Detergent Pods • New category of cleaning product • In 2016, through June 30, poison centers received reports of 6, 429 exposures to highly concentrated packets of laundry detergent by children 5 years and younger. • Children exposed to them experience o o o Excessive vomiting Severe respiratory distress/ pulmonary edema Burns to the esophagus Burns to the eyes and skin Coma

Detergent Pods • Detergent Pods/packets emerged as the biggest contributor to hospitalizations and serious medical effects among any other kind of detergent poisoning • Detergent more highly concentrated • Easier to digest • The water-soluble membrane will dissolve quickly in their mouth or pop when child bites it, which shoots concentrated detergent down their throat and into their airway

Detergent Pods • Laundry detergent Pods have 3 main routes of exposure: ingestion, ocular and dermal • Ingestion most common route (80%) • Polyvinyl membrane is easily soluble when exposed to moist skin or saliva • Ocular exposure can cause burning, irritation, conjunctivitis and eye pain • Dermal exposure results in rash and skin irritation due to alkaline components.

Detergent Pods • Treatments include; o Stabilize airway, breathing and circulation o Eyes should be irrigated early o Contaminated clothing should be removed • As a result of growing awareness many companies in the Unites States have to committed to changing packaging to make less appealing to children

Scenario • You respond for the man “who is acting strangely holding a bat. ” Police are on scene and tell you they were called for a naked man who was swinging a bat and screaming at passing cars in the middle of the street. • Patient is a large obese man and he is screaming “make them stop. ” • Officers are attempting to restrain him , utilizing tasers several times and now have him handcuffed, face down on the street. The patient is now quiet and the police call you over to assume care.

Scenario • • Your assessment reveals : GCS score of 6 (E 1 V 1 M 4) Airway: Snoring respirations Breathing: 8/ RR breath sounds diminished Circulation: Bounding pulse, 160/min Disability: Moves all extremities to pain Pupils are dilated 8 mm

Scenario • • • S- Unconscious responds to painful stimuli A- Unknown M- Medications unknown P- Past medical History unknown L- Last meal unknown E- Acting erratically and was tasered by police several times. Taser barbs in place to back and upper thighs.

Scenario • • • Vitals- B/P 260/130, Pulse 160 bounding RR 8 Sp. O 2 92% Room Air Blood glucose 130 Monitor: Sinus Tachycardia Skin Flushed, very warm to touch, diaphoretic Tympanic temp: 105. 8

Scenario • Treatment • Oxygen? • Patient starts to wake up and now becomes very combative • How do you handle this patient?

Excited Delirium • Relatively uncommon health condition • Characterized by severe agitation, distress, aggression and sudden death • Occurs most commonly in men • First described in mid 1800’s also known as o o Bell’s Catonia Lethal catonia Acute exhaustive mania Agitated delirium • Approximately 75% of individuals with this condition died.

Excited Delirium • The majority of cases since 1985 were associated with stimulant drug reactions • Cocaine appears to have the strongest link • Most weren’t abusing but experiencing an abnormal reaction to cocaine • A metabolite of cocaine “benzoylecgonine” was significantly higher in bloodstream • Most cases of excited delirium are associated with high mortality rate • Has gained increasing public attention

Excited Delirium • Methamphetamine is another culprit • Also similar conditions occur with ingestion of LSD, alcohol, Phencyclidine (PCP)

Excited Delirium • Two most common causes of death for EMS include o Cardiac arrest as a result of cardiac arrhythmia or tachycardia o Respiratory failure due to inability to get sufficient levels of oxygen and eliminate sufficient carbon dioxide • Police restraint due to o compression leading to decreased oxygen levels o arrhythmias o exacerbation of symptoms as a result of hyperventilation o Positional asphyxia o Taser usage resulting in disruption of heart rhythms

Treatment • ABC’s • Treatment will be subject to patient presentation • Benzodiazepines: most commonly used. They slow activity in the CNS and cause sedation • Sodium Bicarbonate: If in cardiac arrest or shock will mitigate severe acidosis patient may be experiencing with consent of medical control • Hyperthermia: reduce body temperature with cold packs, water sprays or fanning, intravenous saline • Monitoring

Status Epilepticus • Status epilepticus refers to the occurrence of a single seizure lasting longer than 5 -10 minutes refractory to intervention or frequent clustered seizures without a return to baseline. • Not associated with increased mortality but is linked to prolonged hospitalization and poorer functional outcomes • Benzodiazepines remain the first-line treatment for status epilepticus

Diastat Drug of the Month • • Rectal gel formulation of diazepam Provides rapid delivery of the drug Onset of action is 5 -10 minutes Using Diastat in the home situation controls the seizure more quickly and often prevents the need to call 911 • Comes in easy to use prepackaged, premeasured doses • Requires no refrigeration or special handling • Has a 4 year shelf life

Diastat • There are times when 911 should be activated. • The healthcare provider that ordered the Diastat sets parameters for calling 911 with caregiver • They would include o o The seizure continues for 15 minutes after administering Diastat Seizure behavior is different from usual episodes Caregiver is alarmed by patient color or breathing The person is having unusual or serious problems with seizure activity • Adverse effects include: drowsiness, lethargy, hypotension, agitation, confusion, dizziness, slurred speech, headache, flushing, stomach pain and diarrhea , CNS depression

Diastat

Diastat

Scenario • You respond to the home for a medical emergency. On arrival you find a 6 -year old female with a complaint of sudden onset of “My heart is running away. ” • She is alert and in no distress. • Her mother denies that the child has any history of heart disease and is in good health. This came on very suddenly while watching TV.

Scenario • • • Airway: Clear Breathing: 22/ min unlabored BP is 100/70 mm/Hg Pulse oximetry is 95% on room air You place her on the monitor and this is what you see

Scenario • • • S: Feels like her heart is racing A: None M: None P: no past medical history L: Ate breakfast at 8 am E: watching TV when felt “her heart was running away”

Scenario • During transport you note that the child is less responsive. • Current vital signs are o o Heart rate 230 BPM Blood Pressure 80/50 Respirations 30 Pulse oximetry 93% • Stable or Unstable? • Treatment o Oxygen o Adenosine o Cardioversion

Pediatric Tachycardia • Tachycardia is common in the pediatric age group • Often etiology is benign • Requires rapid assessment of patient status and cardiac rhythm • Most life threatening cardiac conditions in children that present as tachycardia consist of supraventricular tachycardias

Supraventricular Tachycardia • Most common symptomatic dysrhythmia of childhood • May present with palpitations, chest pain or shortness of breath in children with heart rates • >180 BPM • In infants symptoms are lethargy, feeding difficulties or irritability with heart rates >220 BPM • SVT most often caused by an accessory atrioventricular pathway

Supraventricular Tachycardia

Supraventricular Tachycardia • May be associated with : o o Drug exposure especially sympathomimetics contained in high caffeine drinks Cough and cold medications Dietary supplements Congenital heart disease (especially Epstein anomaly) • Not to be confused with ventricular tachycardia which is uncommon in the pediatric population

Supraventricular Tachycardia

Supraventricular Tachycardia • Vagal maneuvers may be utilized for children who have mild or no symptoms while ECG is being continuously monitored. • Infants and younger children: an application of a bag filled with ice and cold water over the face for 10 -15 seconds • Older children: bearing down (Valsalva maneuver) for 10 -20 seconds

Supraventricular Tachycardia • Adenosine is considered the drug of choice for medical conversion • Antiarrhythmic agent used to treat supraventricular tachycardia that does not improve with vagal maneuvers • It slows the sinus rate and increases the AV node conduction delay.

Pediatric Tachycardia