Peds Ward NightTime Curriculum 2019 2020 Directions Follow

Peds Ward Night-Time Curriculum 2019 -2020

Directions • Follow along with power point in order to discuss high-yield topics via power point interactive learning, cases, CPGs, Johns Hopkins Modules, and Med Study Videos. • Use the presenter view for this PPT so that the PGY 3 can see the teaching points in the note section • After you are done with the PPT: • Have the PGY 1 pick 3 Med. Study Videos to watch with PGY 3 • Pick a topic that was discussed during a Morning Report Lecture that you missed this month while you are on nights • Ex: Block 1 Intro to Peds/Emergency • Watch a video on toxic ingestions or cardiac emergencies • Complete 10 Prep Questions per week

Topics 4. FEN/GI 1. 2. 3. Neuro I. III. Seizure AMS Pain Management Resp I. III. CV I. II. 5. Heme I. II. IV fluids Electrolytes Blood products Anemia Respiratory Distress Viral Bronchiolitis Asthma 6. ID Shock Heart Murmurs 7. Ward Management I. II. Fever I. Triage Communication/Hand-Offs IPASS

Neurology

Seizures

Case #1 n 14 -month-old developmentally normal boy who presents with generalized tonic -clonic seizures associated with fever. ¨ How would you initiate management? ¨ What other information would be useful to you as you are starting to intervene? ¨ What type of work-up does this patient need?

Case # 2 n 12 -year-old boy with obstructive hydrocephalus and VP shunt who presents with generalized tonic-clonic seizures for the past 15 minutes. ¨ How would you initiate management? ¨ What other information would be useful to you as you are starting to intervene? ¨ What type of work-up does this patient need?

Status Epilepticus n A patient is in status epilepticus if seizure activity has lasted > 5 minutes or there are multiple seizure episodes with failure to regain consciousness between episodes

Management of Seizures n n Initial assessment ¨Airway ¨Breathing ¨Circulation Status Epilepticus Protocol ¨ Where n is this located on the ward? Work-up for underlying cause n Ask for more history ¨ How long has the patient been seizing? ¨ New-onset vs. known seizure disorder ¨ Baseline seizure frequency, is this typical or not? ¨ Events leading up to this episode ¨ Meds/triggers ¨ History of status

BAMC Peds Status Epilepticus Protocol • Assess ABCs, Oxygen, suction prn • LABS: D-stick, i. STAT lytes, Consider other labs prn • Treat metabolic derangements (see reverse side) • No IV access: Midazolam 0. 2 mg/kg IM/nasal, 0. 2 -0. 5 mg/kg buccal; Diazepam 0. 2 -0. 5 mg/kg PR • IV Access: Lorazapem 0. 1 mg/kg x 1 once IV obtained; repeating q 5 minutes (max 2 doses/8 mg) • Prepare Fosphenytoin 20 mg PE/kg IV 0 -10 minutes 10 -15 minutes • FOSphenytoin 20 mg PE/kg IV x 1 (max admin rate 150 mg PE/min) OR • Lorazepam 0. 1 mg/kg IV (2 nd dose) • Consider: Levetiracetam 20 -30 mg/kg IV bolus OR • • 15 -30 minutes Phenobarbital 20 mg/kg IV x 1 Consider Fast MRI or CT (trauma, 1 st sz, other indication) Consider Antibiotics and cultures if clinical sx of infection Expedite Transfer to PICU for EEG/improved monitoring 3 rd - 4 th Line Drug Options: • • Phenobarbital 20 mg/kg IV x 1 (if not already given) Levetiracetam 20 -30 mg/kg IV bolus (if not already given) Midazolam 0. 2 mg/kg IV bolus followed by 0. 1 mg/kg/hr gtt (titrate up to 1 mg/kg/hour) Pentobarbital 10 -15 mg/kg IV bolus followed by 1 mg/kg/hr gtt (titration range 1 - 5 mg/kg/hr)

Altered Mental Status From C. J. Long, Visual Slide Presentation

Workup Depressed mental status is a medical emergency with a broad differential n Determination of etiology is essential for optimal treatment n Workup requires a systematic approach n

AMS Differential A: Alcohol n E: Epilepsy/Electrolytes/Encephalopathy n I: Infection n O: Overdose/oxygenation n U: Uremia n T: Trauma/Tumor (Increased intracranial pressure) n I: Insulin (Hypoglycemia) n P: Psychiatric/Poisoning n S: Shock/Stroke n

Pediatric Glasgow Coma Scale Infant < 1 yr Child 1 -4 yrs > 4 years EYES 4 Open 3 To voice 2 To pain 1 No response VERBAL 5 Coos, babbles Oriented, speaks, interacts, social Oriented and Alert 4 Irritable cry, consolable Confused speech, disoriented, consolable Disoriented 3 Cries persistently to pain Inappropriate words, inconsolable Nonsensical speech 2 Moans to pain Incomprehensible, agitated Moans, unintelligible 1 No response MOTOR 6 Normal spontaneous movement Follows commands 5 Withdraws to touch Localizes pain 4 Withdraws to pain 3 Decorticate flexion 2 Decerebrate extension 1 No response

Labs (adapted from Michelson et al. ) n If cause for depressed mental status is not readily apparent send: Bedside blood glucose Electrolytes with Ca, Mg BUN, creatinine Transaminases n Urine drug screen Complete blood count Blood culture ABG/VBG, ammonia If suspected metabolic abnormality send: UA, urine ketones, plasma amino acids, urine organic acids, plasma free fatty acids, carnitine profile, lactate, pyruvate

Management (adapted from Thompson and Williams) n ABCs / PALS n 3% Hypertonic Saline ¨ Elevate HOB ¨ NSGY Stabilize C-Spine if indicated ¨ Intubate for GCS ≤ 8 ¨ ¨ n n D 10% - 2. 5 m. L/kg IV Lorazepam (0. 1 mg/kg) for clinical seizures Antidote or reversal agent if known/suspected ingestion For Infection Ceftriaxone, Vancomycin ¨ Acyclovir ¨ For increased ICP n For non-convulsive status epilepticus ¨ Lorazepam or Fosphenytoin Treat Underlying Cause

Diagnostic Studies n CT is the initial neuro-imaging test of choice. ¨ MRI with DWI can be considered as an adjunct. n LP after increased ICP has been ruled out n EEG to rule out non-convulsive status epilepticus should be performed in children with depressed mental status where etiology remains elusive.

Pain Management

Case 1 n A 4 year old has recently returned from having an abscess drained and has a JP drain in place. The nurse is asking for pain medication. ¨ How would you assess the patient’s pain? ¨ How would you treat his pain? ¨ What if it is getting worse?

Case 2 n A 10 yo female with a fractured arm is complaining of pruritus with morphine. ¨ How would you assess her pain? ¨ What changes would you make to her pain regimen?

Pain Management Pediatricians often under-treat children’s pain n When initiating pain medications, consider a standing regimen n ¨ Avoid combination products (i. e. Vicodin) at first n Constantly re-assess your pain plan ¨ Is it working? ¨ Any side effects?

Non-Opioid Pain Medications n Acetaminophen ¨ PO/IV: 10 -15 mg/kg every 6 ¨ MAX 5 DOSES in 24 hours n hours NSAIDS ¨ Ibuprofen n PO: 5 -10 mg/kg every 6 -8 hours n MAX 40 mg/kg/day n Contraindicated in active GI bleeding and AKI ¨Ketorolac n Available PO, IV, IM n Potential opioid sparing effect n Cannot be used for a long time ¨ No more than 24 -72 hours in children less than 2 years ¨ No more than 5 days in children 2 and older

Narcotic Medications n Morphine (PO/IV/PCA) ¨ PO: 0. 2 -0. 5 mg/kg every 4 -6 hours ¨ IV: 0. 05 -0. 2 mg/kg every 2 -4 hours ¨ PCA: On demand 0. 015 mg/kg PCA dose q 10 min lockout n n Can consider adding basal if frequent on demand dosing Oxycodone (PO) ¨ 4 -5 n hour duration Hydromorphone (IV/PO) ¨ 5 x more potent than morphine ¨ 4 -6 hour duration n Fentanyl (IV) ¨ Potent (100 x morphine), short duration

Alternatives n Caudal Blocks ¨ Post-op n in urology Epidurals ¨ Post-op n orthopedics Non-Pharmcologic ¨ Heat/Ice Packs ¨ Massage ¨ Feedback training ¨ Acupuncture

Respiratory

Respiratory Distress

What are the signs and symptoms of respiratory distress?

Signs and symptoms of respiratory distress • Increased work of breathing • Tachypnea • Retractions • Intercostal • Subcostal • Suprasternal • • Abdominal breathing Accessory muscle use Nasal flaring Grunting • Decreased oxygen saturations • Wheezing • Cyanosis • Altered mental status

How do you initially assess a patient in respiratory distress?

Initial Assessment • Rapid assessment • Quickly determine severity of respiratory condition and stabilize child • Respiratory distress can quickly lead to cardiac compromise • Airway • Support or open airway with jaw thrust • Suction and positioning patient with shoulder roll • Breathing • Provide high concentration oxygen • NC vs HHFNC vs Bi. PAP vs Intubation Administer medication ie albuterol, epinephrine • Bag mask ventilation • Prepare for intubation • Circulation • Establish vascular access: IV/IO

What high yield history points are you going to ask the parents of a patient in respiratory distress? What are you looking for the PE?

History and Physical Exam History Physical Exam • Trauma • Change in voice • Onset of symptoms • Associated symptoms • Exposures • Underlying medical conditions • Mental status • Position of comfort • Nasal flaring • Accessory muscle use • Respiratory rate and pattern • Auscultation for abnormal breath sounds

During a busy night, you get the following page: FYI: Sally, a 2 year old with PNA had a desat to 88% while on 4 L NC. What do you do next? What initial management steps would you take?

What initial studies would you get for this patient in respiratory distress?

Initial studies • Pulse ox • May be difficult in agitated patient • May be falsely decreased in very anemic patients • Imaging • Chest X Ray • Consider in patients with focal lung findings or respiratory distress of a unknown etiology • Soft tissue radiograph of lateral neck • May identify a retropharyngeal abscess or radiopaque foreign body • Labs • ABG vs CBG vs VBG • Chemistry: calculate anion gap • Urine toxicology and glucose if patient has altered mental status

What are some examples of life threatening conditions?

Life threatening conditions • Complete upper airway obstruction • No effective air movement, speech or cough • Respiratory failure • Pallor or cyanosis, altered mental status, tachypnea, bradypnea, apnea • Tension pneumothorax • Absent breath sounds on affected side, tracheal deviation and compromised perfusion • Pulmonary embolism • Chest pain, tachycardia, tachypnea • Cardiac tamponade • Apnea, tachycardia, hypotension, respiratory distress

Upper Airway Obstruction • Causes/examples: croup, foreign body, tissue edema, trauma, viral infection, intubation, tongue movement to posterior pharynx with decreased consciousness • Symptoms • Partial obstruction: noisy inspiration (stridor), choking, gagging or vocal changes • Complete obstruction: no audible speech, cry or cough • Management • • Rapidly decide if advanced airway is needed Avoid agitation: position of comfort Suction only if blood or debris are present Reduce airway swelling • Inhaled racemic epinephrine • Corticosteroids • Croup and anaphylaxis require additional management • What are these?

Lower Airway Obstruction • Viral Bronchiolitis • Symptoms: copious nasal secretions, wheezes and crackles in child less than 2 years • Management • Supportive care: • Oral or nasal suctioning • Oxygen and flow if needed • Question for PGY 1: Should we use steroids or albuterol? Do we need other studies: RPP, CXR, blood gas, etc? See bronchiolitis section for more…. • Asthma • Symptoms: wheezing, tachypnea, increased work of breathing, hypoxia • Management • Mild-moderate: oxygen, albuterol, oral corticosteroids • Moderate to severe: oxygen, albuterol-ipratropium (Duo-Neb), corticosteroids (IV), magnesium sulfate, Sub. Q epi, and Magnesium sulfate • Impending respiratory failure: oxygen, albuterol-ipratropium, corticosteroids, assisted ventilation (bag-mask ventilation, Bi. PAP, intubation), adjunctive agents (terbutaline), heliox

Upper Level Case Your intern calls you from the bedside of Jonathan, a 2 year old with Pompe’s disease who is Bi. PAP dependent overnight with settings of 18/5 and a backup rate of 18. Over the past few hours, he has had an increase in his oxygen requirement from an Fi. O 2 of 21 to 40% and his temp has spiked to 102 F. What steps do you take to evaluate and manage him overnight? If giving antibiotics what antibiotic(s) would you start and why? Would you transfer to PICU?

Lung Tissue Disease • Etiologies of lung tissue disease • • Infectious pneumonia Aspiration pneumonitis Non-cardiogenic pulmonary edema (ARDS) Cardiogenic pulmonary edema • Consider positive expiratory pressure (CPAP, Bi. PAP or mechanical ventilation with PEEP) if hypoxemia is refractory to high concentrations of oxygen

Disordered Control of Breathing • Abnormal respiratory pattern produces inadequate minute ventilation • Altered level of consciousness • Elevated intracranial pressure • Cushing’s triad • What is this? • Poisoning or drug overdose • Administer specific antidote if available • Hyperammonemia • Metabolic acidosis • Neuromuscular disease • Restrictive lung disease => atelectasis, chronic pulmonary insufficiency, respiratory failure • Support oxygenation and ventilation while treating the underlying problem

BAMC Specific Points • Know what types of respiratory devices are allowed on the ward • WARD: NC, Simple Face Mask, HHFNC, BIPAP/CPAP are ok if at baseline without increased settings • PICU: NC, Simple Face Mask, Non-rebreather, HHFNC, BIPAP/CPAP, Intubation, Trach • Know MAX for HHFNC on ward based on age

Viral Bronchiolitis • Read and discuss GPG https: //pediatrics. aappublications. org/content/134/5/e 1474 PDF saved in Night-Time Curriculum folder

Asthma - Definition • Chronic airway inflammation resulting in episodes of • reversible airway narrowing and increased mucus • production

Asthma Pathology • Triggers are multiple • Allergens • • • Environmental • Food Viral pathogens Air pollution Smoke Exercise Cold • Increased parasympathetic tone • Epithelial denudation • Exposed nerve endings • Increased responsiveness • Immune system overactivation • Th 2 cell predominant

Asthma – Mechanisms of Distress • Air trapping • Auto peep • Increased work of breathing • Airway constriction • Turbulent flow • Increased work of breathing • Increased airway resistance (~ P) • Laminar: P ~ Vel • Turbulent: P ~ Vel 2 • Altered V/Q matching • Increased dead space ventilation • Failure of ventilation, oxygenation • Alveolar flooding • Transcapillary fluid leak • Due to massive swings in intrathoracic pressure and inflammation • Diminished cardiac output • Dehydration • Increased insensible losses • Decreased intake

Asthma • Log on to Johns Hopkins PEAC Module • Complete Asthma Module • Review these slides for acute ward management • Review BAMC Asthma Pathway • • How to calculate a PAS Score? What intensifications can you do? What controllers can you put a patient on? How to fill out an Asthma Action Plan?

CV

Pediatric Shock • What are the main categories of shock? • Can you name examples of each type?

Physiologic profiles of shock states Type of Shock Preload Cardiac Afterload Tissue (PCWP) Output (SVR) Perfusion (Mixed venous sat) Hypovolemic Distributive Or = * Cardiogenic Or = Obstructive

Case 1 • 15 -year-old previously well boy is freshly from the PICU, POD #3 from partial small bowel resection after multiple gunshot wounds to the abdomen. The nurse pages because his HR has increased in the last hour from 90 to 130, despite pain score of 1/10 on morphine drip. On exam, he is afebrile, HR is 140, BP 80/50. Cap refill is >3 seconds in his cool extremities and pulses are 1+. • What is your assessment? • Shock or not shock? • What is the stage of shock? • Compensated vs Uncompensated • What is the classification of shock? • What is your initial management? • What will change last: HR, BP, CR?

Shock: Evaluation pearls • Tachycardia? - Non-specific early finding. Investigate further. • Skin changes? - Typically, prolonged cap refill (vasoconstriction) with compensated shock. Flash refill with early distributive shock and with irreversible shock. • Impaired mental status? - Defining mental status as accurately as possible (GCS) is key to monitoring progression. Assess for yourself -- don’t rely on other providers. • Oliguria? – Place foley to monitor closely • Hypotension? - Late finding. Don’t accept from others that BP is “normal. ” • Widened pulse pressure (>40 mm. Hg)? - May be present in distributive shock, aortic insufficiency, AVMs, Cushing’s reaction

Case 2 6 -year-old previously well girl is admitted to your ward directly from clinic with fever, bloody diarrhea x 1 day. She’s had no urine x 24 hrs and is becoming harder to awaken. On exam, her HR is 150, BP 72/30, temp 103. She’s sleepy but arousable. She’s flushed with capillary refill <1 second. • What is your assessment? • Shock or not shock? • What is the stage of shock? • Compensated or uncompensated? • What is the classification of shock? • What is your differential for the etiology? • What is your initial management? If a higher level of care is needed, how would you obtain it? • Where can you find our BAMC Pediatric Septic Shock Algorithm?

1 st Hour IV or IO ABP

Refractory to fluids? Remember VO 2!!!

Warm Normotensive ABP **Frequent reassessment and monitoring Cold

Pressors/inotropes Epinephrine Norepinephrine Dopamine Dobutamine Common Dose (mcg/kg/min) 0. 03 -0. 1 >0. 1 0. 05 -2 5 -10 10 -20 2 -20 α 1 β 2 1+ 3 -4+ 2+ 3+ 4+ 1+ 2+ 2+ 4+ 2+ 2 -4+ 1+

Case 3 4 -month-old boy ex-term, previously well boy presents to ED with decreased desire to feed x 2 days with 2 times daily emesis, following what sounds like viral URI. Urine output has been 3 wet diapers daily. He is afebrile with HR 180; BP has not been obtained. He has a weak cry, is mottled with 3 -second capillary refill, pulses 1+ in all extremities. Liver is palpable 4 cm below RCM. S 4 is present without murmur. • What is your assessment? • Shock or not shock • What is the stage of shock? • Compensated or uncompensated • • What is the classification of shock? What is your differential for the etiology? What is your initial management? What if this was a 7 day old? What medication should you order?

Shock Highlights Hypovolemic shock • IV fluids • Do not delay PRBCs if suspect hemorrhage. Septic shock • Antibiotics early • If not improved after 60 ml/kg crystalloid, consider pressors • Epi or dopamine • Norepi if warm shock • Cardiogenic shock • Consider in any patient worsening with fluid therapy. • Epinephrine and dopamine • Consider milrinone if diastolic dysfunction, dobutamine if increased SVR leading to organ dysfunction. • Don’t forget PGE if concern for PDA dependent lesion • Obstructive shock • Causes of obstructive shock require specific interventions • Chest tube for tension pneumothorax • Removal of fluid for tamponade

Take-Home Points • Shock is a progressive process. • Intervene early. • Identifying the stage and classification of shock is important. • Stage: Compensated, uncompensated, or irreversible? • Classification: Hypovolemic, distributive, cardiogenic, or obstructive? • Management should be directed at normalizing tissue perfusion and blood pressure. • Consider using the consensus-based goal-directed algorithm for shock management.

Heart Murmurs Log on to Johns Hopkins PEAC Module • Complete Heart Murmurs Module • Optional: • If you would like to learn more please view the Med. Study Video on Murmurs

FEN/GI

IV Fluids This section will answer: • How do you calculate the MIVF rate? • What type fluids should I give? Electrolytes • This section will answer: • How do I treat hypoglycemia? • How do I recognize and treat hyperkalemia?

Total Body Water Composition • Regulated by Antidiuretic hormone (ADH) and aldosterone • Are secreted in reaction changes in blood volume • Disturbances in either ADH or aldosterone will cause large effects on water homeostasis

Electrolyte Composition of Intra and Extracellular Fluids • Sodium is the predominant cation in the extracellular space • Alterations in sodium concentrations can have significant effects on water homeostasis • Potassium is the predominant intracellular cation • Medical conditions and drugs can cause movement in potassium from the intracellular to extracellular space

Intravenous Fluid Composition Fluid Na Cl Normal Saline (0. 9%) 154 meq ½ Normal Saline 77 meq (0. 45%) 77 meq 1/4 Normal Saline (0. 2%) 34 meq Lactated Ringers 130 meq 109 meq K Ca Lactate 4 meq 3 meq 28 meq

Osmolality = 2 × [Na] + [glucose]/18 + [BUN]/2. 8 • Measure of solute particles per weight of solvent • Normal ranges are 280 -295 m. Osm/kilogram • Water shifts from a low to high osmolality in the body • Rapid shifts adversely effect the central nervous system more than the rest of the body as seen to the right with central pontine myelinosis -

Goals of Maintenance Fluids • Infants and children require more fluids per unit of body weight due to high metabolic rates • Maintenance fluids should be initiated for infants who are required to go over 4 hours without fluid intake- as occurs prior to surgery and procedures • Maintenance fluids replace the daily loss of: urine+ stool+ insensible losses Fluid Goals • Prevent Dehydration • Prevent Electrolyte Disorders • Prevent Ketoacidosis* * Guidelines assume that there is no disease process present that would require an adjustment in either the volume or the electrolyte composition of the maintenance fluids

Maintenance IV Fluids: Holliday Segar Method of Calculation What to run in general? <10 kg: D 5 1/2 NS + 20 meq. KCl/L or D 5 NS + 20 meq KCl/L >10 kg: D 5 NS + 20 meq KCl/L How much ml/day? 1 st 10 kg: 100 ml/kg 2 nd 10 kg: 50 ml/kg kg >20 kg: 20 ml/kg How fast ml/hr? 1 st 10 kg: 4 ml/kg 2 nd 10 kg: 2 ml/kg kg >20 kg: 1 ml/kg

Maintenance IVF Practice: Write hourly rates for each patient weight 8 kg = 10 kg = 15 kg = 80 kg = 8 x 4 = 32 cc per hr of D 5 ½ or D 5 NS 10 x 4 = 40 cc per hr of D 5 NS 10 x 4 + 5 x 2= (40 + 10)= 50 cc per hr of D 5 NS 10 x 4 + 10 x 2 +60 x 1= (40+20+60)= 120 cc per hr Note- 120 cc is maximal rate for normal maintenance In oncology patients meters squared is used in lieu of kilograms

Clinical Picture of Dehydration Signs & Symptons Mild 3 -5% Moderate 6 -9% Severe > 10% General Thirsty, restless, Drowsy alert Drowsy, limp, cold, mottled Peripheral pulses Normal Rapid and weak Rapid, thready Breathing Normal Deep, rapid Fontanelle Normal Sunken Very sunken Capillary Refill < 2 Seconds Prolonged 3 -4 sec Very prolonged > 4 sec Mucous membrane Moist Dry Very dry Blood Pressure Normal Hypotension

Fluid Resuscitation/Treatment of Dehydration For dehydration, shock, blood loss-isotonic • Normal Saline or Lactated Ringers • Can also bolus albumin • Give 20 ml/kg as bolus…. then repeat your exam • Repeat bolus if symptoms of dehydration are still present • Monitor for signs of HSM or heart failure • After patient shows improvement you can change to glucose containing IV fluids • Calculate fluid need based on degree of dehydration and cover for 24 hours • Consider Colloid for large blood loss or greater than 3 boluses of 20 cc/kg

Electrolyte Composition of Body Fluids Fluid Replacement of ongoing fluid loss Replacement rate Gastric fluid Na 60 meq/L K 10 meq/L Cl 90 meq/L Normal Saline + 10 meq KCL/Liter ml/ml every 1 -6 hours Diarrhea Na 55 meq/L K 25 meq/L HCO 3 meq 15/L D 5 ¼ NS + Na. HCO 3 20 meq/L + KCL 20 meq/L ml/ml every 1 -6 hours

Intern Case History You are receiving an admission from the same day sick clinic. It is a 2 month old with vomiting and diarrhea for 3 days. Failed oral rehydration therapy due to vomiting. Two days ago the patient was seen for the same symptoms- weight at that time was 5500 grams. Today you are told the weight is 5000 grams. Questions 1. What is the degree of dehydration? 2. What would be the fluid deficit of this child in cc? 3. What is the maintenance IV rate? 4. What would be your initial fluid order? 5. What vital signs would you expect initially? 6. Write admission orders for this child

Senior Level Case You are covering Hem/Onc. A nurse calls to report that a 2 year old with recently diagnosed ALL has not urinated for 8 hours. He has been on no IV fluids and has oral lesions due to recent chemotherapy. This child has Down’s Syndrome and a “large” VSD and is on lasix and digoxin. You have no recent laboratory work available. What potential electrolyte abnormalities do you expect on a chemistry? What underlying pathology in this child could cause potential complications in fluid resuscitation? What would be your initial fluid order to the nurse and why? What physical exam findings would be helpful in your decision? What ominous physical signs would you look for after initial treatment?

Take Home Points! • Maintenance fluid calculations are based on the composition of maintenance water and use the Holiday Segar, or 4: 2: 1 method • Dehydration can be a medical emergency. Identification of the degree of deficit is based on patient history and physical signs on exam. Fluid resuscitation should be with isotonic fluid. • Correction of ongoing fluid losses is based on the body fluid lost and should be added to maintenance fluid requirements

Hypoglycemia Management • If patient conscious and able to drink, give PO rapidly absorbed carbohydrate • Glucose tablets/gel, table sugar, fruit juice, honey* • IV therapy • Initial bolus 2 -4 ml/kg D 10 administered slowly • Infusion of dextrose at 6 -9 ml/kg/min • Rate of infusion (mg/kg/min)=% dextrose x 10 x rate of infusion (ml/hr) ÷ (60 x wt in kg) • Use D 10 if peripheral IV (max concentration in PIV) *No honey in babies < 1 year of age!

Hypoglycemia Management continued • Goal is to keep serum glucose between 80 -100 mg/dl initially until determine cause of hypoglycemia • If no IV access, can give glucagon IM or SQ • 0. 03 mg/kg up to 1 mg • Vomiting may follow administration so must monitor closely • Check glucose Q 30 -60 mins initially until stable

What are some of the causes of hyperkalemia?

CAUSES OF HYPERKALEMIA I. Shifting of K into extracellular space A. Tissue (lots of cells) damage: burns, crush injury, rhabdomyolysis, tumor lysis B. Acidosis C. Hyperosmolar states D. Insulin deficiency II. Impaired Renal Excretion ( total body K) A. Renal insufficiency/failure B. Endocrine: adrenal insufficiency, renin, aldosterone, pseudohypoaldosteronism III. Iatrogenic A. K in IVF or TPN B. Medications: NSAIDS, ACE inhibitors, beta blockers, K sparing diuretics, trimethoprim, and many, many others

HYPERKALEMIA SIGNS AND SYMPTOMS I. Muscle A. Ascending muscle weakness and paralysis B. Respiratory muscle weakness rare II. Cardiac A. Conduction abnormalities and arrhythmias B. EKG Changes 1. Peaked T waves 2. Loss of P wave 3. Widened QRS 4. Sine wave pattern

HYPERKALEMIA TREATMENT I. Do no harm A. Remove any K containing fluids B. Remove any medications that could be contributing II. Stabilize cell membranes: IV calcium III. Drive K back into cells A. Insulin and glucose B. Albuterol IV. Remove excess K from the body A. Loop diuretics B. Cation exchange resin: Sodium polystyrene sulfonate (Kayexalate) C. Hemodialysis

Heme

Anemia • Log on to Johns Hopkins PEAC Module • Complete Anemia Module

Blood Products • Where do you find our guide to blood products on the ward?

ID

Fever

What etiologies cause fever? • Infectious • Inflammatory • Oncologic • Other: CNS dysfunction, drug fever • Life-threatening conditions

Infectious • Systemic • Bacteremia, sepsis, meningitis, endocarditis • Respiratory • URI, sinusitis, otitis media, pharyngitis, pneumonia, bronchiolitis • Abdominal • Urinary tract infection, abscess (liver, kidney, pelvis) • Bone/joint infection • Hardware infection • Central line, VP shunt, G-tube

Which patients are high-risk for sepsis? • Neonates • Transplant recipients • Bone marrow • Solid organ • Oncology patients • Undergoing therapy, mucositis, central line • Most chemotherapy: nadir ~ 10 days after rx • Asplenic patients, including sickle cell

Inflammatory • Kawasaki disease • Juvenile inflammatory arthritis • Lupus • Inflammatory bowel disease • Henoch-Schonlein purpura

Others • CNS dysfunction • Drug fever

Life-threatening conditions • Sepsis, febrile neutropenia • Vital sign instability, poor-perfusion, may have altered mental status, disseminated intravascular coagulation • Hemophagocytic lymphohistiocytosis • Splenomegaly, bicytopenia, elevated ferritin, elevated triglycerides, low fibrinogen, hemophagocytosis, low/absent NK cell function, elevated soluble IL 2 receptor • Malignant hyperthermia • Following administration of inhaled anesthetics or depolarizing neuromuscular blockers (succinylcholine), at-risk patients include those with myopathy • Muscle rigidity, rhabdomyolysis, acidosis, tachycardia

Assessment • First Impression • Sick or not sick • Vital signs • Repeat physical exam • • • Overall appearance (sick, toxic) Central/peripheral lines Incisions/wounds VP shunt/tracheostomy/gastrostomy tube Oral mucosa/perineal area for neutropenic patients Perfusion • Call for help if concerning vital signs/exam • Fellow or attending • Rapid response team (RRT)/PICU

Case 1 • 4 -month-old well-appearing girl admitted for croup and respiratory distress. Develops fever to 39. 1 C. • What additional evaluation would you do at this point?

Case 2 • 4 -month-old girl admitted fever to 39. 1 C x 4 days and noted to have poor PO intake. No signs of respiratory distress or URI. • What evaluation would you do at this point?

Laboratory evaluation • What would you do if the patient has hardware (VP shunt, tracheostomy, gastrostomy tube) or central line? • CBC with differential • Blood culture • CSF (tap VP shunt)

Laboratory evaluation • What would you do if the patient has a high risk for sepsis? • Immunocompromised • Transplant recipient • Oncology patient • • CBC with differential Blood culture Urinalysis and urine culture CXR

Laboratory evaluation • What would you do for an infant 0 -28 days of age? • • CBC with differential Blood culture Catheterized urinalysis and urine culture Lumbar puncture • ME panel • CSF culture, gram stain, protein and glucose • RPP • CXR • What antibiotics would you start? • Answer later in ppt…

Laboratory evaluation • Who needs a urinalysis and urine culture? • • • Circumcised males < 6 months Uncircumcised males < 1 year Females < 2 years Immunocompromised patients Patients with history of UTI/pyelonephritis

Laboratory evaluation • Who needs a lumbar puncture? • Neonates ≤ 1 month • Consider if less than 2 months without a source • Ill-appearing • Altered mental status • What tests do you send? • • ME Panel: #1 priority Gram stain and culture: #2 priority Cell count and differential: #3 priority Protein and glucose: #4 priority

Laboratory evaluation • Consider CRP, ESR • Consider chest x-ray • For immunosuppressed patients consider: • Additional imaging (ie ultrasound, CT scan)

Treatment for non-high risk patients • May not need empiric antibiotics • Consider the following issues: • Is patient clinically stable? • Are the screening laboratory studies suggestive of infection?

Treatment for patients with central lines • Ceftriaxone • Vancomycin

Treatment for Neonatal Fever • If < 28 days old • Ampicillin AND cefotaxime OR • Ampicillin AND gentamicin Where do you find the dosing for the antibiotics? !? ! **TRY TO NEONATAL FEVER ALGORITHM** - Located in the Night-time curriculum folder and in ppt • Consider acyclovir if presenting with seizures Pop Quiz: Why not ceftriaxone in infants less than 1 month? • If 29 -60 days old • Ceftriaxone ± Ampicillin **Until CSF results are known (ME panel, cell count, protein, glucose), initiate therapy with meningitic dosing regimen

Take home points • Infections are the most common cause of fever in children • During assessment of a child with fever, pay close attention to vital sign changes, overall appearance, and potential sites of infection • Closely monitor for clinical decompensation after antibiotic administration, particularly in patients at high-risk of developing sepsis

Ward Management

Triage

Case 1 You are the intern on-call and simultaneously receive the following 5 pages. How do you prioritize them? What do you do? 1. “Josh has bad abdominal pain. ” 2. “Sophia’s mom just arrived from work and would like to hear how she is doing. ” 3. “Dr. Smith (Zach’s private physician) just called and is upset that you didn’t start him on Ceftriaxone. He would like a call back immediately. ” 4. “Molly [12 with pre-B cell ALL just admitted with fever and neutropenia] has a blood pressure that’s 70/30. ” 5. “Alex is breathing harder. Would like to start Albuterol. ”

General Principles to Improve Ability to Triage on the Wards • Get good sign-out • Check on sicker patients at beginning of shift • Anticipate how patients will get sicker and what you will do in response • Look/ask for trends • Trends in vitals, trends in pain, etc • Check-in with each other • Know your resources ahead of time (physicians in-hospital (and outside), nurses, respiratory therapists, etc)

General Principles to Improve Ability to Triage on the Wards cont • Communicate delays/concerns to your attending • Some delays can lead to poor patient outcomes (and your attendings can be helpful mobilizing resources, if they know) • Communicate delays to families and nurses (when possible) • Most people are remarkably understanding if they just have appropriate expectations

Case 2 You are the nighttime senior resident and receive several calls from nurses that they are concerned that your intern isn’t returning her pages. You have noticed that your intern tends to have a “deer in the headlights” look when receiving new information and has a hard time multitasking. What can you do to help your intern prioritize and multitask?

How to Help Learners Who Are Having a Hard Time Triaging Some of the following strategies may work: • Share organizational strategies with the intern. • Practice making “To Do” lists. • Discuss expectations regarding how quickly pages need to be returned. • Discuss how helpful it can be to let nurses know how long it will take to return the page. • Discuss strategies for triaging duties (as discussed on prior slides). • Check in with the intern periodically.

RRT Code Blue BAMC Peds Rapid Response: • PICU RN • RT • PICU Attending during the day • PICU Resident BAMC Peds Code: Slightly Slower Response Time Faster Response Time • • PICU Resident PICU Attending PICU RN PICU RT Anesthesia Surgery +/- Pharmacist

Take Home Points 1. Take proactive steps to aid you in triaging pages and phone calls at night. 2. Pay attention to the learners you are supervising and help them to appropriately triage their tasks. 3. Know who and what your resources are at night. 4. Remember that there is always back-up – even if it means bringing in a fellow or attending from home.

Communication/Hand-Offs IPASS • Insert I-PASS

Miscellaneous • Have the PGY 1 pick 2 -3 Med. Study Videos to watch with PGY 3 • Pick a topic that was discussed during a Morning Report Lecture that you missed this month while you are on nights • Ex: Block 1 Intro to Peds/Emergency • Watch a video on toxic ingestions or cardiac emergencies • Complete 10 Prep Questions per week • This is not mandatory but highly suggested