1. Handbook for the
MUSC Pediatric Emergency
Department
2013-2014
Editors: Carrie Busch MD, Kate Hewett MD,
Dan Park MD, and Amanda Price MD

2. Table of Contents
Common Medical Complaints:
PALS
Anaphylaxis
Asthma
Burns
Croup
Congenital Heart Disease
Febrile Neonate
Fever
Urinary Tract Infection
Ingestions
Seizures
Adolescent Medicine
STI Treatment
Endocrine Emergencies
DKA/HHS
Headaches/Migraines
Acute Scrotum
p4-6
p7-8
p9-10
p11-12
p13
p14-16
p17-18
p18
p19
p20
p21-22
p23
p24
p25-26
p27-29
p30-31
p32
Hematology/Oncology in the PED:
Fever and Neutropenia
Hyperleukocytosis
Tumor Lysis Syndrome
Anemia
Thrombocytopenia
ITP
DIC/Coagulopathy
Transfusion Guidelines
Hemophilia
p33-34
p35
p36
p37-38
p39
p40-41
p41
p42-46
p47-49
2

3. Table of Contents Continued
vonWillenbrand’s Disease
SVC syndrome
p50-51
p52
Sickle Cell Disease
Fever/Sickle Cell Disease
Pain/Sickle Cell Disease
Acute Chest Syndrome
p53
p54-56
p57
Sedation and Injuries:
Wound closure
Mammalian Bites
Snake Bites
Puncture wounds
Sedation
Splinting
p58
p59-61
p62-63
p63
p64
p65-66
Psychiatric Considerations
Organic vs. Functional Psychosis
p67
Resuscitation Protocols:
Trauma Guidelines
Rapid Sequence Intubation
Tube sizes, etc
Vasoactive and inotropic drugs
Shock
p68-70
p71-72
p73
p74-75
p76-77
Radiology Helpful Hints
p78
The online and paper ED resident manuals have lots more detailed information,
references and articles, in addition to specific treatment guidelines developed in EBM
fashion. Please consult them and use this handbook as a quick reference.
3

4. PALS PROTOCOLS
Start w/ checking for Pulse (circulation), then airway, breathing
For infants to adults:
Compression rate 100/min
Compression:ventilation ratio
Single rescuer: 30:2
2 rescuers: 15:2
Rescue breathing with advanced airway: 8- 10 breaths/min
(1 breath every 6-8sec)
Compression method (push hard and fast + allow full recoil):
• <1 yo: 2 thumb-encircling technique
• 1-8 yo: 1 hand technique or 2 hand technique
• >8 yo: 2 hand technique
AED:
•
•
•
•
Infant pads: Up to 1 year or 10 kg
child pads <1-8 yrs
>8 years: use adult pads
Epi doses: 0.01mg/kg (1:10,000); IO/IV= 0.1ml/kg;
0.1mg/kg (1:1000) ETT= 0.1ml/kg
PEA/ASYSTOLE
• Epi q3-5 min; CPR
• Evaluate for reversible causes:
Hypothermia
Hypoxia
Hyper or Hypo K+
Hypovolemia
H+/acidosis
Tension Pneumo
Toxins
Thrombosis (MI)
Tamponade
Thromboembolism (PE)
4

5. UNSTABLE BRADYCARDIA (CV compromise)
• Chest compressions for hr <60 if under 8 years old
• Epi, repeat every 3-5 min
• Atropine 0.02 mg/kg IV/IO q5 min (min dose 0.1mg),
may repeat x1 (for increased vagal tone or primary AV
block)
• Consider pacing
SVT
•
•
Consider ice to face if patient stable (no carotid
massage)
Adenosine 0.1 mg/kg IV/IO (max 6 mg), then 0.2
mg/kg (max 12 mg) if no response OR synchronized
cardioversion 0.5-1 J/kg, may repeat at 2 J/kg
STABLE VT (wide QRS, >0.08sec)
• Lidocaine 1mg/kg over 2-3min; may repeat every 5min
for total of 3mg/kg OR amiodarone 5mg/kg over 20-60
min IV/IO
• OR procainamide 15 mg/kg over 30-60 min IV/IO
UNSTABLE VT (CV compromise)
• Cardioversion 0.5-1 J/kg
• OR try drugs (amiodarone, procainamide bolus)
5

6. V-FIB/PULSELESS VT
• Shock: 2 J/kg
• 5 cycles of CPR
• Check rhythm: Shock 4 J/kg
• Epi, repeat every 3-5 min
• 5 cycles of CPR
• Check rhythm: Shock 4 J/kg
• Lidocaine 1mg/kg OR Amiodarone 5 mg/kg bolus
IV/IO
• OR Mag 25-50 mg/kg IV/IO if torsades (max 2g)
HELPFUL FORMULAS
• ETT size: 4 + (age/4): subtract 0.5 for cuffed tube
*Downsize tube 0.5 for inhalation injury and croup
• Insertion Depth: tube size x 3
• Weight (kg): 8+ 2 x (age)
6

7. Anaphylaxis
Definition: Acute, potentially life-threatening syndrome caused
by the release of inflammatory mediators involving 2
or more organ systems
Causes:
Foods (Milk, eggs, wheat, soy, peanuts, fish)
Preservatives
Allergens
Insect venom
Blood products
Radiocontrast dye
Latex
Drugs (antibiotics, local anesthetics, analgesics)
Signs and Symptoms:
Skin:
Urticaria, angioedema
Respiratory:
Cough, chest pain, wheezing, stridor,
hoarseness, or throat tightness
Gastrointestinal:
Nausea/vomiting, abdominal pain, diarrhea
Cardiovascular:
Tachycardia, hypotension, arrhythmias,
Decreased peripheral perfusion
Central Nervous System
Dizziness, syncope or AMS
*** Hymenoptera Caviat:
If > 16 years of age and hives are the only symptom literature
suggests IM Epinephrine, due to risk of progression to severe
symptoms. If less than 16 years treat as below.
7

8. Anaphylaxis Continued:
Initial Management:
1) Establish ABC’s
2) Consider Epinephrine: 0.01mg/kg (1:1000)IM;
0.01ml/kg, max 0.5ml
*Repeat every 15 min not to exceed 4 doses
3) Albuterol neb
4) H1-receptor antihistamine: diphenhydramine 1-2 mg/kg
IV/IM/PO (max dose 50 mg)
5) H2-receptor antagonists: ranitidine 1-2 mg/kg IV/IM
every 12 hours or 3-5mg/kg PO q 12(max dose 100mg)
6) Corticosteroids- may prevent late phase reactions
Methylprednisolone 2mg/kg IV bolus, then 2mg/kg/day
OR Prednisone 2 mg/kg po, repeat daily for 2-3 days.
IF Hypotensive:
*Establish IV or IO (if under age 8 years)
1) Bolus with normal saline 20ml/kg rapidly. Repeat bolus
as necessary
2) Epinephrine 0.01mg/kg (1:10,000) IV/IO over 2-5
minutes (0.1ml/kg)
3) Epinephrine infusion: 0.1-1mcg/kg/min, titrate until
normotensive
Disposition:
Mild (urticaria only): Observe in ED for 2-4 hours
Moderate or severe symptoms and/or
sig. history of atopy: ADMIT
Discharge Medications:
* H1 and H2 blockers for 24-72 hours
* May consider short course of oral steroids
*Any patient with history of life-threatening symptoms should
be discharged from hospital with Epi-pen (Epipen JR if <30kg)
8

9. Asthma
Asthma Score: for patients 1 year old and greater ; nonbronchiolitis
Parameters
Score 0
Score 1 for each
item
Score 2 for each item
Respiratory
effort
Full
sentences,
babbles
Short phrases or
cries
Max ability single
words or grunts
Accessory
muscle
use
No
retractions
Inter / subcostal
retractions
Inter / subcostal,
supraclavicular
retractions +/flaring
Auscultation
Clear /
minimal
expiratory
wheeze
Inspiratory and
expiratory
wheezes
Diminished or absent
breath sounds
O2 sat on
room
air
> 95%
91-95%
< 91%
Sensorium
Normal
Slightly
decreased or
agitated
Markedly depressed
or non-responsive
Total Score
9

10. Practice Guideline Considerations for patients 1 year and
older:
If Mild (asthma score 0-2), recommend:
• Albuterol HHN 2.5 or 5mg with ipratropium bromide
500 micrograms nebulized or albuterol 4-6 puffs MDI with
spacer with ipratropium bromide 4-6 puffs MDI with spacer
• Consider Prednisone/Prednisolone PO 2 mg/kg (max
60 mg) or dexamethasone 0.6mg/kg (max 15mg)
If Moderate (asthma score 3-6), recommend:
• Albuterol HHN or CNB 10-20 mg/hour nebulized with
ipratropium bromide 500 micrograms nebulized OR
albuterol 6-10 puffs MDI with spacer with ipratropium
bromide 4-8 puffs MDI with spacer
• Prednisone/Prednisolone PO 2 mg/kg (max 60-100 mg)
or Methylprednisolone IV (same dose) or dexamethasone
If Severe (asthma score 7-10), recommend:
• Albuterol CNB 10-20 mg/hour nebulized with
ipratropium bromide 500 micrograms nebulized OR
albuterol 6-10 puffs MDI with spacer with ipratropium
bromide 4-8 puffs MDI with spacer
• Prednisone/Prednisolone PO 2 mg/kg (max 60-100 mg)
or Methylprednisolone IV (same dose)
• Magnesium sulfate 50-75 mg/kg IV (max 2 grams)
over 20-30 minutes (max rate 150 mg/minute)
10

11. Burns Remember MUSC is a pediatric (<16y) burn center!
1) Airway Stabilization: see trauma/RSI
•
•
•
100% humidified 02 for all pts with possible inhalational
injury.
Measure carboxyhemoglobin and ABG.
Intubate for evidence of inhalational injury.
2) Aggressive fluid resuscitation: based on BSA burned
(see below) on infants with >10% BSA and children with
>15% BSA.
•
Parkland formula (updated 2013): 3cc/kg x wt (kg) x
percent of body with second or third degree burns. Give half
of total fluids in first 8 hours and the rest in the next 16
hours. Remember to always add maintenance fluids to total
calculation for <5yo.
•
Calculate body surface area (BSA) burned based on
second and third degree burns only (see page 12).
o
First degree/ superficial: Painful and erythematous; only
epidermis
o
Second degree/ partial thickness: Any blistering, painful,
may progress to third degree; epidermis and dermis
involved
o
Third degree/ full thickness: Leathery, white and
painless; involve all layers of epidermis and dermis; best
treated with skin grafting
3) IV analgesia is necessary for pain for moderate to
severe burns. Give po pain meds for milder burns.
4) Remember tetanus prophylaxis.
11

12. Source: UpToDate 2013
12

13. Croup
Croup Scoring System
0
1
Stridor
none only with
agitation
Retractions
none
mild
Air Entry
nml
Color
nml
Mental Status nml
2
at rest
3
severe
moderate
severe
mild decr mod decr
severe
nml
nml
restless
v. restless
cyanotic
lethargic
Croup Severity/ Management
Score
< or =4
5-6
7-8
> or =9
Severity
mild
mild-mod
mod
severe
Management
steroids*
steroids, racemic epi**
steroids, racemic epi, admit
steroids, r.epi, PICU
*0.6 mg/kg oral dexamathasone or 0.3-0.6mg/kg IM
** observe 2-3hrs after racemic epi
Admission for hypoxia, poor po, underlying laryngeal dz,
or moderate dz with parental anxiety or distance from ED
13

14. Congenital Heart Disease
*Cyanotic babies WITHOUT known cardiac disease:
1.
Think SEPSIS
2.
Give fluid gently and gradually (10ml/kg)
3.
Check pulses and BP in ALL 4 extremities
4.
Minimize positive-pressure ventilation and O2
5.
Hyperoxia challenge (if SaO2 <85%= ductal dependent
lesion)
6.
Call for prostaglandin E1 (0.05mcg/kg/min) and call
cardiology
7.
Intubate or have airway equipment immediately
available as prostaglandin E1 may cause apnea
*Differential Diagnosis for Cyanotic Heart Lesions:
1. Truncus Arteriosus
• single trunk supplying syst., pulm. and coronary beds
• CXR: cardiac enlargement, incr pulm vasc.
2. Transposition of Great Arteries
• Aorta from RV and Pulm Art from LV
• CXR: “Egg on string”
3. Pulmonary Atresia/Tricuspid Atresia
• Atretic valve with poorly formed RV
14

15. • CXR: hyperlucent lungs (decr vasc.) absent PA
4. Tetralogy of Fallot (most common Cyanotic CHD)
• RVOT obstr, RVH, Overriding Aorta, and VSD
• CXR: RVH, up-tilting of apex
5. TAPVR
• Pulm veins do NOT return to LA
• CXR: Ground glass, incr. Pulm vasc.
*Cyanotic babies WITH known cardiac history--things to
remember:
1) Tetrology: “Tet spells”
Goal: In cr SVR to reverse shunt
(IVF, knee to chest, morphine, O2 or ketamine)
TOF normal sat >80%
2) Tricuspid Atresia/Hypoplastic Left Heart Syndrome
•
•
•
•
After BT shunt: avoid dehydration (shunt can clot);
May have sx of failure if shunt too big
After Glenn: SVC syndrome is sign of increased PVR
and pulm hypertension
After Fontan: sats should be in 90’s but can be in 80’s
if has a fenestration; watch for thromboemboli through
fenestration
15

16. 3) Truncus Arteriosus: Arrhythmias, valvar insufficiency
4) TAPVR: Pulmonary edema, pulmonary hypertension if
re-stenosed at the anastamosis
5) Transposition: May have cardiac ischemia
*Acyanotic Lesions complications s/p repair:
1. Coarctation: assess for re-coarctation
•
•
Check 4 pulses and BP
Usually occurs w/in 1st year if going to occur
2. VSD:
•
•
•
•
Failure to Thrive
Congestive Heart Failure
Pulmonary Hypertension
Arrhythmias
3. ASD: Arrhythmias
4. Heart Transplant: Bradycardia can be sign of rejection as pt
will have no angina. Epi and atropine might not work in this
situation as no innervations so consider pacing. Always consider
rejection if presenting with viral symptoms (remember HR is
UNRELIABLE)
16

17. Febrile Neonate
IF Temp>100.4F or 38.0C AND Age < 8weeks, THEN:
= Septic Infant until proven otherwise
*If neonate/child is ill-appearing, evaluate fully for sepsis
and consider admission regardless of results. Refer to
Febrile Neonate Order Set!
Workup
•
Accucheck glucose
•
CBC, BCx, CMP, HSV PCR blood*
•
UA, UCx
•
CSF gluc/prot, cell count/gram stain &culture
•
HSV PCR if ill or less than 4 weeks*
•
CXR if tachypnea or hypoxemia
•
Consider CRP and Procalcitonin
*See HSV treatment guidelines in online manual which includes serum HSV
PCR, LFT’s and appropriate skin and mucous membrane cultures as indicated.
Antimicrobials (Less than 4 weeks):
Ampicillin 50mg/kg/dose q8h <1wk, q6h >1 wk
AND Gentamicin (<7d) 2.5mg/kg/dose q12h
(>7d) 2.5mg/kg/dose q8h
OR Cefotaxime 50mg/kg/dose q8h <1wk, q6h >1wk
AND Acyclovir 20mg/kg/dose q8h*
17

18. AFTER 4 weeks:
May use Ampicillin AND
Cefotaxime 50mg/kg/dose q8h
OR
Ceftriaxone 50mg/kg/dose q12h
* Goal is to have antibiotics given within 1 hour of arrival
Fever (T 102.2F or 39.0C)
61 days to 2 years:
Well or mildly ill-appearing with no source of fever:
•
•
•
Cath UA and urine cx on all females and
circumcised males <6mos and uncirc <12mos
CXR if tachypnea or hypoxemia
Stool studies if blood in stool or known contact
Ill-appearing:
• Stabilize ABC’s
• Consider full septic evaluation and antibiotics
*With universal Prevnar immunization, occult bacteremia is
very rare and does not cause sig. adverse outcomes to warrant
CBC or blood culture in well-appearing children.
*Please consult online or paper resident manuals for specific
articles and references.
18

19. UTI Recommendations
*See the formal guidelines on the portal for more details and the
MUSC antibiogram.
We recommend a 3rd generation cephalosporin (ie. Cefdinir)
as empiric therapy for the following patients:
1.
2.
3.
Any child less than 2 with a suspected urinary tract infection
Those diagnosed with pyelonephritis at any age
Children at high risk of having underlying genitourinary
abnormalities (i.e. a patient with ear anomalies)
Empiric options for uncomplicated cystitis in an older
child/adolescent:
1.
2.
3.
4.
Cephalexin - good choice for patients who can swallow
pills and demonstrate ability for good compliance (do note it
is bad tasting in liquid form and is q6 hour dosing)
Amoxicillin –inexpensive and good tasting; do note the
listed resistance is very high but in discussion with our ID
experts the concentration sustained in the urine is likely high
enough to overwhelm this documented resistance
Cefprozil – another broader choice that is good tasting
Nitrofurantoin – good first line for the adolescent with no
systemic symptoms
*If history of recurrent/resistant UTI’s always check previous
sensitivities to guide antibiotic choice!
*Consider admission if <3 months, ill appearing, inability to
take PO, severe pain, or immunocompromised.
19

20. Ingestions/ Toxicology
*Poison Control Center is staffed 24 hrs/ day: 1-800-222-1222
• Assess ABC’s and evaluate mental status/level of
consciousness
• Detailed history re: substance(s), quantity, strength,
time of ingestion, medical history, treatments prior to
ED.
*Lab tests should be individualized but consider:
• Glucose (ALWAYS with mental status changes)
• CBC, CMP, ABG, serum osmolarity, UA, UDS
• Serum acetaminophen, aspirin and ethanol levels
• Urine pregnancy test
• EKG/cardiac monitor
• CXR/KUB
*GI decontamination options:
• NO IPECAC!!
• NO Single-Dose activated charcoal; exception is within
one hour in acetaminophen ingestions;
weigh risks/benefits
• MDAC (multi-dose activated charcoal) for potentiallylethal ingestions within one hour of presentation and
for drugs specifically absorbed by charcoal including:
ACT PDQ (aspirin, carbamazepine, theophylline,
phenobarbital, dapsone and quinine).
• NO Gastric Lavage
• Whole-bowel irrigation: theoretical benefit for heavymetal ingestions or packets of illicit-drugs or extendedrelease drugs.
20

21. Seizures
Types:
•
•
•
•
•
febrile or afebrile
complex or simple
patient with known seizure or new seizure
focal or generalized
ongoing sz activity/ status epilepticus
RESUSCITATION:
• ABC's first--position airway, sniffing position
establish IV access; glucose accucheck
If hypoglycemic, give dextrose 0.5g/kg:
D10 5ml/kg; D25 2ml/kg
MEDICATIONS
• 1st line: Ativan 0.1mg/kg IV, max dose 4mg at a time
May repeat q5min for total of 3 doses
OR Versed 0.1m/kg IV/IM
•
2nd line: phenytoin 15-20mg/kg IV over 20-30min;
max infusion rate 1mg/kg/min
OR fosphenytoin 10-20PE/kg
•
3rd line: phenobarbital 20mg/kg IV load over 20min
*Watch for resp. depression and BP
OR Depakon (iv form of depakote) 15-20mg/kg
OR Keppra 20-40mg/kg IV
•
4th line: pentobarb coma---must consult neurology at
this point for continuous EEG
21

22. Seizures: THINGS TO CONSIDER:
• Be prepared to bolus with IVF and provide ventilatory
support
• Avoid paralytics in patients that seize--unable to assess
ongoing seizure activity if paralyzed
• Further evaluation once ABC's intact
o ct? lp? uds?
o in young infants--metabolic reasons (nh4,
urine organic acids, plasma amino acids)
o Consider hyponatremia/ hypocalcemia
o Pregnancy—eclampsia (magnesium)
o After each medication, re-check ABC’s and
glucose.
22

23. Adolescent Medicine
•
All physicians doing pelvic examinations must be
accompanied by a female nurse or MD.
•
Please do a urine pregnancy test on all females of
child-bearing age with trauma, abdominal pain, vaginal
bleeding or discharge, UTI, when considering x-rays
and before feto-toxic drugs.
•
Please DO NOT trust your intuition as to who might
or might not be sexually active.
•
EVERY work-up for STD (including pubic lice) must
include GC and Chlamydia.
*Consider evaluation for RPR, Hepatitis and HIV.
•
Abdominal pain, cervical motion tenderness or adnexal
tenderness on exam equals PID and treatment is
different. Consider ultrasound to rule out TOA.
•
Encourage patient to tell partner so treatment can be
obtained if cultures positive. Encourage patient to
discuss openly with parents.
•
Arrange follow-up in STD clinic or Adolescent
Medicine
23

24. STI TREATMENT
Uncomplicated Cervicitis/ Urethritis
Chlamydia: Azithromycin 1g po x1 or Doxy 100mg po bid x7d
Gonorrhea: Ceftriaxone 250mg IM x1 or Cefixime 400mg pox1
BV: Metronidazole 500mg po bid x7 days
Trichomonas: Metronidazole 2 g po x1
PID
Ceftriaxone 250mg IM x1 (there is no non IM option)
+
Doxycycline 100mg po bid x10 days
+/Meronidazole 500mg po bid x14 days
Epididymitis
Ceftriaxone 250mg IM x1
+
Doxycycline 100mg po bid x10 days
ASA PPX
Ceftriaxone 250mg IM x1 or Cefixime 400mg po x1
+
Metronidazole 2 g po x1
+
Azithromycin 1 g po x1
24

25. Endocrine Emergencies
Hypoglycemia: 5-10 ml/kg D10 IV/IO if <6 months OR
2-4 ml/kg D25 IV/IO if >6 mos
*Dobson’s Rule: ___ cc/kg x D___W = 50 (0.5g/kg)
*If necessary, continuous infusion is 6-8mg/kg/min or
4 x wt(kg) = ml/hr D10.
*When blood sugar is <45-50, repeat test and if persistently
<45-50, get the following per endocrinology recs:
CMP, insulin, C-Peptide, proinsulin, cortisol, growth hormone, lactate,
pyruvate, ammonia, plasma and urine amino acids, urine organic acids,
serum beta-hydroxybutyrate, free fatty acids, plasma acyl carnitines,
urine for acylglycines and ketones and urine drug screen (ie, oral
hypoglycemia agents, send out to Mayo Clinic)
25

26. Hyperglycemia: Check VBG to check for acidosis. *In known
patient with IDDM, IVF and appropriate SQ insulin should
correct hyperglycemia if no evidence of DKA or HHS (see
below).
Hypocalcemia: 30mg/kg calcium gluconate over 30min or
20mg/kg of calcium chloride 10%
Hypercalcemia: Lasix, hydration, glucocorticoids
Adrenal Insufficiency: NS bolus and IVF, dextrose for
hypoglycemia, hydrocortisone 2mg/kg IV STAT. As outpatient,
stress dose steroids are 3-4x regular dose.
CAH: IVF and Hydrocortisone (Solu-cortef) as below:
*2mg/kg IV OR <2yrs: 25mg, 2-8yrs: 50mg or >8yrs: 100mg
Thyrotoxicosis: give
1) High dose PTU 200-400mg q6h
2) beta blocker (IV propranolol 0.5 to 1 mg over 10 min)
3) cooling blanket
4) IVF
26

27. Diabetic Ketoacidosis:
*See treatment guidelines in online and paper manual for
complete references.
Labs: bedside glucose, VBG, BMP w/ Ca, Mg, Phos, UA
EKG if K> 6
*If new onset, also get HbA1C, TFT, anti-GAD, ICA-512,
anti-islet and anti-insulin cell antibodies
Management: Fluid bolus 20ml/kg NS over first hour then
repeated as necessary for cardiovascular instability or evidence
of moderate to severe dehydration.
NO insulin boluses.
If pH <7.24 and/or HCO3 <16 and urine ketones:
Start Insulin Drip at 0.1U/kg/hr and Normal Saline at 1.5-2
times MIVF for first 6-8hrs, then change to ½ NS
Labs:
Q1h
glucose at bedside
Q1-2h
VBG and BMP
If K+ <5.5-6, add K+ as 20mEq/L KCl and 20mEq/L KPhos
If BG <300, add D5 to fluid to support glucose but continue
insulin drip to correct acidosis. Add D10 with lower glucoses.
Cerebral Edema:
If patient shows alteration in mental status, give Mannitol
0.5mg/kg or 3%NS 2-4cc/kg then get Head CT. Decrease IVF
to 2/3 MIVF.
27

28. 28

29. Hyperosmolar Hyperglycemia Syndrome:
Often presents late with severe dehydration and associated
morbidity.
Diagnosis: Glucose >600, pH >7.3, small to no ketones;
Osmolality > 320
Watch for risk of thrombosis, rhabdomyolysis, renal failure,
hyperthermia, cerebral edema, and arrhythmias
Treatment:
•
NS boluses at a rate to restore perfusion (often enough
to correct glucose)
•
Change to 0.45% - 0.75% NS: to replace deficit (goal
is drop Na by 0.5mEq/L/hr)
•
Electrolyte abnormalities as in DKA (can be much
worse)
•
Insulin drip at 0.025-0.05U/kg/hr if fluid alone does
not drop glucose >
50mg/dL/hr
29

30. Headaches:
Indications for imaging: progressively worsening headache;
early morning headaches or pain that awakens children from
sleep; abnormal neurologic exam; children < 3y with
unexplained severe headache.
**Consider blood sugar/urinalysis for patient with
new onset recurrent headaches
30

31. Migraines:
*See portal for additional information.
Diagnosis: based almost exclusively on the history, supported
by the absence of abnormalities on exam.
Treatment: Regimens address 3 major mechanisms in the
pathogenesis of migraine:
• dopaminergic hypersensitivity
• inflammation
• 5-hydroxytryptamine (5-HT) metabolism
**Hydration with NS
Analgesics:
• Acetaminophen 15mg/kg po, max 1000mg
• Ibuprofen 10mg/kg po, max 600mg
• Ketorolac 30-60mg IM or IV
Antiemetics:
• Prochlorperazine 0.1mg/kg PO/IV/IM, max10mg
• Reglan 0.5-2mg/kg PO/IV, max 10mg
• Phenergan 0.25-1mg/kg PO/ IV/IM, max 25mg
Antimigraine agents:
• Sumatriptan 10mg intra-nasal, 6 to 11 years of age;
20mg intra-nasal, 6mg SC or 100mg PO, 12 or greater
years of age OR
• Dihydroergotamine 0.5-1mg/dose IV/IM
Other options:
• Dexamethasone 10 to 20mg PO/IV/IM
31

32. Acute Scrotum Pathway
Patient presents to ED with complaint of scrotal pain concerning for testicular
torsion
•Acute onset < 6 hours, tenderness to palpation, swelling, abnormal testicular
lie, loss of cremasteric reflex
•High suspicion for testicular torsion
•Make NPO, obtain IV
•Consult urology resident immediately
• Obtain US* to confirm diagnosis but do not delay
consult *notify radiology resident the need for urgent
US looking for torsion
•Negative or indeterminate US
•Exam and history less concerning for torsion and/or labs and exam
consistent with epididymitis
•Pain developing over several days, + Prehn's sign, dysuria, urethral
discharge, point tenderness
•Treat epididymitis with antibiotics and ASAP to urology
for follow-up in 1 week
•STD/STI Suspected: Doxycycline 100mg PO BID for
10-14 days PLUS cetriaxone 250mg IM once or cefixime
400mg PO once
•STD/STI Not Suspected: Ciprofloxacin 500mg PO BID
for 10-14 days or Levofloxacin 750mg PO daily for 10-14
days for children >8 years. < 8 years TMP/SMX 8-12
mg/kg/day divided BID
•Exam or history concerning for intermittent torsion
•Discuss with urology resident; arrange for patient to be seen within
24 hours in urology clinic
•Intermittent pain, pain > 6 hours, suspicion for infection, fever
•Obtain US* and urine dip and culture *notify radiology resident
the need for urgent US looking for torsion
•US positive for testicular torsion
•Consult urology immediately
•US positive for torsion of the testicular appendix
•Discuss with urology and advise family on pain control.
D/C with specific instructions: loose-fitting underwear,
testicular elevation, NSAIDS. ASAP to urology for
follow-up in 1 week
32

33. Hematology/Oncology:
Neutropenia
Defintion: Based on Absolute Neutrophil Count (ANC
cells/cmm)
• Mild: 1000-1500 Moderate: 500-1000
• Severe: <500
Profound: <200
Etiology:
-Viral infection (most common)
-Drugs (2nd most common): Anticonvulsants, antibiotics,
antipsychotics, anti-thryroid medication,
-Malignancy and chemotherapy,
-Autoimmune neutropenia including lupus, IBD
-Congenital disorders: Kostman syndrome, Schwachman
diamond syndrome etc,
-Cyclic neutropenia
-Storage diseases: GSD type1b.
Fever and Neutropenia (in oncology patients)
Definition: ANC < 500/cmm and Fever >38.5ºC (orally) or
>38ºC twice 4 hours apart
Examine fully and monitor VS closely
Special Considerations:
No suppositories or rectal temperatures
No IM injections
If you believe you need a urine cx and patient is in diapers,
Use a bag…NO CATH (can introduce bacteria).
33

34. Risk of serious infection increased when ANC < 500/ mm3
•
•
•
Bacteremia risk increases w/ decreased ANC
Fever can be the only sign of serious infection
Neutropenia often occurs 7-10d after chemo
Labs ASAP: (use neutropenia order set!)
–
–
–
–
–
–
CBC with diff and plt
Blood cx from each lumen of CVL, no peripheral cx
BMP
Hold type and screen
Coags (w/ fibrinogen and D-dimer) if ill-appearing
UA and urine cx in small infants but NO CATH (can
introduce bacteria)
– Culture and PCR of any wound/lesion
– CXR if respiratory symptoms
START ABX as soon as cxs obtained; do not delay!
All Patients:
Cefepime 50mg/ kg/dose q8h (max 2gm) OR
Meropenem 40 mg/kg/dose (max 2gm)
If Hypotensive with chills:
Cefepime OR Meropenem PLUS
Tobramycin AND Vanc
Bolus IVF
If Abdominal pain:
Cefepime, Tobra AND Flagyl (7.5mg/kg)
Consider CT or KUB to look for typhlitis
Consider stool cx for C. diff
Presumed CVL and tunnel infections:
Cefepime and Vancomycin (20mg/kg)
34

35. Hyperleukocytosis:
*Acute leukemia esp. T cell ALL often presents with
hyperleukocytosis
*Usually symptoms seen if WBC >100,000. The risk of
hyperviscosity is greater with AML than with ALL (myeloid
cells are “stickier” than lymphoid cells.)
Clinical sequalae:
• Hyperviscosity and sludging leading to stroke, altered
mental status, renal failure and hypoxia with increased
pulmonary markings diffusely on chest x-ray
• DIC
• Tumor lysis syndrome
Management:
• Hydration, alkalinization, allopurinol, monitoring renal
function (see tumor lysis syndrome management)
• Correct coagulopathies (more prominent with AML)
• Keep Hbg< 10mg/dL as PRBC’s will increase viscosity
Leukopheresis:
• Symptomatic patients regardless of WBC count
• Asymptomatic patients with WBC >100,000 (Recent
evidence suggests that >300,000 esp. in ALL patients)
• Avoid in AML type3 (acute promyelocytic) as it may
induce DIC due to granular blasts
• Treatment of underlying malignancy
35

36. Tumor Lysis Syndrome:
•
Secondary to spontaneous (Burkitt’s) or treatment-related tumor
necrosis
•
Acute lysis of tumor cells results in rapid release of K,
phosphates and nucleic acids which results in:
•
Hyperkalemia: cardiac arrhythmias
•
Hyperuricemia: renal failure
•
Hyperphosphatemia, and resultant hypocalcemia: Tetany,
seizures, cardiac arrhythmias
•
Multi-organ system failure
Management:
•
Vigorous hydration: IVF D5 1/2NS +40 meq/L NaHCO3 at 2x
maintenance OR 3000 ml/m2 *NO K+ in IVF*
•
Alkalanize urine, goal urine pH 7-7.5 (uric acid is more soluble
in alkaline pH), don’t overshoot >7.5 as calcium stones may form
•
To inhibit production of uric acid from xanthine, start Allopurinol
(po): <20kg: 50mg tid, 20-40kg: 100mg tid, >40kg: 200mg tid
•
Consider using Rasbiuricase for severe hyperuricemia
(Recombinant urate oxidase converts already existing uric acid to
water soluble inert Allantoin)
•
Monitor lytes, Mag, Ca, Phos, uric acid and renal function; Q4-6 h
labs for high risk pts and Q12h for lower risk
Consider dialysis if symptomatic HyperK and Hyperphos/
HypoCa, worsening renal function and/or volume overload
•
36

37. Anemia
•
•
Check vital signs, hypoxia and bleeding manifestations
See tables below and perform labs pertinent to your
clinical suspicion
Refer to PRBC transfusion guideline
•
•
Low or Normal Reticulocytes
High
Reticulocytes
Hypochromic Microcytic (MCV < 78)
iron deficiency
• thalassemia
• lead poisoning
• chronic disease
• sideroblastic anemia
Normochromic Normocytic (80 < MCV <
100)
• chronic disease
• liver disease
• uremia
• endocrine disorders
(hypo/hyperthyroid, Addison’s)
• connective tissue diseases
• primary marrow abnormalities
• myelodysplasia
• infiltration (leukemia, metastates)
• myelofibrosis
• aplasia
*Treated
nutritional
deficiency
*Hemolytic
anemia
*Post
hemorrhagic
anemia
37

38. Macrocytic/Megaloblastic (MCV > 100)
• Megaloblastic
o B12 / folate deficiency
o drugs (MTX,
cyclophosphamide,
o nitrous oxide, arsenic)
• Macrocytic
o hypothyroidism
o hypoplastic marrow, aplasia
o liver disease
o alcohol
o smoking
Differentiation of common causes of microcytic anemia
Fe def
Thal Trait
Infectious
Hgb
MCV
Normal
RDW
Normal
FEP
Normal
TIBC
Normal
Ferritin
Normal
Normal
Norm/
38

39. Thrombocytopenia
*Normal platelet count is 150,000-400,000/cmm (including
premies and newborns)
Etiology:
1) Increased destruction (most common)
•
•
•
•
Immune
Primary: Idiopathic thrombocytopenic purpura (ITP)
[most common & a diagnosis of exclusion]
Secondary: Drugs (heparin), SLE, Common Variable
immunodeficiency, Evans syndrome
Non-immune
TTP/HUS
DIC
Drugs: anticonvulsants (valproate)
2)
•
•
•
•
•
Decreased production
Infection/sepsis
Malignancy/chemotherapy
Aplasia
Thrombocytopenia-absent radiai syndrome (TAR)
Congenital amegakaryocytic thrombocytopenia
•
•
•
3) Sequestration
• Hypersplenism
• Kasabach-Meritt syndrome (kaposiform
hemangioendothelioma with DIC)
39

40. Idiopathic Thrombocytopenic Purpura (ITP)
•
Peak age 3-4 years
•
Prodromal viral symptoms in 2/3 of cases
•
Mainly mucocutaneous bleeding: Petechiae, epistaxis, ICH
very rare
**RED FLAGS: presence of LAD, HSM and decrease in
other cell lines
**Initial investigations: CBC with diff and platelets, Peripheral
smear, DAT, Rh type, serum Ig G,A,M levels, ANA, C3&4.
Treatment:
•
Symptomatic patients other than petechiae (regardless
of platelet count)
•
Asymptomatic patients with platelet count <20,000
Drugs: (premedication often necessary)
• WinRho 75 microgram/kg IV (only for Rh+ patients
with normal Hb) OR
• IVIG 1g/kg IV infusion
• Prednisone 4mg/kg/day for 4 days (NEED BMA prior
to starting steroids)
• Avoid NSAIDS (causes platelet dysfunction)
40

41. •
Platelets transfusions are used only in patients with
intractable bleeding refractory to other treatments. (see
transfusion guidlelines)
DIC/Coagulopathy:
Etiology:
Shock, Hemorrhage, Infection, Acidosis, Liver failure,
Malignancy (esp APML), TTP/HUS etc
Diagnosis:
–
–
–
–
–
Plt count
PTT/ PT
Fibrinogen
Fibrin Split Products
Peripheral Smear
decreased
prolonged
decreased
increased
microangiopathic changes
(helmet cells, schistiocytes)
Supportive Care:
•
•
•
FFP
*Contains all clotting factors
*Give 10ml/kg to keep PT/PTT < 1.5 x uln
Platelets
Cryo
*Prepared from solid fraction of thawed FFP
*Enriched in fibrinogen, vWF, Factor VIII
*Give 5ml/kg (each unit contains 20ml) to keep
fibrinogen >100mg/dL
41

42. Transfusion Guidelines: Red Cell Transfusions
Product Parameters:
• hematocrit: 50-65%
• volume: 250-300mL
• shelf-life: 42 days
Indications:
• patients with a symptomatic deficiency in oxygencarrying capacity
• children/adolescents:
o Hgb any level with symptomatic anemia
o Hgb < 8.0g/dL perioperative period
o Hgb < 13.0g/dL with severe
cardiovascular disease
o Acute blood loss > 25% blood volume
• infants:
o Hgb any level with symptomatic anemia
o Hgb < 10.0g/dL perioperative period
o Acute blood loss > 25% blood volume
Compatibility; ABO selection:
Patient
Type
AB
A
B
O
1st
Choice
AB
A
B
O
2nd
Choice
A
O
O
Red Cell Type
3rd
4th Choice
Choice
B
O
42

43. Dosing/Response:
• Dosage: 10-15mL/kg infused over 2-4 hours for
anemia (STAT if acute blood loss)
• Expected response: Hgb ↑ 2-3 g/dL
Clinical considerations:
• Leukoreduction:
o all products are leukoreduced
o reduces risk of febrile reactions
o CMV-safe
• Irradiation (Graft versus Host Disease risk)
o Must be requested
o Immunocompromised patients including:
blood for intrauterine transfusion,
premature neonates, congenital
immunodeficiency, exchange transfusion
for HDFN, bone marrow (stem cell)
transplant patients, hematologic
malignancy or solid tumor on ablative
chemotherapy or radiotherapy, recipient
of familial blood donation
• Washed:
o Remove residual plasma
o IgA deficient patients (anaphylaxis)
o Intractable allergic reactions
43

44. Transfusion Guidelines: Platelet Transfusions
Product Parameters:
• Single donor (apheresis platelets): 3.0 x 1011
platelets/unit
• Volume: ~250mL
• Shelf-life: 5 days
Indications:
• bleeding due to thrombocytopenia
• prophylaxis in thrombocytopenic patients
o < 50,000/µL with significant bleeding or
planned invasive procedure
o < 50,000/µL neonates
o < 20,000/µL with risk factor for bleeding
(sepsis, fever, etc.)
o < 10,000/µ with no risk factor for
bleeding
Dosing and Response:
• Dosing: 5-10mL/kg
• Expected response: ↑~50,000/µL
Clinical considerations:
• Leukoreduction:
o Same as red cell transfusion
• Irradiation (Graft versus Host Disease risk):
o Same as red cell transfusion
• Washed:
o Same as red cell
o Washing procedures tend to cause
damage to platelets and should be
avoided if possible (expect 20-40%
reduction in post-transfusion platelet
count)
44

45. Transfusion Guidelines: Plasma and
Cryoprecipitate Transfusion
Product Parameters:
• Frozen plasma: stored -18°C for 1 year; volume
~250mL
• Cryoprecipitate: stored frozen -18°C for 1 year;
each unit contains ~440mg fibrinogen in a volume
of 10-30 mL
Indications:
• Plasma: PT or aPTT > 1.5 times normal due to a
deficiency of clotting factors (do not use when
coagulopathy due to a deficiency of factors VIII or
IX alone)
• Cryoprecipitate: ↓fibrinogen
Compatibility:
• Plasma and cryoprecipitate should ABO
compatible with patient’s red cells
Dosing and Response:
• Plasma: 10-15mL/kg; should ↑factor levels 1520%
• Cryoprecipitate: 1 unit/10kg; should ↑fibrinogen
60-100mg/dL
Clinical considerations:
• Irradiation (Graft versus Host Disease risk):
o Need for irradiation controversial
45

46. Transfusion Guidelines: Granulocyte Transfusion
Product Parameters:
• 1.0 x 109 neutrophils/unit
• Must be ordered 24-48 hours before need
• Shelf-life 24 hours (transfuse as soon as possible)
• Will be provided before infectious disease testing
completed
Indications:
• Documented infection
• Failed trial of antibiotics
• Granulocyte count < 500/mm³
• Neonatal sepsis
Compatibility:
• Must be ABO compatible (same as red cell
transfusion)
Dosing and Response:
• 15 mL/kg; repeat daily
• Daily until clinical improvement (5-7 days)
• Most effective in bacterial infections; less effective
in fungal infections
Clinical considerations:
• Irradiation (Graft versus Host Disease risk):
o Same as for red cells
46

47. Hemophilia A and B
Hemophilia A: Factor VIII deficiency and Hemophilia B: Factor
IX deficiency (Christmas Disease)
Both are X-linked recessive disorder
Normal Factor activity is 50-150%
Severity of Hemophilia A and B (based on factor activity level)
Mild: 5-25% - bleeding with surgery or trauma
Moderate: 1-5% - bleeding with mild injury
Severe: <1% (most common) – spontaneous bleeding
Clinical manifestations (hemophilia A & B are
indistinguishable)
- Hemarthrosis (most common)
- Soft tissue hematomas (e.g., muscle)
- Other sites of bleeding: 1. Urinary tract
2.CNS, neck (may be life-threatening)
- Prolonged bleeding after surgery or dental extractions
Laboratory diagnosis
- Both will cause prolonged aPTT with normal pT
- DO NOT OBTAIN BLEEDING TIME (NOT
DONE ANYMORE)
- Low Factor VIII (hemophilia A) and Factor IX
(hemophilia B)
47

48. - Factor VIII deficiency can be diagnosed at birth as
newborns including premies have normal levels
- Factor IX deficiency may be difficult to diagnose at
birth as it is low up to 6 months of age (exception
severe cases with positive family history)
Treatment guidelines
Recombinant Factor products:
• Factor VIII (Helixate-FS), Factor IX (Benefix)
• Dosing: One unit/kg of Factor VIII increases plasma
factor activity by 2%. Example: To obtain 50%
factor activity in a 25kg child with hemophilia A, you
need to give 625 Units of Helixate (FVIII dose (U) =
body weight (kg) X desired FVIII increase (%) X 0.5
U/kg)
• Whereas, one unit/kg of Factor IX increases plasma
factor activity by 1%. Example: To obtain 50%
factor activity in a 25kg child with hemophilia B, you
need to give 1250 Units of Benefix (FIX dose (U) =
body weight (kg) X desired FIX increase (%) X 1U/kg)
•
Mild bleeding


Hemarthrosis, oropharyngeal or
dental, epistaxis, hematuria
Target increase: 30-40% factor
activity; 1-2 days
48

49. •
Major bleed





CNS trauma, hemorrhage, lumbar
puncture
Surgery
Retroperitoneal hemorrhage
GI bleeding
Target increase: 80-100% factor
activity; 7-14 days
Adjunctive therapy
Amicar (epsilon aminocaproic acid)
Anti-fibrinolytic agent useful in mucocutaneous bleeds
Dose: 100mg/kg/dose q6hours PO for 4-5 days
Contraindicated in patients with hematuria (it can
cause clots in urogenital system)
DDAVP
• Useful only in mild Hemophilia A patients (it releases
FVIII from endothelial cells)
• Dose: 0.3 µg/kg q 12 hr IV for only maximum of 3
days Or Stimate nasal spray (150 mcg) (for children >5
years) one spray if < 50Kg or two sprays >50kg for
only maximum of 3 days
• Dose and formula is different from treatment of
enuresis
• Side effects: Flushing, hyponatremia –seizures,
tachyplaxis.
• Need to have DDAVP challenge test to assess the
patient’s response (done soon after diagnosis)
• Contraindicated in children <2 years (causes
dilutional hyponatremia)
49

50. vonWillebrand’s Disease
Most common inherited bleeding disorder worldwide
von Willebrand factor is synthesized in endothelium and
megakaryocytes and forms a large multimer to carry factor VIII
and anchors platelets to subendothelium as bridge between
platelets
Inheritance - autosomal dominant
Clinical features - mucocutaneous bleeding; epistaxis,
menorrhagia etc.
Classification
- Type I: Partial quantitative deficiency of vWF (70%
of cases, mild-moderate disease)
- Type II: Qualitative deficiency of vWF (25% of
casese, mild to moderate disease)
- Type III: Total or near total deficiency of vWF (5%
of cases, severe disease)
Diagnosis
- Prolonged aPTT in 50% of cases (due to low factor
VIII). Normal aPTT does not rule out vWD.
- Normal PT
- Prolonged bleeding time; DO NOT PERFORM. This
is replaced by PFA-100 which is not available at MUSC (assess
platelet function)
- Send vWF antigen level and activity, Factor VIII,
Ristocetin cofactor assay, vWF multimeric analysis
50

51. Treatment
• DDAVP: Useful in mild cases (Type I),
contraindicated in Type IIB, not useful in Type III. See
hemophilia section for dosing details
•
•
vWF replacement therapy: Humate-P (recombinant
product): The dosage of Humate-P® required (IU
VWF:RCo) = body wt. (kg) x desired % increase in
VWF activity ÷ 1.5. As a rule, 40-80 IU VWF:RCo per
kg body weight are given every 8-12 hours. The dose
should be adjusted according to the type of VWD and
the extent and location of the bleed.
Adjunctive therapy with Amicar (see hemophilia
section)
51

52. Superior Mediastinal/Vena Cava Syndrome
Usually seen in Hodgkin’s and Non-Hodgkin’s lymphoma,
T cell ALL
Clinical features
• Plethora, facial swelling
• Engorged neck and facial veins
• Orthopnea, hypoxia, dizziness
• Dysphagia and drooling are late ominous signs (as
espophagus is posterior)
Management:
• Airway control is very important
• Supplemental Oxygen
• CXR, CT or MRI to access the airway. Avoid sedation
• Place IV in legs. DO NOT PLACE IV IN UPPER
EXTREMITIES (as it drains to SVC which is already
obstructed)
• Emergency treatment includes Steroids, radiation
which often precedes any diagnostic study
• Attempt to diagnose underlying malignancy if possible
(eg. BMA and Bx under local anesthesia, pleural or
pericardiocentesis)
52

53. Fever and Sickle Cell Disease
Temperature ≥ 38.5C
Presume bacteremia until proven otherwise
Labs:
-CBC with diff and reticulocyte count, BCx if <12yrs
-CXR if any respiratory symptoms
-Other cultures as indicated (or in neonate)
Treatment:
-Ceftriaxone 75 mg/kg IV or IM immediately; max 2G
Disposition:
-Once labs available, discuss all patients with H/O fellow or
attending; Augmentin po for 3 days if discharged
-Admit febrile patients with SCD if exclusion criteria for outpt
not met (see manual for specific criteria).
-Arrange follow-up for all patients in 24H for repeat dose of
Ceftriaxone, to review blood culture, and for clinical evaluation.
*Notes on Blood Transfusions for Sickle Cell Patients
1. Antigen-match blood when time allows
2. Goal Hgb <10 (>10 causes blood to be viscous)
*Note on Supplemental Oxygen for Sickle Cell Patients
Avoid unnecessary O2 which may suppress reticulocyte
count and exacerbate anemia
53

54. Sickle Cell Pain Crisis
History
- Nature, location, duration, and severity of pain
- Character of pain similar to previous sickle pain
- Analgesics already used for this episode
- Associated symptoms- esp fever or dehydration
- Consider etiologies other than sickling
- Previous experience with analgesics (efficacy and
side effects). What does patient / family feel best alleviates
pain?
Physical Exam: complete with emphasis on:
a. Vital signs
b. Hydration status
c. Degree of pallor
d. Evidence of infection
e. Cardiopulmonary status
f. Spleen size (compare with baseline exam)
g. Penis (priapism)
h. Neurological
Laboratory
- CBC, diff, platelets, and reticulocyte count (compare
with patient’s baseline values)
- Blood culture if febrile (T > 38.5oC)
- Type and crossmatch if extreme pallor, respiratory or
neurological symptoms, or acute splenic enlargement present.
- CXR and pulse ox if: chest pain, cough, tachypnea or
respiratory symptoms
- Consider abdominal ultrasound and liver function
tests for RUQ, epigastric pain (R/O cholelithiasis/cholecystitis)
54

55. Treatment:
- IVF: D5 ½ NS at 1.5 times maintenance
If acute chest syndrome, D5 ½ NS at ¾ maint.
- Medications
NSAIDs: Ketorolac (Toradol) 0.5 mg/kg (30 mg
maximum dose) IV OR
Ibuprofen 10 mg / kg PO (800 mg maximum dose)
Antipruritic: Diphenhydramine 1 mg/kg PO prn
itching (50 mg max dose)
Opioids: < 50 kg: Morphine 0.1-0.15mg/kg IV
OR Hydromorphone (Dilaudid) 0.015-0.02 mg/kg
> 50 kg: Morphine 5-10 mg IV OR
Hydromorphone (Dilaudid) 1.5 mg IV.
Titrate Opioid for 2 hours
-Titrate with ¼ to ½ of the initial opioid dose q 30 minutes until
patient experiences relief or is sedated (Opioid sedation scale
>=3, see below)
-Reassess pain and degree of relief q 15-30 min. Adequate
pain control is defined as a 50-60% reduction in the pain score
(see Wong-Baker Faces Pain Rating Scale below).
Disposition:
- Treat patient as outlined above for 2 hours. If pain is
controlled, give dose of the patient’s prescribed oral
opioid analgesic(s).
- If pain relief is maintained for 1 hour following oral
analgesic, discharge home with appropriate
prescriptions and follow-up per Hematologist on-call.
- If pain is not controlled, start scheduled opioid, notify
Hematologist on-call and admit to hospital.
55

56. Schedule opioid q 1-2 hours and calculate scheduled
dose as in Section 4b. above.
- Give “rescue doses” at ¼ to ½ scheduled dose at 30
minute intervals between scheduled doses.
OR start PCA pump (consult Hematologist on call).
Opioid Sedation Scale
Sleep, easy to arouse
Awake and alert
Slightly drowsy, easily aroused
Frequently drowsy, arousable, drifts off to sleep during
conversation
4 = Somnolent, minimal or no response to physical stimulation
McCaffery M, Pasero C: Pain: Clinical manual, p. 267. Coypright
© 1999, Mosby, Inc.
S=
1=
2=
3=
56

57. Sickle Cell And Acute Chest Syndrome
-Any acute illness associated with lower respiratory symptoms,
chest pain, hypoxia, or a new infiltrate on CXR
Labs:
-CBC with diff/plt and reticulocyte count
-CXR
-Blood culture if febrile
-Consider renal function and liver function tests if severe pain
-ABG if severe respiratory compromise
-Type and cross match for PRBC (minor antigen matched,
sickle negative)
Treatment:
-IVF at 0.75 x maintenance
-Oxygen to maintain O2 sats ≥94%
-Incentive Spirometry on all patients
-Morphine or dilaudid boluses
-Ketorolac 0.5mg/kg/dose IV Q6H (max 30mg/dose)
-Ceftriaxone 75mg/kg/dose IV
-Zithromycin
-Consider bronchodilators if patient has a history of reactive
airway disease
-Consider RBC transfusion for severe illness or HgB>1g/dL
below baseline
Admit anyone with acute chest syndrome to the PICU
.
57

58. Wound Closure/Suturing
1. LET (takes 20-30 min. to work) or injected lidocaine (1%)
-buffered lido (1mL Bicarb:9mL Lido) to reduce pain
-lido with epi for hemostasis but avoid on digits, penis,
tip of nose and ears
-toxic dose of lido 5ml/kg; buffered or with epi max
dose is 7ml/kg
2. Preparation: Irrigation; Betadine prep
Suture Types:
Skin:
Face: 6-0 Ethilon/Nylon or Prolene
Or 5.0 Fast absorbing gut
Hands: 5-0 Ethilon/Nylon or Prolene
Extremities: 3-0 or 4-0 Ethilon/Nylon or Prolene
Scalp: Consider staples, sutures, hair apposition technique
Subcutaneous suture: Vicryl/ Absorbable suture;
usually same size as skin
Oral cavity: Chromic gut 5-0 or 6-0
Other options: Steri strips and/or Dermabond
Time to suture removal (non-absorbable sutures):
Scalp: 5-7 days for staples
Face: 3-5 days
Extremities: In general, re-check at 5-7 days, may take
8-10days for full healing, especially joints.
Don’t forget tetanus! <7years DTaP; 7-10y Td; >10y TdaP
Give tetanus booster if risky wound (e.g. rusty nail) and >5 yrs
since vaccine or if >10 yrs since vaccine and clean wound
58

59. Care of Animal and Human Bites
History:
Type of animal involved
Behavior of animal:
Provoked versus Unprovoked.
Location and current owner of animal
Animal’s rabies vaccination status
Patient’s immunization status—last tetanus booster
Physical Exam:
Inspect wound
Document tissue damage, tendon or bone exposure, foreign
bodies, circulatory compromise, motor or sensory deficits.
Imaging Studies:
Radiographs generally not helpful in routine evaluation
except:
1) To exclude the presence of a foreign body
2) In cases of deep scalp wounds. A large dog may be
able to fracture a young child’s skull
3) Exam consistent with possible fracture—may see
with bites to hands and fingers.
Consider Speciality Consultation:
Plastic Surgery: if wound potentially disfiguring
Hand Specialist: hand injuries involving tendons, joints, or
vasculature
Orthopedics: joint, tendon, or bony injuries
Neurosurgery: penetrating wounds to skull
Pediatric Surgery: deep neck wounds
59

60. Bites, con’t:
- Irrigate with Normal Saline
Use a minimum of 200mL/ bite, approx 100-200ml/inch
- Suture:
Wounds on the face
Wounds less than 6 hours old.
Use minimal number of interrupted, nylon sutures.
Avoid deep sutures.
- Discuss with ED attending before suturing the following
bites: (prone to infection)
Puncture wounds
Bite wounds of hands and lower extremities
Cat and human bites
Immunocompromised or asplenic hosts.
Wounds older than 6 hours old
Inpatient Admissions:
Severe soft-tissue injuries
Penetrating skull injuries
Consider admission if infection present
Follow-up care:
DHEC called for any dog bite
Wound check: 24-48 hours
Patient/ family Education:
Review signs and symptoms of wound infection.
Advise family to promptly seek medical attention if signs of
infection occur.
Inform family of risk of infection despite proper wound care
and antibiotics
60

61. Antibiotics for Bites:
Prophylactic antibiotics indicated in:
Cat bites
Human bites
Puncture wounds
Hand and foot wounds
Wounds with care delayed beyond 12 hours
Immunocompromised hosts
Animals
Organisms
Antibiotics
Bat,
Skunk,
Raccoon
Cat
Unknown
Augmentin or
Doxycyline
Dog
Human
Fish
(oyster/
fish hook)
Rabies
Vaccine?
YES
Pasturella Multicida/
Staph
Augmentin or
TMP/SMX
PLUS Clinda
NO
P. muticida, Staph,
Bacteroides,
Fusobacterium, EF4, Capnocytophagia
Viridans Strep,
Staph,
Corynebacterium,
Eikenella,
bacteroides,
Peptostrep
Vibrio
Augmentin or
TMP/SMX
PLUS Clinda
YES
Augmentin
(Unasyn) or
Clindamycin
AND
TMP/SMX
Doxy (if >8)
or Omnicef
NO
NO
61

62. Snake Bite Management Algorithm
62

63. Snake Bite Antivenom: CroFab
* See portal for treatment algorithm (and help for management
for Coral snake bite)!
•
•
•
•
Works for Crotalid snakes only (not Coral snakes)
Give with signs of envenomation: Swelling, pain,
ecchymosis
Give with coagulation abnormalities
Monitor closely for hypersensitivity reaction during
administration (Benadryl and epi at bedside)
Puncture Wounds
Obtain history on time of injury, object causing injury, tetanus
status and footwear worn if foot involved. Administer tetanus.
Obtain xray to rule-out retained foreign body even if low
suspicion for foreign body. Consider Ortho consult for deep
punctures that could enter bone or joint space.
Vigorous cleaning and debridement after local anesthesia or
regional block. Dress wound with bacitracin and sterile gauze.
Instruct family how to dress wound at home.
Antibiotic therapy should be initiated to cover staph and strep
with first-generation cephalosporin or Augmentin. Cover for
Psuedomonas if rubber shoe sole involved in wound.
63

64. Sedation and Analgesia
Monitor patient during procedure and until fully awake.
Use End-tidal CO2 monitor with all sedations if available.
Have all airway equipment readily available.
Wall suction and BVM must be set-up and working.
Remember Time-Out Forms
For general procedures (anxiety, mild pain):
Versed: po or intranasal: 0.5-0.7mg/kg
onset 15-30min; lasts 2hrs
IV: 0.05- 0.1mg/kg, max 4mg
Fentanyl: 1-3mcg/kg IV (max 100mcg/dose)
onset 5-10min; lasts 1hr
1.5-2mcg/kg intranasal (max 100mcg/dose)
For more painful procedures, including ortho:
Versed (only small doses necessary to ease pt into sedation and
for amnesia) generally 0.5-1.0mg TOTAL
Ketamine 1mg/kg IV or 2-4mg/kg IM; titrate to effect
Onset 1 min; duration 5-10min
Contraindicated in CHI or eye injuries as increases ICP/IOP
Other options for sedation include Propofol and Etomidate.
Must add analgesia for painful procedures.
64

65. Splinting
Arm fractures:
Sugar tong splint - ulnar and radial fx,
Double sugar tong- fracture was reduced, manipulated, or very
proximal.
Thumb spica - thumb fractures, scaphoid fx
Ulnar gutter - fractures of 4 and 5th metacarpal or phalanges.
Posterior long arm splint - supracondylar fractures
Distal Leg Fractures:
Posterior splint with stirrup
Toddlers’ fractures (spiral distal tibial fractures) ultimately
require Ortho to place long leg cast.
Salter Harris Classification:
65

66. Splinting continued.
66

67. Organic vs. Functional Psychosis
ORGANIC
FUNCTIONAL
* Sudden Onset *
Gradual Onset
* Pre-pubertal *
Young Adulthood
Abnormal VS
Normal VS
Psychomotor Retardation
Ataxia
Repetitive Activity
Rocking
* Visual Hallucinations *
Auditory Hallucinations
Emotional Lability
Flat Affect
Disoriented
Oriented
Islands of Lucidity
Continuous Scattered Thoughts
Impaired Consciousness
Alert & Awake
Remember that this is not an all exhaustive list and should be based on each individual case
in conjunction with consulting services. Remember to consult Neurology early.
Labs/ Studies:

CBC c diff, CMP, Mg, Phos

TFTs, Heavy Metals

UDS, EtOH, Salicylates, Acetaminophen

VBG, UA, CXR, EKG, Head CT v MRI, LP
Learning Points:

New Onset Psychosis is Organic until proven otherwise

IOP is not equipped to complete a medical evaluation

New Onset Psychosis → plan for General Pediatric Admission

Consult Psychiatry for help with 
Work up

Inpatient management of symptoms

Mutual Respect – Willingness & Support
67

68. Trauma Resuscitation
Primary Survey and Resuscitation
*Intervene at each step as appropriate

A
Airway
Establish and maintain airway with C-spine
precautions

B
Evaluate Breathing
Place on O2
Symmetric movement and sounds

C
Circulation
Check CENTRAL pulses, manual BP
IV access x2 (large bore) – 20ml/kg NS
Control hemorrhage

D
Disability
Brief Neuro assessment (pupils, AVPU)

E
Exposure
Completely undress patient
Obtain history from EMS
Avoid Hypothermia!!
Always check GLUCOSE in setting of AMS.
68

69. Trauma Resuscitation cont.
Secondary Survey

AMPLE history
(allergies, medications, PMHx, last meal, events)
 Listen to EMS report!
 Thorough exam from head to toe:
“Finger in every orifice”
- Studies:
Portable CXR +/- pelvis film if sx of LE trauma
“Trauma labs:” CBC, CMP, Amylase, UA, VBG, T&S
Additional imaging based on exam
Don’t forget Tetanus!
Assume spine precautions
Leave C-collar on, but don’t forget to examine the neck while in
in-line stabilization
Log-roll patients to examine spine
Remove from spine board ASAP if no obvious abnormalities
but keep flat if any spinal process pain on exam
Indications for Mass Transfusion Protocol
Trauma + Instability post 2 crystalloid bolus’ + evidence of
on-going bleeding.
Requires attending order for: Infuse emergent uncrossed
blood and charge nurse to notify blood bank.
69

70. Guidelines for Activation of Trauma Team
Pediatric Trauma Alert Level Criteria (scene transport)
Age 15 and under
Level A
- Respiratory distress/intubated
- Hypotension/shock*
- Unconscious patient (GCS 9 or less)
- Penetrating injury to head, neck, or torso
- Open or depressed skull fx
- Flail Chest
- Limb-threatening injury
□ Amputation proximal to wrist or ankle
□ Crushed, degloved, or mangled extremity
□ Penetrating injury proximal to elbow or
knee plus diminished or absent pulse,
expanding hematoma, or ongoing bleeding
- Paralysis
- Burns 2nd or 3rd degree > 40% BSA or if suspicion
of smoke inhalation or hemodynamic compromise
- Suspected pelvic fx with hemodynamic instability
Level B
- Altered mental status (GCS 9-13)
- Burns 2nd or 3rd degree 20-40% BSA
- Fall >20 feet (one story is approx 10 feet)
- Ejection from vehicle; Death in same vehicle
- Auto/ped or Auto/bicycle with pt thrown, run over, or
with impact >20 MPH
-Motorized off road vehicle or motorcycle crash
>20MPH
- MVC > 35mph
- Attending Physician concern for serious injury
70

71. 8 P’s for Rapid Sequence Intubation
1. Preparation:
O2
ECG Monitor
BVM
Tracheal tube size and +/-0.5 tube size
Stylet
Suction
Drugs as below
Consider NG tube
2. Pre-assessment
Difficult to bag? Difficult to intubate?
3. Pre-oxygenate - Use NRB, have BVM available
4. Pretreatment (LOAD):
a. Lidocaine 1-1.5mg/kg if suspected head injury
*most effective if given 4 min prior to intubation
b. Opiod (Fentanyl) 2-3mcg/kg
c. Atropine 0.02mg/kg (0.1mg min -0.5mg max)
*decreases vagal response and oral secretions, use when <1yo
and always when using Succ
d. Defasciculation: 1/10 nondepolarizing paralytic if
using depolarizing paralytic such as succinylcholine
5. Paralysis after induction:
a. Sedative/Hypnotic
Versed 0.1-0.2 mg/kg
Onset 1-5min, duration 30-60min
Etomidate 0.3mg/kg
Onset 15-30sec, duration 1-5min
* Good for head trauma with stable hemodynamics,
because can decrease bp
Thiopental 2-5 mg/kg
Onset 15-20sec, duration 5-10min
* Can cause decreased bp and histamine release
Ketamine 1-2mg/kg (see sedation)
* Good for asthma, shock states
71

72. Propofol 1-3mg/kg
Onset 15-30sec, duration 10-15min
* Can cause decrease in bp.
* Avoid in soy or egg allergy patients
b. Paralytic Agents
Rocuronium 1mg/kg
Onset 30 sec, Duration 30-45min
Succinylcholine 1-2mg/kg (non-depolarizing)
* Not preferred in increased ICP, crush injury, burns,
hyperK, neuromuscular disorders, penetrating eye
injuries
Onset 45 sec, Duration 4-5min
Vecuronium 0.1-0.2mg/kg
Onset 30 sec, Duration 30-60min
6. Placement: shoulder roll, sniffing position, cricoid pressure
7. Placement with proof: (CO2 detector, auscultation)
8. Post-intubation care:
Sedation and Paralysis; continuous ETCO2 monitoring
72

73. Tube/Line sizes
Uncuffed ETT= (age/4) + 4 ETT depth= 3 x internal diameter
ETT
CVL
NGT
Chest
Foley
tube
Cathet
er
Newborn
3.0-4.0
3F
5-8F
10-14F
5-8F
2-12mo
3.5-4.0
3F
8-10F
14-20F
8F
12-24mo
4.0-4.5
4F
8-10F
14-24F
8F
2-3 yrs
4.5
4F
8-10F
14-24F
8-10F
4-5 yrs
5.0-5.5
4-5.5F
10-12F
20-32F
10F
6-7yrs
5.5-6.0
5.5F
12F
20-32F
10F
8-11yrs
6.0
cuffed
5.5F
14F
28-38F
12F
12-15yo
6.5-7.0
cuffed
5.5-6F
14F
28-38F
12-16F
>15yo
7.0-8.0
cuffed
7-8.5F
16-18F
28-38F
14-16F
73

74. Vasoactive and Inotropic Drugs
Rule of 6: mix 6mg/kg in 100ml D5W: 1ml/hr = 1ug/kg/min
Drug
Dopamine
Dosage
0.53ug/kg/min
5-10
10-25
Receptors
Dopaminergic
β-adrenergic
∝-adrenergic
Usual
Effect/Usage
Dilation in renal,
mesenteric, cerebral
vasc.
Mostly inotropic
(↑cardiac output)
↑HR, vascular
resistance, BP
Dobutamine
120ug/kg/min
β-adrenergic
Inotropic,
vasodilation
Epinephrine
0.020.1ug/kg/min
0.1-1
β-adrenergic
Inotropic
∝ and βadrenergic
↑Vascular resistance
and BP:
for “cold shock”
Norepinephrine
0.050.5ug/kg/min
Mostly ∝adrenergic,
some β1
↑Vascular resistance:
for “warm shock”
Phenylephrine
(neosynephrine)
0.58ug/kg/min
∝-adrenergic
only
↑Vascular resistance;
maintain MAP
and CPP
Milrinone
(primacor)
Loading dose:
50ug/kg
slowly
Infusion:
0.250.75ug/kg/min
P-diesterase
inhib:
potentiate β
receptor
stimulation
Inotropic,
vasodilation
74

75. Nitroglycerin
1-5 ug/kg/min
None
Systemic and
pulmonary
vasodilation
Sodium
Nitroprusside
0.5-10
ug/kg/min
None
Systemic and
pulmonary
vasodilation
Labetolol
Hypertensive
emergency:
intermittent
dose @ 0.31mg/kg/dose
Q 10min
PRN; max
20mg/dose.
Infusion:
Harriet Ln
∝ and βadrenergic
antagonist
Patient should be
supine.
Refer to Harriet Lane
and
other sources for side
effects,
contraindications
75

76. Goal-Directed Shock Guidelines
*See Septic Shock Order Sheet and portal for Flowchart
Identify Shock:
Compensated - Tachycardia, tachypnea with
poor perfusion (cap refill >2s) and/or
AMS
Decompensated- Above sx and systolic BP
low for age ( < 70 + age x 2; newborn <60;
10y and above <90)
0-5 mins -Start O2 and airway management; consider ETCO2
monitor
-IV access x 2 ; IO if unsuccessful
-Labs: Accucheck, Blood culture, cbc, cmp,venous
blood gas, cortisol, lactate, coags
-Calculate baseline shock index (HR/SBP)
-Bolus IVF: 60 ml/kg NS (Ringers lactate for burns)
over 15 minutes
-Pressure bag, Push/Pull method or Rapid Infuser – no
IV pump
-If any concern of sepsis, start antibiotics
15-20
mins
-Reassess vitals, cap refill and mental status with each
20ml/kg
Fluid-refractory shock:
1) Catecholamines:
A) Dopamine: begin 10mcg/kg/min
B) Next line: Epinephrine (0.05mcg/kg/min) if
cold shock
76

77. Norepi (0.01mcg/kg/min) if warm shock or
spinal cord injury
2) If hypotension unresponsive to IVF:
A)Consider bedside US to rule out cardiac
tamponade
B) If rales/hepatomegaly, consider
Dobutamine for cardiogenic shock
3) Consider sedation with ketamine for CVL
placement, CVP monitor, foley catheter
Caveats: 1) Trauma: Transfuse pRBCs 10-20ml/kg after
60ml/kg NS if no improvement
2) RSI: consider Atropine/Ketamine/Paralytic
3) Hydrocortisone: Shock dose 50 mg/kg for
catecholamine resistant shock and/or
suspected adrenal insufficiency
Goals : Cap refill <3s; normal systolic BP for age; improving
shock index (HR/SBP), normal mental status
77

78. Radiology Helpful Tips:
•
CT:
o
o
o
o
o
•
Ultrasound:
o
o
o
•
Trauma head – WITHOUT contrast
Mass head – WITH contrast (consider CTA/ MRI
for vascular issues)
Soft tissue neck– WITH contrast
Abdominal (for appy)– WITH IV and PO contrast
Facial & Orbit fractures – “limited facial bones
non-contrast CT”
Abd (for appy or intussusception)-empty bladder
Pelvic for ovaries/torsion – full bladder, WITH
Doppler (can use foley to fill bladder if necessary)
Testicular – WITH Doppler
Xrays:
o
o
o
o
o
o
o
All Extremity films-order as “***** Series”
Knees –always include sunrise view (for patella)
Hips – “bilateral AP with Frog-leg”
Cspine – adequate views must include top of T1 &
odontoid view (if able)
CXR AP = portable
CXR lateral can only be portable if <10kg
Skeletal Surveys: preferred in daytime for tech
skill
78