Paediatric Scenarios for
Medical Students
23/03/11
Dr. John Twomey
Department of Paediatrics/ Emergency
Department
ETA 5 min…….
Weight
• Centile Charts
• Broselow Tape
• Formula (1-10yrs):
Wt (kg) = (age + 4)2
• Estimate (0-1 yrs):
Newborn = 3.5 kg
6/12 = 7 kg
12/12 = 10 kg
• Estimate (>10 yrs):
10 yrs = 30 kg
12 yrs = 40 kg
14 yrs = 50 kg
16 yrs = 60 kg
Energy
• 4 J/kg asynchronous shock
• Except:
- Ventricular Tachycardia with Pulse - Synchronous
cardioversion 0.5-1J/kg, 2J/kg
- Supraventricular Tachycardia (SVT) - If No IV access &
shocked – Synchronous cardioversion 1J/kg, 2J/kg
Synchronous cardioversion:
• shock given @ “R” of QRS complex; relies on the ability
of the defibrillator to recognise QRS complexes
• The shocks may have to be given asynchronously if
synchronous shocks are ineffectual (may => VF or
asystolé)
Tube
Estimate (>1)
• Internal Diameter (mm) = (Age/4) + 4
• Length (cm) = (Age/2) + 12 (oral)
+ 15 (nasal)
Term Neonate
• 3.5 (3.0,4.0)
Preterm Neonate
• 3.0 (2.5,3.5)
Fluids
• 0.9% NaCl 20 ml/kg (10ml/kg in DKA or Trauma)
• >/= 3 boluses (60ml/kg = ¾ of total circulating blood
volume!) = consider RSI
• Larger volumes => haemodilution - Albumin??
• Use CVP (~cardiac preload) as a guide
• Blood –
 fully cross-matched = 1º
 type-specific non-cross –matched = 15 min
 O-negative = 0 min
• NOT dextrose because => hyponatraemia
Adrenaline
• 10 μg/kg IV/IO (0.1ml/kg of 1:10,000);
100 μg/kg (0.1ml/kg of 1:1,000) ETT Cardiac Arrest
• 10 μg/kg IM (0.01ml/kg of 1:1,000) –
Anaphylaxis
• 5ml of 1:1,000 nebulised in O2 –
Laryngotracheobronchitis (Croup)
/Anaphylaxis
Glucose
• Dextrose 10% 5ml/kg IV (APLS)
• Except:
- Neonates – Dextrose 10% 2ml/kg IV (NRP)
WETFAG
•
•
•
•
•
Weight = (Age + 4)2
Energy = 4 J/kg asynchronous shock
Tube = (Age/4) + 4 ---- +/- 0.5
Fluids = 20 mls/kg 0.9% NaCl
Adrenaline = Adrenaline 10 μg/kg IV/IO
(0.1ml/kg of 1:10,000); 100 μg/kg
(0.1ml/kg of 1:1,000) ETT
• Glucose = Dextrose 10% 5ml/kg IV
Scenario 1
• You are called to the ED to see a 10 year
old boy in respiratory distress with a
history of asthma. You have a few minutes
to make your calculations. You estimate
his weight to be … kg?
Scenario 1
• As you approach the ED, the student
nurse swings the door open and screams,
“Come in quick!”. As you enter the room
you note a young boy, approximate age
10, leaning forward in a tripod position. He
is alert but unable to answer questions. He
is diaphoretic with audible wheezing. He
has signs of respiratory distress. His
colour is pale.
Questions?
• What is your general impression of this
patient?
• What are your initial management
priorities?
Answers
• What is your general impression of this
patient?
 Severe respiratory distress - increased work of breathing with
retractions and tripod position, audible wheezing, pale and
diaphoretic skin
 Alert, however, it is clear that he is struggling to breathe
 This patient has potential to progress rapidly into respiratory failure
• What are your initial management
priorities?





Address airway and breathing
Leave in a position of comfort
Pulse oximeter
100% oxygen given by a non-rebreather mask
Salbutamol neb
Case Continuation
• After 3 nebulisers the child’s saturations
suddenly drop to mid 70s despite
supplemental O2 therapy. His respiratory
rate increases to 40 bpm. He has very
shallow respirations. He becomes
increasingly distressed.
Case Continuation
• His trachea is noted to have deviated to
the left and the right side of his chest is
hyper-resonant to percussion
• What is the diagnosis?
• What immediate and subsequent
interventions are required?
What is the Diagnosis?
• Tension Pneumothorax
What immediate and subsequent
interventions are required?
• Needle Thoracocentesis
• Chest drain placement
Tension Pneumothorax
PM Film
Asthma
• ABC
• High-flow O2
• β-agonist – Salbutamol inhaler + spacer +/- face mask – 1,000μg
{10 sprays}
• Salbutamol Nebuliser 2.5mg (<5 yo); 5 mg (>5 yo) with O2 (flow
rate 4-6 l/min) + Ipratropium Bromide (250μg)
• PO Prednisolone (2mg/kg) or IV Hydrocortisone (4mg/kg)
• Salbutamol Nebuliser Continuously
• IV Salbutamol 15μg/kg over 10 min over 2 years fb infusion of 15μg/kg/min (ECG & K+)
• IV Aminophylline 5mg/kg over 20 min fb infusion of 1 mg/kg/hr
(omit ld if received oral theophylline or other methylxanthine in
previous 12º)
• IV Magnesium Sulphate 25-40mg/kg over 20 min (max 2g)
• Intubation & Mechanical Ventilation – Increasing exhaustion;
progressive deterioration in clinical condition; PCO2 > 8 kPa; PO2 <
8 kPa with FiO2 = 60%
Scenario 2
• You are called by one of the ED nurses
that a 3 year old boy is on his way to the
ED. He was fine earlier in the day when he
went shopping with his mother, but began
to act strangely and then became lethargic
about 1 hour after their return home. You
have time to make your calculations. You
estimate his weight to be … kg?
Scenario 2
• In the ED the child is lying on the examination
couch, with his eyes closed, and does not react
to you entering the room. His breathing is not
laboured, and his colour is pink. Initial
assessment reveals that his airway is open,
respiratory rate is 16 per minute, with slightly
shallow respirations, heart rate 104 with strong
distal pulses, capillary refill 2 seconds, blood
pressure 84/50. He withdraws from painful
stimuli, and moans, but does not respond to
verbal stimuli, his pupils are 6 mm and briskly
reactive, and there are no bruises or evidence of
trauma.
Questions?
• What are the BLS treatment priorities?
• What are some possible causes for this
altered level of consciousness?
• What test would you do now to guide
therapy?
Questions?
• What are the BLS treatment priorities?

Provide oxygen and support respirations with bag-valve mask ventilation. A respiratory rate of 16
is low for a 3 year old. (normal rage is 24-40 respirations/minute)
• What are some possible causes for this altered level of
consciousness?









A – Alcohol/acidosis/ammonia (metabolic disease)
E – Epilepsy
I – Infection
O – Opiates
U – Uremia
T – Trauma
I – Insulin/Hypoglycemia
P – Poisoning/Psychogenic
S – Shock/Sepsis
• What test would you do now to guide therapy? – Blood glucose
Case Continuation
• Blood Glucose – 1.2 mmol/l
• What other investigations would you
consider?
Case Continuation
• Blood Glucose – 1.2 mmol/l
• What other investigations would you
consider?
• “Newcastle” Work Up
• Urine toxicology screen is negative
• Blood alcohol level is 115 mg/dl!!!
?
Case Continuation
• Further history reveals that upon returning
home the child was thirsty and opened a
bottle containing a red liquid. He drank
some (thinking it was his favourite rasberry
flavoured drink). This turned out to be
mouthwash, which contained 25% alcohol
Scenario 3
• It is January in Limerick. You receive a
call that a 2 year old girl is on her way into
the ED having been found in a shallow
pond. BLS is in progress but no advanced
interventions have been performed. The
ambulance crew report that a rescuer at
the scene said the child may have been
lost for 25 minutes. You have a few
minutes to make your calculations. You
estimate his weight to be … kg?
Questions?
• On arrival the child is apnoeic and
pulseless.
• What are the BLS treatment priorities?
Questions?
• What are the BLS treatment priorities?
 Stop BLS & assess
 Airway – Patent
 Breathing – Apnoeic – oral endotracheal
intubation & bag-valve mask ventilation with
added 02
 Circulation – Pulseless – attach to monitor
Monitor shows this rhythm –
what is it?
Ventricular Fibrillation
• Bizarre, irregular, random waveform
• No clearly identifiable QRS complexes or
P waves
• Wandering baseline
Case Continuation
• What do you do next?
Case Continuation
• What do you do next?
 Shockable Rhythm Algorithm
Shockable Rhythm Algorithm
Case Continuation
• After repeated asynchronous shocks –
child remains in Ventricular Fibrillation
Eh, What’s Up Doc?
Case Continuation
• This child was found in a shallow pond in
Winter. Her initial temperature was 27°C.
She needs active rewarming to >32°C
before a decision can be made to stop
resuscitative efforts
• How can this be done?
Active Rewarming
• External Rewarming (T> 30°C)





Remove cold, wet clothing
Supply warm blankets
Infrared radiant lamp
Heated blanket
Warm air system
• Core Rewarming (T< 30°C)





Warm IV fluids (39°C)
Warm ventilator gases (42°C)
Gastric/bladder lavage with 0.9% NaCl (42°C)
Peritoneal/pleural/pericardial lavage
Extracorporeal blood rewarming
NB Rewarming Shock -↓ PVR >> ↑Temp => ↓BP
Case Continuation
• Her temperature was gradually increased
to 35°C and a further DC shock of 4 J/kg
brought her rhythm back to normal sinus
rhythm
Scenario 4
• A 1 year old male infant was admitted to a
peripheral unit with shortness of breath and poor
feeding. He was found to have his first episode
of supraventricular tachycardia. This was treated
correctly with adenosine but reverted and
needed several doses. After appropriate
discussion with the Regional Cardiac Centre,
flecainide was given orally. You are the retrieval
doctor about to receive hand over of this patient
from the registrar on call in the peripheral unit.
You have a few minutes to make some
calculations. The baby’s weight is 10 kg.
Scenario 4
• The infant is just about to be transferred to
the Cardiac Unit when he suddenly stops
breathing and is pulseless. You discover
that 10 times the correct dose of flecainide
was given!
Questions?
• What do you do?
Sure YOU might feel better but it
won’t really be of any help to the
child!!
Questions?
• What do you do?
 Commence BLS
 Airway – Patent
 Breathing – Apnoeic – oral endotracheal
intubation & bag-valve mask ventilation with
added 02
 Circulation – Pulseless – attach to monitor
Monitor shows this rhythm –
what is it?
Ventricular Tachycardia
• Wide complex (>/= 0.08 sec)
• No P-wave or if present not associated
with QRS
Case Continuation
• What do you do next?
 Shockable Rhythm Algorithm
Shockable Rhythm Algorithm
Case Continuation
• The child is in pulseless ventricular
tachycardia which reverts to sinus rhythm
after the 1st shock of 4 J/kg. A palpable
pulse is achieved.
THE AUTHOR WISHES TO ASSURE ALL
CONCERNED THAT NO NURSE WAS
HARMED IN THIS SCENARIO!
Scenario 5
• You are called to the Medical Ward to
attend a 6 week old child. This baby girl
was admitted 2 days previously with
bronchiolitis. She suddenly became
apnoeic and the nurse suctioned her
airway. During suction she became pale
and floppy. You have a few minutes to
make some calculations. You estimate her
weight to be 5 kg.
Scenario 5
• On your arrival the nurse is bagging the
child and there is no spontaneous
respiratory effort. The baby is pulseless.
There is an IV cannula in situ in the
dorsum of her left hand.
Questions?
• What are the BLS treatment priorities?
Questions?
• What are the BLS treatment priorities?
 Stop bagging the baby & assess
 Airway – Patent
 Breathing – No spontaneous respiratory effort –
oral endotracheal intubation & bag-valve mask
ventilation with added 02
 Circulation – Pulseless – chest compressions
(15:2) - attach to monitor
Monitor shows this rhythm what is it?
Asystolé
• Commonest arrest rhythm in children
• Hypoxia => acidosis => progressive
bradycardia => asystolé
• Almost a straight line with occasional Pwaves
• ? Artifact – loose wire/disconnected
electrode
• ↑ gain on the ECG monitor
Case Continuation
• What do you do next?
Case Continuation
• What do you do next?
 Non-Shockable Rhythm Algorithm
Non-shockable Rhythm
Algorithm
What causes Asystolé?
Causes of Asystolé?
4 Hs:
• Hypoxia
• Hypovolaemia
• Hyper/hypokalaemia/Metabolic D/O
• Hypothermia
4 Ts:
• Tension Pneumothorax
• Cardiac Tamponade
• Toxic Substances
• Thromboembolic Phenomena
What caused this infant to
become asystolic?
What caused this infant to
become asystolic?
• Apnoeic attack => hypoxia => suctioning
=> vagal stimulation => asystolé
Case Continuation
• The baby responded to the second round
of adrenaline
Scenario 6
• You are on your way to the resuscitation
area in the ED to review a 2 year old girl
who has been brought in in a collapsed
state. She has a history of pyrexia and
lethargy for the preceding 24 hours. You
have a few minutes to do some
calculations. You estimate her weight to be
…kg
Scenario 6
• On arrival to the ED you notice that she is
grey and hypotonic. As you expose her
torso you notice that she has a purpuric
rash on her chest and abdomen. She is
attached to a monitor which shows a sinus
rhythm but she is apnoeic, pulseless and
unresponsive
What could this rhythm be?
PEA (EMD)
• Recognisable complexes on ECG monitor
• No pulse or other signs of circulation
Case Continuation
• What do you do next?
 Non-Shockable Rhythm Algorithm
Non-shockable Rhythm
Algorithm
Questions?
• What other treatments should be initiated
in this scenario?
Questions?
• What other treatments should be initiated
in this scenario?
IV fluid bolus(es)
IV Broad Spectrum Antibiotics
Scenario 7
• A 17 month old girl is brought into the ED
by ambulance. She was eating a packet of
“mini-eggs” in the kitchen with her father
when the telephone rang. He went out to
answer it. Ten minutes later he looked for
her and found that she had managed to
unlock the back door and had fallen in the
garden. You are on you way to see her.
You have time to do some calculations.
You estimate her weight to be …kg
Scenario 7
• As you reach the ED paramedics are
performing bag-valve-mask ventilation on
the child but they are struggling to move
the chest. They tell you that she had
vomited at the scene and that there were
“mini eggs” in the vomitus. She is apnoeic
but conscious.
Questions?
• How will you initially manage this child?
Questions?
• How will you initially manage this child?
Clear airway with suction or removal under
direct vision
FBAO Protocol
Management of a Choking Child
Ineffective Cough & Conscious
Infants (<1)
• Back Blows (x5) and
Chest Thrusts (x5)
(1/second)
Ineffective Cough & Conscious
Children (1-14)
• Back Blows (x5)
and Abdominal
Thrusts (x5)
(1/second)
(Heimlich
Manoeuvre)
Case Continuation
• The child expectorates a large piece of
chocolate and has a further vomit. She
begins to breath normally once again and
is positioned in the recovery position
The Recovery Position
Scenario 8
• A 2.5 year old boy became pyrexial and vomited
once 6 hours before admission. He was seen by
his GP prior to admission and was noted to have
a sore throat. The GP prescribed penicillin but
his Mum had not yet obtained his medication as
the local chemist was shut. He now will not
drink. You are going to see him in the ED but
have a few minutes for some calculations. You
estimate his weight to be…kg
Scenario 8
• When you see him you note that his
respiratory rate is 40 with marked
recession. His pulse rate is 160 with
normal capillary refill. He is very pale. He
has a soft inspiratory stridor with no cough
and he is drooling profusely from his
mouth. His Mum believes that vaccines
have not been adequately tested and can
do more harm than good
Questions?
• How will you initially manage this child?
Questions?
• How will you initially manage this child?
 DON’T:
 Inspect the airway
 Attempt to insert an IV cannula
 Lie the patient down
 Send for lateral neck x-ray
 DO:
 Give High-flow O2
 Call Anaesthetist/ENT
Case Continuation
• Minutes later his respiratory rate falls to 10
gasps/minute. He loses consciousness
and the stridor disappears
• What do you do next?
Case Continuation
• What do you do next?
Bag-and-mask ventilation with high flow
O2
Attempt orotracheal intubation
Needle cricothyroidotomy and transcricoid
ventilation
IV/OI access (AFTER AIRWAY
MANAGEMENT)
IV Broad Spectrum Antibiotics
Cricothyroidotomy Cannulae
• Different sizes
12 gauge – adult
14 gauge – child
18 gauge – infant
OR
• IV Cannula
Surgical Airway –
Needle Cricothyroidotomy
• A last resort!
• Cricothyroidotomy
cannula-overneedle/IV cannula +
5ml syringe
• Identify cricothyroid
membrane
Surgical Airway –
Needle Cricothyroidotomy
• 45º angle caudally,
aspirate as the needle is
advanced
• Advance cannula over
needle & withdraw the
needle
• Y-connector to oxygen
flowmeter
• Flow rate = child’s age
(yrs)
• Ventilate – “1 second on;
4 seconds off”
• Secure
Transcricoid Ventilation
• Cannot ventilate with self-inflating bag
(P= 4.5kPa) but can ventilate with
oxygen flow meter (P= 400kPa);
O2 rate = 1l/min/year of age
• Cannot expire through the cannula;
expiration must occur through the upper
airway => complete UA obstruction => ↓
gas flow to 1-2l/min => some oxygenation
but very little ventilation
Surgical Airway –
Surgical Cricothyroidotomy
• Only in >12 yoa
• Vertical incision in skin &
press the lateral edges of
the incision outwards to
minimise bleeding
• Transverse incision
through cricothyroid
membrane
• Insert scalpel and twist
through 90º
• Insert appropriately sized
ETT/tracheostomy
• Secure
• Check position
Scenario 9
• A 7 year old girl is brought into the ED by
her mother who has noticed that she has
become sleepy and has laboured
breathing. 24 hours previously, she had
been seen at another hospital with
abdominal pain. A diagnosis of
constipation was made. You are on your
way to see her. You have some time to do
some calculations. You estimate her
weight to be …kg
Scenario 9
• When you arrive you notice that she has a
respiratory rate of 40. Her pulse rate is
160 with a poor volume. Her capillary refill
time is 5 seconds. She responds to her
mother’s voice by briefly opening her eyes.
• What do her vital signs indicate?
• How are you going to manage her?
Questions?
• What do her vital signs indicate?
 Increased respiratory rate; increased heart rate
with poor volume; increased capillary refill time;
responding to voice => compensated =>
decompensated shock
 >/= 10 % dehydration
• How are you going to manage her?
 Airway – patent
 Breathing – high flow O2 by face mask
 Circulation IV access; Bloods – FBC, U&E, VBG,
glucose; IV fluid bolus 10ml/kg
Case Continuation
• pH 7.03; Blood glucose 34mmol/l
Fluids = (Maintenance)2 + Deficit/ 48°
Insulin 0.1 IU/kg/hr
Diabetic Ketoacidosis (DKA)
Relative/absolute lack of insulin => inability to metabolise
glucose => hyperglycaemia, osmotic diuresis, dehydration,
fat breakdown => ketones & metabolic acidosis,
compensatory hyperventilation (respiratory alkalosis) =>
coma
CF:
• Wt loss
• Abdominal pain
• Vomiting
• Polyuria
• Polydipsia
• Moderate=>severely dehydrated
• Kussmaul Respiration
• Ketotic breath
Management of DKA
•
•
•
•
•
•
•
•
•
•
•
•
•
ABC
High-flow O2
IV access x2
Bloods – U&E, glucose, FBC, VBG, blood culture (if clinically indicated)
Urine – Glucose, Ketones, C&S
10ml/kg 0.9% NaCl bolus
Fluids – {(Maintenance)x2 + Deficit}/48 – 0.9% NaCl (BM> 15 mmol/l)
=>0.45% NaCl + 5% Dex (BM 8-15 mmol/l) => 0.45% NaCl + 10% Dex (BM
< 8 mmol/l)
Add KCl 20mmol/500mls once PU
Insulin – 0.1IU/kg/hr
NaHCO3 – avoid unless pH <7.1 despite replacement of intravascular
volume & appropriate insulin & fluid therapy for several hours
1º vital signs, BMs, Neuro-obs, UO & fluid balance
2-4º U&E, VBG, serum glucose
Watch for complications
Complications of DKA
• Cerebral Oedema – head ache,
recurrence of vomiting, ↓GCS, ↓HR, ↑BP
• Cardiac Arrhythmias - 2º to electrolyte
disturbances
• Pulmonary Oedema
• Acute Renal Failure
Scenario 10
• A 4 year old boy presents with a generalised
convulsion. He has received rectal diazepam
from the paramedics in the ambulance and on
arrival is not convulsing but is responsive only to
painful stimuli. You are on your way to see him
(It does seem strange that you’re never actually
in the ED when these patients present!!) You
have some time to do some calculations. You
estimate her weight to be …kg
Scenario 10
• When you arrive he starts to seize again
and he becomes apnoeic. His pulse, which
was initially 170 bpm, subsequently falls
after apnoea. You cannot determine his
blood pressure. He is now unresponsive.
His temperature is 39.8°C.
• What do his vital signs indicate?
• How are you going to manage him?
Scenario 10
• What do his vital signs indicate?
Apnoea => bradycardia which could =>
asystolé
• How are you going to manage him?
• Airway & Breathing – AVPU score is U =>
need for RSI
• Circulation – IV access; Check Blood
glucose; Status Epilepticus Protocol
“Status Epilepticus” Algorithm
Time
IV access
No IV access
5 min
Lorazepam 0.1mg/kg (max.
2mg) IV/IO
Diazepam 0.5mg/kg PR
OR Midazolam 0.5mg/kg
buccal
10 min
Lorazepam 0.1mg/kg (max.
2mg) IV/IO
Paraldehyde
400mg/kg (max 10g) PR
CALL FOR
SENIOR
20 min
Phenytoin (Phenobarbitone if
already on Phenytoin) 18mg/kg
(max. 1g) IV over 30 min +
Pyridoxine 100mg IV (if <3yoa
with unexplained afebrile status)
40 min
Phenobarbitone 20mg/kg IV
(max. 800mg) over 20 min
REFRACTORY
STATUS
HELP
EPILEPTICUS
Refractory Status Epilepticus
Still seizing after 60 min:
• RSI
• Midazolam infusion IV (0.15mg/kg ld fb 1-10μg/kg/min)
OR
• Phenobarbitone 5mg/kg boluses IV every 15 min x 3
OR
• Thiopental (Thiopentone) 4mg/kg IV/IO
NB
• Fosphenytoin: 75mg of fosphenytoin ~ 50mg phenytoin
• Fluid restrict to 60% maintenance
Case Continuation
• He responds only when IV phenytoin is
commenced
• What about the fever?
Case Continuation
• What about the fever?
2° to first seizure
or
Prolonged Febrile Convulsion – look for
cause
Further reading (viewing)!