Pediatric On Call Pearls
General
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Tylenol is 15mg/kg per dose Q6 PRN pain or fever [>100.4/38]. Remember you can give PR if the kid is
not tolerating po. Don’t use in liver failure patients.
Motrin is 10mg/kg per dose Q6 PRN pain or fever ***Do NOT give to infants under 6 months due to
immaturity of kidney & inability to properly excrete*** Also do not use for children at risk for bleeding
[low platelets, oncology pts, DIC, going to OR tomorrow etc]
IVF: for infants [less than 10-20kg or 1 yr] use D5 ¼ NS, for older children use D5 ½ NS. If you know
the child has good urine output, or if you have lytes that show good kidney function and potassium is not
high – add 10-20meq/L of KCl. If this isn’t known – write to add KCl after 2nd void & check on UOP later.
For any young child who will be NPO for >4-6 hours evaluate the need for IVF
Pain – if Tylenol or Motrin isn’t working, consider using a Tylenol with codeine [elixir for babies, #1-4 for
older kids], Toradol [don’t use in oncology pts, or pts with gastritis, dehydration, or renal insufficiency –
can cause renal failure]. For severe pain consider opiates – [morphine, fentanyl, hydromorphone,
meperidine]
Any kid the nurse is very concerned about or you have to make major changes on during the night – GO
SEE & document an on call note.
If you are concerned in ANY way – your upper level will happy to help you! However, it’s a good idea to
see the patient & check the chart for important info before calling them [unless it’s an emergency,
obviously ]
If they call because the patient has lost an IV, ask
1. What all is being given IV?
2. Depending on this, think if the kid still needs the IV –
 If only IVF are running & the kid is now tolerating po just fine – leave the IV out
 If the kid is not tolerating po but they can’t get an IV [after calling either anesthesia
during the day, or NICU, PICU or ER during the night] you can place an NG tube & do
pedialyte down the NG
 If IV meds were running – think if the kid still needs those meds. Is it just an IV
antibiotic & they are going home first thing in the morning on po ABX? Then just leave it
out
 If it’s an IV antibiotic that was just started & the kid is still febrile &/or sick – they
have to get IV access. If ~3 attempts have been made – consider doing one IM shot to
keep the kid covered until the am. For example – Ceftriaxone can be given IV or IM at
the same dose. If the antibiotic the child was receiving isn’t available IM, just pick one
that has similar coverage that does.
Abnormal Vitals
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They don’t call them “VITALS” for nothing!!!! Any call for crazy abnormal vitals should be addressed. Know
age appropriate norms for all vital signs.
1.
Fever – Ask if the kid has been having fever - if so, is the fever trending up or down & is there a
known source for the fever. If the source is known & it’s trending down – no worries mate!
Treat with Motrin or Tylenol & go back to sleep. If the fever is trending up, no source is known
or it’s the first fever - you need to do some investigation to discover why the child is having
fever….. do a physical exam to look for a source. If it’s a very sick child – do blood cx to look for
bacteremia & consider LP for meningitis, ask about urinary or resp symptoms to decide if UCx or
Chest Xray are needed ***Fever in a Heme/Onc Patient is treated differently – see below***
2. Tachycardia – most commonly it’s pain, anxiety or fever. However, for persistent high heart
rates – makes sure you evaluate for dehydration, sepsis or less commonly SVT or other
arrhythmias.
3. Hypertension – make sure they’re using the correct cuff size, the child is as calm as possible &
they’re measuring on upper extremities before acting on an elevated BP. For older children – ask
about symptoms [CP, HA, vision changes etc] If it’s asymptomatic & not crazy high – just repeat
frequently & monitor. If symptomatic or very high – evaluate the child. Ask if any thing has
been used in the past for HTN. Procardia [5mg for young kids, 10 for older] usually works but if
it’s the first time the kid is having HTN, the more important question is why??
4. Hypotension – EVALUATE & ACT ON IMMEDIATELY. Don’t delay treatment for shock if that’s
what you think it is. Bolus, bolus & bolus at 20cc/kg of NS!!!!!
5. Tachypnea – any resp distress should be evaluated immediately. See resp section below
GI
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Remember not to use motrin in any child at risk for GI bleeds [or any other bleeds]
Reasons to use H2 blocker or PPIs – any kid you’re concerned for gastritis [acutely ill patients, esp in
ICU, high dose or long term steroids etc].
For patients getting a GoLytely clean out – if they aren’t tolerating at a certain rate consider holding for
an hour then restarting at lower rate & increasing Q30-60 minutes up to a rate tolerated by patient
GoLytely should continue running until the poop is CLEAR
Renal
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For ANY child with renal insufficiency [just about every kid on your renal service!!] - make sure you
check the 2 charts in the back of Harriet before you write any meds [1 chart for antimicrobials & 1 for
other meds]. There are adjusted doses & intervals for kids with renal insufficiency. These are based
on creatinine clearance. You can use the estimated GFR. Formula = k[height in cm]/plasma creatinine
where k is 0.33 for LBW babies in first year of life, 0.45 for term AGA in first year, 0.55 for children
& adolescent girls, 0.70 for adolescent boys
Be sure to document urine output daily in cc/kg/hour – usually over 3 in well hydrated kids. Below 1 is
definitely abnormal. If there is low UOP, compare this to the overall Is & Os & ask
1. Is the kid dehydrated? Give more fluids!!
2. Is there renal failure & fluid overload? May need to fluid restrict!
3. Is it a very sick kid in the ICU [or should be in ICU!] & developing multiorgan failure??
4. Is there 3rd spacing that would be responsive to lasix?
Cardiology
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Supraventricular tachycardia – HR>220 in infants or >180 in children; not varying with activity – call for
an EKG stat, but don’t wait for EKG for intervention. Have someone call cards & the attending. Evaluate
patient for adequate perfusion. Can consider vagal maneuvers if good perfusion [ice pack for babies,
blowing against occluded straw for older kids], adenosine if have an IV or immediate cardioversion if
poor perfusion
Bradycardia – evaluate patient to see if bradycardia is causing cardioresp compromise – check pulses,
cap refill, blood pressure, resp status, mental status. If all okay – call for EKG but it doesn’t have to be
stat, continue to closely monitor patient. If any of these are compromised with HR <60, provide 100%
O2 bagging and chest compressions. If despite oxygenation & ventilation HR <60 & CR compromise – give
epi
Always carry your PALS card with you for these situations!!!
Heme/Onc (see H/O guidelines)
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For standard chemo admits – make sure you know the side effects of the chemo they are receiving to
appropriately monitor for side effects
Fever in an onc patient MUST BE EVALUATED!! NO PRN Tylenol/motrin for heme/onc patients. They
MUST be evaluated & placed on antibiotics for any fever. Blood cx [central AND peripheral] & urine
cultures must be done. Also do a CXR for any resp symptoms. Once this is ordered, start Ceftaz if
ANC >500, Cefepime if ANC <500. If they continue to have fever, consider adding Vanc or antifungals.
They need repeat cultures for every fever UNLESS they have had cx in the last 24 hours. Even if
<24hrs and fever is very high, re-culture.
Blood transfusions for onc patients – If Hg >5, then 10cc/kg of irradiated, leukopoor, CMV appropriate
PRBCs over 3-4 hours. Premed with 0.5mg/kg of Benadryl IV and 15 mg/kg Tylenol po 30 min prior to
blood.
If Hg < 5, don’t just use 10cc/kg - transfuse the number of cc/kg equal to the hemoglobin at a time to
give smaller aliquots [too much volume in a severely anemic patient who is already trying to compensate
with tachycardia may precipitate heart failure.] Ex – Hg 4 give 4cc/kg PRBCs, Hg 2 give 2cc/kg PRBCs.
Platelets for onc patients – ½ unit for infants, 1 unit for older kids of irradiated leukopoor CMV
appropriate SDP [single donor platelets] over 1 hour. Same pre meds.
Typically give blood when the Hg < 8 for onc patients.
Typically give platelets when plts <10-20 for regular onc patients, <20-40 for transplant patients, <50
for brain tumor patients or any active bleeding even if the plts are higher than these numbers. Also
platelets need to be >50 for all procedures so be sure to check the day before!!!
Watch out for transfusion reactions when giving blood.
1. Acute hemolytic reactions – the life threatening one!!! Due to ABO incompatibility so transfused
RBCs are lysed. Symptoms are fever, chills, tachycardia, hypotension, shock, dark urine. STOP
BLOOD IMMEDIATELY & GIVE FLUIDS!!!!!!!!!!!!!!!
2. Febrile nonhemolytic reactions – due to host antibodies to donor WBC antigens. Symptoms
include fever, chills, diaphoresis. [Try to prevent with premeds & leukopoor RBCs so not
confused with the life threatening hemolytic reaction]
3. Urticarial reaction – due to donor plasma proteins. Stop blood & treat with antihistamines &
steroids
****The nurses closely monitor vitals during transfusions. If the kid gets a fever during the
product the blood must be stopped in case it is a hemolytic reaction. However, usually these
patients have been having fever & an increase in temp is just their baseline fever. As there is no
way to know this, you still have to treat it as a reaction & stop the blood. For this reason, its usually
better to wait until they are afebrile to start blood. If you absolutely can’t get the fever to break –
you’ll have to just start the blood & use a 2 degree increase in temp as the rule for stopping the
blood. The nurses have a standard protocol to follow when this happens – they send transfused
blood for culture, send patients blood for coombs, to confirm blood type and an antibody screen, and
they send urine for hemoglobinuria. Notify fellow or attending if you are stopping products***
NO rectal temps, rectal exams, NG tubes, or other introduction of ANYTHING which may cause an
bleeding/infection in heme/onc patients!!!!!!!!!!!!!! They have no immune system to fight bugs.
For sickle cell patients – they typically live at hg 7-8 so NEVER use only the level of their hemoglobin to
decide when to transfuse!!! Look at their hemoglobin & reticulocyte count compared to their baseline.
Look for signs of SYMPTOMATIC anemia [tachycardia, any resp distress, hypoxia]. Typically get
transfused for acute chest, priapism, splenic sequestration, CVA.
For pain crisis severe enough for hospitalization – morphine PCA plus scheduled motrin [unless fever]
plus adequate hydration [but NOT aggressively OVERhydration b/c can precipitate acute chest]
If needs blood - 10cc/kg leukopoor, cmv appropriate sickle free PRBCs over 3-4 hours. [Remember to
only use 10cc/kg of blood if the hemoglobin is >5]. Premed same as onc patients
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Fever also must be evaluated then treated with antibiotics in sickle cell pts. After cultures/XRay
obtained start Ceftriaxone 75mg/kg/day. They also need repeat cultures with each fever unless there
has been one in the last 24 hours.
Infectious Disease
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Vancomycin, Gentamicin, Tobramycin and Amikacin have peaks and troughs that need to be followed
Order peaks 30 min after 3rd dose & trough 30 min prior to 3rd dose. For HIGH TROUGHS – space out
the dosing interval. For HIGH PEAKS decrease the dose [or vice versa for subtherapeutic peaks, then
increase the dose]
Don’t forget to check the chart for allergies before writing any antibiotic
If the patient has Redman’s syndrome to vanc [direct histamine release – NOT an allergy] – stop the
infusion check BP, & give benadryl. Next time try running over longer time period & premed with
antihistamine. This is usually benign but can become hypotensive!
If you get called with positive blood cultures – evaluate the patient for signs of sepsis. Many times it
ends up being just a contaminant [usually Staph Epi that grows out >48 hours] However, if patient has
central line or other reason to be bacteremic, it may be real. Repeat cultures regardless. Check
perfusion, HR, BP, resp status. Start antibiotics if there is any concern [Vanc or clinda for gram +, 3rd
gen ceph or aminoglycoside for gram neg. Ceftaz or other anti pseudomonas if you have some reason to
expect that.] If the patient has a central line, make sure to get central & peripheral cultures. – FEVER
in a patient with a central line should ALWAYS ALWAYS be taken seriously. It is a line infection until
proven otherwise.
If you have a patient with a central line – ask how long it has been in, evaluate if it still needed.
The same goes for a foley cath – this is a set up for a UTI so take it out AS SOON as it’s no longer
needed.
Neurology
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NEURO STAFF LIKES TO BE CALLED BEFORE GIVING ATIVAN FOR SEIZURES ON THEIR
PATIENTS. You can give the seizure at least 5 minutes to stop on its own. Have the nurse draw up the
ativan & call staff if you are getting close to that 5 minute mark to let them know you’re giving it!!!!
For seizures lasting longer than 5 minutes – give Ativan 0.1mg/kg IV up to max 4mg. Can repeat multiple
times. Can also give rectal valium [Diastat] 0.5mg/kg up to 10 mg if no IV access
If seizure is persisting despite multiple rounds of ativan – can load with Cerebyx [fosphenytoin] 20mg
phenytoin equivalents/kg IV or Phenobarbital 20mg/kg IV
As these meds are being given – monitor resp status CAREFULLY – they can cause resp depression & you
will likely need to secure an airway if giving multiple rounds
Also call if the seizure frequency is dramatically increasing over the night, even if none are long enough
for ativan. They will sometimes want to load with an AED to break these clusters
Keep the patient NPO if seizure frequency is increasing & you think there is a chance for using these
meds with resp depression as side effect.
Use caution when giving any meds that lower the seizure threshold to known sz patients [benadryl,
imipenem, phenergan]
Respiratory
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For new onset resp distress
1. Remember ABCs – if no airway or severe resp depression ask RT for equipment to intubate &
always have PALS card with quick info to know ETT size etc. If no need for immediate
intubation or bagging……… begin to ask questions as you evaluate patient [count RR, look for
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retractions, listen to lungs. Call for pulse ox, chest xray or CBG if you think it’s needed after
this quick physical exam
Get a pulse ox ASAP and start O2 for <95%
Is there a history of asthma/RAD or wheezing on exam? Try Albuterol neb 2.5mg for infants or
5mg for children.
Is there decreased BS on one side with other signs of tension pneumothorax [severe resp
distress, distended neck veins, tracheal deviation, poor systemic perfusion] – get large bore
needle [16 to 22 gauge depending on size] – insert into anterior second intercostals space in
midclavicular line ON TOP of rib. Insert until hear air – attach to 3 way stopcock & syringe &
aspirate air.
Is there fever & focal findings on exam? Get a CXR to look for pneumonia & start ABX
Is there stridor [indicating the problem may be the UPPER airway not the lower]?
 Is there possibly foreign body aspiration? Assess your ABCs, get films – lateral neck,
inspiratory & expiratory chest. Eventually may have to call ENT to scope to look
 Is there fever & other URI sx – Croup? Try racemic epi [vaponephrine] nebulized
treatment 2.25% - 0.05cc/kg/dose in 3mL NS [max 0.5mL] or Dexamethasone 0.6mg/kg
IM/IV/PO x 1 dose
 Is there drooling or other signs of airway compromise?? May need to be in PICU for
closer monitoring or have an airway placed.
Does the child have a history of anemia?
 What was the last hemoglobin? Is there tachycardia or a flow murmur?? – order quick
finger prick for stat H&H if lab can’t draw immediately & give blood if needed.
Does the child have a history of heart disease? Listen to lungs, feel for hepatomegaly.
 Do the lungs sound wet or CXR look fluffier? Consider lasix 0.5 - 1mg/kg IV x 1
Allergic Reactions
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If a medication is running & patient develops hives, wheezing, GI upset, resp distress – STOP THE
MEDICATION IMMEDIATELY. Evaluate patient – including complete set of vitals, skin exam to look
for hives, listen for wheezing & evaluate for other resp distress.
1. ABCs – If severe resp distress get ready to intubate patient. Supply 100% oxygen & assess
need for fluid boluses & epinephrine if hypotension
2. If ABCs stable but…..
a. Slight wheezing – give albuterol treatment 2.5mg nebs for infants, 5mg nebs for older kids
b. Slight itching or hives – give Benadryl or other antihistamine 1mg/kg IV/PO. Can also
consider an H2 receptor antagonist
c. Corticosteroids help prevent the late phase of the allergic reaction. Give
methylprednisolone 2mg/kg IV bolus then 2mg/kg per day divided Q6 if severe reaction.
Updated 6/17/10
lw