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CRITICAL CARE

MEDICINE Edward E. Conway Jr., M.D., M.S.

FAAP, FCCM, FCCP

Professor and Chairman

Department of Pediatrics

Chief Pediatric Critical Care Medicine

Beth Israel Medical Center

Professor of Pediatrics @ Icahn School

of Medicine @ Mount Sinai

2014

1) A two month old infant is brought to the

emergency room for poor feeding and

“breathing funny”. Mother had a normal birth

and was sent home on day 2. Which of the

following is the earliest finding suggestive of

impending respiratory failure??

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1. Nasal flaring

2. Grunting

3. Use of accessory

muscles

4. Presence of a pectus

excavatum

5. Respiratory rate of

70 10

2

2) A 2 month old male with Trisomy 21 is brought to

you for noisy breathing. He has had no choking or

difficulty feeding. The noise appears to occur on

inspiration and is loudest when the infant is supine.

Which of the following is the MOST likely explanation

for the infants symptoms?

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1. A) laryngomalacia

2. B subglottic tracheal web

3. C) tracheomalacia

4. D) vascular ring

5. E) vocal cord paralysis

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RESPIRATORY FAILURE

• FAILURE TO VENTILATE (PaCO2)

- Increasing PaCO2 with a decreasing PH

• FAILURE TO OXYGENATE (PaO2)

- PaO2 < 60 TORR while breathing

FIO2 > .60

3

PEDIATRIC VERSUS ADULT AIRWAYS

• Narrower Airways (Higher resistance)

• Decreased cartilaginous support

• Decreased number and size of alveoli

• Decreased elastic recoil

• Orientation of ribs

• Insertion of diaphragm

• Increased oxygen consumption

• Higher minute ventilation

LARYNGOMALACIA

SYNDROMES ASSOCIATED WITH

RESPIRATORY FAILURE

PIERRE-ROBIN SEQUENCE

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3) A 13 month old infant is brought to your office for a

five day history of low-grade fever, rhinorrhea and a

harsh non-productive barking cough and inspiratory

stridor. Today the child is irritable, has a fever of 102oF

and is not feeding well. You obtain a radiograph shown

below. Which of the following is the MOST likely

diagnosis at this time?

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1. spasmodic croup

2. retropharyngeal

abscess

3. epiglottis

4. bacterial tracheitis

5. laryngomalacia

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CROUP

5

EPIGLOTTITIS

EPIGLOTTITIS

4) A 13 mos old infant was previously healthy and fully

immunized. On physical exam he has a temperature of

1010F, heart rate 150 bpm, respiratory rate 36 bpm

while crying and pulse oximetry on room air is 97%.

Once the infant settles down you note inspiratory

stridor and mild suprasternal retractions. He prefers to

sit up and looks slightly anxious. Which of the

following is MOST likely to provide for clinical

improvement?

1. 2. 3. 4. 5.

20% 20% 20%20%20%

1. ceftriaxone intramuscularly

2. dexamethasone orally or intramuscularly

3. humidified oxygen by face mask

4. nebulized albuterol

5. nebulized budesonide

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6

RETROPHARYNGEAL ABSCESS

Rapid Drill 1

• Diagnosis

• Bugs

• Drugs

• Management

• Complications

TONSILLAR HYPERTROPHY

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Obstructive Sleep Apnea • Complete or partial airway collapse leads to

hypoxemia & hypercarbia

• Occurs during REM sleep

• Loud snoring, excessive respiratory effort

during sleep, profuse nocturnal sweating,

enuresis and daytime sleepiness

• Long term effects include sleep disturbance,

failure to thrive, systemic and pulmonary

hypertension, polycythemia and behavioral

abnormalities

5) You have admitted a 13 month old

infant with poor feeding and respiratory

distress. The infant has rhinorrhea and

fever to 101oF for 2 days. Which of the

following best explains the scenario and

x-ray?

1. PCP

2. Mycoplasma

3. Streptoccocus

4. RSV

5. Chlamydia

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RSV

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VIRAL INFECTION/ LOWER RESPIRATORY TRACT

Edema

Sloughed Epithelium

Bronchospasm

Secretions

Small Airway Obstruction

Atelectasis & Hyperinflation

V/Q Mismatch

Hypoxemia

Shock and Respiratory Arrest

Decreased

Compliance

Increased WOB

Resp Muscle Fatigue

Hypercarbia

Apnea Acidosis

REMEMBER NOT ALL THAT

WHEEZES IS ASTHMA!!!!!!

Vascular Rings and Other

Things

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“It’s not always the lungs”

Resuscitation & Stabilization

• Airway

• Breathing

• Circulation

• Depressed level of consciousness

• Disability

• Dextrose

REVIEW BASIC LIFE SUPPORT AND PALS

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Managing the Airway

DON’T BE A “DOPE”

• DISLODGEMENT

• OBSTRUCTION

• PNEUMOTHORAX

• EQUIPMENT

Right Main stem Intubation

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RMS Intubation and Left Lung Collapse

PNEUMOTHORAX

Tension Pneumothorax

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DIFFERENTIAL DIAGNOSIS of

Altered Mental Status

• Alcohol

• Encephalitis/Endocrinopathy

Electrolytes

• Ingestion/Insulin

• Opiates

• Uremia

DIFFERENTIAL DIAGONSIS of

Altered Mental Status

• Trauma

• Hypo/Hypertension

Hyper/Hypothermia

Hypoglycemia/Hyperglycemia

• Infection/Intussception

• Psychogenic

• Structural/Syncope/Seizures

CNS INJURY

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LAYERS OVER THE BRAIN

EPIDURAL HEMORRHAGE

1) What is the

mechanism of

injury?

2) What vessel is

injured?

3) What bony area

is involved?

6) A 2 month old is brought to the office because of fussiness,

increased sleeping and poor feeding. He was well until 3 days ago

when he was taking less formula and had to be awakened for his

feedings. On physical exam she is difficult to console,

temperature is 36.8 0C, HR 160 bpm and RR 30 bpm. Anterior

fontanelle is full and pupils are 4mm and reactive.. Of the

following which is the MOST likely cause of the CT findings?

1. Arteriovenous Malformation

2. Galactosemia

3. Encephalitis

4. Nonaccidnetal head Injury

5. VonWillibrand Deficiency

0%

0%

0%

0%

0%

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SDH WITH MIDLINE SHIFT

CNS BLEEDS

A

B

C

D

A Subarachnoid Hemorrhage

B Subdural Hemorrhage

C Intracerebral Hemorrhage

D Epidural Hemorrhage

HYDROCEPHALUS

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VENTRICULOPERITONEAL

SHUNT

CLASSIFICATION OF SHOCK

• HYPOVOLEMIC Enteritis/Hemorrhage

• SEPTIC Bacterial/Viral/Fungal

• CARDIOGENIC CHD,Cardiomyopathy

• DISTRIBUTIVE Anaphylaxis, toxins

• OBSTRUCTIVE Tension PTX &

Cardiac Tamponade

Shock Pathophysiology

“Common Themes”

• Extracorporeal fluid loss

• Lowering of plasma oncotic forces

• Vasodilatation

• Increased vascular permeability

• Cardiac dysfunction

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Epidemiology of Pediatric Sepsis

• Blood Borne

• Pneumonia

• Urinary Tract

• Surgical site/wounds

Advances in Sepsis 2003;3(2):45–55.

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7) A 4 year old child is brought to the Emergency

Department with a 12 hour history of fever and rash.

Physical exam reveals: temperature of 104oF, heart rate

164 bpm, respiratory rate 42 bpm and a blood pressure

of 75/45 mmHg. You decide to administer an

immediate dose of antibiotics. Which of the following is

the MOST appropriate therapy?

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1. ceftriaxone

2. penicillin

3. vancomycin

4. vancomycin and ceftriaxone

5. vancomycin and gentamicin

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8) The child described in the question above has

required multiple fluid boluses and inotropic support to

maintain her blood pressure. She has been intubated

for respiratory distress. Her white blood cell count is

1.2 X 103/mc/L and a platelet count of 32 X 103 mc/L .

Which of the following is the MOST important additional

laboratory test?

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1. erythrocyte sedimentation rate

2. creatine kinase

3. fibrinogen

4. lactic acid

5. peripheral blood smear

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51

Most Common Serious Infections in

Children

Site Organism Treatment

Bacterial meningitis

Viral meningitis

Haemophilus influenzae,

Streptococcus pneumoniae,

Neisseria meningitidis,

Salmonella

Herpes simplex virus

encephalitis

Cefotaxime

50 mg/kg/dose OR

Ceftriaxone

50 mg/kg/dose

Dexamethasone

0.15 mg/kg/dose for

H. influenzae and

S. pneumoniae

Acyclovir 15 mg/kg/dose

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Most Common Serious Abdominal

Infections in Infants and Children

Site Organism Treatment

Peritonitis

Gram-negative organisms: Escherichia

coli, Klebsiella

Gram-positive organisms:

Pneumococcus, Staphylococcus,

α-hemolytic streptococci, Enterococcus

Anaerobes: Bacteroides

Cefotaxime

50 mg/kg/dose, clindamycin

10 mg/kg/dose, and

ampicillin 50 mg/kg/dose

OR

ampicillin

50 mg/kg/dose, gentamicin

2.5 mg/kg/dose, and

clindamycin or Flagyl

7.5 mg/kg/dose

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Most Common Serious Infections in

Infants and Children

Site Organism Treatment

Immunocompromised patients

Gram-positive organisms: Coagulase-negative staphylococci, α-hemolytic

streptococci, Enterococcus, Coryneform

Gram-negative organisms:

Klebsiella, Bacillus, Pseudomonas, Escherichia coli

Fungi: Candida, Aspergillus

Vancomycin 10-15 mg/kg/dose,

cefepime 50 mg/kg/dose, OR

ceftazidime 50 mg/kg/dose

Fluconazole: Loading dose 10

mg/kg, maximum loading dose

400 mg Amphotericin B: 0.25-1.0

mg/kg/day OR

caspofungin: 70 mg IV

infusion on day 1, then 50 mg IV daily thereafter

Mottling ACROCYANOSIS

WHAT’S YOUR DIAGNOSIS??

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9) The mother of one of your patients calls frantically

because she found her 2 year old daughter with an

open bottle of prenatal vitamins and several tablets in

her mouth. The label states there is 30mg elemental

iron per tablet and 5 tablets are missing as she just

bought the bottle this morning. The child weighs 25

lbs. Which of the following is the MOST appropriate

advice to give the mother?

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1. Bring the child to the office in the morning for a

serum iron concentration

2. Give the child activated charcoal

3. Give the child syrup of ipecac

4. Observe the child at home for symptoms

5. Take the child to the nearest emergency

department 10

Iron Toxicity Clinical Stages

1 – Vomiting, diarrhea, pain

2 – Latency

3 – Hypovolemia, shock, acidosis

4 – Hepatic failure

5 – Gastric outlet obstruction

PATHOPHYSIOLOGY OF

SALICYLATE POISONING

• Stimulation of respiratory medullary center produces tachypnea, hyperpnea – Metabolic acidosis and respiratory alkalosis

• Uncoupling of oxidative phosphorylation, inhibition of Krebs cycle enzymes, and inhibition of amino acid synthesis produces – Lactic and metabolic acidosis (wide anion gap)

– Hypoglycemia

– Rhabdomyolysis

• Hematologic effects: inhibition of vitamin K dependant clotting factors, platelet dysfunction, hypothrombinemia and leukocytosis

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ONE PILL CAN KILL

Peds Annals :34(12) ;December 2005

DECONTAMINATION

• Ocular saline lavage

• Skin water, then soap and water

• Gastrointestinal

• Ipecac/gastric lavage/cathartics: not

recommended

• Whole Bowel Irrigation (500 mL/hr in

toddlers, otherwise 2 L/hour)

– Helpful for: iron, lead, theophylline, crack

vials/packets overdoses

DECONTAMINATION

• Activated charcoal (1 gm/kg,

adolescents 50-100 grams PO) – Not helpful for: lithium, iron, alcohols,

cyanide, acid/alkali, hydrocarbons

• Multidose activated charcoal

(1 gram/kg q4-6 hours)

– Helpful for: theophylline, phenobarbital,

digoxin, salicylate, tricyclic

antidepressants, carbamazepine, phenytoin

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ANTIDOTES I • Acetaminophen n-Acetylcysteine (NAC)

• Anticholinergic Physostigmine

• Anticholinesterase Atropine

• Organophosphates Atropine/pralidoxime

• Carbamate Atropine/pralidoxime

• Benzodiazepine Flumazenil

• Beta adrenergic blocker Glucagon

• Calcium channel blocker Calcium chloride/calcium gluconate

• Botulism Botulin antitoxin trivalent (A,B,E)

• Carbon monoxide Oxygen

• Cyanide Amyl nitrate

• Digitalis Fab antibodies

• Ethylene glycol Fomepizole (4-Methylpyrazole)

• Fluoride Calcium gluconate

• Heavy Metals BAL

• Arsenic BAL

• Mercury BAL, DMSA

ANTIDOTES II • Iron Deferoxamine

• Isoniazid Pyridoxine

• Lead BAL, EDTA, penicillamine. DMSA

• Methanol Fomepizole (4-Methylpyrazole)

• Methemoglobin Methylene blue

• Neuroleptic syndrome Dantrolene

• Opioids Naloxone

• Phenothiazine (dystonic) Diphenhydramine

• Sulfonylurea Octreotide

• Tricyclic antidepressants Sodium bicarbonate

• Warfarin Vitamin K

• Snakes, spiders:

• Black widow Antivenin

• Coral Antivenin

• Crotaline Antivenin

• Elapid Antivenin

Recommendations

Critically ill, Charcoal &

life-threatening Consider lavage

ingestion

Asymptomatic,

mild/moderate Charcoal

poisoning

Benign Observation

ingestion

RECOGNIZE TOXIDROMES

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SYMPATHOMIMETIC SEDATIVE/

HYPNOTIC

Cocaine, amphetamines Benzodiazepines,

barbiturates,

Mental

Status

Restless, insomnia,

hallucinations

Sedations, delirium,

ataxia

Pupils Mydriasis Blurred vision (miosis

or mydriasis)

Vital Signs Tachycardia, hypertension,

hyperthermia

Bradycardia,

hypotension,

hypothermia

Physical

Exam

Tremor, warm skin,

diaphoresis

Decreased bowel

sounds, nystagmus

Treatment Benzodiazepines, Mixed

alpha/beta blockade, Treat

MI, CVA

Decontamination,

Supportive, Flumazenil

(rarely)

CHOLINERGIC ANTICHOLINERGIC

Organophosphates,

muscarinic mushrooms,

nerve gases

Atropine, TCA,

antihistamine

Mental

Status

Altered mental status,

confusion, weakness,

drowsiness, coma

Psychosis, delirium,

seizures, coma

Pupils Miosis Mydriasis

Vital Signs Bradycardia, hypothermia,

tachypnea

Tachycardia, fever,

hypertension

Physical

Exam

Salivation, lacrimation,

urination, defecation

(SLUDGE)

Dry as a bone, blind as a

bat, etc. depressed,

confused

Treatment Decontaminate, atropine,

pralidoxime

Decontaminate, treat

seizures, fever,

hypertension,

benzodiazepines

OPIATES

Heroin, morphine

Mental Status Sedation, confusion, euphoria,

coma

Pupils Miosis

Vital Signs Shallow respirations,

hypotension, bradycardia,

hypothermia

Physical Exam Decreased bowel sounds,

hyporeflexia

Treatment Decontaminate, narcan

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Neurologic Findings Pupillary Exam

• Amphetamine/cocaine

• Anticholinergics

• Antihistamines

• Sympathomimetics

• Cholinergics

• Narcotics

• Organophosphates

CO POISONING

• Binds to Hb with

high affinity

• Non specific early

symptoms (Flu-like)

• Administration of

100% FiO2

• Hyperbaric therapy

• Pregnancy & Fetal

effects

NEAR DROWNING

• ASPHYXIA

1) Pulmonary System

2) Central Nervous System

3) Cardiac

4) Renal

• WATER OVERLOAD

1) Pulmonary

2) Central Nervous System

3) Gastrointestinal

4) Dilution Effects

• HYPOTHERMIA

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10) Which of the following statements regarding

pediatric trauma is NOT correct??

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1. The most common type of shock is hypovolemic

2. Head injury accounts for the majority of deaths

3. Pulmonary contusions occur more frequently

4. Pancreatic and small bowel contusions &

hematomas are the most common abdominal

lesions

5. On arrival to the ED many children are

hypothermic

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Pediatric Burns

Indications for Admission

• Burns great than 15% BSA

• High tension electrical burns

• Inhalation injury

• Inadequate home situation

• Suspected abuse

• Burns to the genitals, hands, feet

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