s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Preface s s r s r s e r e r k e k e o k o k o o o o b o b o e b “Why this child? Why this disease? Why now?” e b mme e/ / e The Harriet Lane Handbook was first develompmed ine 1e9/5—3/ Baafetretro nH Carhriilsdosn, MD h ht tt tp ps s: /: // t/ .t . Swewdpritiiehtteono rcua eot rpf[ otT(hcchehke]ie e tsHhf-u sarpiehzrersetirieddvttt ie s“Lnipotatpen nia nepro lf H1 bso9aou5nsor0:dk –eb.”/1:lod 9oAe//5ksrs,1 t /r,)“ e Sms.tciuoxeg.u eogntfiet neusgdts e sdbbp yeot ghrHaaadent ni rcweraysilt ilhSdyo eeauindrtto esful u,sn nhtdhdo esau lfiadrn sdt table in the library of the Harriet Lane Home.” The product of their efforts was a concise yet comprehensive handbook that became an indispensable tool for the residents of the Harriet Lane Home. Ultimately, Robert Cooke (department chief, 1956–1974) realized the potential of the hsandbook, and, with his backing, the fifth edition was published for s e r wr idsespread distribution by Year Book. Since that time, the handbook has e r r s k e k e o k been regularly updated and rigorously revised to reflect the most o k b o o o up-to-date information and clinical guidelines available. It hasb growono fromo e b a humble Hopkins resident “pearl book” to become a naetionallyb and m e e/ / e internationally respected clinical resource. Nmow traensela/te/d iento many m languages, the handbook is still intended as amn easy-to-use manual to p s s: /: // t/ .t . helpT opdeadyia, tTrihceia nHsa rprrieotv ipLdaen cesu Hrrsae:nnd/t: ba//onodt/k cc.toomn.tpinreuheesn tsoiv bee p uepddiaatrteicd caanred. h ht tt t p rceavnis bede ibnyc lhuoduehsdeh itnof fiattc petorsc kpfoert hguouidsee, oafdfidcietirosn. aRl eincfoogrnmizaitniogn t hhea sli mbeite tno what placed online and for use via mobile applications. This symbol throughout the chapters denotes online content in Expert Consult. The online-only content includes expanded text, tables, additional images, and other references. r s sIn addition to including the most up-to-date guidelines, practice r s s k e e pr arameters, and references, we will highlight some of the most k e e r o k important improvements in the twenty-first edition of The Harriet Lane o k o o o o b o Handbook: b o e b e b m e e/ / e conTtehnet Pdreodciecdauterdes t oc hualtpratesro uhnasd baenedn u eltxrpaasonmudnedd-, gwueiitdhee /din /cprreoeacseeddu roensl.ine m m p s s: /: // t/ .t . sexuTTahhleely ADtrdeaornmlesamstcoietltonegtd yM icnehfdpeaiccptitineoesrn sicns h:acanlup/:ddt ee//prse ti/lnnvice.tclw ui. ndsfleeasc mteioxmnpasat noodrnye dnd aiisinle fdaosirsmeo.radtieorns oann d h ht tt t p dfoisr oarcdneers. of pihgmhetntttattionp as well as an updated discussion of treatment The Fluids and Electrolytes chapter has been restructured to aid in fluid and electrolyte calculations at the bedside. The Genetics chapter has been expanded to include many more genetic conditions relevant to the pediatric house officer as well as a s s r stresamlined discussion of the relevant laboratory work-up for these r s e r e r k e conditions. k e o k o k b o o o b o o oix e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p x Preface s s r sThe Microbiology and Infectious Disease chapter includes expanded r s e r e r k e information related to fever of unknown origin, lymphadenopathy, and k e o k o k o o viral infections. o o e b b o Medications listed in the Formulary Adjunct chapter heave bbeebn mooved mme e/ / e to thTeh eF oHrmarurliaert yL faonre e Hasaen dofb oreofke,r ednecseig.ned fmor mpedeiateric/ h/ouese staff, was h ht tt tp ps s: /: // t/ .t . mctshclaaehsdierse d.s ukIptli oelhlsssas sadibin nlbedche ebpe hyneint r ttsaheottnernn hatesploxh tnlirippvoa.ero s sTrt dohwsi e:nwhyaia /l:rehtyc a //ahevu fet/ftto hhbre.totassrlie a.no ngfif c nttehhedi es d tcoyhehceataiorrp r’bstse u srmssey an tthiwuoaorrt er rk feoa slnlioddwe rn.e tWfi nee are grateful to each of them along with their faculty advisors, who selflessly dedicated their time to improve the quality and content of this publication. The high quality of this handbook is representative of our residents, who are the heart and soul of our department. s s r s r s k e e Crhapter Title Resident Faculty Advisor k e e r o o o k 1. Emergency Management Vanessa Ozomaro Jeffries, MD Justin M. Jeffers, MDo o o k b o 2. Poisonings Michael Hrdy, MD Mitchell Goldstebin, MD o m e e/ /e e b 3. Procedures JMaamttehse Hw. MMoilalekre,, MMDD, PhDm eEThriukey S /Lu., N/MegDo, eDO, MbEd m 4. Trauma, Burns, and Amanda O’Halloran, MD m Branden Engorn, MD h ht tt tp ps s: /: // t/ .t . 5. ACEdmoomelermgseocnnenc Cite rMsitiechdailc iChnaetre tt tpKipmbserlys :M. /:Dic//kint/son.t, M.D, KLMDeryeiwlslaihisnsns SRaat oUeJm wpSeaaardrc,t ch,M oyM,Da D,M MDD, MPH MPH Renata Sanders, MD, MHS, ScM 6. Analgesia and Jessica Berger, MD Myron Yaster, MD Procedural Sedation Keri Borden Koszela, MD 7. Cardiology Madiha Raees, MD Jane Crosson, MD William Ravekes, MD s W. Reid Thompson, MD s r s r s e r8. Dermatology Taisa Kohut, MD Bernard Cohen, MD e r k e k e o k Angela Orozco, MD o k b o o o 9. Development, Behavior, Julia Thorn, MD Emily Frosch, MbD o o o e b and Mental Health Alexandere Hoon, MDb, MPH mme e/ / e 10. Endocrinology* JSeasrsaihc aB Jraucnke,l lMi YDoung, MD,m MSmeDaveid/ Co/oke,e MD p s s: /: // t/ .t . 1112.. FGlausidtrso eanntde rEolleocgtyrolytes pCNainnads iGcueso M:, M. N/:Dall//ey,t/ MD.t . EMDraiiccrhl aBa aeSllh igBohraeiraso,nn M,e ,MD MDD, MPH h ht tt t p 13. Genetics: Metahbolhistm tt t ACmphrmisatirnaah PIqebroaul,t kMaD, ,M MDPH Joann Bodurtha, MD, MPH and Dysmorphology Ada Hamosh, MD, MPH 14. Hematology Katherine Costa, MD James Casella, MD Clifford Takemoto, MD 15. Immunology and Allergy Jeremy Snyder, MD Robert Wood, MD s M. Elizabeth M. Younger, CRNP, PhD s e r 1r6. sImmunoprophylaxis Alejandra Ellison-Barnes, MD Ravit Boger, MD e r r s o k k e 17. Microbiology and Devan Jaganath, MD, MPH Pranita D. Tamma, MD, MHSo k k e o o Infectious Disease Rebecca G. Same, MD o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Preface xi s s e r Crhapster Title Resident Faculty Advisor e r r s o k k e 18. Neonatology Jennifer Fundora, MD Susan W. Aucott, MD o k k e o o 19. Nephrology Riddhi Desai, MD, MPH Jeffrey Fadrowski, MD,o MHS o e b b o 20. Neurology Clare Stevens, MD Thomas Cerawforbd, bMD o m e e/ / e m eREryiacen K/ Foesls/lionfgf,,e MMDD, PhD m m p s s: /: // t/ .t . 21. Nutrition and Growth pBJernainfsedro nTsh :Somm/:ipths,o// nM, Dt/MS.t, RD., CSP CDharrilsat oSphhoerer sO, aMkDley, MD h ht tt t p 22. Oncology h ht tt t CZaphrealshe Yau Ksoutfc, hM, DMD PNaictorilcek A Brwroowond,, MPhDarmD, BCPPS 23. Palliative Care Daniel Hindman, MD Nancy Hutton, MD Matt Norvell, MDiv, MS, BCC 24. Pulmonology Jason Gillon, MD Laura Sterni, MD 25. Radiology Kameron Lockamy Rogers, MD Jane Benson, MD 26. Rheumatology Nayimisha Balmuri, MD Sangeeta Sule, MD, PhD s s r 27. sBlood Chemistries and Helen K. Hughes, MD, MPH Allison Chambliss, PhD r s e r e r k e Body Fluids Lauren K. Kahl, MD Lori Sokoll, PhD k e o k o k o o 28. Biostatistics and Anirudh Ramesh, MD Megan M. Tschudy, MDo, MPH o b o Evidence-Based Medicine b o e b e b m e e/ / e 2390.. DDrruugg sD ions aRgeensal Failure CElaizraltboent hK .AK..S L.e Geo, sPwhaamrmi,D , mMPH eCarelt/on K/.K. eLee, PharmD, MPH p s s: /: // t/ .t . m *A special thank you to Paula Neira, pMSHNe,Pl eJhDnsa, rKRm.Ns ,D:H C,u EgB/:NhC, ePas//nS,d , M tB/RDeCn,P .taMPtaSP .HSandmers, MD, MPH, ScM, for their gracious time h ht tt t p and efforts on the genhder hdytsphttoriat sectipon of this chapter. The Formulary, which is undoubtedly the most popular handbook section, is complete, concise, and up to date thanks to the tireless efforts of Carlton K.K. Lee, PharmD, MPH. With each edition, he carefully updates, revises, and improves the section. His herculean efforts make r thse sFormulary one of the most useful and cited pediatric drug reference r s s k e e trexts available. k e e r o k We are grateful and humbled to have the opportunity to build on thoe k o o o o b o great work of the preceding editors: Drs. Henry Seidel, Harrisbon Speoncer, m e e/ /e e b WDeilnlianmis HFreieaddmingasn,, KReonbneertt hH Sacshlaumb,e rJtehr,r yB Wasiminl kZeitlestlleie,i nJe,e /Hffee/rreyb eBeritl lSerwb, icAkn,d rew m m p s s: /: // t/ .t . YBNeaearcoghneyreb,, a CG, yeJnaotsrhgoiean SCRiobolbee,re rrPytp,se otRenor, bs RNeosrict:w oIeal/:e,n Mn//Sohat/nirlyke.t o,G fVs.rekerie,o nnJeai,cs aKo neG vuCinnu nsJt,oe hCr,nh sRroisantci,ah Mne li cRhaaue,l h ht tt t p MMeagnayn o fT sthcehsuedh yp,hr eKtvriiottsutitsn eAdprictoarrsa ,c Joanmtinieu eF letor lamgaek, ea nimd pBorratanndte cno Enntrgibournti.o ns to the education of the Harriet Lane house staff. As recent editors, Megan Tschudy, Jamie Flerlage, and Branden Engorn have been instrumental in helping us to navigate this process. We hope to live up to the legacy of these many outstanding clinicians, educators, and mentors. s s r sAn undertaking of this magnitude could not have been accomplished r s e r e r k e without the support and dedication of some extraordinary people. First, k e o k o k o o thanks to Kathy Mainhart, who is an invaluable asset to our prograom. o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p xii Preface s s r Withsout her guidance, we would all be lost. We are indebted to Dr. r s e r e r k e George Dover, whose tireless promotion of the Harriet Lane housestaff will k e o k o k o o be forever remembered – you will always have a home in our officoe. o e b b o Thank you to Dr. Julia McMillan for your advocacy, wisdoem, abndb kinodness mme e/ / e iyno uoru er xepaerrlyt ldeaaydse rassh iepd. itToors o. uWr en eoww eD mepuacrhtm moefm ntht eD eiHreaecnt/odrb/, oDoerk.’ sT isnuac cCehsesn tgo, h ht tt tp ps s: /: // t/ .t . wsgueonee w t aoyar oveoue usrrri on v fgigrsi reisoanunthedp fsfpuho olart rnfttoh dttare nmy tCdpoeu htnpriilm tdomsrereselysn,n : ’Jtrsoee /:rCafsflrehi//etniyypt t/ e cFarh.ta netdadc.rk kogeswu .s sidFhkaiain npaacenlle.dy ,O – Tt uhhwrau ensy pk cNe aycngoio’aut, l wtftooha raio tn yutokorus r program director, Janet Serwint, whose leadership and passion for education have enriched our lives, and the lives of hundreds of other Harriet Lane house staff. Your endless enthusiasm for pediatrics is inspiring to us all. s s r s Residents Interns r s e r e r k e Ifunanya Agbim Megan Askew k e o o o k Suzanne Al-Hamad Brittany Badesch o o o k b o Madeleine Alvin Samantha Bapty b o m e e/ /e e b CStaerpehna Anrime sBtaroknerg JVeicatnoemrt tBee Bneevaeundeurytoe/ /e e b p s s: /: // t/ .t . m MJAulaissrtsiijnau BCBeearrlknupyyot s s: /: // t/ EKD.tvraiasn. tiCeelnale tCem dneearcCcocanimoepo h ht tt t p hKJohrhistnt eCnttr eCaotglehttip CJoanraotlihnaen D EeiBseonebrerg Matthew DiGiusto Amnha Elusta Dana Furstenau Lucas Falco Zachary Gitlin RaeLynn Forsyth Meghan Kiley Hanae Fujii-Rios Keith Kleinman Samuel Gottlieb r s s Theodore Kouo Deborah Hall r s s k e e r Cecilia Kwak Stephanie Hanke k e e r o k Jasmine Lee-Barber Brooke Krbec o k o o o o b o Laura Livaditis Marguerite Lloyd b o e b Laura Malone Nethra Madurai e b m e e/ / e Lauren McDaniel Azeemm Muritalea e/ / e m Matthew Molloy Anisha Nmadkarni h ht tt tp ps s: /: // t/ .t . hJKRCoheohsrbeteeitpnnnh attMO MrPutaultilznlpelderreps s: /: // t/ CMJH.tehaasirxsoi.itimncaea aS PRhNoaantthtanemenrgdei-rEmetarom Thomas Rappold Soha Shah Emily Stryker Rachel Troch Claudia Suarez-Makotsi Jo Wilson Jaclyn Tamaroff Philip Zegelbone Lindy Zhang s s r s Helen K. Hughes r s e r e r k e Lauren K. Kahlk e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e GLASGOW COMA SCALE k e o k o k o o Activity Score Child/Adult Score Infant o o b o b o e b Eye opening 4 Spontaneous 4 Spontaneoues b m e e/ / e 32 TToo sppaeinech 32m TTooe sppaeeine/fcuhl/ /ssotiumneudli m m p s s: /: // t/ .t . Verbal 154 NOCporoinneefnutsesedds: /: // t/ .t 154. NCIroorinotsae/bblea bcbryles h ht tt t p h32ht tt tIInnacoppmprporperhiaetnesible 32 CMroieasn st ot op apianin 1 None 1 None Motor 6 Obeys commands 6 Normal spontaneous movement 5 Localizes to pain 5 Withdraws to touch 4 Withdraws to pain 4 Withdraws to pain s 3 Abnormal flexion 3 Abnormal flexion (decorticate) s e r r s 2 Abnormal extension 2 Abnormal extension (decerebrate) e r r s o k k e 1 None 1 None (flaccid) o k k e o o o o b o Adapted from Hunt EA, Nelson-McMillan K, McNamara L. The Johns Hopkins Children’s Center Kidsb Kard, 2016o. e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Desired dose(mcg/kg/min) mg druug IV INFUSIONS* 6¥ ¥Wt(kg)= Desired rate(mL/hr) 100mL fluid s s r s Dilution in 100 mL in r s k e e Mredication Dose (mcg/kg/min) a Compatible IV Fluid IV Infusion Rate k e e r e b bo oo o k AADlmOpPriooadsmtaairndoeinl e(prostaglandin E1) 055.––012550–0.1 066. 3mm mgg//gkk/ggkg e111 mmmLLL///hhhbrrr === b011. 0mmo5cc ggm//ockkggg///kmmogii/nnmoin k mme e/ / e DEPOIBNUETPaHmrininee 20–.02c10i–rc0u.2m, sutapn tcoe s1 in severe 60 .6mm mg/gmk/gkg e e/ /11 mmeLL//hhrr == 10. 1m mcgc/gk/gk/gm/minin p s s: /: // t/ .t . LPTiehdreobncuyatlaeinpliehn,r epinoest resuscitation 2000..01–c5–5i–4r0cp2 u(,u mupsp tt oato ns1 c50e sihsna: sse bv/:eeeren // uset/d).t 600. ..36m mmg/ggk//gkkgg 111 mmmLLL///hhhrrr === 100.. 01m5 mc gmc/gckg/gk//gkmg/mi/nminin h ht tt t p *SVtaasnodparredsiszeind (cpornecsesnort)rathionsh atre 0rtte.5co–mt2 mmeilnpliduendi tws/hkegn/ maivnailable. For a6d dmitiilolinuanli tisn/fkogrmation, see1 LmaLrs/hern =G Y1, mPailrlkiu HnBit /ektg./ mali.n Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005; 116(1):e21-e25. RESUSCITATION MEDICATIONS Adenosine 0.1 mg/kg IV/IO RAPID BOLUS (over 1-2 sec), Flush with 10 mL normal saline s Supraventricular tachycardia May repeat at 0.2 mg/kg IV/IO, then 0.3 mg/kg IV/IO after 2 min s r s Max first dose 6 mg, max subsequent dose 12 mg r s o k ke e Armiodarone 5 mg/Akdgm IVin/iIsOter using a 3-way stopcock attached to a 10 ml NS fluosh k ke e r o o Ventricular tachycardia No Pulse: Push Undiluted o o b o Ventricular fibrillation Pulse: Dilute and give over 20-60 minutes b o e b Max first dose 300 mg, max subsequent edose 150 mbg m e e/ / e MStornonitgotlory fpcorore nvhseyinpdtoe trhe ypnmprseoitotrenenastiionng ewithe I/V ca/lciume in patients with a pulse m m h ht tt tp ps s: /: // t/ .t . ACCtaarlloccpiiuuiBPHnmmrryeiap mGcdoahyclucraloycal crorAidendVmiaea bti ae((l1oi n(c01ck%r0eh%)as)ehd tvagttal totnpe)ps026.000 s2mm: mggMRMM//gekkaaa/:p/ggxxxke gsddIIaVV/i/ ootnI// ssVIIgieenOO/l t/Ie 13O5 d /ggmIo.trrMsaaine,mm u00.st..e05s4 m–if0g n.0e6e dmedg /(kugp EtToT twice) to max total dose 1 mg Dextrose <5 kg: 10% dextrose 10 mL/kg IV/IO 5-44 kg: 25% dextrose 4 mL/kg IV/IO ≥45 kg: 50% dextrose 2 mL/kg IV/IO, max single dose 50 grams = 100 mL Epinephrine 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/IO every 3–5 min (max single dose 1 mg) Pulseless arrest 0.1 mg/kg (0.1 mL/kg) 1:1000 ETT every 3–5 min (max single dose 2.5 mg) Bradycardia (symptomatic) Anaphylaxis: 0.01 mg/kg (0.01 mL/kg) of 1:1000 IM (1 mg/mL) in thigh Anaphylaxis every 5-15 min PRN; max single dose 0.5 mg s Standardized/Autoinjector: s k e er r s <101-03 0k gk: gn: o0 .A1u5t omingj eIcMtor, see above k e er r s o k >30 kg: 0.3 mg IM o k o o Insulin (Regular or Aspart) 0.1 units/kg IV/IO with 0.5 gram/kg of dextrose o o b o Hyperkalemia Max single dose 10 units b o e b Magnesium sulfate 50 mg/kg IV/IO e b mme e/ / e THoyrpsoamdeasg ndees epmoiinates NPMuoal xsP eus:li snGegi:vl eeP udosovhseer 220 mg-r6a0mm msinutees e/ / e p s s: /: // t/ .t . NaloxoOCnpoemioiad overdose p sRFuelssl p:RirM0ea.vo1/:teno rmirtsyo/g/a rD l fi/feAort/prsrr rthe edys.tspots osiDote.eon,n s:m se0i:ao. 0y0n0 ./t1b1i tr-mra0ad.gt0ye/0ck a5tgor dm IeViagf/fI/eOkcg/It/M)do/Ssueb IcVu/tI O(/mIMax/S duobsceu t2 ( mmagx) h ht tt t p SodiumAd mBiicnaisrtbeorn oantley (w8hi.t4h% ch l=eta 1r imttndEiqct/amtiLo)np: 1 mEqED/TiklTug t deIoV s8/Ie.O4 2%– 3s otdimiuems IbVi cdaorsbeo.n Mataey 1g :i v1e w eivtehr ys t2e rmilein w PaRteNr for patients Metabolic acidosis <10 kg to a final concentration of 4.2% = 0.5 mEq/mL Hyperkalemia Hyperkalemia: Max single dose 50 mEq Tricyclic antidepressant overdose Vasopressin 0.4 units/kg/dose IV/IO Max single dose 40 units ETT Meds (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine)—dilute meds to 5 mL with NS, follow with e rpSopserictsiiavle -stphraenskssu rteo vLeenAtnilna tMiocnN.amara, Clinical Pharmacy Specialist, and Elizabeth A. Hunt, MD, MPH, PhD, for their expert e r rs s k e guidance with IV infusion and resuscitation medication guidelines. k e o o o k Adapted from Hunt EA, Nelson-McMillan K, McNamara L. The Johns Hopkins Children’s Center Kids Kard, 201o6 and tohe o k b o American Heart Association, PALS Pocket Card, 2010. b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Chapter 1 s s r s r s e r e r k e k e o k o k o o Emergency Management o o b o b o e b e b m e e/ / e Vanessa Ozomaro Jeffries, MDm e e/ / e m m p s s: /: // t/ .t . Pediatric emergency mpanagsems:en/:t b//egt/in.ts .with a general observational h ht tt t p aqsusaelistsym oef nbtr—eahath bhinrtige,ftt aantsdse cpsosmlore ncta no f hae lppa otinene t’qsu giceknley riadl eanptipfye athraen ce, presence of a life threatening condition and determine next steps for intervention.1 In the event of sudden cardiac arrest, providers should use the acronym C-A-B (circulation/chest compressions–airway– breathing), of which immediate chest compressions is the first step in msanagement (see 2015 American Heart Association CPR guidelines). s r s r s e Tr his section is presented in the C-A-B format to emphasize the e r k e k e o k importance of immediate, high-quality chest compressions in improvinog k b o o o patient outcomes. The original A-B-C pathway remains the acbceptoedo o e b method for rapid assessment and management of any creitically bill m e e/ / e patient.2,6 If no imminent life threatening prmoblem eis eid/en/tifieed, then m one should proceed with a rapid primary assemssment of the A, B, C, p s s: /: // t/ .t . Dcl,o saenldy fEosll.o Twh.e history,p physsicsa:l e/:xa//mt/, a.tnd. laboratory studies should h ht tt t p I. CIRCULATIOhN2h-9t tt t p A. Assessment 1. Perfusion: a. Assess pulse: If infant/child is unresponsive and not breathing (gasps do not count as breathing), healthcare providers may take up to 10 s s e r r sseconds to feel for pulse (brachial in infants, carotid/femoral in e r r s o k k e children).2 o k k e o o (1) If pulseless, immediately begin chest compressions (see o o b o b o e b Circulation, B.1). e b mme e/ / e b. (A2s)s eIfs sp uclaspei,l labreyg irne fiAll- B(<-2C sp a=t hnwoarmy aolf, e2v matolu m5at iso ne=. dee/la/yede, and >5 s p s s: /: // t/ .t . spulagcgee)s.ts shock), mepntatsions:, a/:nd// ut/rin.te .output (if urinary catheter in h ht tt t p 2. Rasaytest/orhley.t hGmhe:n hAetsrasttlelys,st bforpar dbyrcaadrydciaa rrdeiqa,u itrainchg ycchaerdstia c, oambnporermssaiol nrsh yisth <m6,0 o r beats/min; tachycardia of >220 beats/min suggests tachyarrhythmia rather than sinus tachycardia. 3. Blood pressure (BP): Hypotension is a late manifestation of circulatory compromise. Can be calculated in children >1 year with following s formula: s r s r s e r e r k e Hypotension=Systolic BP<[70+(2×age in years)] k e o k o k b o o o 2 b o o o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Chapter 1 Emergency Management 3 s s e r rTAsBLE 1.1 e r r s o k k e MANAGEMENT OF CIRCULATION3-5 o k k e b o o o Infants Prepubertal Children Adolesbcents/oAduolts o 1 e b Location 1 fingerbreadth below 2 fingerbreadths below Leower halfb of sternum m e e/ / e intermammary line intermammmary lienee/ / e m Rate 100–120 per minute — m — h ht tt tp ps s: /: // t/ .t . *DeCDpoetVmph etophnfr* tecilosamstipioornenss†s: ionhs shho113ut501l2d::22 ttbi ne((21c aht trrpe eelsess acc(psuu4tee ocrrsns)me)-)tsh:ird /:of a//n213te 50tr/io::n22pc o.th((s21ete srrr. ieeo(ss5r cc dcuuiameemrr)s)e)ter of the che23st–0. :2D2.e 4(p 1tihn o cvrha 2leu ser se( s5ac rceu mer)s) approximations for most infants and children. †If intubated, give one breath every 6–8 seconds (8–10/min) without interrupting chest compressions. If there is return of spontaneous circulation, give one breath every 3–5 seconds. s s r s r s e r e r o k k e B. Management (Table 1.1)3,4 o k k e b o o o 1. Chest compressions b o o o e b a. Press hard (see Table 1.1 for age-specific depth of coempresbsion) and m e e/ / e fast (100–120 per minute) on backboarmd basee aned/ a/llowe full recoil m and minimal interruption. m p s s: /: // t/ .t . b. Fporer feinrrfaendt.s U, tsweo t-wthou-fipmnbg etsre ctseh:cnhi/:qnui//qeu t/we it.tfhor . hinanfadnst se nif coirncllyin sgin cghlee srte sisc uer h ht tt t p c. aUvsaeil aebnlde-.tihdahl tCOtt tto epstimate effectiveness (<20 mmHg indicates 2 inadequate compressions). 2. Use of automated external defibrillator (AED): To determine whether rhythm is shockable, use an AED/defibrillator. In infants aged <1 year, a manual defibrillator is preferred. If not available, use available AED. r s sPediatric dose attenuator preferred (if available). r s s k e e 3r . Resuscitation with poor perfusion and shock: k e e r o k a. Optimize oxygen delivery with supplemental O. o k o o 2 o o b o b. Support respirations to reduce work of patient. b o m e e/ /e e b c. Pinltarcaev einnotruaso s(sIVe)o uasc c(eIOss) ancoct eosbst aiminmede dwiaitmtheilny 9if0 ie ns eeacr/roen/sedt sae.nd/obr if m m p s s: /: // t/ .t . d. Ro(1re )sn uGosrimvceita ault ipsoa ntloi nfl etuh)i.drese p a2re0 -simsoLst:o/kng/:ic b //corlt/uyss.tteasl.l oeiadcsh ( lwacitthaitne d5 Rmininguetre’ss sfoorlu ati on h ht tt t p troetaasls oefhs s6 h0pt amtttieLn/tktg a pinnd t hceh eficrks t fo1r5 hmepinautotems eagfatelyr apfrteesre enatacthio bno; lus. The 2015 AHA guidelines recommend extreme caution with administration of bolus IV fluids, especially if critical care resources are not available. (2) 5- to 10-mL/kg bolus in patients with known or suspected cardiac s s r s insufficiency. r s e r e r k e (3) Consider inotropic support (see Chapter 4 for shock management).k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p 4 Part I Pediatric Acute Care s s r s(4) Consider colloids such as albumin, plasma, or packed red blood r s e r e r k e cells if poor response to crystalloids. k e o k o k o o e. Identify type of shock: Hypovolemia, cardiogenic (congenital hoeart o e b b o disease, myocarditis, cardiomyopathy, arrhythmia), diestribbutibve (soepsis, mme e/ / e acnaradpiahcy lataxmis,p noenuardoeg,e tneincs),io onb pstnrueuctmivoet h[pomuralmmx]o.naerye e/m/boelus (PE), p s s: /: // t/ .t . f. Pcohratircmoastceortohidesra apnyd (/spoere a innstsibisdi:oet /i:fcrso// niftt/ acp.topve.lirc aabnlde .)consider stress-dose h ht tt t p II. AIRWAY7-10h ht tt t p A. Assessment 1. Assess airway patency; think about obstruction: Head tilt/chin lift (or jaw thrust if injury suspected) to open airway. Avoid overextension in infants, as this may occlude airway. s s r 2. sAssess for spontaneous respiration: If no spontaneous respirations, r s e r e r k e begin ventilating via rescue breaths, bag-mask, or endotracheal tube. k e o k o k o o 3. Assess adequacy of respirations: o o e b b o a. Look for chest rise. e b b o m e e/ / e b. Rreetrcaocgtnioinzes , saigcncse sosfo dryis mtreusssc l(eg ruusnet,in wgh, esetmrzideos)r., teaceh/yp/neae, flaring, m m p s s: /: // t/ .t . B1.. MEaqnuaipgmemenetnt7-17 p s s: /: // t/ .t . h ht tt t p a. B(loaogk-m aat sckh heveshtn ttriilsatteti)o.t nC rmpicaoyid b pe ruessseudr ein (dSeefillnicitke lmy iaf nveeunvteilar)t incagn e fbfeec utisveedly to minimize gastric inflation and aspiration; however, excessive use should be avoided as to not obstruct the trachea. b. If available, consider EtCO as measure of effective ventilation. 2 c. Use oral or nasopharyngeal airway in patients with obstruction: r s s(1) Oral: Unconscious patients—measure from corner of mouth to r s s k e e r mandibular angle. k e e r o k (2) Nasal: Conscious patients—measure from tip of nose to traguso of k o o o o b o ear. b o m e e/ /e e b d. Llaarryynnggoesaclo mpya snke eadirewda)y, : eSsipmepcliea llwy ainy tdoi ffismeccuultr ea iraewnae ay/sir;w /deaoyee (sn no obt prevent m m p s s: /: // t/ .t . 2. aIansirtpwuibraaaytt iipoonrno.:t eIncdtiiocna,t epdph aformr s(aimcso:pthe/:nerd//ainpt/gy,).t orer. snpeireadto froyr flaikileulrye ,p oroblostnrugecdtio n, h ht tt t p a. sEuqpupipomrtenth: ShOtAPtt-MtE p(Suction, Oxygen, Airway Supplies, Pharmacology, Monitoring Equipment) (1) Laryngoscope blade: (a) Miller (straight blade): (i) #00–1 for premature to 2 months s s r s (ii) #1 for 3 months to 3 years r s e r e r k e (iii) #2 for >3 years k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p s s r s r s e r e r k e k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p Chapter 1 Emergency Management 5 s s r s (b) Macintosh (curved blade): r s e r e r k e (i) #2 for >2 years k e o k o k o o (ii) #3 for >8 years o o 1 e b b o (2) Endotracheal tube (ETT): Both cuffed and uncuffeed EbTTb are o mme e/ / e apcocoer plutanbgl ec, obmupt lciaunfcfeed, hisi gphr eafierwrraeyd rmiens mcisetartnaecinee ,p /golp/outtliacet iaoinr sle (ai.ke,. ,o r h ht tt tp ps s: /: // t/ .t . b(ae)t w((Seii)ii)ze h enCU hdauntegfctfeeeuttsrdf mf1 teEp–idnT2 apTE ty Tis(oeTmna sr:m(s:m))/ m:=) // (=at/ g(ea.t/g4e)./ 4+) 3+. 54 (iii) Use length-based resuscitation tape to estimate (b) Approximate depth of insertion in cm = ETT size × 3 (c) Stylet should not extend beyond the distal end of the ETT (d) Attach end-tidal CO monitor as confirmation of placement 2 s and effectiveness of chest compressions if applicable s e r r s(3) Nasogastric tube (NGT): To decompress the stomach; measure e r r s k e k e o k from nose to angle of jaw to xiphoid for depth of insertion o k b o o o b. Rapid sequence intubation (RSI) recommended for aspirabtion orisok: o e b (1) Preoxygenate with nonrebreather at 100% O for eminimubm of 3 m e e/ / e minutes: m e e2/ / e m (a) Do not use positive-pressure ventimlation (PPV) unless patient p s s: /: // t/ .t . (b) eCfhfoilrdt reisn i nhaadpveeq luessastes o:xy/:ge//nt//re.tsp.iratory reserve than adults, h ht tt t p orewshiindghu tatol tt chaitpghacepirt yoxygen consumption and lower functional (2) See Fig. 1.1 and Table 1.2 for drugs used for RSI (adjunct, sedative, paralytic). Important considerations in choosing appropriate agents include clinical scenario, allergies, presence of neuromuscular disease, anatomic abnormalities, or hemodynamic r s s status. r s s k e e r (3) For patients who are difficult to mask ventilate or have difficult k e e r o k airways, consider sedation without paralysis and the assistanceo of k o o o o b o subspecialists (anesthesiology and otolaryngology). b o mme e/ /e e b c. P(r1o)c ePdrueroex y(agtetnematep tws isthh o1u0ld0 %no Ot 2e.xceedm 30m seceoned/s)/:e e b p s s: /: // t/ .t . ((23)) mAUdsaems kion fvi sectnreitcri loainitditou ppnbr aeatsnisosdun sr i:nem tute/:odb //iapctraite/otvinoe.t nniss.t o(aspsetpieoir naFatiiglo.. n (1 Nd.1out reain:n gNd obT aabgbe-lnveae l1fivt.e 1-o)f. h ht tt t p cinrticeorfihedr ehpstr ewsttistuhtr eve phnatisla btioenen o rd esmpeoends toraf tiendtu. bDaot ionno.t) continue if it (4) Use scissoring technique to open mouth. (5) Hold laryngoscope blade in left hand. Insert blade into right side of mouth, sweeping tongue to the left out of line of vision. (6) Advance blade to epiglottis. With straight blade, lift up, directly s s r s lifting the epiglottis to view cords. With curved blade, place tip in r s e r e r k e vallecula, elevate the epiglottis to visualize the vocal cords. k e o k o k o o o o b o b o e b e b m e e/ / e m e e/ / e m m p s s: /: // t/ .t . p s s: /: // t/ .t . h ht tt t p h ht tt t p