Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics
881
Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics
881Paperback(3rd ed.)
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Overview
Product Details
| ISBN-13: | 9781610026321 |
|---|---|
| Publisher: | American Academy of Pediatrics |
| Publication date: | 05/01/2023 |
| Edition description: | 3rd ed. |
| Pages: | 881 |
| Sales rank: | 467,345 |
| Product dimensions: | 4.40(w) x 7.30(h) x 0.00(d) |
About the Author
Jeffrey C. Gershel, MD, FAAP, is a professor of pediatrics at Albert Einstein College of Medicine in Bronx, NY, and the former vice chairman of the department of pediatrics at the Jacobi Medical Center.
Daniel A. Rauch, MD, FAAP, SFHM is a Professor of Pediatrics at Tufts University School of Medicine. Dr Rauch has been very involved in the development of the field of pediatric hospital medicine (PHM) with leadership roles in the American Academy of Pediatrics (AAP) and Academic Pediatric Association, planning the national PHM conference and 2 separate regional conferences, starting the national PHM Fellows meeting, and helping move forward the PHM certification effort. He is coeditor of Caring for the Hospitalized Child: A Handbook of Inpatient Pediatrics, 3e, and Challenging Cases in Pediatric Hospital Medicine.
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Caring for the Hospitalized Child
A Handbook of Inpatient Pediatrics
By Daniel A. Rauch, Jeffrey C. Gershel
American Academy of Pediatrics
Copyright © 2013 American Academy of PediatricsAll rights reserved.
ISBN: 978-1-58110-754-8
CHAPTER 1
Anaphylaxis
Introduction
The term anaphylaxis applies to both anaphylactic (immunoglobulin [Ig] E mediated) and anaphylactoid (non-IgE mediated) reactions resulting in the release of immune mediators from basophils and mast cells. It is a severe, potentially fatal, multi-organ system allergic reaction. Therefore, it is imperative to recognize the signs and symptoms of anaphylaxis and treat it rapidly and appropriately. The most common causes are peanuts, tree nuts, and shellfish, although anaphylaxis in an inpatient may be triggered by latex, radiocontrast material, medications, or foods (Table 1-1).
As many as 20% to 30% of patients will have a biphasic response, with most responses occurring within 1 to 8 hours after the initial reaction has abated. Protracted anaphylaxis (up to 72 hours) is rare and usually occurs when there is continued exposure to the trigger.
Clinical Presentation
History
The patient usually presents with some combination of flushing, pruritus, urticaria and/or angioedema, tightness of the throat, respiratory distress, vomiting and/or diarrhea, and a sense of impending doom (Table 1-2).
Ask about possible triggers and previous episodes, as well as treatment given and whether the patient is receiving any chronic medications, especially a β-blocker.
Physical Examination
Perform a rapid examination, assessing vital signs, airway patency, respiratory sufficiency, cardiac rhythm, and mental status. Otherwise, the most frequently involved organ system is the skin, followed by the respiratory and gastrointestinal tracts (including oral mucosa).
Differential Diagnosis (Table 1-3)
The diagnosis of anaphylaxis is based on specific signs and symptoms of involvement of, by definition, at least 2 organ systems. If any of the following 3 criteria are present, the diagnosis of anaphylaxis is likely:
• Rapid onset of illness involving hives and/or mucosal tissue changes along with any of the following:
— Respiratory compromise
— Cardiovascular involvement
— Evidence of end organ dysfunction
• Two or more organ systems involved following a known exposure
• Hypotension minutes to hours after an allergen exposure
Treatment
Anaphylaxis is a medical emergency and requires immediate care and attention. Address the ABCs, provide oxygen as needed, discontinue all ingoing intravenous (IV) antibiotics or contrast infusions, avoid any latex products, remove any indwelling latex catheters, and begin continuous cardiorespiratory monitoring and pulse oximetry. If the patient has stridor at rest or respiratory compromise despite epinephrine (see page 5), prepare to intubate. Place a hypotensive patient in the supine position with elevation of the lower extremities. Note that treatment may prove especially challenging if the patient is receiving a β-blocker.
Epinephrine
Epinephrine is the first and most important treatment; there are no contraindications. It will reverse peripheral vasodilatation and bronchoconstriction, decrease angioedema and urticaria, shrink upper airway edema, enhance myocardial contractility, and suppress further release of immune mediators from mast cells and basophils.
Normotensive patient: Give 0.01 mL/kg (0.5 mL maximum) of 1:1,000 epinephrine intramuscularly into the lateral thigh. Repeat the dose every 5 to 15 minutes, as needed.
Hypotensive patient: Arrange for transfer to an intensive care unit and give 0.01 mg/kg (0.1 mL/kg, 10 mL maximum) of 1:10,000 epinephrine intravenously. Repeat every 3 to 5 minutes and increase subsequent doses to 0.1 to 0.2 mg/kg (0.1-0.2 mL/kg of 1:1,000). In the absence of IV access, give 0.01 mg/kg of 1:1,000 epinephrine intramuscularly (0.1 mL/kg, 3 mL maximum). If the patient remains hypotensive, initiate an IV drip, starting with 0.1 mcg/kg/min (1.5 mcg/kg/min maximum).
Vasopressor Infusion
If the patient remains hypotensive despite epinephrine and volume repletion, start a dopamine drip (2-20 mcg/kg/min).
Antihistamines
Histamine 1 (H1) and H2 antihistamines block the effect of circulating histamines without affecting further mediator release. Antihistamines are therefore secondary treatment, and epinephrine is still necessary. In addition, antihistamines do not exert an immediate effect. Give diphenhydramine (H1), 1 to 2 mg/kg (100 mg maximum) intravenously or orally every 6 hours and ranitidine (H2), 2 mg/kg (50 mg maximum) every 6 to 8 hours intravenously or orally.
Albuterol
If the patient continues to have bronchospasm after epinephrine has been given, treat with nebulized albuterol (0.15 mg/kg/dose; 2.5 mg minimum, Chapter 1: Anaphylaxis 10 mg maximum), either hourly or continuously.
Corticosteroids
Give either IV or oral methylprednisolone or oral prednisone (1-2 mg/kg/day divided every 6 hours, 80 mg/day maximum) for 3 days. This will decrease the risk of recurrent or protracted anaphylaxis but has no effect on the immediate reaction.
Glucagon
A patient taking β-blockers will have a limited response to epinephrine, increasing the risk for bronchospasm, hypotension, and paradoxical bradycardia. Give a loading dose of 20 to 30 mcg/kg (1 mg maximum) intravenously over 5 minutes, followed by a continuous infusion of 5 to 15 mcg/min, titrating the dose to the ideal blood pressure.
Indication for Consultation
• Allergist: First or severe episode of anaphylaxis, recurrent anaphylaxis, unknown etiology/exposure
Disposition
• Intensive care unit transfer: Severe respiratory distress requiring intubation, continuous epinephrine drip, hypotension requiring vasopressor infusion, patient on a β-blocker
• Discharge criteria: Normotensive on oral therapy after minimum observation period of 24 hours, without respiratory distress or significant end-organ dysfunction; family has a prescription for an epinephrine autoinjector and are educated about its use (store at room temperature, administer through clothing at the anterolateral aspect of the thigh and avoid holding thumb over the tip), as well as the importance of avoidance of food and environmental triggers; family instructed on ordering a MedicAlert bracelet (888/633-4298 or www.medicalert.org).
Discharge Management
• Continue the diphenhydramine and H antihistamine for 2 to 3 days after discharge.
• Stop glucocorticoids after 3 days without a taper.
Follow-up
• Allergist: 2 to 3 weeks
• Primary care: 2 to 3 days
Pearls and Pitfalls
• The resuscitation will be challenging if the patient is taking a ^-blocker.
• Anaphylaxis can be triggered by foods or medications received while on an inpatient service.
• Response may be seen as late as 72 hours postexposure.
• A biphasic response most occurs within 8 hours following resolution of initial symptoms.
Coding
ICD-9
• Anaphylaxis 995.0
• Angioedema 995.1
Arrhythmias
Introduction
Arrhythmias are encountered in 2 types of inpatients. One is the patient with a history of known heart disease or recently diagnosed heart disease who is admitted for medical or surgical management of the heart disease or a complication of either the heart disease or its treatment. The second type of patient may not have a history of heart disease and the arrhythmia is either an incidental finding or related to a noncardiac disease process such as hyperthyroidism, fever, toxic ingestion, or medication side effect.
Clinical Presentation
When a child presents with a suspected arrhythmia (see Table 2-1 on page 12), it is critical to focus on the history and physical examination findings. However, the detail is determined by the stability of the patient.
In an unstable patient, a directed history and examination are critical so as not to delay lifesaving treatment.
History
A patient with an arrhythmia can present in a variety of ways, depending on the age and underlying rhythm/heart disease. An infant may have nonspecific signs and symptoms, such as tachypnea, diaphoresis and/or cyanosis with feeds, irritability, and inconsolability. An older patient may complain of chest pain, nausea, palpitations, syncope/near syncope, or shortness of breath. Any age patient can present with cardiovascular collapse.
Have the patient or family describe the episode and whether there were any previous similar episodes. Assess for other symptoms, including chest pain, lightheadedness, dyspnea, palpitations, fatigue, irritability, and altered mental status. Ask about recent illnesses and review any medications or possible ingestions. Determine the medical history, especially if there are any chronic illnesses, as well as a family history of heart disease or sudden or unexplained death.
Physical Examination
Perform a directed physical examination to determine stability, focusing on the vital signs and ABCs. A stable patient has a maintainable airway, minimal to no respiratory distress, and adequate perfusion. Adequate perfusion is defined as appropriate mental status, capillary refill of 2 seconds or less, appropriate minimal blood pressure for age, appropriate heart rate for age, normal oxygen saturation, and adequate urine output. Auscultate for breath sounds as well as heart rate, rhythm, murmur, and additional sounds such as clicks or gallops. Check for hepatosplenomegaly, jugular venous distension, and peripheral edema.
Treatment of Specific Arrhythmias
The priority is determining whether a patient with an arrhythmia is stable, with palpable pulses, adequate perfusion with a normal blood pressure for age, normal urine output, normal oxygen saturation, and normal mental status. In such a case there is time to systematically evaluate the situation. In addition, many arrhythmias have underlying reversible causes for which the American Heart Association has coined the mnemonic of "Hs and Ts" (Box 2-1). It is imperative that these conditions are diagnosed and treated.
Asystole
Confirm that the monitor leads are properly attached to the patient's chest and the monitor, then change the monitor lead setting (change from lead I to lead II or lead II to lead III) and confirm asystole in a second lead. Initiate CPR, secure an airway, obtain intravenous/intraosseous (IV/IO) access, and provide oxygen and adequate ventilation.
Give 0.01 mg/kg (0.1 mL/kg, 1 mg maximum = 10 mL maximum) of 1:10,000 epinephrine intravenously or intraosseously. If there is no IV/IO access, use 0.1 mg/kg (0.1 mL/kg, 3 mg maximum = 3 mL maximum) of 1:1,000 epinephrine followed by 5 to 10 mL of normal saline via the endotracheal tube every 3 to 5 minutes until vascular access is achieved.
Atrial Fibrillation and Atrial Flutter
Investigate for underlying medical conditions. The goals are to convert the atrial rhythm, control the ventricular response, and prevent recurrences. The approach varies, depending on the patient's clinical status.
In an acute, life-threatening situation, attempt direct current cardioversion (0.5-1 J/kg). Consult with a pediatric cardiologist to initiate anticoagulation with heparin and ventricular rate control with digoxin, a ^blocker, or a calcium channel blocker. If the patient is stable, with atrial fibrillation or flutter of unknown duration, consult with a pediatric cardiologist and delay cardioversion until the patient is adequately anticoagulated.
First-Degree Atrioventricular (AV) Block
No treatment is needed except in the setting of structural heart disease and drug toxicity.
Second-Degree AV Block, Type I
Treat the underlying disease causing the arrhythmia.
Second-Degree AV Block, Type II
Treat the underlying disorder. Be aware that this has a high risk for progression to third-degree AV block. Refer the patient to a pediatric cardiologist for potential pacemaker placement.
Third-Degree A V Block
Treat with atropine 0.02 mg/kg intravenously every 5 minutes for 2 to 3 doses (minimum dose 0.1 mg; maximum single dose 0.5 mg in children, 1 mg in adolescents; maximum total dose of 1 mg for children and 2 mg for adolescents). Use this to increase heart rate while arranging for transcutaneous or transvenous pacing until a permanent pacemaker can be placed. Indications for pacemaker therapy include
• Signs and symptoms of congestive heart failure
• Infant with a structurally normal heart and a ventricular rate less than 50 bpm
• Infant with structural heart disease and a ventricular rate less than 70 bpm
• Patient with a wide QRS escape rhythm, ventricular ectopy, or ventricular dysfunction
Long QT Syndrome
If the patient presents with torsades de pointes, obtain serum electrolytes and urine drug screens and treat with magnesium sulfate 25 to 50 mg/kg IV (2 g maximum). Contact pediatric cardiology and monitor the patient closely, as further resuscitation may be necessary.
If the long QT is an incidental finding or discovered during the evaluation for syncope, immediately refer the patient to pediatric cardiology and arrange to screen all first-degree relatives.
Symptomatic Sinus Bradycardia
Initiate basic life support, obtain IV/IO access, provide oxygen, and place the patient on a monitor. Assess for reversible causes (Hs and Ts) and treat the underlying disease. Start transcutaneous pacing, if readily available. Otherwise, treat with epinephrine as described for asystole.
If there is increased vagal tone or the patient has an AV block, give atropine as described above for third-degree AV block. Situations where increased vagal tone is encountered include inferior myocardial disease, hypoglycemia, hypothyroidism, increased intracranial pressure, sick sinus syndrome, and potassium abnormalities. Numerous drugs, such as digoxin and β-blockers, can also cause increased vagal tone.
Supraventricular Tachycardia (SVT)
Initiate basic life support, obtain IV/IO access, provide oxygen, and place the patient on a monitor. Assess for reversible causes (Hs and Ts) and treat the underlying disease. Initial treatment depends on whether or not the patient is well perfused.
If the patient is well perfused, initially attempt vagal maneuvers, such as covering the face with a bag full of slushy ice water, attempting a Valsalva maneuver, or performing unilateral carotid artery massage. If unsuccessful, give adenosine 0.1 mg/kg rapid IV push (6 mg maximum) with the syringe as close to the IV site as possible, followed by a rapid IV push of 5 to 10 mL of normal saline. Using a stopcock can facilitate the rapid infusion of the adenosine and flush. If the first dose is not successful, repeat at a dose of 0.2 mg/kg rapid IV push (12 mg maximum). If the second dose of adenosine does not convert the rhythm, give another 0.2 mg/kg rapid IV push (12 mg maximum). If the patient continues in SVT, consult a pediatric cardiologist to discuss the next step (further antiarrhythmics or synchronized cardioversion).
If the patient is poorly perfused, use synchronized cardioversion at 0.5 to 1 J/kg. If unsuccessful, increase to 2 J/kg. If cardioversion is unsuccessful or the SVT recurs, consult with a cardiologist whenever possible and give either amiodarone 5 mg/kg IV over 20 to 60 minutes or procainamide 15 mg/kg IV over 30 to 60 minutes. Be prepared to treat bradycardia or other dysrhythmias that may result following amiodarone or procainamide administration.
Ventricular Fibrillation (VF)
Initiate basic life support, obtain IV/IO access, provide oxygen, ensure adequate ventilation, and place the patient on a monitor. Once VF is noted, proceed to immediate defibrillation. Give a single shock of 2 J/kg followed by 2 minutes of CPR; second shock of 4 J/kg followed by 2 minutes of CPR; subsequent shocks 4 J/kg or greater to a maximum of 10 J/kg or adult levels of energy. After the second defibrillation attempt, give epinephrine every 3 to 5 minutes as for asystole. After the third defibrillation attempt, start an antiarrhythmic, either amiodarone (5 mg/kg IV/IO bolus; may be repeated twice for refractory VF/pulseless VT) or lidocaine 1 mg/kg IV/IO bolus. Continue cycles of "CPR-shock-drug" until return of spontaneous circulation, rhythm change, or termination of resuscitative efforts.
Ventricular Tachycardia (VT)
Initiate basic life support, obtain IV/IO access, provide oxygen, ensure adequate ventilation, and place the patient on a monitor. If the patient is pulseless, treat identically to VF. If the patient has pulse and good perfusion, give amiodarone (5 mg/kg IV over 20 minutes), or consult a pediatric cardiologist to assist with further management (possible procainamide infusion or synchronized cardioversion).
If the patient has a pulse and poor perfusion, use synchronized cardioversion as for SVT. Consult a pediatric cardiologist or intensivist to assist with further management (possible procainamide infusion or synchronized cardioversion).
(Continues...)
Excerpted from Caring for the Hospitalized Child by Daniel A. Rauch, Jeffrey C. Gershel. Copyright © 2013 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
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