Acute Care Exam #2

-Alterations in metabolism that hospitalized children experience in response to injury or illness
-Increased production and release of catecholamines, cytokines, glucocorticoids and glucagon
-As the body regulates the impact of hormonal release, other metabolic changes occur, including hypermetabolism, hyperglycemia, catabolism, and dyslipidemia

-Preexisting conditions
-Malnutrition
-Underlying systemic disease
-Age

-Catecholamine
-Cytokines
-Glucose
-Hyperglycemia
-Lipids
-Acute Phase Proteins

Reduction of insulin secretion and peripheral insulin action stimulates the production of glucagon and adrenocorticotropic hormone (ACTH), causing increased corticosteroid production

Injured tissue causes the release of proinflammatory cytokines, causing growth hormone resistance, catabolism, and growth halt

-The primary fuel source for the brain
-It is utilized to repair injured tissues and depletes quickly during acute illness and injury

-A multifactorial stress response commonly seen in hospitalized pediatric patients
-It is important to evaluate and adjust exogenous sources of carbohydrates

-Increased serum lipid levels are commonly seen in children who experience surgery, trauma, or critical illness
-Many factors contribute to this, including malnutrition, metabolic stress, organ dysfunction, and some medications

-Inflammation during inflammatory responses causes hepatic protein synthesis
-Positive acute phase proteins include C-reactive protein (CRP), ceruloplasmin, and fibrinogen, which increase during inflammatory periods
-Negative acute-phase proteins include albumin, prealbumin, retinol-binding protein, and transferrin, which decrease during inflammatory periods
-Alterations in protein metabolism can predict mortality in children who have had surgery and those hospitalized in intensive care

-2-3 months:
102 calories/kg/day
-4-6 months:
82 calories/kg/day
-7-12 months:
80 calories/kg/day
-13-35 months
82 calories/kg/day

1.5 gm/kg/day

-3 years:
boys: 85 calories/kg/day
girls: 82 calories/kg/day
-4-5 years:
boys: 70 calories/kg/day
girls: 65 calories/kg/day
-6-7 years:
boys: 64 calories/kg/day
girls: 61 calories/kg/day
-8 years:
boys: 59 calories/kg/day
girls: 59 calories/kg/day

-9-11 years:
boys: 49 calories/kg/day
girls: 42 calories/kg/day
-12-13 years:
boys: 44 calories/kg/day
girls: 40 calories/kg/day
-14-16 years:
boys: 39 calories/kg/day
girls: 33 calories/kg/day
-17-18 years:
boys: 37 calories/kg/day
girls: 31 calories/kg/day
->18 years:
boys: 36 calories/kg/day
girls: 34 calories/kg/day

-3 years:
1.1 gm/kg/day
-4-13 years:
0.95 gm/kg/day
-14-18 years:
0.85 gm/kg/day
->18 years:
0.8 gm/kg/day

Can cause:
hyperglycemia
lipogenesis
increased CO2 production
-Increasing the risk of morbidity and mortality

-Commonly occurs in hospitalized children for various reasons, including:
NPO status
fluid restrictions
-Can cause:
protein-energy malnutrition
increased infections
poor wound healing

1. Meet nutrient needs that cannot be met by enteral intake alone.
2. Avoid nutrient toxicity and/or deficiency.
3. Optimize nutritional status.

-Intestinal failure (short bowel syndrome)
-Severe malabsorption
-Obstruction or ileus
-Intractable vomiting or diarrhea
-Necrotizing enterocolitis
-Congenital anomalies of the GI tract
-Bowel ischemia

-Malignancies
-Body surface burns
-Cardiac failure
-Kidney failure
-Chylothorax
-Extracorporeal membrane oxygenation (ECMO)

-Limited to 10-14 days
-Limited to a dextrose concentration of <12.5%
-Osmolarity per liter is limited to 700-900 mOsm

-Nutritional status is not adequate
-GI tract is not funcitonal
-<7-14 days needed
-Able to tolerate increased fluid volumes
-Needs dextrose <12.5%

-Nutritional status is not adequate
-GI tract is not funcitonal
->7-14 days needed
-Not able to tolerate increased fluid volumes
-Needs dextrose >12.5%

-Infant NPO for 3-5 days
-Children NPO for 5-7 days
-Has a functional GI tract
-If oral feedings are inadequate, then consider enteral
-If goal feeds are not tolerated, then supplement with parentral nutrition

-Total grams of amino acids per liter of solution ___ gm × 10 = ___ mOsm
-Total grams of dextrose per liter of solution __ gm × 5 = __ mOsm
-Total mEq of sodium and potassium per liter of solution __ mEq × 2 = __ mOsm
-Total mEq of calcium per liter of solution __ mEq × 1.4 = __ mOsm
-Total mEq of magnesium per liter of solution __ mEq × 1 = __ mOsm
-Total osmolarity = __ mOm

-Protein
-Carbohydrates
-Lipids

-Protein is supplied as crystalline amino acids
-Neonatal amino acid solutions are used for infants through one year of age
-After one year of age, adult amino acid products are typically used
-Minimum protein intake of 1.5 gm/kg/day is needed to prevent cumulative protein deficits in critically ill children
-Protein may be limited if kidney or liver dysfunction is present

-Carbohydrates are supplied as dextrose monohydrate and provide 3.4 Kcals per gram
-Carbohydrates are the primary source of calories in parenteral nutrition
-Complications of excessive carbohydrate infusion include phlebitis, refeeding syndrome, hepatosteatosis, cholestasis, CO2 retention, hypoglycemia, and hyperglycemia

-Intravenous fat emulsions (IVFE) provide the essential fatty acids, linoleic acid and α-linoleic acid, which are isomolar and a concentrated source of energy
-IVFE can be given as a separate infusion, part of a total nutrient admixture, or as a 3-in-1 solution

-Zinc
-Copper
-Chromium
-Manganese
-Selenium

-Electrolytes can be ordered individually or in preset combinations
-Vitamins can be added to PN as a multivitamin preparation or as single vitamins
-Adding medications directly into PN is not recommended

-Metabolic alkalosis and acidosis
-Electrolyte imbalance
-Volume overload
-Anemia
-Cholestatic jaundice

-Initial:
daily
-When Stable:
daily

-Initial:
weekly
-When Stable:
weekly

-Initial:
daily
-When Stable:
2-3 times per week

-Initial:
weekly
-When Stable:
weekly

-Initial:
2-3 days after starting
-When Stable:
2 times per week

-Initial:
1-2 hours after initiation
changing glucose concentration
if cycled, midinfusion and one hour after stopping PN
-When Stable:
as needed

-Initial:
1 month after initiating PN
-When Stable:
monthly

-Provider
-Dietitian
-Pharmacist

-Intracellular processes
-Bone formation
-Neuronal activity
-Muscular contraction
-Blood coagulation

-Regulation of calcium concentration is primarily controlled by the parathyroid hormone
-Increased the concentration of PTH causes an increase in serum calcium concentration

-Caused by the binding of ionized calcium to the citrate of banked blood during or following cardiac bypass, with massive transfusion after trauma, or during plasmapheresis
-Renal replacement therapy
-Tumor Lysis Syndrome
-Pancreatitis
-Syndromic etiology
-Medications
-Other electrolyte abnormalities

-Numbness
-Tingling
-Muscle cramps
-Irritability
-Confusion
-Trosseau sign
-Positive Chvostek sign
-Prolonged QT interval on ECG
-Laryngospasm
-Seizures
-Tetany

-IV replacement with careful monitoring during infusion
-Chronic hypocalcemia-oral supplements such as:
calcium carbonate
calcium citrate

-Associated with malignancy
-Can result from:
immobility
leg fractures
spinal cord damage
critical illness
-Syndromic etiology:
familial hypocalciuric hypercalcemia
hyyperparathyroidism

-Vague symptoms
-Mild to moderate is typically asymptomatic
-Constipation
-Anorexia
-Headache
-Depression
-Hypotonia
-Nephrolithiasis
-Nephrocalcinosis
-Coma
-Anxiety
-Shortened QT interval on ECG
-Renal tubular dysfunction

-Hydration with normal saline
-Avoid thiazide diuretics
-For rapid treatment:
glucocorticoids
calcitonin
bisphosphonates

-Excreted by the kidneys
-Balance is hormonally regulated
this appears when the cell appears
-Homeostasis is impacted by acid-base imbalance and osmolarity
-Acidosis can cause a rise in serum potassium
-Alkalosis can cause a decrease in serum potassium

-Most often drug induced:
laxatives
diuretics
penicillin
enemas
-Drugs that have B sympathetic activity:
bronchodilators
decongestants
dopamine
dobutamine

-Generally asymptomatic
it may present as ventricular arrythmias in individuals with underlying cardiac issues
these individuals should maintain a potassium level >4.5
-It can cause hypertension and increases the risk of digoxin toxicity

-Treated with potassium replacement, usually supplemental potassium in hospitalized patients
-Oral supplementation can be given in non-emergent situations
3 Formulations
potassium chloride
potassium phosphate
potassium bicarbonate

-Emergency treatment may include IV supplementation with potassium chloride at 0.5 to 1 mEq/kg with a max dose of 20 mEq:
cardiac monitoring should occur throughout infusion
preferable through a central vein when possible
never given IV bolus

-Hemolysis of the sample should first be considered in any lab value revealing hyperkalemia, and another lab should be drawn, while also preparing to treat the condition
-Most common cause in a hospitalized patient is the use of potassium sparing diuretics
-Hyperkalemia may also be found in impaired renal conditions

-Acute rise in potassium:
individual may be in an acidotic state
-Chronic hyperkalemia:
associated with kidney excretion impairment

-May be life threatening
-Can present with cardiac arrythmias

-First: Peaked T waves
-Progressing to prolonged PR and QRS intervals
-Leading to a loss of the PR interval
And, merging of the QRS and T wave to produce a sine wave pattern
-Hyperkalemia with ECG changes is an emergency and should be treated immediately
Stop all exogenous forms of potassium and confounding medications

-Calcium chloride (10 mg/kg) or calcium gluconate (100 mg/kg)
-Insulin and glucose therapy
-Bicarbonate
-Beta agonists IV or aerosolized
-Kayexalate administered rectally
-Hemodialysis

-Involved in most metabolic processes
-Important part of glycolysis
-Kidneys primarily control phosphate excretion
-Levels vary according to circadian rhythms
-Most variable electrolyte by age

-DKA
-Rapidly growing tumors
-Respiratory alkalosis
-Hyperventilation
-Panic attacks
-Sepsis
-Salicylate poisoning
-Mechanical ventilation
-Chronic use of aluminum-containing antacids
-Extensive burns
-Chronic phosphorus depletion can cause rickets

-Muscle weakness (including diaphragmatic weakness)
-Rhabdomyolysis
-Decreased respiratory function
-Rickets
-Malformation of the skull
-Bowing of the arms and legs
-Delayed tooth eruption with enamel defects
-Long bone fractures
-Abnormalities of the spine and pelvis

-IV phosphorus supplementation for severe hypophosphatemia
-Oral phosphorus supplementation for mild or chronic hypophosphatemia
-Give oral supplementation in divided doses to avoid diarrhea or GI distress

-Kidney failure
-Tumor lysis syndrome
-DKA
-Disorders causing lactic acidosis

-Hypocalcemia
-Tetany
-Increased osteoblastic activity
-Abnormal bone formation

-Dietary phosphate restriction for mild cases with normal kidney function
-Reduce protein intake
-IV fluids
-Calcium carbonate
-Calcium acetate

-Most abundant anion in the extracellular fluid
-Regulated by the kidneys and intestine
-Maintains electrical neutrality
-Has an inverse relationship with bicarbonate

-Metabolic alkalosis
-Emesis
-Nasogastric suctioning
-Diuretic use
-Respiratory failure
-Cardiac failure
-Chronic hypercarbia
-Cystic fibrosis
-Chloride-losing diarrhea

-Symptoms of metabolic alkalosis and underlying disorder
-Thirst
-Lethargy
-Tachycardia
-Tachypnea
-Delayed capillary refill
-Seizures (severe)

-Treat the underlying cause
-Volume repletion (except in heart failure)
-Sodium chloride or potassium chloride replacement
-Use sodium chloride cautiously in congestive heart failure
-Arginine hydrochloride or hydrochloric acid for rapid correction in emergent situations with monitoring

-Metabolic acidosis
-Diarrhea
-Excessive chloride-containing substances

-No specific symptoms
-Commonly occurs with hypernatremia and hyperkalemia
-Kussmaul respirations
-Lethargy
-Headache
-Confusion
-Coma (severe)

-Treat the underlying cause
-Treat associated acidosis
-IV bicarbonate for severe acidosis

-Half of body stores are in bone
-Involved in ATP generation
-DNA transcription
-Protein synthesis
-40% of dietary magnesium is absorbed in the upper small intestine

-Medications (amphotericin, cisplatin, potassium-sparing diuretics, calcium)
-GI losses
-Renal losses
-Diarrhea
-Steatorrhea
-Treatment of DKA
-Fluid administration
-Infants of diabetic mothers

-Associated with hypocalcemia and hypokalemia
-Seizures
-Paresthesia
-Ataxia
-Tetany
-Muscle weakness
-Delirium
-Hyperglycemia
-Arrhythmias

-IV magnesium sulfate or magnesium chloride
-Slow IV infusion is preferred
-IV magnesium may treat torsades de pointes, ventricular arrhythmias, preeclampsia, and status asthmaticus
-Emergent bolus for symptomatic seizures or arrhythmias with monitoring
-Oral magnesium in divided doses for mild cases

-Excessive magnesium intake
-Magnesium-containing laxatives
-Antacids
-Inappropriate magnesium concentration in TPN
-Infants of mothers treated with magnesium for preeclampsia
-Chronic kidney failure
-Tumor lysis syndrome
-Milk-alkali syndrome
-Lithium ingestion
-DKA

-Lethargy
-CNS depression
-Hypotension
-Flushing
-Prolonged PR, QRS, and QT intervals
-Abdominal cramping
-Nausea and vomiting

-Basic stabilization
-Inotropes and ventilatory support for severe muscle weakness
-Exchange transfusion
-Loop diuretics
-Dialysis for life-threatening cases
-Stop magnesium intake for mild cases with normal kidney function

-Associated with skeletal muscle, nerve, and myocardial action potentials
-Maintains acid-base balance
-Normal range: 135-145 mEq/L

-Hypervolemic
-Hypovolemic
-Normovolemic

-Congestive heart failure
-Acute or chronic kidney failure
-Nephrotic syndrome
-Water intoxication
-Cirrhosis

-Renal losses
-Diarrhea
-Vomiting
-Burns
-Pancreatitis

-SIADH
-Adrenal insufficiency
-CNS disease
-Pulmonary disease
-Excessive diuretic use

-Irritability
-Poor feeding
-Nausea and vomiting
-Lethargy
-Seizures
-Coma
-Death
-Chronic hyponatremia may be asymptomatic until sodium is very low
-Acute hyponatremia increases risk of cerebral edema

-Associated with hyperlipidemia
-Hyperproteinemia
-Hyperglycemia
-Serum sodium appears low but total body sodium may be normal

-Restore intravascular volume
-Replace sodium deficit
-Treat underlying cause
-Monitor serum sodium closely
-Urgently treat neurologic symptoms
-Raise sodium to 125 mEq/L if seizures are present
-Use hypertonic saline if available
-If unavailable, give 20 mL/kg NS bolus
-Avoid rapid correction to prevent neurologic injury

-Excessive sodium intake
-Free water loss
-Concentrated formula
-Breastfeeding without supplementation
-Salt supplements
-Sodium bicarbonate
-Diarrhea
-Diabetes insipidus
-Renal tubular disorders
-Post-obstructive diuresis

-Irritability
-High-pitched cry
-Lethargy
-Seizures
-Renal failure
-Rhabdomyolysis
-Permanent CNS dysfunction may occur with sodium >165-170 mEq/L

-Correct sodium slowly to prevent cerebral edema
-If shock is present, give 20 mL/kg isotonic crystalloid boluses until perfusion is restored
-Replace fluid deficit over 48-72 hours after shock is corrected
-Provide maintenance fluids and replace ongoing losses
-Hypovolemic hypernatremia may require loop diuretics and decreased sodium

-Symptom resulting from medical, psychosocial, and environmental conditions that lead to poor growth
-Also called faltering growth
-State of inadequate weight gain velocity
-If untreated, results in poor health outcomes

-Growth measurements below the 3rd-5th percentile
-2 or more standard deviations below baseline on the growth chart

-Environmental factors
-Chronic comorbidities
-Social challenges
-Poverty

-Imbalance between energy, protein, and micronutrient requirements and consumption or utilization
-Can be undernutrition or overnutrition

-Illness-related
-Environmental causes
-Behavioral causes
-Acute or chronic

Significant decline in weight-for-height occurring within 3 months

-Length/height deficit lasting 3 months or longer
-Common in chronic illnesses
-Neurologic disorders
-Cystic fibrosis
-Childhood cancer
-Cardiovascular disease
-GI disease

Evaluate growth charts using weight and height

Weight-for-length >95th percentile

-Anemia
-Decreased vitamin levels
-Altered lipid metabolism
-Insulin resistance
-Altered glucose control

-Decreased skin integrity
-Increased infection risk
-Reduced GI function
-Prolonged hospitalization
-Muscular dysfunction
-Vitamin and micronutrient deficiencies

-Recognition, assessment, and accurate classification
-Hospitalization for severe malnutrition
-Ongoing assessment of weight gain
-Monitor cognitive and motor development
-Assess social and emotional environment

-Individualized care
-Catch-up growth
-Target weight gain 2-3 times the average rate

-Used as part of nutrition assessment
-Preterm infant growth charts
-Term infant and child (<2 years) growth charts
-Children 2-20 years growth charts
-Condition-specific growth charts

-Compare a child to the reference population
-Range from 0-99%
-Always positive values

-Number of standard deviations from the mean
-More precise measure of abnormal growth
-Useful when above or below the growth chart limits
-More negative = more severe malnutrition
-Used to quantify malnutrition

-Compare infant growth to intrauterine growth
-Fenton Growth Chart: 22-50 weeks gestational age
-Olsen Growth Chart: 22-42 weeks gestational age
-Olsen includes racially diverse children

-Used for term infants and children 0-2 years
-Includes length, weight, head circumference, and weight-for-length
-Length measured lying down until age 2
-Head circumference measured until age 2
-Correct preterm infants for gestational age until 2 years corrected age
-Assess growth by corrected gestational age rather than chronological age

-Used for children 2-20 years
-Includes height, weight, and BMI

-Underweight: <5th percentile
-Normal weight: 5th-84th percentile
-Overweight: 85th-94th percentile
-Obese: >95th percentile

-Cerebral palsy
-Down syndrome
-Turner syndrome
-Marfan syndrome

-Measures muscle, fat, and bone
-Independent marker for mortality
-Correlates with BMI
-Used to diagnose and document malnutrition

-Occurs when previously malnourished children are aggressively fed
-Carbohydrates stimulate insulin secretion causing fluid and electrolyte shifts
-Hypophosphatemia is most common
-May also cause hypokalemia and hypomagnesemia

-Recent weight loss
-Prolonged poor nutritional intake
-Malnutrition

-Start oral, enteral, or parenteral nutrition slowly
-Gradually increase feeds
-Closely monitor serum electrolytes
-Monitor fluid status
-Monitor cardiopulmonary function

-25% extracellular
-19% interstitial
-6% plasma, protein, and lipids
-45% intracellular
-Higher water-to-lean body mass ratio increases dehydration risk

-20% extracellular
-50% intracellular

Include physiologic losses from urine, stool, and insensible losses

-100 mL/kg/day
-4 mL/kg/hr

-1,000 mL + 50 mL/kg for each kg over 10
-40 mL/hr + 2 mL/hr for each kg over 10

-1,500 mL + 20 mL/kg for each kg over 20
-60 mL/hr + 1 mL/hr for each kg over 20

-Viral
-Bacterial

-Antibiotic therapy
-Malnutrition
-Overfeeding
-Protein allergies
-Chronic diarrhea
-DKA
-Capillary leak (sepsis)
-Burns
-Hemorrhage
-Inadequate fluid intake

-Etiology of fluid loss
-Chronic illness
-Close contacts with similar symptoms
-Heat or sun exposure
-Fever
-Oral intake compared to baseline
-Activity level
-Medications or treatments
-Duration of illness
-Wet diapers in last 24 hours
-Toxic ingestion
-Metabolic disorders
-Prior surgeries
-Normal diet

-Poor skin turgor
-Tachycardia
-Delayed capillary refill
-Weight loss
-Mottled skin
-Sunken fontanel
-Sunken eyes
-Increased respiratory and heart rate
-Hypovolemic shock

-Infants: 5% (50 mL/kg)
-Older children: 3% (30 mL/kg)
-Normal skin turgor
-Normal or sticky mucous membranes
-Normal eyes
-Tears present
-Flat fontanel
-Alert
-Normal pulse
-Normal capillary refill
-Normal urine output or mild oliguria

-Infants: 6-10% (100 mL/kg)
-Older children: 4-6% (60 mL/kg)
-Mildly decreased skin turgor
-Dry skin and mucous membranes
-Deep-set eyes
-Decreased tears
-Sunken fontanel
-Irritable or lethargic
-Slightly increased pulse
-Weak pulse
-Delayed capillary refill (>1.5 sec)
-Mild oliguria

-Infants: >10%
-Older children: >6%
-Delayed skin elasticity
-Cold, mottled skin
-Parched, cracked lips
-Sunken eyes
-No tears
-Sunken fontanel
-Lethargic or obtunded
-Increased pulse
-Weak or absent pulse
-Capillary refill >3 seconds
-Severe oliguria

-Most common type
-Normal sodium (135-145 mEq/L)
-Usually secondary to gastroenteritis

-Sodium <135 mEq/L
-Seizures
-Noncardiogenic pulmonary edema
-Respiratory arrest
-Brain herniation

-Sodium >145 mEq/L
-Often secondary to vomiting
-May cause rapid brain volume reduction
-Subarachnoid hemorrhage
-Subdural hematoma
-Hyperreflexia
-Confusion
-Seizures
-Coma

-BUN increases with dehydration
-Assess sodium level
-Follow daily weights
-Monitor intake and output
-Monitor blood pressure
-Assess for edema

-Used for mild to moderate dehydration
-Goal: 15 mL/kg/hr or 60 mL/kg over 4 hours

-Severe dehydration or shock
-Severe vomiting or ileus
-Lack of caregiver supervision

-Reassess every hour
-Hospital admission not always necessary
-Restart feeds after hydration
-Outpatient follow-up the next day

-20 mL/kg isotonic fluid bolus
-Use NS or LR
-Repeat until perfusion improves
-Up to 60 mL/kg in the first hour

-Improved level of consciousness
-Improved pulses
-Decreased capillary refill time

-Replace deficits based on type of dehydration
-Use NS or LR
-Avoid glucose-containing or hypotonic fluids initially

-Replace deficits, maintenance, and ongoing losses
-Complete over 24 hours
-Base replacement on fluid, sodium, and potassium deficits
-Subtract initial boluses from 24-hour total
-Reassess ongoing losses every 4-6 hours

-Most dangerous type
-Improve perfusion
-Lower sodium to ~155 mEq/L
-Decrease sodium no faster than 10-12 mEq/L per 24 hours
-Replace fluids over 48 hours or longer
-Subtract initial boluses from total fluids
-Reassess ongoing losses every 4-6 hours

-Treat like isonatremic dehydration if no neurologic symptoms
-Raise sodium to ~125 mEq/L
-Increase sodium no faster than 10-12 mEq/L per 24 hours
-Rapid correction can cause osmotic demyelination syndrome
-Subtract initial boluses from total fluids
-Reassess ongoing losses every 4-6 hours

-Mild to moderate dehydration can be discharged after completing 3-4 hours of ORT
-If IV fluids were given, complete ORT before discharge
-Follow up the next day after urgent care or ED evaluation

-Provides continuous blood pressure monitoring
-Allows frequent blood sampling
-Ultrasound guidance is recommended

-Continuous blood pressure monitoring
-Hemodynamic instability
-Vasoactive medication administration
-Active volume resuscitation
-Unreliable or unobtainable noninvasive blood pressure
-Frequent arterial blood gases
-Significant respiratory support

-Infection
-Trauma to the artery
-Thrombosis
-Hematoma

-Infection at insertion site
-Traumatic injury proximal to insertion site
-Inadequate collateral circulation
-Failed Allen's test

-Slide-off (Thread-off): shallow angle, easier catheter advancement
-Through-and-through: steep angle, uses guidewire
-Do not switch techniques after starting
-If unable to thread catheter, remove it, hold pressure, and reattempt

-Radial artery (preferred)
-Ulnar artery
-Brachial artery (not recommended)
-Dorsalis pedis artery
-Posterior tibial artery

-Easily accessible
-Pulse easily palpated
-Good collateral circulation

-Sole blood supply to the distal arm
-Compromise may decrease blood flow to the lower arm

-Sterile procedure
-Used when distal pulses cannot be palpated
-Indicated in profound shock or severe extremity trauma

-Femoral artery
-Axillary artery

-Patient clenches fist
-Occlude radial and ulnar arteries
-Allow palm to become pale
-Release one artery and assess return of color
-Repeat on opposite side
-Determines adequate collateral circulation

-24G: Infant
-22G: Toddler
-22-20G: Small children
-20-18G: Larger children and adults

-Assess distal perfusion
-Monitor insertion site for infection
-Monitor arterial waveform
-Monitor blood pressure values

-Used in acutely ill children
-Strict protocols for medications, blood sampling, and dressing changes

-Pressure in the intrathoracic vena cava
-Approximates right atrial pressure
-Depends on cardiac output and venous return

-Blood volume
-Vascular tone
-Heart rate
-Ventricular contractility

-Decreases with hypovolemia
-Increases with increased circulating volume

-Assess cardiac function
-Assess central circulation pressure
-Monitor fluid therapy
-Prevent fluid overload
-Assess intravascular volume status
-Evaluate right atrial compliance

-Occurs late in diastole
-Corresponds with the P wave
-Represents atrial contraction

-Occurs during early systole
-Corresponds with the R wave
-Represents tricuspid valve bulging into the right atrium
-May merge with the A wave during tachycardia

-Occurs during mid systole
-Corresponds with the QRS complex
-Represents atrial relaxation and downward movement of the tricuspid valve

-Occurs during late systole
-Corresponds with the T wave
-Represents right atrial filling during ventricular systole
-Large V wave suggests tricuspid regurgitation or a noncompliant right atrium

-Occurs during early diastole
-Represents emptying of the right atrium into the ventricle

>16 French

<14 French

-Pneumothorax
-Pneumomediastinum
-Air leak after pulmonary resection
-Bronchopleural fistula
-Hemothorax
-Chest trauma
-Postoperative complications
-Pleural effusion
-Empyema
-Parapneumonic effusion
-Chylothorax
-Compression from air, fluid, or blood

-Skin infection at insertion site
-Use caution with coagulopathy
-Platelet count <50,000
-Pulmonary bullae
-Pleural adhesions
-Diaphragmatic adhesions

-Insert at the anterior axillary line
-Level of the 4th-5th intercostal space (nipple landmark)
-Placing too low risks entering the peritoneal cavity

-Occlusive dressing
-Atrium collection system
-20 cm H2O suction
-2 cm H2O water seal

-No further air or fluid leak
-Place to water seal
-Obtain chest x-ray
-Remove if no reaccumulation of air or fluid

-Injury to lungs
-Injury to heart
-Injury to liver
-Injury to other organs
-Bleeding
-Pneumothorax
-Infection

-Monitor vital signs
-Monitor oxygen saturation
-Monitor amount of air, fluid, or blood drained
-Assess patient comfort

-Central line inserted through a peripheral vein into the SVC or IVC
-Reduces repeated needle sticks

-Basilic vein
-Median cubital vein
-Cephalic vein
-Axillary vein
-Superficial temporal vein
-Retroarticular vein
-Great saphenous vein
-Small saphenous vein
-Popliteal vein
-Femoral vein

-Active relaxation phase
-Ventricles relax creating negative pressure that pulls blood from atria
-Atrial kick occurs at end of diastole and contributes 20-30% of ventricular filling
-Mitral and tricuspid valves open
-Aortic and pulmonary valves closed

-Active contraction phase
-Ventricles contract and eject blood
-Aortic and pulmonary valves open
-Mitral and tricuspid valves closed
-Ends with ventricular relaxation and return to diastole

-Heart grows as blood flows
-Blood follows the path of least resistance
-Pressure leads to hypertrophy
-Volume leads to dilation

-Blood flow stimulates growth of the heart and vessels
-Example: HLHS with PDA allows aortic arch growth despite small left heart

-Increased pressure or resistance causes ventricular muscle thickening
-Example: Hypertension

-Increased volume causes ventricular dilation
-Occurs with poor ventricular function or shunting lesions

-1 umbilical vein carries oxygenated blood from placenta
-2 umbilical arteries carry deoxygenated blood to placenta
-Right ventricle does little work
-Left ventricle performs most systemic work

-Patent foramen ovale (PFO): Right atrium → Left atrium
-Patent ductus arteriosus (PDA): Pulmonary artery → Aorta

-Umbilical vein enters fetus
-50% flows through ductus venosus to liver
-50% enters IVC and right atrium
-Most blood crosses PFO to left atrium
-<5% reaches lungs
-PDA shunts blood from pulmonary artery to aorta
-60% of descending aortic blood returns to placenta

-Begins at birth
-Oxygen causes pulmonary vasodilation
-Pulmonary vascular resistance decreases
-PDA flow reverses from aorta to pulmonary artery
-PDA gradually closes

-Right atrium = CVP
-Right ventricle = Tall systolic waveform
-Pulmonary artery = High pressure waveform
-Pulmonary capillary wedge = Reflects left-sided heart pressure

-Normal pressure: 2-6 mmHg
-Mean: 3 mmHg
-Target 8-12 mmHg in vasodilatory shock

-Pressure: 25/3 mmHg
-RV pressure is normally 1/4 to 1/5 of LV pressure
-Systemic RV pressure suggests pulmonary hypertension

-Pressure: 25/10 mmHg
-Mean: 16 mmHg
-Mean >25 mmHg suggests pulmonary hypertension
-RV pressure > PA pressure suggests pulmonary stenosis

-Normal: 6-12 mmHg
-Reflects left-sided filling pressure
-Assesses left ventricular diastolic function

Mean pressure: 8 mmHg

-Pressure: 100/8 mmHg
-Mean: 16 mmHg

-Normal: 3-12 mmHg
-Pressure at end of diastole before systole
-Assesses diastolic function
-Elevated in diastolic cardiomyopathy

-Pressure: 100/83 mmHg
-Mean: 83 mmHg
-LV pressure > aortic pressure suggests aortic stenosis or coarctation

-Right atrium: 75%
-Right ventricle: 75%
-Pulmonary artery: 75%
-Left atrium: 100%
-Left ventricle: 100%
-Aorta: 100%

-Step-up in oxygen saturation from right atrium to right ventricle
-Oxygenated blood shunts from left atrium to right atrium

-Step-up in oxygen saturation from right ventricle to pulmonary artery
-Oxygenated blood shunts from left ventricle to right ventricle

-Amount of blood pumped into systemic circulation each minute
-Assessed clinically and in the cath lab

-CVP
-Volume status
-Ventricular filling at end diastole

-Strength of ventricular contraction
-Measure of cardiac pump performance

-Amount of blood ejected with each beat
-Normal: 50-80 mL

-Systemic vascular resistance
-Resistance ventricle must overcome to eject blood

-Cardiac output corrected for body surface area
-Normal: 3.5-5.5 L/min/m²

-Ratio of pulmonary to systemic blood flow
-Normal: 1:1

<1.5:1

1.5-2:1

>2:1

-Relaxed pulmonary vessels
-Oxygen
-Nitric oxide
-Sildenafil
-Acetylcholine
-Prostaglandins
-Milrinone
-Calm state

-Sympathetic stimulation
-Stress
-Agitation
-Hyperinflation
-Hypoxemia
-Hypercarbia
-Acidosis
-Increased blood viscosity

-Autonomic nervous system
-Hormones
-Catecholamines
-Vasoactive medications
-Inotropes
-Environmental temperature
-Exercise
-Blood viscosity

-Neonates often present with nonspecific signs and symptoms
-Parents may underestimate illness severity
-Presentation may progress rapidly
-Sepsis is the most common cause of shock
-Early consideration of a broad differential is essential

-Appearance
-Work of breathing
-Circulation to skin
-Helps identify the affected organ system

-Airway
-Breathing
-Circulation
-Disability (neurologic exam)
-Dextrose (glucose) in infants

-Identify major problems before creating a differential
-Example: Respiratory distress, shock, lethargy, hypothermia

-Trauma
-Heart
-Endocrine
-Metabolic
-Inborn errors of metabolism
-Sepsis
-Formula dilution/overconcentration
-Intestinal catastrophes/dehydration
-Toxins
-Seizures

-Sepsis
-Viral infection
-Cardiac disease
-GI disorders
-Dehydration
-Feeding problems
-Metabolic disorders
-Endocrine disorders
-Hematologic disorders
-Neurologic disorders
-Trauma

-Intubate early if indicated
-Use sedatives cautiously
-ETT size: 3.0-3.5 mm
-Depth: 10-10.5 cm at the lip
-Confirm placement with CO₂ and CXR

-Rate approximately 20 breaths/min
-Try to ventilate in phase with the child's breathing

-Obtain IV or IO access
-UV line or saphenous cutdown if needed
-NS 20 mL/kg IV push
-Avoid LR in neonates
-Consider epinephrine, norepinephrine, or dobutamine

-Preferred site: Tibial plateau
-Distal femur may be used in neonates
-Can administer anything given through an IV
-Rare complications: Osteomyelitis, fractures, epiphyseal injury
-In cardiac arrest, place IO while IV is attempted

-Check bedside glucose
-D10 4 mL/kg IV push if low
-Recheck glucose frequently

-ABG
-CBC
-Blood cultures
-BMP
-LFTs
-Urinalysis with Gram stain

-Ampicillin
-Gentamicin
-Ceftazidime preferred over ceftriaxone
-Vancomycin if meningitis suspected

-Often require calcium
-Ceftriaxone and calcium can crystallize and damage the kidneys

-Acyclovir 30 mg/kg/day every 8 hours
-Consider HSV infection

-Prolonged rupture of membranes (>18-24 hours)
-Maternal Group B strep
-Nosocomial exposure after 7 days

-E. coli
-Other gram-negative bacteria
-Group B Streptococcus
-Listeria monocytogenes
-Staphylococcus aureus
-Streptococcus pneumoniae
-Haemophilus influenzae

-Fever or hypothermia
-Lethargy or irritability
-Poor feeding
-Vomiting
-Diarrhea
-Tachypnea
-Tachycardia
-Poor perfusion
-Petechiae
-Purpura

-Leukocytosis or leukopenia
-Bandemia
-Acidosis
-Hypo- or hyperglycemia
-Pyuria or bacteriuria
-CXR infiltrates

-Elevated hepatic transaminases
-Hepatic failure
-Positive Tzanck prep or immunofluorescence
-Severe pneumonitis on CXR
-PCR testing

-Elevated hepatic transaminases
-Hepatic failure
-PCR testing

-Rapid RSV testing
-Patchy infiltrates
-Atelectasis
-Hyperinflation

-HSV
-Enterovirus
-RSV

-Vesicles
-Hepatomegaly
-Icterus
-Petechiae
-Purpura

-Myocarditis
-Diffuse maculopapular rash

-Apnea
-Hypothermia
-May initially lack lower respiratory symptoms

-Supportive care
-Aggressive fluids
-Vasopressors if needed
-Empiric acyclovir if HSV suspected

-Gastroenteritis
-Volvulus
-Pyloric stenosis
-Hirschsprung disease
-Necrotizing enterocolitis

-Vomiting
-Diarrhea
-Poor feeding
-Decreased urine output
-Bloody stools
-Bilious vomiting
-Abdominal distention
-Palpable olive (pyloric stenosis)
-Visible peristaltic waves

-CBC
-Stool leukocytes
-Abdominal x-ray
-Abdominal ultrasound
-Upper GI study
-Barium/Gastrografin enema
-Metabolic alkalosis in pyloric stenosis

-Fluid resuscitation
-NG decompression for obstruction
-Antibiotics if indicated
-Early surgical consultation

-Poor breastfeeding may cause hypernatremic dehydration
-Formula over-dilution causes hyponatremia
-Formula over-concentration causes hypernatremia

-Restore intravascular volume
-Slow correction of electrolyte abnormalities

-Vomiting
-High-pitched cry
-Lethargy
-Irritability
-Seizures
-Coma
-Unusual urine odor
-Hepatomegaly
-Jaundice
-Hypothermia
-Bulging fontanel

-Hypoglycemia
-Abnormal electrolytes
-Severe acidosis
-Hyperammonemia

-Fluid resuscitation
-D10 2.5-10 mL/kg IV push
-D10 at 1.5-2x maintenance
-Treat electrolyte abnormalities
-Early metabolic specialist consultation

-Enzyme defect in cortisol production
-Usually presents during the second week of life

-Poor feeding
-Vomiting
-Irritability
-Lethargy
-Dehydration
-Hyperkalemic arrhythmias
-Females: Ambiguous genitalia
-Males: Small phallus or hyperpigmented scrotum

-Severe hyponatremia
-Severe hyperkalemia
-Hypoglycemia
-Peaked T waves

-NS resuscitation
-Treat severe hyperkalemia
-Stress-dose hydrocortisone
-Later fludrocortisone

-Maternal hyperthyroid antibodies cross the placenta
-May present after 10 days of life

-Marked tachycardia
-CHF
-Arrhythmias
-Irritability
-Respiratory distress
-Hyperthermia
-Shock

-Careful fluid resuscitation
-ABCs
-Propylthiouracil
-Potassium iodide
-Propranolol
-NICU/PICU monitoring

-Occurs in infants <1 year
-Spores colonize the gut

-Constipation
-Weak cry
-Lethargy
-Dehydration
-Afebrile
-Hypotonia
-Hyporeflexia
-Mask-like facies
-Increased oral secretions
-Decreased gag reflex
-Respiratory failure

-Supportive care
-Avoid aminoglycosides
-BabyBIG antitoxin

-Respiratory distress
-Apnea
-Irritability
-Vomiting
-Lethargy
-Bulging fontanel
-Seizures
-Retinal hemorrhages

-Dilated retinal exam
-Head CT
-MRI
-LP
-CXR
-Skeletal survey
-Coagulation studies
-Abdominal CT if unstable

-Fluid resuscitation
-Drug-assisted intubation
-Treat seizures
-Notify CPS and law enforcement

-Tachycardia
-Tachypnea
-Pallor
-Cyanosis
-Poor perfusion
-Slow feeding
-Murmur
-Gallop
-Hepatomegaly
-Rales or wheezing

-Metabolic acidosis
-Hypoxia
-CXR
-ECG

-Supportive care
-Fluid boluses
-Prostaglandin E1 for left-sided obstructive lesions

-Potent vasodilator
-0.05-0.1 mcg/kg/min
-May increase to 0.2-0.4 mcg/kg/min
-Dilute in D5W or NS
-Administer through a large vein

-Monitor oxygen saturation
-Perfusion
-Blood pressure
-pH

-Hyperpyrexia
-Flushing
-Hypotension
-Seizures
-Hypocalcemia
-Bleeding
-Diarrhea
-Apnea

-Abrupt transient loss of consciousness and postural tone due to decreased cerebral blood flow
-Sudden and temporary
-Self-terminating with rapid recovery

-No loss of postural tone or consciousness
-Nausea/vomiting
-Lightheadedness
-Visual disturbances
-Sweating
-Flushing

-Traumatic
-Non-traumatic syncope
-Reflex syncope
-Orthostatic hypotension
-Cardiac (arrhythmia or structural)
-Epileptic seizures
-Functional/Psychogenic

-Vasovagal syncope
-Carotid sinus syndrome
-Situational (cough, post-micturition, pain)
-Orthostatic hypotension
-ANS failure
-Drug-induced (diuretics)

-Aortic stenosis
-Cardiomyopathy (HCM, DCM, ARVC)
-Coronary artery anomalies
-Pulmonary hypertension
-CHD
-LQTS
-SQTS
-Brugada
-CPVT
-Idiopathic VF
-WPW with RVR
-Bradyarrhythmias

-Brief interruption of cerebral blood flow
-Most common pediatric cause is vasovagal syncope
-Vasovagal syncope accounts for ~50% of ED cases
-Usually does not require testing

-Exaggerated vasovagal reflex
-Sympathetic response causes hypotension
-Parasympathetic response causes sinus bradycardia or varying degrees of heart block

-Mixed response
-Blood pressure falls before heart rate
-Heart rate does not fall below 40 bpm
-Most common type in children

-Cardioinhibitory without asystole
-Heart rate <40 bpm for >10 seconds
-No pauses >3 seconds

-Cardioinhibitory with asystole
-Heart rate <40 bpm for >10 seconds
-Pauses >3 seconds

-Vasodepressor
-No significant heart rate decrease (>10% from peak)

-Alcohol
-Illicit drugs
-Psychosocial stressors
-Psychogenic syncope may begin as true vasovagal syncope

-Prescription medications
-Non-prescription medications
-QT-prolonging drugs

-Orthostatic blood pressure and heart rate
-Neurologic examination
-Cardiac examination

-Evaluate for murmurs and structural disease
-Most cardiac causes will not be detected on auscultation alone

-ECG abnormalities
-Known heart disease
-Family history of sudden unexplained death
-Supine or seated syncope
-Palpitations before syncope
-Syncope while driving
-Syncope during exercise
-Chest pain or shortness of breath
-Anemia or electrolyte abnormalities
-Stokes-Adams attacks

-History
-Physical examination
-Lying and standing blood pressure
-ECG

-Echocardiogram
-ECG monitoring
-Carotid sinus massage
-Exercise tolerance test
-Implantable loop recorder if initial workup is negative

-Stop evaluation if syncope is rare
-Recurrent syncope likely due to neurally mediated syncope: ECG monitoring
-If not likely neurally mediated: Head-up tilt test
-If tilt test negative: ECG monitoring

-Most useful initial test
-Assess rhythm
-Assess hypertrophy
-Assess ischemia/strain
-Calculate QTc manually
-Look for Brugada pattern
-Epsilon waves
-Abnormal T waves

-Blood tests (BNP, troponin)
-EEG
-CT
-MRI
-Imaging has low yield and is overused

-Recreates postural change
-Evaluates heart rate and blood pressure
-Poor reproducibility
-Poor sensitivity and specificity
-Time consuming

-Limited indications
-Useful when structural heart disease is suspected

-Recurrent unexplained syncope
-High-risk CHD
-Severe syncope with injury
-Vasovagal syncope with concern for heart block or pacing need

-Increase salt and water intake
-Education
-Avoid triggers
-Hydrate before exercise
-Tilt training
-Compression stockings
-Exercise training
-Counter-pressure maneuvers
-Symptom recognition
-Psychotherapy if needed

-Mineralocorticoid
-Increases sodium and water retention
-Use with increased salt and water intake
-Side effects: Weight gain, hypertension, hypokalemia
-May take 2-3 months to work

-Peripheral alpha-1 agonist
-Increases PVR and cardiac output
-Side effects: Supine hypertension, nausea, urinary retention, rash
-Dose: 2.5-10 mg

-Anticholinergic
-Used for breath-holding spells causing vasovagal syncope
-Side effects: Dry mouth, urinary retention
-Dose: 50-200 mcg/kg/dose TID-QID

-Extracorporeal support that removes blood from the patient, oxygenates it, removes CO₂, and returns it to the patient
-Provides temporary life support for reversible pulmonary or cardiac failure
-Bridge to recovery
-Bridge to decision
-Bridge to transplant

-Desaturated blood is drained through a venous cannula
-CO₂ is removed
-O₂ is added through the oxygenator
-Blood is returned through a vein (VV ECMO) or artery (VA ECMO)

-Ensure adequate oxygen delivery to organs
-Allows time for heart/lung recovery
-Decrease ventilator-induced lung injury
-Allow weaning of vasoactive medications

-Blood drained from venous circulation and returned to arterial circulation
-Provides cardiac and respiratory support

-Blood drained from venous circulation and returned to venous circulation
-Requires preserved native cardiac function
-Used for isolated respiratory failure

-Centrifugal pump
-Oxygenator
-Controller

-Replaces roller pumps
-RPM controlled (0-4000 RPM)
-Flow up to 8 L/min
-Reliable up to 21 days