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62: Pediatric Considerations

Fernando L. Soto; Ariel E. Vera

INTRODUCTION

Pediatric visits account for 20–25% of visits to emergency departments in the United States. Most of these encounters will occur in general emergency departments, which may have limited capabilities to care for the critically ill child.1–3 The priorities in the assessment and management of the pediatric patient are similar to those of the adult patient. The quoted ABCs of airway, breathing, and circulation still apply and are first and foremost in the evaluation of the young infant and child. However, there are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and that must be taken into account during the evaluation and treatment. This chapter will focus on the key differences in the treatment of the critically ill child. A complete discussion of the many procedures, and the presentation of every critical condition in pediatric patients, is well outside the scope of this text. See Table 62-1 for a list of medications used in pediatric resuscitation.

TABLE 62-1:Common Medications Used in Pediatric Resuscitation
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TABLE 62-1: Common Medications Used in Pediatric Resuscitation
Epinephrine 0.01 mg/kg (0.1 mL/kg) IV every 3–5 min (1:10,000) in active resuscitation
Atropine 0.02 mg/kg IV every 5 min (minimum dose 0.1 mg, maximum dose 1.0 mg)
Adenosine 0.1 mg/kg IV (maximum dose 6 mg). May double to 0.2 (maximum dose 12 mg)
Amiodarone 5 mg/kg bolus for pulseless VT and over 20–60 min if perfusing arrhythmia—expert consultation advised
Narcan 0.1 mg/kg/dose IM/ET/IV/IO every 2–3 min (maximum dose 2 mg/dose)
Glucose

5–10 mL/kg of D10W in neonates and infants

2–4 mL/kg of D25W in young children

1–2 mL/kg of D50W in older children and adults
Calcium 100 mg/kg 10% calcium gluconate or 20 mg/kg of 10% calcium chloride
Lidocaine 1 mg/kg IV, and then infusion
Bicarbonate 1 mEq/kg, may repeat every 10 min
Prostaglandin E1 Start at 0.5 μg/kg/min IV (at lowest effective dose)

AIRWAY

Recognition of Respiratory Distress

Compared to adults, infants and children have anatomic and physiologic characteristics that make them more susceptible to respiratory emergencies. During the first 6 months of life, they are obligate nose breathers, and their narrow nasal passages tend to increase resistance to flow and can easily become occluded with a simple upper respiratory illness that will lead to obstruction. Following Poiseuille's law of resistance in which resistance is inversely proportional to the radius to the power of four (R ∝ 1/r4), small changes in the radius (mucosal edema, debris, etc.) will cause great increases in resistance. Infants and children have weak abdominal muscles and diaphragm, which may tire easily if strained. In addition, they have faster metabolic rates, which require a higher oxygen demand. This higher oxygen demand, coupled with a decreased functional residual capacity, makes them more vulnerable to decreases in their oxygen levels compared ...

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