What to do if…

What to do if…  (Common or serious issues on the wards)

ACUTE DETERIORATION:  Codes are relatively uncommon in pediatrics (thank goodness!).  Junior residents and medical students are not official members of the “code team” during the day, but each resident carries a code pager on call at night.  If you hear “Pediatric CODE BLUE” overhead (or the pager goes off), you should respond.  If you are the first medical provider to arrive, provide care to the best of your abilities until a more experienced individual arrives.  

If you are assessing a patient and are concerned about his or her clinical status, CALL YOUR SENIOR OR STAFF FOR HELP.  If you are really worried, call the RAPID RESPONSE TEAM (if patient is breathing) or a CODE BLUE (if not breathing or no pulse).   Nobody will ever fault you for calling if you are worried about a patient.  Provide care to the best of your abilities until help arrives.  

REMEMBER YOUR ABC’s

A = AIRWAY – make sure it is open

B = BREATHING – are they breathing?  If not, get the bag-mask and use it.  If they are, consider giving oxygen.

C = CIRCULATION – do they have a pulse?  If not, start compressions.

* “CAB” is the new “ABC” - In an unconscious patient who does not appear to be breathing, start compressions !!

FEVER:  Fever is a common problem, particularly in hospitalized pediatric patients.  Fever itself is not usually dangerous, but the underlying cause of it can be.  It also makes kids feel miserable.  If you are called to assess a patient who has a fever, your job is to decide whether it is “just” a fever, or whether it might indicate something more ominous.  If in doubt, call your senior!

RED FLAGS – if any of the following, be extra careful!

• immuno-compromised patient (oncology patient, asplenia, long-term steroids, immunodeficiency, …)

• young infant (< 2 months)

• associated with altered level of consciousness

• patient doesn’t have a diagnosis that would be expected to cause fever

If you assess the patient and think that they are “OK” except for the fever, go ahead and treat.  First line is acetaminophen 15 mg/kg per dose q4h prn, maximum 75 mg/kg/day.  If that doesn’t work, can give ibuprofen 10 mg/kg/dose q6h prn.  Know the contraindications to these meds!

VOMITING:  In the majority of cases, we do NOT give anti-emetics (eg. Gravol, ondansetron) to kids for acute nausea or vomiting in the inpatient setting.  These medications are sedating and can mask serious underlying problems.  You need to find out WHY the patient is vomiting or nauseated and address that problem.  

CRYING / PAIN:  Children cannot often communicate the source of their distress.  We know that pain is often under-estimated and under-managed in pediatrics.  Pneumonia, osteomyelitis, and various inflammatory states can be extremely uncomfortable.  IVs can go interstitial and be very painful.  Acute abdominal conditions are sometimes missed, and can present just with pain.  If you are called to see a crying patient, you need to assess them and try to figure out why they are distressed.  If you think a patient is in significant pain that is not relieved by acetaminophen or ibuprofen, call your senior for help.  Do NOT use sedation to quiet a crying child.  

IV FELL OUT:  If you were told in handover that you could switch to PO meds if the IV comes out, go ahead and do that.  Otherwise, you will have to assess the situation.  Bear in mind that not all patients necessarily need IVs.  

• Why did the patient have the IV? 

  • If it is for fluids, can you try PO?  What about an NG tube?

  • If it is for antibiotics, for what problem?  For how long?  Could you switch to PO?  (hint – if the patient has a serious infection, unless you were specifically told otherwise, the answer is probably ‘no’).  

  • For other meds, is there a PO alternative?   

• If you think the IV is needed, look for sites and take your time.  Check hand/antecub/foot/saphenous.  Once you’re ready, call the senior resident to help.  

RASH:  Kids get rashes a LOT.  Most are not dangerous.  A few are.  Your job on-call is to make sure that it isn’t one of the dangerous ones.

RED FLAGS

• child looks sick and/or has abnormal vital signs

• progressive petichial / purpuric rash (meningococcemia)

• diffuse targetoid rash involving palms and soles with oral and/or conjunctival involvement (Stevens-Johnson syndrome)

• progressive emergence of small vesicles (varicella – not necessarily dangerous for the patient, but very important to identify for infection control purposes)

If the patient looks well, and you are not worried about a “dangerous” rash…

• Patient asymptomatic – document your findings, watch and wait

• Itchy – can try oatmeal baths, non-medicated ointment or lotion (Glaxal base), if really bad can try a dose of systemic antihistamine (diphenhydramine or hydroxizine – Benadryl or Atarax), but beware of sedation side effects.  Best to let the day team decide re: steroid creams etc.

• Diaper rash – look in the creases!  If the rash is better in the creases, it is more likely contact, so use a barrier cream (Ihle’s paste is great).  If it is worse in the creases, it is more likely yeast, so use an antifungal (nystatin or cotrimazole) twice daily plus a barrier cream with every diaper change.

ABNORMAL VITAL SIGNS:  The Stollery is using the Bedside Pediatric Early Warning (BPEWS) vital signs sheets.  These conveniently indicate the normal range for various vital signs for patients of a similar age.  

BRADYCARDIA:  When a child is sleeping or resting we often see the HR fall, sometimes to a lower-than-normal range.  Don’t panic, it is almost always normal but you need to assess the pt.  Has the pt’s condition changed in the last few hours?  Check BP, stable rhythm, perfusion & respiratory rate.  What happens when you wake them up?  If the HR normalizes and they scream at you, things are probably OK.  

RED FLAGS (get help ASAP)

• Cushing’s Triad (bradycardia, hypertension, irregular resp rate)

• Other abnormal vital signs

• Patient not rousable / HR doesn’t increase

• Poor perfusion, child looks “sick”

TACHYCARDIA:  The most common reasons for tachycardia are fever and pain, along with medications (especially salbutalmol and nebulized epinephrine).  The heart rate should settle once you deal with the underlying cause.  Some dangerous causes that you don’t want to miss are shock and cardiac arrhythmia.  

RED FLAGS (get help ASAP)

• Signs of poor perfusion – slow central capillary refill, decreased urine output, poor colour, altered LOC

• Other abnormal vital signs

• Very high HR that does not vary (think SVT)

HIGH RESPIRATORY RATE / RESPIRATORY DISTRESS:   You need to think about the child’s underlying diagnosis and possible reasons for the high RR.

• Asthma - try giving extra bronchodilator (salbutalmol).  

• Bronchiolitis - you can try a bronchodilator (salbutalmol), a vasoconstrictor to decrease airway edema (nebulized epinephrine), or something to loosen and mobilize secretions (nebulized hypertonic saline, saline nose drops, suctioning etc.).  Don’t be surprised if nothing works very well.

• Croup, try a vasoconstrictor (nebulized epinephrine).  

• Pneumonia, give oxygen, can also try bronchodilator.  

RED FLAGS (get help ASAP, and if in doubt, get CXR and blood gas)

• associated with a significant drop in O2 saturation / increase in O2 needs

• abnormal / absent breath sounds in some lung fields

• patient looks “worn out”

LOW RESPIRATORY RATE:  The RR often falls when patients are sleeping deeply.  If the HR, BP and oxygen saturation are all normal, especially if the RR increases when you bother the patient, this is probably the case.  

RED FLAGS (get help ASAP)

• low RR associated with low HR, especially if no response to stimulation

• associated low O2 sat

DECREASED O2 SATURATION

• Don’t ignore subtle increases in oxygen requirement

• Remember - increased O2 requirement is NOT expected with upper airway problems such as croup, while it is more common in kids with lower airway disease such as bronchiolitis, pneumonia and asthma.

• Giving oxygen to a patient who is chronically hypercarbic (e.g. a patient with severe obstructive sleep asthma) can make them WORSE (it might fix their saturation, but it might also make them stop breathing)

• If they are requiring more than 3-5 L/min via nasal prongs, switch to a face mask and CALL YOUR SENIOR FOR HELP (unless this is their baseline)

INFUSION REACTION:  Most likely to happen with oncology patients, those receiving blood products (RBCs, platelets, IVIG …), and those on exotic mediations.

KEY STEPS

• stop the infusion

• ABCs

• put on monitor and give O2

• get help (call your senior)

• if you are concerned re: anaphylaxis, call a code, give epinephrine 1:1000, 0.01 mL/kg INTRAMUSCULAR (max 0.3 mL).

LOW URINE OUTPUT / FLUID BALANCE ISSUES:   Nursing units are often asked to call if a patient’s fluid balance falls outside of a specified range.  The most common reason is decreased urine output.  Your job is to determine whether this is a sign of a problem or not.  

RED FLAGS

• clinical signs of dehydration (tachycardia, dry mucous membranes, irritability, absence of tears, decreased skin turgor, decreased level of consciousness…)

• clinical signs of circulatory compromise (poor perfusion, lethargy, pallor, decreased capillary refill, tachycardia, …) ** especially in young infants

• ongoing losses (watery diarrhea, vomiting, high fever, …)

• known kidney or urologic problem

• reason to suspect SIADH (intracranial pathology, bad lung disease)

If you think the child looks OK and is not dehydrated, it is OK to watch and wait and reassess in a couple of hours.  If you think the child might be dehydrated, can give fluid bolus (10-20 cc/kg NORMAL SALINE IV) to see if that improves things.  If in doubt, call your senior!

SEIZURE:  This happens a lot and can be very frightening for parents and hospital staff, but is rarely acutely life threatening.  Don’t panic!  When you are called about a seizing patient, you should go see them immediately.   Ask the unit to call the senior resident while you are on your way.

FIRST STEPS

• Manage ABC’s.  Give oxygen.  

• if generalized seizure, get a bedside glucose measurement

• Get the story – try to figure out why the patient is seizing.  If they have a known seizure disorder, find out about their “usual” seizures 

• If the seizure has been going for longer than about 5 minutes, consider giving a medication to stop it

  • start with a benzodiazepine (ativan or diazepam)

  • if no effect, can give a 2nd dose, sometimes a 3rd.  Watch for and manage respiratory depression

  • if still seizing, consider phenobarbitol or dilantin load

OTHER SUGGESTIONS

• We are privileged to work with many very experienced pediatric nurses and other allied health professionals.  

• If it seems that another member of the health care team is unusually worried about something that you are not that worried about, make sure

  • that you understand what it is that they are worried about

  • that you are not missing something

  • that you have clearly articulated your thinking and your plan

  • it is really helpful to communicate your “back-up” plan – what you will do if your initial management (or decision to observe) doesn’t work

• If you are being called more than once for the same issue in a particular patient, and if other team members seem uncertain or nervous, get a more senior person (your senior resident or staff) involved.  It may be that they are being unnecessarily alarmed, but it may also be that you are missing something.

• Do NOT feel bad or inadequate for seeking help from someone with more experience.  You are NOT expected to independently manage everything, and we would MUCH rather you call us if you are worried.