Pediatric ED

SCHEDULE: Dr. Heather Kuntz sets the schedule during your peds ED month. Get vacation requests at least 3 months in advance. All requests go through MedRez as usual. Depending on how well staffed the ED is, it is typical to have fewer than your normal 22 shifts per month as an intern; but don’t expect it (just enjoy it if it happens).


UNIQUE ASPECTS OF THE PEDS ED: As interns you will work some shifts where you will take sign out (it is good practice before becoming a senior). You will also be taking presentations from medical students as interns. You will also be writing notes on EPIC.


IMPORTANT THINGS TO KNOW: Patients waiting to be seen will be on the Board in red. Residents tend to ‘claim’ a particular computer for their shift so look for an open one. On the adult side sharing a computer is more common. Attendings tend to be a bit more particular about some of the subtleties of the discharge paperwork so make sure you run it by them before you send a kid home (you will pick up the preferences pretty quick).


CONSULTS: Secretaries will call consults for you, so just let them know when needed. Various services have agreements for coverage every month (Peds surgery and GI take esophageal foreign bodies at different times during the month). Some schedules are posted in the physician workroom. If you are not sure ask another resident or secretary.


IMAGING: In some cases you may need sedation for imaging. CT sedation is done by Peds ER. If patient needs sedation for MRI this will be done by transport nurses or anesthesia.


PROCEDURAL SEDATION: When it is necessary to sedate a patient for a procedure be sure to obtain consent and fill out the presedation note on EPIC. It’s a verbal consent only, so there is nothing for them to sign. Then let the charge nurse know early what you are planning to do so they can orchestrate respiratory therapist and room availability. We typically use ketamine or propofol.


OTHER STUFF:

  • Review some of you pediatric doses (especially for common meds like Tylenol, ibuprophen, decadron, common abx, etc.), and remember to include weight-­based doses on all your medication orders. Writing in “adult dose” is acceptable.
  • Review pediatric resuscitation medications and ET tube sizes.
  • It would also be helpful to use a system for estimating the weight of a patient by age.
  • Fun stickers for the kids are under the computer closest to the rack (use them!).


SOME TIPS:

ESTIMATING WEIGHT BY AGE

Finger counting video

​The original paper


GIVING A CHILD EPINEPHRINE: "SLIDE THE DECIMAL"

  • 20 kg child gets 2.0 mL of 1:10,000 code epi, which is 0.2mg


SHOCKING A KID

  • Defibrillate a child with 2 J/kg, then 4 J/kg
  • Cardiovert a child with 0.5 J/kg, then 1 J/kg


BAGGING A KID

  • Best bag to use is roughly the size of one of the child's lungs


CHEST COMPRESSIONS

  • Chest compressions should be at least at a rate of 100/min (sing "Stayin' Alive" in your head, it has a beats-per-minute of 100) and should be at a depth of 1/3 of the child's chest


GIVING DEXTROSE TO KIDS: "RULE OF 50"

  • Newborns and infants get 5 ml/kg of D10 (5x10=50)
  • Toddler and school age kids get 2 ml/kg of D25 (2x25=50)
  • Bigger kids get 1 ml/kg of D50 (1x50=50)


CHOOSING AN ETT FOR A CHILD

  • Age/4 + 4 = uncuffed tube size
  • Age/4 + 3.5 = cuffed tube size (take off 0.5 to account for the cuff)
  • "3.5 at birth, 5.0 at 5 years"


CHOOSING A LARYNGOSCOPE BLADE FOR A CHILD

  • 0 at birth, 2 at 2 years


THE "2-3-4" RULE

  • 2x ETT size = Foley and OG/NG size
  • 3x ETT size = ETT depth (just like in adults)
  • 4x ETT size = chest tube size


HYPOTENSION

  • Defined as SBP lower than (Age x 2) + 70 (lower than 60 for newborns.