11. BRADYCARDIA 53 C. Intracranial Hypertension 1. Bradycardia is part of Cushing triad, along with hypertension and irregular respirations. 2. Head injury, CNS space-occupying lesion (tumor; abscess; epidural, subdural, or intracranial hemorrhage), hydrocephalus, malfunctioning ventricular shunt, meningitis, cerebrovascular event, or diabetic ketoacidosis. D. Hypothyroidism. E. Hypothermia. F. Primary Heart Conditions 1. Complete heart block. The most common cause of signifi- cant primarily cardiac bradycardia in infants and children. May be asymptomatic or cause shock and congestive heart failure (CHF). Usually does not respond to normal resuscitative meas- ures such as ventilation, oxygenation, treatment of acidosis, and catecholamine support. a. Congenital i. Idiopathic. ii. Associated with congenital heart defects such as cor- rected transposition of the great arteries or left atrial iso- merism and polysplenia syndromes (heterotaxy). iii. Associated with collagen disease in mother. b. Acquired, nonsurgical heart block i. Idiopathic. ii. Associated with congenital heart defects. iii. Infectious diseases: myocarditis (viral or Lyme) or endo- carditis. iv. Connective tissue diseases: lupus, rheumatic fever. v. Kawasaki disease. vi. Muscle disease. vii. Cardiac tumor. viii. Cardiac sclerosis. c. Postsurgical. Incidence < 1% because of improved opera- tive technique. i. Transient. Resolves within 8 days. ii. Permanent. Usually develops immediately after surgery but may occur many years later. 2. Sick sinus syndrome. Depressed sinus node function. a. Presentation. Sinus bradycardia or slow junctional rhythm alternating with episodes of tachycardia. May present with syncope. b. Causes. Surgery to correct atrial septal defect, Mustard procedure for d-transposition of the great vessels, Fontan repair for single ventricle complexes, viral myocarditis, idio- pathic. G. Toxins. Common drugs and toxins that can cause bradycardia include: 54 I: ON CALL PROBLEMS 1. Antidysrhythmics. 2. ␣-Adrenergic agonists. 3. ␤-Adrenergic agonists. 4. Calcium channel blockers. 5. Ciguatera. 6. Clonidine. 7. Digitalis glycosides. 8. Opioids. 9. Organophosphates and carbamates. IV. Database A. Physical Exam Key Points 1. Vital signs and general appearance. Assess vital signs; airway, breathing, and circulation (respiratory rate, BP, temper- ature, and pulse oximetry); level of consciousness; peripheral pulses; and skin perfusion. 2. Chest and lungs a. Observe for old surgical scars suggesting past cardiac surgery. b. Rales and wheezing may indicate CHF or infection. 3. Heart. Rhythm, murmurs? 4. Abdomen. Hepatomegaly may indicate CHF. 5. Skin. Perfusion, rashes (eg, meningococcemia, lupus, endo- carditis, rheumatic fever)? B. Laboratory Data 1. ECG. Will differentiate sinus bradycardia from complete heart block. 2. Blood gas analysis. Will confirm hypoxemia or acidosis. C. Radiographic and Other Studies. Chest x-ray may reveal car- diomegaly, congenital heart defect, or CHF. V. Plan. Figure I–3 depicts an approach to the patient with bradycardia. A. Support ABCs. Secure airway, administer 100% oxygen, and obtain IV access. B. Attach patient to a cardiorespiratory monitor or defibrillator. C. If patient remains hemodynamically compromised despite ade- quate ventilation and oxygenation, begin chest compressions. D. Identify and treat possible causes of bradycardia (6 H’s and a T; see III, earlier). Refer to Figure I–3. E. If patient does not improve, administer epinephrine or atropine, or both. F. If patient remains bradycardic or has a history of cardiac disease, consult a cardiologist emergently. For complete heart block, con- sider isoproterenol, epinephrine infusion, or transcutaneous or transthoracic cardiac pacing. VI. Problem Case Diagnosis. The 9-month-old infant was in respirato- ry distress and hemodynamically compromised when admitted to the emergency department. Endotracheal intubation was performed and 11. BRADYCARDIA 55 Low heart rate ABCs Attach monitor/defibrillator Hemodynamic compromise (LOC, pulse, perfusion, hypotension) No Observe Yes Chest compressions HR < 60 beats/min and poor perfusion despite oxygenation and ventilation Identify and treat possible causes: 6H′s and a T Hypoxemia: Attempt/verify ET intubation High acid: Correct acidosis Intracranial Hypertension: Maintain euvolemia, avoid hypercarbia and fever, controlled hyperventilation, consider mannitol Hypothermia: Rewarming measures Hypothyroidism Primary Heart (cardiac) condition: Cardiology consult Toxins: Antidote, if available Epinephrine No Cardiac history Complete heart block? Consider cardiac pacing AtropineConsider isoproterenol or epinephrine infusion Figure I–3. Management algorithm for bradycardia. (ABCs = airway, breathing, circulation; ET = endotracheal; HR = heart rate; LOC = level of consciousness.) 56 I: ON CALL PROBLEMS ventilation with 100% oxygen was provided. Patient’s heart rate imme- diately improved to 120 beats/min. VII. Teaching Pearl: Question. What is the most common cause of clin- ically significant bradycardic rhythms in infants and children? VIII. Teaching Pearl: Answer. Hypoxemia; therefore, immediate support of airway, ventilation, and oxygenation is warranted. REFERENCES Gewitz MH, Vetter VL. Cardiac emergencies. In Fleisher GR, ed. Textbook of Pediatric Emergency Medicine. Lippincott Williams & Wilkins, 2000:659–700. Hazinski MF, Zartsky AL, eds. Pediatric Advanced Life Support Provider Manual. American Heart Association Publication, 2002. 12. CARDIOPULMONARY ARREST I. Problem. A 4-month-old boy is brought to the emergency depart- ment by his parents, who found him lifeless, apneic, and pulseless this morning. II. Immediate Questions A. Is patient unresponsive? Establish unresponsiveness using vocal or physical stimulation. B. Is airway patent? Open airway using the head tilt–chin lift maneuver. C. Is there a history or suspicion of injury to head or neck? If injury is present or suspected, immobilize cervical spine and per- form the jaw-thrust maneuver to open the airway. If airway remains obstructed, patient should be repositioned and maneuvers for relieving airway obstruction attempted. D. Is patient breathing? If patient does not have spontaneous respi- rations, assist ventilation using a bag-valve-mask device, while delivering 100% oxygen (rate of 1 breath every 5 seconds in infants). E. Does patient have a pulse? Recommended sites to assess presence of a pulse in infants are brachial and femoral. If patient is pulseless, start chest compressions (rate of 100 per minute or ratio of 5 compressions to 1 ventilation in infants). Establish IV access rapidly. If attempt at peripheral IV access is unsuccessful, place an intraosseous (IO) line immediately. Administer epineph- rine by endotracheal (ET), IV, or IO route every 3–5 minutes. Reassess pulse between dosages of epinephrine. F. Is patient in shock? If patient is in shock, secure the airway, pro- vide 100% oxygen, and obtain IV access. Provide fluid boluses of 20 mL/kg of isotonic (NS or Ringer lactate) solution at least twice. Reassess patient after each fluid bolus. Consider an inotropic agent drip if there is no or minimal improvement in BP or perfusion after second fluid bolus. Some patients will require additional fluid boluses. 12. CARDIOPULMONARY ARREST 57 G. Are there treatable causes of cardiopulmonary arrest? Consider the 5 H’s and 4 T’s: Hypoxemia; Hypovolemia; Hypothermia; Hyperkalemia or hypokalemia and metabolic disorders; intracranial Hypertension; cardiac Tamponade; Tension pneumothorax; Toxins, poisons, and drugs; and Thromboembolism. III. Differential Diagnosis A. Upper Respiratory Conditions. Airway obstruction, croup, epiglottitis, retropharyngeal abscess, suffocation, strangulation, trauma, or tracheitis. B. Lower Respiratory Conditions. Pneumonia, asthma, bronchioli- tis, foreign body aspiration, drowning, smoke inhalation, or pul- monary edema. C. Infection. Sepsis or meningitis. D. Cardiac Disorders. Congenital heart disease, pericarditis, or rhythm disturbances. E. Shock. Hypovolemic shock from dehydration or hemorrhage, car- diogenic shock from myocardial dysfunction, or distributive shock from sepsis or anaphylaxis. F. Neurologic Disorders. CNS infection, meningitis or encephalitis, head injury, or cerebrovascular event. G. Trauma or Environmental Causes. Hypovolemia, hypothermia, hyperthermia, or submersion injury. H. Metabolic Disorders. Hypoglycemia, hypocalcemia, or hyper- kalemia. I. Sudden Infant Death Syndrome. IV. Database A. Physical Exam Key Points 1. General assessment and vital signs. Assess responsive- ness and obtain vital signs. a. Respiratory rate. Fast rate can indicate a toxic or metabol- ic abnormality. Slow rate is often an ominous sign that is suggestive of impending respiratory arrest, a toxin, or intracranial hypertension. Assess oxygenation by pulse oximetry. b. Heart rate and rhythm. Is heart rate absent or is a collapse rhythm present? Identify asystole, pulseless electrical activ- ity, ventricular fibrillation, and pulseless ventricular tachy- cardia. Is rate slow (sinus bradycardia, complete heart block) or rapid (sinus tachycardia, supraventricular tachycar- dia, or ventricular tachycardia)? Evaluate rate and rhythm, and listen for murmurs suggestive of congenital heart defect or acquired heart disease. c. BP. Is BP high (intracranial hypertension, toxin, or hyperten- sive emergency) or low (decompensated shock)? d. Temperature. High or low temperature suggests an infection or toxin. Hypothermia may be indicative of the environment. 58 I: ON CALL PROBLEMS 2. CNS. Low Glasgow Coma Scale score may indicate head injury. Examine head and fontanelle; bulging fontanelle can occur with intracranial hypertension or meningitis, whereas sunken fontanelle indicates hypovolemia and dehydration. Look for boggy swelling, palpable fracture, or other signs of trauma. Note presence of a ventricular shunt. 3. Eyes. Examine for signs of trauma (raccoon’s eyes) or hypov- olemia and dehydration (sunken). Assess pupil size and reac- tion. Pupillary size can give clues to the presence of a toxin. Depressed or absent reaction may indicate structural CNS lesion, herniation or impending herniation, or cardiopulmonary arrest. Asymmetry can indicate structural CNS lesion. Papilledema of the optic disk may occur with intracranial hyper- tension; however, absence of papilledema does not rule it out. Hemorrhages of the disk suggest intracranial injury. 4. Neck and trachea. Palpate for injury to the cervical spine or tracheal deviation. Look for venous distention that may indicate tension pneumothorax. 5. Thorax. Observe for old surgical scars or signs of rib fractures. 6. Lungs. Auscultate lungs and assess effectiveness of ventila- tion. Listen for decreased breath sounds (consolidation, pneu- monia, pleural effusion, or pneumothorax), rales (pneumonia, bronchiolitis, or pulmonary edema), and wheezing (asthma, bronchiolitis, foreign body aspiration, pulmonary edema), which are suggestive of lower airway disease, or stridor (foreign body, croup, tracheitis, epiglottitis, retropharyngeal abscess), suggestive of upper airway disease. 7. Abdomen. Palpate for signs of injury, tenderness, and hepatomegaly. 8. Skin and extremities. Look for any signs of injury or bruising, perfusion, and rash. B. Laboratory Data 1. Blood gas analysis. Hypoxemia, acidosis. 2. CBC. a. WBC count. Infection, sepsis. b. Hemoglobin and hematocrit. Hemorrhage. 3. Bedside dextrose determination. Hypoglycemia. 4. Basic metabolic panel. Electrolyte abnormalities, acidosis. 5. Blood and urine cultures. Sepsis. 6. CSF cell count, chemistry, Gram stain, and culture. CNS infection. Perform lumbar puncture only if patient is stable. 7. Serum or urine drug screening. Toxin. C. Radiographic and Other Studies 1. Chest x-ray. ET tube placement, pneumonia, foreign body aspiration, pneumothorax, rib fractures, congenital heart defect, congestive heart failure. 2. ECG. Rhythm abnormalities, congenital heart defect. 12. CARDIOPULMONARY ARREST 59 3. Trauma series. Cervical spine series, chest, and pelvis. 4. CT scan of head. Head injury (epidural, subdural, or intracra- nial hemorrhage), CNS infection (abscess), tumor, cerebral edema, cerebrovascular event. 5. Abdominal CT scan. Abdominal injury. 6. Skeletal survey. Suspected inflicted injury or child abuse among children younger than 3 years of age. V. Plan A. Responsiveness. Establish using vocal or physical stimulation. B. Airway 1. Open airway using the head tilt–chin lift maneuver. 2. If head or neck injury is present or suspected, immobilize cer- vical spine and perform jaw-thrust maneuver to open airway. 3. If airway remains obstructed, reposition patient and attempt maneuvers to relieve airway obstruction. C. Breathing. If patient does not have spontaneous respirations, assist ventilation using a bag-valve-mask device, while deliver- ing 100% oxygen. If patient continues to have ineffective or no respirations, perform ET intubation and ventilate through the ET tube. D. Circulation 1. Palpate brachial or femoral pulse. 2. Attach patient to cardiorespiratory monitor or defibrillator. 3. Establish IV access rapidly. If attempt at peripheral IV access is unsuccessful, place an IO line immediately. a. Patient is pulseless i. Monitor shows asystole or pulseless electrical activity: Start chest compressions. Administer epinephrine via ET, IV, or IO route every 3–5 minutes. ii. Monitor shows ventricular fibrillation or pulseless ven- tricular tachycardia: Defibrillate immediately (time should not be spent on ET intubation or IV or IO access), up to 3 times as needed. Start with 2 joules/kg, then 4 joules/kg, then 4 joules/kg. If no response, administer epinephrine via ET, IV, or IO route. Perform CPR. Defibrillate. If no response, administer antiarrhythmics (amiodarone, lidocaine, or magnesium) ET, IV, or IO. Perform CPR. Defibrillate. b. Patient has slow pulse (< 60 beats/min) and shows severe cardiorespiratory compromise despite adequate oxygena- tion and ventilation. i. Start chest compressions. Administer epinephrine via ET, IV, or IO route every 3–5 minutes. ii. Consider atropine if primary AV block or increased vagal tone is suspected. iii. Consider cardiac pacing. 60 I: ON CALL PROBLEMS c. Patient has rapid pulse and shows severe cardiorespiratory compromise despite adequate oxygenation and ventilation. i. Monitor shows narrow complexes (probable supraven- tricular tachycardia): Perform cardioversion immedi- ately with 0.5 joules/kg. Increase dose to 2 joules/kg if initial dose is ineffective, or administer adenosine IV or IO if immediately available. ii. Monitor shows wide complexes (probable ventricular tachycardia): Perform cardioversion immediately with 0.5 joules/kg. Increase dose to 2 joules/kg if initial dose is ineffective. Consider antiarrhythmics (amiodarone, procainamide, lidocaine). 4. If patient is in shock, provide fluid boluses of 20 mL/kg of iso- tonic (NS or Ringer lactate) solution at least twice. Reassess patient after each fluid bolus. Consider infusion of inotrope if there is no or minimal improvement after second fluid bolus. 5. Consider the 5 H’s and 4 T’s (see II, G, earlier). 6. Involve consultants promptly for the following conditions: con- genital or acquired heart disease, arrhythmias (cardiologist); injuries (trauma surgeon); head injury, and intracranial hyper- tension (neurosurgeon). 7. Other actions a. Administer antidote when available for suspected toxins. b. Provide empiric antimicrobial therapy for suspected sepsis or meningitis. VI. Problem Case Diagnosis. The 4-month-old boy was unresponsive and apneic on arrival in the emergency department. He underwent ET intubation and received 100% oxygen but remained pulseless and asystolic. Cardiac compressions were initiated. IO access was obtained, and epinephrine was given every 3 minutes for a total of three times. Patient remained pulseless. Postmortem examination was consistent with sudden infant death syndrome. VII. Teaching Pearl: Question. Among industrialized nations, what is the leading cause of death from the age of 6 months through young adulthood? VIII. Teaching Pearl: Answer. Injury; therefore, injury prevention is the first link in the so-called pediatric chain of survival. REFERENCES Hazinski MF, Zartsky AL, eds. Pediatric Advanced Life Support Provider Manual. American Heart Association Publication, 2002. Seidel JS. Cardiopulmonary resuscitation. In Barkin RM, ed. Pediatric Emergency Medicine. Mosby, 1997:104–117. 13. CHEST PAIN 61 13. CHEST PAIN I. Problem. A 15-year-old boy complains of chest pain 1 week after experiencing minor trauma. For the past 3 days he has had low- grade fever and achy, stabbing chest pain that is worse with exertion or walking, as well as mild dizziness with standing and nocturnal shortness of breath. II. Immediate Questions. Most children with chest pain have a benign, noncardiac cause of pain. However, the complaint should be taken seriously because of patient and parental concerns, and because underlying heart disease or other serious pathology can sometimes exist. Thorough history and careful physical exam can guide diagno- sis and determine when laboratory studies should be ordered. A. When did pain begin? Children with sudden onset of pain (within 48 hours of presentation) are more likely to have an organic cause (pneumonia, asthma, trauma, pneumothorax) of pain. Chronic, undiagnosed pain is more likely to be idiopathic or have a psy- chogenic cause. B. What precipitates pain? Are there associated symptoms? Chest pain precipitated by exercise should be taken seriously (suggesting cardiac disease or, more commonly, exercise- induced asthma). History of trauma, rough play, or choking on a foreign body may be relevant. Chest pain associated with syn- cope or palpitations is more significant and may also relate to car- diac disease. History of fever suggests an infectious process (eg, pneumonia, myocarditis). C. What is patient’s past medical and family history? Past med- ical history may reveal asthma that places patient at risk for more serious causes of pain. Previous heart disease or conditions such as diabetes mellitus (hyperlipidemia) or Kawasaki disease (coro- nary artery aneurysms) may increase risk of cardiac pathology. Obtain family history, because cardiac disorders can be familial. Patients with hypertrophic cardiomyopathy may relate a family history of chest pain or sudden death. D. How severe is pain? Determine if pain is frequent, severe, or interrupts child’s daily activity. Pain that awakens child from sleep is more likely to have an organic etiology. E. How is pain characterized (location, quality)? Young children may be imprecise in language and description, which can decrease usefulness of the history. Suspect esophagitis if burning sternal pain is present; pericarditis if there is sharp pain that is relieved by sitting up and leaning forward and associated with fever. F. How old is patient? Young children are more likely to have a car- diorespiratory cause for their pain (eg, cough, asthma, pneumo- nia, or heart disease); adolescents are more likely to have pain associated with stress or a psychogenic disturbance. [...]... genital or anal openings Urethral Disorders Painless genital spotting or bleeding is associated with urethral prolapse, most often found in prepubertal African-American girls Anal Conditions Midline perianal tags are common normal variations Anal fissures and bleeding may be associated with constipation Perianal lesions may accompany inflammatory bowel disease Nonsexual Trauma Straddle injuries can be associated... 62 I: ON CALL PROBLEMS III Differential Diagnosis A Cardiac Causes Previously undiagnosed cardiac disease is a rare cause of chest pain in children (< 5%) 1 Myocardial ischemia or infarction Conditions that place children at risk of angina or myocardial infarction include anomalous coronary arteries, long-standing diabetes mellitus, past medical history of Kawasaki disease, chronic anemia (eg,... collagen, arachidonic acid, and ristocetin are measured Patients with vWD show decreased aggregation with ristocetin as do those with Bernard-Soulier syndrome In platelet storage pool disease, abnormal aggregation to ADP, EPI, and collagen is seen Patients with Glanzmann thrombasthenia show abnormal aggregation to ADP, EPI, collagen, and arachidonic acid 7 Plasma fibrinogen concentrations Decreased... trauma Foreign body ingestion or aspiration Fever ■ ABNORMAL PHYSICAL EXAM Respiratory distress Palpation of subcutaneous air Decreased breath sounds Cardiac findings (eg, murmurs, rubs, arrhythmias) Fever Trauma or is otherwise concerning for cardiac disease If there is pain with exertion, be particularly concerned about cardiac disease or asthma and obtain an ECG and chest x-ray If patient has a history... evaluation of sexual abuse of children: A subject review Pediatrics 1999;103:186–191 80 I: ON CALL PROBLEMS American Academy of Pediatrics, Committee on Adolescence Care of the adolescent sexual assault victim Pediatrics 20 01;107:1476–1479 American Academy of Pediatrics Visual Diagnosis of Child Abuse on CD-ROM, 2nd ed AAP, 20 03 Reece R, Ludwig S, eds Child Abuse: Medical Diagnosis and Management, 2nd ed Lippincott... spontaneously? What are the other vital signs? As in all emergencies, rapid evaluation and support of airway, breathing, and circulation (ABCs) are initial management priorities All patients should receive 100% oxygen via face mask Comatose patients may not have effective spontaneous respirations or may have lost their protective airway reflexes and therefore may require assisted ventilation with a bag-valve-mask... Dermatologic Conditions Genital signs and symptoms are commonly associated with improper hygiene, irritant or contact dermatitis, atopic dermatitis, or seborrhea Lichen sclerosus et atrophicus may present with hemorrhagic, bruised, or abraded appearance in anogenital area Congenital Conditions Congenital variations of anal and genital structures are common Midline fusion abnormalities suggesting injury may involve... Erythema is a common nonspecific finding, often associated with hygiene problems Anal fissures, perianal abrasions, midline anal tags, and anal dilation are common nonspecific findings Anal tears or scars that extend through the anal sphincter are diagnostic for anal penetration B Laboratory Data 1 Testing for STDs a Prepubertal children Routine testing for STDs is not needed, but STD testing should be considered... rarely cause chest pain; however, severe pulmonic stenosis with associated cyanosis and aortic valve stenosis can lead to ischemia In these latter conditions, pain is described as squeezing, choking, or a pressure sensation in the sternal area These conditions are almost always diagnosed before child presents with pain, and associated murmurs are found on physical exam Mitral valve prolapse may cause... discharge Other nasopharyngeal or respiratory pathogens can produce purulent vaginitis Shigella infection may produce bloody vaginal discharge Genital lesions can be associated with varicella and molluscum contagiosum Pinworms are associated with either genital or anal pain, itching, and excoriation Other Conditions Intravaginal foreign bodies are associated with purulent or bloody discharge Normal physiologic . infarction. Conditions that place chil- dren at risk of angina or myocardial infarction include anom- alous coronary arteries, long-standing diabetes mellitus, past medical history of Kawasaki. Organophosphates and carbamates. IV. Database A. Physical Exam Key Points 1. Vital signs and general appearance. Assess vital signs; airway, breathing, and circulation (respiratory rate, BP, temper- ature,. exertion, be particularly concerned about cardiac disease or asthma and obtain an ECG and chest x-ray. If patient has a history of heart disease, chest x-ray or ECG may also be desir- able. 4.