Test your PEDS critical care knowledge

[NotReady4PrimeTime]

This is an offshoot of another thread that strayed far off its path.

I will be posting questions that spring from situations I see on my quaternary level PICU to test your knowledge of critical care topics that apply to children. As we know, children are not small adults and the reasons they are admitted to ICU are very different from those of adults. For example, PICUs see virtually NO life-style related comorbidities such as COPD from a 2 pack-per-day cigarette habit, cardiovascular disease from a 10 Big-Mac-per-week habit or end-stage cirrhosis from a 6-drink-per-day habit. Congenital anomalies, trauma (accidental and non-accidental), metabolic disorders, ingestions and respiratory infections are our biggest offenders.

Question #1:

Name the 4 main treatments for JET (junctional ectopic tachycardia).

[NotReady4PrimeTime, RN]

Don't forget that asthmatics air-trap and get very hyperinflated...

[kessadawn, BSN, RN]

ah, yes, very true!

[littleneoRN]

I think you might see a low CO2/respiratory alkalosis earlier in an acute asthma event due to tachypnea, but in this case, the asthma has progressed to a more severe/prolonged situation, in which I would think that the increasing airway obstruction would interfere with ventilation in such a way that you would start seeing a more elevated CO2. But seeing as how we don't see much asthma in the NICU, I'm not sure!

[NotReady4PrimeTime, RN]

A pediatric respirologist once told me that it was not appropriate to make a diagnosis of asthma in any child younger than 2. There are so many other conditions that cause wheezing and airway inflammation in the tiny ones that to say they have asthma is often incorrect. littleneo I bet you're familiar with BPD though, aren't ya? Oh, 'scuse me, aren't we calling it chronic lung disease now?

[littleneoRN]

True, true. But this child is two. Are you suggesting that we have a wrong diagnosis or just adding a tidbit of info? Most of our docs have been around for a long time (and our nurses too for that matter)...so we still say BPD. Often the docs notes say BPD/CLD.

[NotReady4PrimeTime, RN]

That was just FYI since you said you don't see asthma in NICU... you shouldn't!

So the K+ response was correct; albuterol causes hypokalemia that worsens over time unless it's corrected. It also causes tachycardia, so the first answer would be totally expected. Gas exchange is impaired by hyperinflation, airway inflammation and bronchospasm so the other two responses wouldn't be unusual either. Good job! (Side-stream nebulized albuterol causes headache, tachycardia, palpitations, light-headedness, jitters and irritability in the nurse holding the screaming, flailing, arching, kicking toddler too! SO not my favourite patients!)

(... pardon me while I watch the hockey game...)

While we're on the subject of hockey...

Your patient is a 14 year old male admitted through the ED following a midget AAA hockey game. The history you receive is that he had collided with an opposing player halfway through the third period and had been knocked off his skates, coming down hard on his back. He regained his feet after lying unmoving on the ice for nearly a minute, sat on the bench for two plays then finished out the game on the ice. In the dressing room after the game he complained of a slight headache, some nausea and a stitch in his left side, but said he felt "okay". An hour after arriving home he collapsed in the kitchen while getting himself a snack. On arrival in the ED he had a GCS of 12 (localizing, eye opening to voice and confused speech), pupils 4 mm and briskly reactive, DTRs normal, HR 126, RR 22, T 36.6C, BP 118/60, sats 94% in room air. He was mildly dyspneic, pale and diaphoretic with cool extremities. Over the first 20 minutes in the ED, his LOC decreased, his dyspnea worsened with sats falling to 88% and his HR increasing to 138 with a BP of 112/59. He was intubated and transferred to PICU with a 1L NS bolus infusing.

Your primary survey is consistent with the ED assessment. On secondary survey you note a swelling to the occipital area of his head with intact skin, pupils are still 4 mm but sluggish, HR 133, BP 108/54 with moderate central pulses and weaker peripheral pulses. Air entry is adequate but noticeably decreased to the left base, breath sounds are clear. Abdomen is rounded and slightly tense. A reddened bruise is noted just slightly to the left of midline and about 10 cm above the umbilicus. No other marks are visible on his skin. The saline bolus is complete giving him a BP of 114/54. The unit clerk brings in the lab report on the bloodwork drawn in the ED which are unremarkable except the hemoglobin of 11.3 and the hematocrit of 0.28.

What is your patient's most serious injury?

[ittybabyRN, RN]

I am not a PICU nurse, I am a new grad (5 weeks off a 6mo orientation) in the NICU but this summer we get to cross train in PICU & PCICU(which I can't wait for!) but I like the little game here and hopefully might find something useful for when I cross train :)

That being said, I think I'll go out on a limb here and guess something spleen related? and some blood STAT?

ps...maybe something like this could be started in the NICU thread? hint to those more experienced nurses

[NotReady4PrimeTime, RN]

Welcome to our little group EK.

Is a splenic lac the only thing that could explain what you're seeing? Is a hemoglobin of 11.3 bad? Is the BP really low? What else could be going on?

[NotReady4PrimeTime, RN]

Oh, I've passed the NICU request along. prmnrs and SteveNNP may be able to handle it,

[ittybabyRN, RN]

I was looking at the crit I guess

broken rib leading to punctured lung?

or should I go back to the occipital swelling?

...hmm I'll have to sleep on it I think

[ittybabyRN, RN]

ahhh and I guess a HR of 133 is not normal for a 14 year old :doh:

I'll be checking in first thing tomorrow morning :)

[littleneoRN]

Trauma! Even more foreign to an NICU nurse. I love it! :)

I don't think that a hemoglobin of 11.3 is all that low. I think that it would be lower with a splenic laceration or rupture. And wouldn't also be lower if significant internal bleeding was to blame for the tense abdomen?

I'm thinking we have a tension pneumothorax here. Would explain the decreased breath sounds on the left, the weakened pulses, slightly low BP, abdominal fullness, hypoxia, and hypoxia. Due to affecting breathing and circulation, I think this would be considered the priority concern. I'm sure we also have a concussion here, and it seems a CT might be valuable in ruling out more extensive injury to the head.

Teach me! :)