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).

[NeoPediRN]

I'm thinking splenic trauma/lac, starting to get hypovolemic which caused the BP drop? What does the head CT show? Sometimes certain bleeds won't show initially and then do with a repeat, but a concussion I assume is most likely.

Actually I just looked at the BPs and they're not bad, even before the bolus. What about a hemothorax? Were serial H&Hs drawn? If so, what'd they show?

[NeoPediRN]

Also, any tracheal deviation?

[Humbled_Nurse]

I think the head injury is more than a concussion. He could possible have a significant intracranial bleed. Not sure about the pneumothorax but definitely possible.

Betsey

[NotReady4PrimeTime, RN]

Great answers!!! The real patient this scenario is based on had a splenic fracture, a pneumothorax and a mild concussion. All of these could have been very serious. He underwent a splenectomy, had a chest tube for several days and came through the concussion with no long term effects. The injury was caused by the butt of the opposing player's stick; he had not been speared intentionally but that's what happened. Adolescent hockey players wear more and more protective gear all the time but there's nothing that protects that area just below the diaphragm. This boy was very lucky.

Hmm, where to go now... Oh, I know!

The patient is an 18 month old toddler. She's in respiratory distress, her RR is 45 with tracheal tug, supraclavicular, intercostal, subcostal and substernal retractions and an audible inspiratory wheeze. O2 sats are 88% on 3 L by nasal cannula; cap gas results are pO2 55, pCO2 58, pH 7.26, SaO2 87% and HCO3 25.8. Chest x-ray shows some patchy perihilar streaks and right middle lobe atelectasis. Nebulized albuterol makes no difference and neither does nebulized epinephrine. She's afebrile but starting to look really unwell. What could be causing her symptoms?

[NeoPediRN]

Is it respiratory failure secondary to RSV?

[NotReady4PrimeTime, RN]

Good guess but no...

[AUicuRN]

one of the top items on my differential list would be a foreign body airway obstruction. I'd request neck films to rule it out. And give her some more O's in the mean time.

[NotReady4PrimeTime, RN]

And the winner is jtau1980. The patient aspirated a peanut. It didn't show up on xray ever, just the lung changes associated with it. Unfortunately the outcome wasn't a good one.

Okay, time to stump the chump. Your turn to come up with a situation for me to puzzle through! Take your best shot...

[AUicuRN]

YAY!! Lets see how I do.

This one may make our NICU nurses a little happy.

3 week old presents to an outside hospital ED with resp. distress poor feeding and listlessness. Mom says she this all started 4-5 hours ago and isn't getting better. Patient is cool and has a decreased cap refill. VS: HR 187, RR 62, BP 87/48 O2Sat 86 RA. Patient is transported to your PICU and has progressively gotten worse. Cap refill in her extremities are now 6-8 seconds HR 190, BP 69/50. Sat's 92 on closed FM 100% and 8L. Retractions noted. ABG is 7.18 PaCO2 48, PaO2 60, Bicarb, 12. (I made that gas up so the bicarb and pH may not correlate but the idea is the same) What do you think is wrong and what can we do to make this better? This is my first one to write so let me know if I didn't make it clear.

Enjoy

[NotReady4PrimeTime, RN]

What are we seeing on CXR? Any vomiting or diarrhea? Has the baby had a fluid bolus? (Your pH and bicarb correlate... metabolic acidosis)

[AUicuRN]

No GI symptoms. CXR is unremarkable. The patient has had 2 10ml/kg boluses in route. Yes we do have metabolic acidosis. Perhaps I should add that brachial pulses are 2+ femoral pulses are 1+ and not palpable in the feet.

[NotReady4PrimeTime, RN]

Well, my first impulse was transposition of the great arteries with VSD. It fits the chronology, sort of... except the sudden onset. It's not like the ductus snaps shut! Anyway, the kiddie should have more fluid, some bicarb, a STAT echo... if TGA is confirmed then a prostin infusion, a visit to the cath lab for an atrial septostomy then surgery... either an arterial switch/VSD closure if possible or a Rastelli if the VSD is too big and unrestrictive.