Pediatric emergency medicine trisk 0151 0151
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Exposure/Environment
A complete physical examination requires removal of all clothing, log rolling, and
checking axillary and perineal areas of the patient. Hypothermia is a particular risk in
ill and injured children, due to their larger relative surface area. Hypothermia can
develop in the prehospital setting and can worsen in the ED, as proper assessment and
treatment requires exposure of the patient. The dangers of hypothermia include
impaired hemodynamics and coagulation, increased peripheral vascular resistance,
and increased metabolic demand. Monitor and maintain body temperature using
increased ambient temperature, warm blankets, and warmed fluids and oxygen. While
the use of therapeutic hypothermia in arrested pediatric patients remains understudied,
hyperthermia should be treated aggressively.
IV Access
Vascular access is an early but often challenging necessity in resuscitation.
Percutaneous cannulation of bilateral upper extremity veins with two large-bore
intravenous (IV) cannulas is ideal. For patients in pulseless arrest, for those with
severe trauma, or for patients with known difficult access, intraossesous (IO) access
provides a quick, reliable route to provide fluid resuscitation and medications. ED
clinicians should have an IV escalation plan in place with resources to assure timely
IV access. This has become a more important aspect of care due to the increasing
numbers of children with difficult IV access due to success in treating chronic
illnesses ( Table 7.6 ).
Fluid Resuscitation
Deliver isotonic fluids (normal saline or lactated Ringer’s) rapidly in 20 mL per kg
aliquots up to 60 mL/kg and reassess VS, MS, and skin perfusion. The push–pull
technique using a 20-mL syringe with a macrodrip setup with a three-way stopcock
and a T-connector is useful for rapid fluid resuscitation in children <50 kg. For
children >50 kg, fluids can be infused using a pressure bag or a rapid infuser. To date,
evidence has not shown benefit for the use of albumin or synthetic colloids in
pediatric septic shock, cardiopulmonary arrest, or trauma. Dextrose-containing
solutions should not be used for initial resuscitation due to risk for hyperglycemia and
secondary osmotic diuresis and neurologic injury. Nevertheless, bedside glucose
testing is important; treat hypoglycemia with 10% dextrose solution, and follow with
an infusion of dextrose-containing fluids in persistently hypoglycemic patients. If
volume resuscitation of 60 mL/kg has not been effective, consider initiating
procontractility agents or vasopressors. Treat hypoxemia, metabolic acidosis, and any
other critical electrolyte abnormalities discovered during the resuscitation.
Among traumatically injured patients, failure to respond to crystalloid resuscitation
is an indication for early transfusion. Blood transfusion is preferentially performed
