WASHINGTON, D.C.—The first 30 minutes of managing a sick infant in the emergency department consists of identifying and managing airway, breathing, and circulation problems early and aggressively, according to Jennifer D. H. Walthall, MD, FACEP, deputy health commissioner at the Indiana State Department of Health and associate professor of clinical emergency medicine at Indiana University School of Medicine in Indianapolis.
Early identification of critically sick children is essential to effective resuscitation. While emergency physicians are trained to distinguish “sick” from “not sick” in adult patients, pediatric patients present a third category of “could be sick.” A fussy but consolable child is a reassuring sight; an infant that is inconsolable, irritated, and not interacting with the environment is the first sign of a potentially critical situation. Activating a team response early in these situations will help set the stage for a successful resuscitation.
Performing noninvasive steps to correct hypoxia, using humidified oxygen and CPAP/BiPAP can help avoid intubation and subsequent chances of ventilator-acquired pneumonia, according to Dr. Walthall. For those who are lethargic or obtunded secondary to respiratory failure, have signs of a lung injury, or can be anticipated to have high metabolic demands (think of severe meningitis, complex congenital heart disease), intubation is indicated.
Cool extremities, capillary refill greater than three seconds, tachycardia, and tachypnea are indications that circulatory support is necessary. Interventions must begin before the child becomes altered or obtunded. Establish two large bore peripheral IVs, using ultrasound-guided insertion techniques if available. Alternatively, inserting a feeding catheter into a neonatal umbilical vein allows fluid resuscitation to begin while establishing peripheral access. Intraosseous placement is also a viable access route. If central venous catheter placement through the femoral route is performed, the leg may turn blue or become swollen despite correct catheter placement.
Fluid rates remain at 20 mL/kg for pediatric patients. For the neonate or for cardiac conditions, 10 mL/kg is appropriate. Fluid therapy is goal directed toward decreasing capillary refill times and improving mental status. Continuing down the treatment tree, Dr. Walthall suggested using peripheral or inhaled routes of administration for vasopressor management. Extracorporeal membrane oxygenation is indicated for shock situations of all types refractory to treatment.
For patients suspected of sepsis, antibiotic treatment should begin by the end of the first thirty minutes of treatment. Corticosteroids should be considered for refractory shock situations. Biomarkers including lactate, C-reactive protein, procalcification, interleukin-18, and CD-64 should be added to standard lab draws.