Rosen & Barkin's 5-Minute Emergency Medicine Consult (113 page)

Atropine, epinephrine, pacing

Treatment for specific disorders

FOLLOW-UP

• ICU:
  
  • Hemodynamically unstable bradycardia
    
  • 2nd-degree type II or 3rd-degree block
    
  • Transcutaneous or transvenous pacer
    
  • Pressors
    
  • Acute myocardial infarction or ischemia
    
• Telemetry:
  
  • Hemodynamically stable bradycardia
    

Asymptomatic sinus bradycardia

• All patients without existing primary care physicians should be referred to a generalist for follow-up as needed.
  
• 1st- and 2nd-degree type I AV block need cardiology referral.
  
• Severe endocrine, rheumatologic, infectious, renal, or neurologic disorders require appropriate specialty referral.
  

• Minor lab abnormalities that do not require admission require PCP follow-up.
  
• All patients except asymptomatic sinus bradycardia require cardiology follow-up.
  
• Specific disorders require appropriate specialty follow-up.
  

• Asymptomatic sinus bradycardia is the ONLY potentially “normal” bradycardia. All others require treatment or follow-up.
  
• O
  ₂
  , O
  ₂
  sat, IV, ECG, cardiac monitor for all patients.
  
• Pediatric bradycardia is likely secondary to hypoxia.
  
• Have pacing pads available for all symptomatic patients.
  
• The most important treatment targets the underlying cause.
  

• Dovgalyuk J, Holstege C, Mattu A, et al. The electrocardiogram in the patient with syncope.
  Am J Emerg Med
  . 2007;25:688–701.
  
• Haro LH, Hess EP, Decker WW. Arrhythmias in the office.
  Med Clin North Am
  . 2006;90:417–438.
  
• Mottram AR, Svenson JE. Rhythm disturbances.
  Emerg Med Clin North Am.
  2011;29(4):729–746.
  
• Ufberg JW, Clark JS. Bradydysrhythmias and atrioventricular conduction blocks.
  Emerg Med Clin North Am
  . 2006;24:1–9.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acute Coronary Syndrome
  
• β-Blocker Overdose
  
• Calcium Channel Blocker Overdose
  
• Digoxin Overdose
  
• Hyperkalemia
  
• Hypothermia
  
• Pacemaker
  

CODES

• 427.81 Sinoatrial node dysfunction
  
• 427.89 Other specified cardiac dysrhythmias
  

BASICS

Lower respiratory tract infection by airway inflammation and bronchoconstriction with wheezes/tachypnea and respiratory distress and upper respiratory prodrome

• Respiratory syncytial virus (RSV) in 85–90% of cases
  
• Influenza
  
• Parainfluenza
  
• Adenovirus
  
• Normally occurs during the winter months
  

DIAGNOSIS

• Age <2 yr (usually 1 yr or younger)
  
• Nasal congestion, often with marked rhinorrhea
  
• Cough, sometimes associated with vomiting
  
• Wheezing
  
• Crackles, rhonchi
  
• Respiratory distress manifested by tachypnea, nasal flaring, retractions, grunting. Often progressive over a period of 1–3 days
  
• Fever usually <39.5°C
  
• Hypoxemia may be present (usually mild). Cyanosis rare
  
• Decreased fluid intake common, frank dehydration uncommon
  
• Apnea may occur, particularly in young infants with history of prematurity
  
• Synagis, an RSV specific immunoglobulin, may be administered IM monthly during winter months in high-risk children. This reduces risk of RSV infection.
  

• Clinical diagnosis
  
• Defining viral cause may be useful for cohorting in hospital if admitted.
  
• Assess ventilation clinically.
  
• Pulse oximetry:
  
  • Confirms proper oxygenation on continuing basis
    
  • Follows trends over the course of illness
    

• Most patients need no specific tests beyond oximetry.
  
• Nasopharyngeal aspirate/wash:
  
  • Viral cultures
    
  • Fluorescent antibodies
    
  • Commercial kits are available.
    
  • Consider when:
    
    • Clinical symptoms suggestive of other cause (pertussis, chlamydia)
      
    • Critically ill child
      
    • Febrile child <3 mo old with bronchiolitis (consider UTI as coexistent cause of fever)
      
    • Coexisting signs suggesting significant bacterial infection (positive aspirate does not exclude coexisting significant bacterial infection but such infections are uncommon)
      
    • Bronchopulmonary dysplasia or chronic lung disease
      
    • Coexistent cardiac disease
      
    • Prematurity
      
    • Other conditions warranting antiviral therapy (rare)
      

CXR:

• Usually hyperinflation, airway disease, atelectasis, variable infiltrate:
  
  • Atelectasis in young infants indicates more severe disease.
    
• Minority have airway + airspace disease; pneumonia usually viral
  
• Rarely changes management acutely
  
• Consider when:
  
  • Need to exclude other diagnoses such as CHF, aspiration, congenital airway anomaly (rare)
    
  • Chronic course with lack of resolution over 2–3 wk
    
  • Critically ill infants with impending respiratory failure
    
  • Atypical presentation in toxic or deteriorating child
    
  • Not routinely indicated in typical clinical presentation
    

• Septic workup in febrile bronchiolitis <28 days of age if respiratory status permits
  
• In febrile infants 1–3 mo of age, consider catheterized urine culture
  
• Oximetry during significant distress
  

• Asthma/recurrent virus-induced wheezing: Severe bronchiolitis requiring hospitalization, and family history of atopy are risk factors for future asthma.
  
• Pertussis: No respiratory distress between coughing spasms, no wheezing
  
• Bacterial pneumonia: Often toxic appearance, no wheezing, isolated airspace disease (consolidation) with no airway abnormality on chest radiograph
  
• Foreign body: Sudden onset of symptoms, usually afebrile
  
• CHF: Pre-existing clinical red flags (failure to thrive [FTT], feeding problems)
  

TREATMENT