Rosen & Barkin's 5-Minute Emergency Medicine Consult (615 page)

• 1st or loading dose unless otherwise noted
  
• All IV doses may be given IO if necessary
  
• LEAN (lidocaine, epinephrine, atropine, naloxone) may be given by endotracheal route
  
• Epinephrine: Multiple uses:
  
  • Pulseless arrest/symptomatic bradycardia: 0.01 mg/kg 1:10,000 IV q3–5min (max. 1 mg) or 0.1 mg/kg 1:1,000 ETT q3–5min
    
  • Asthma: 0.01 mg/kg 1:1,000 SC q15min
    
  • Anaphylaxis: 0.01 mg/kg 1:1,000 IM in thigh q15min (max. 0.3 mg); if hypotensive, 0.01 mg/kg 1:10,000 IV q3–5min (max. 1 mg)
    
  • Shock/hypotension: 0.1–1 mcg/kg/min IV
    
  • Toxins/overdose: 0.01 mg/kg 1:10,000 IV; may repeat to max. 0.1 mg/kg 1:1,000 IV.
    
• Rapid-sequence intubation
  
  • Pretreatment:
    
    • Atropine: 0.02 mg/kg IV (min. 0.1 mg)
      
    • Lidocaine: 1–2 mg/kg IV
      
  • Induction:
    
    • Etomidate: 0.3 mg/kg IV
      
    • Ketamine: 1–1.5 mg/kg IV; 4–5 mg/kg IM
      
    • Midazolam: 0.1–0.2 mg/kg IV
      
    • Thiopental: 3–5 mg/kg IV
      
  • Paralytics:
    
    • Succinylcholine: 1–2 mg/kg IV
      
    • Rocuronium: 0.6–1.2 mg/kg IV
      
    • Vecuronium: 0.1–0.2 mg/kg IV
      
    • Pancuronium: 0.1 mg/kg IV
      
• Antiarrhythmic agents:
  
  • Adenosine: 0.1 mg/kg (max. 6 mg) IV rapid push; 2nd dose 0.2 mg/kg (max. 12 mg).
    
  • Amiodarone: 5 mg/kg IV, max. dose 300 mg. Give as bolus for pulseless VF/VT, load over 20–60 min for SVT/VT.
    
  • Lidocaine: For VF or pulseless VT: 1 mg/kg IV bolus, 20–50 ug/kg/min IV infusion
    
  • Magnesium sulfate: 25–50 mg/kg (max. 2 g) for pulseless VT with torsades de pointes
    
  • Procainamide: 15 mg/kg IV over 30–60 min
    
• Inotropes and pressors:
  
  • Dobutamine: 2–20 ug/kg/min IV
    
  • Dopamine: 2–20 ug/kg/min IV
    
  • Inamrinone: Load 0.75–1 mg/kg IV over 5 min; maintenance 5–10 mcg/kg/min
    
  • Milrinone: Load 50 ug/kg IV over 10–60 min; maintenance 0.25–0.75 ug/kg/min
    
  • Norepinephrine: 0.1–2 ug/kg/min IV
    
• Other agents:
  
  • Albuterol: For asthma or anaphylaxis, multidose inhaler 4–8 puffs q20min or nebulizer 2.5 mg/dose (5 mg/dose if >20 kg) q20min; severe symptoms: 0.5 mg/kg/h by nebulizer (max. 20 mg/h)
    
  • Alprostadil: 0.05–0.1 ug/kg/min IV for ductal-dependent congenital heart disease
    
  • Calcium chloride: 20 mg/kg slow IV push in hypocalcemia, hyperkalemia, Ca channel blocker overdose
    
  • Dexamethasone: 0.6 mg/kg IV (max. 16 mg) for severe croup or asthma
    
  • Dextrose: 0.5–1 g/kg IV. D
    ₂₅
    W 2–4 mL/kg or D
    ₁₀
    W 5–10 mL/kg.
    
  • Diphenhydramine: 1–2 mg/kg IV q4–6 hr
    
  • Ipratropium: 250–500 mcg q20min ×3
    
  • Naloxone: 0.1 mg/kg IV q2min (max. 2 mg)
    
  • Sodium bicarbonate: 1 mEq/kg IV
    
  • Terbutaline: 10 mcg/kg SC q10–15min or 0.1–10 mg/kg/min IV for status asthmaticus
    
• Cardioversion: 0.5–1 J/kg, increase to 2 J/kg
  
• Defibrillation: 2 J/kg, increase to 4 J/kg
  

FOLLOW-UP

• All patients with impending or ongoing respiratory or cardiovascular compromise
  
• Survivors of cardiopulmonary arrest require continuous monitoring for decompensation postresuscitation in an ICU setting.
  
• Consider transfer to pediatric critical care center.
  

Patients with mild dehydration who respond to fluid resuscitation without signs of hemodynamic instability may be considered for discharge.

• Consultation as appropriate depending on specific etiology
  
• Involve authorities if abuse is suspected.
  

• Educate patients, parents, and caregivers regarding household products and toxins
  
• Educate patients about self-administration of epinephrine in anaphylaxis (if age appropriate).
  

• Empiric treatment is often necessary.
  
• Be vigilant for signs of early sepsis in children.
  
• Consider abuse if history contradicts exam
  
• Early recognition and stabilization
  

• Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatrics and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
  Crit Care Med
  . 2009;37(2):666–688.
  
• Fuchs S. Cardiopulmonary resuscitation and pediatric advanced life support update for the emergency physician.
  Pediatr Emerg Care
  . 2008;24(8):561–565.
  
• International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Pediatric basic and advanced life support.
  Pediatrics
  . 2006;117(5):e955–e977.
  
• Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  Circulation
  . 2010;122:S876–S908.
  
• Ralston M, Hazinski MF, Zaritsky AL, et al.
  Pediatric Advanced Life Support
  . Dallas, TX: American Heart Association; 2006.
  

CODES

• 427.5 Cardiac arrest
  
• 518.81 Acute respiratory failure
  
• 785.50 Shock, unspecified
  

BASICS

• 3 types of retinal detachments with common final pathway:
  
  • Rhegmatogenous retinal detachments (RRD)
    
  • Tractional retinal detachments (TRD)
    
  • Exudative retinal detachments (ERD)
    
• RRD:
  
  • Most common
    
  • Break or tear of sensory retina allows vitreous fluid to separate the sensory and pigmented parts of retina from each other.
    
  • Acute event, flashes secondary to tearing of nerve fibers, floaters secondary to bleeding
    
• TRD:
  
  • Contraction of fibrous vitreous bands, as a result of previous insult, pulls the sensory retina off the pigmented retina.
    
  • Chronic and progressive
    
  • Asymptomatic unless hemorrhage or retinal tear occurs
    
• ERD:
  
  • Subretinal fluid accumulates and separate retinal layers without violating either layer.
    
  • Do not usually require surgery
    
  • Usually secondary systemic disease such as severe acute hypertension, sarcoid, cancer
    

• RRD:
  
  • Myopia
    
  • Cataract surgery
    
  • Marfan syndrome
    
  • Structural degeneration of underlying anatomy of vitreous body, sensory or pigmented retina
    
  • Trauma
    
• TRD:
  
  • Proliferative diabetic retinopathy
    
  • Vasculopathy
    
  • Perforating injury
    
  • Chorioretinitis:
    
    • Retinopathy of prematurity, sickle cell disease, or toxocariasis
      
  • Trauma
    
• ERD:
  
  • Malignant hypertension, preeclampsia
    
  • Tumors of the choroid or retina (melanoma, retinoblastoma)
    
  • Inflammatory disorders (Coats or Harada disease, posterior scleritis)
    

DIAGNOSIS

• Flashes of light
  
• Floaters
  
• Curtain-like vision loss
  
• Peripheral/central vision loss or other visual field defects
  
• Asymptomatic
  

• Symptoms onset, course, description:
  
  • May progress over hours or weeks
    
  • Dark curtain or veil
    
  • Usually begins peripherally
    
• Associated symptoms: Flashing lights, floaters, painless
  
• Ophthalmologic history:
  
  • Baseline eyesight, myopia, surgery, eye disease, trauma
    
• Systemic disease
  

• Visual acuity, visual fields by confrontation—prior to dilation:
  
  • May have normal visual acuity if macula spared
    
  • Detachment is on opposite side of field defect
    
• May have afferent pupillary defect
  
• May have loss of red reflex
  
• Fundoscopy:
  
  • Pale, opaque, wrinkled retina
    
  • Cannot rule out detachment on fundoscopy alone
    
• Slit-lamp exam: Anterior vitreous pigment granules (“tobacco dust”) suggest retinal tear.