Resuscitation of the crashing infant

An approach the the initial resuscitation of the critically ill child

Case

It is your last of 3 night shifts, but so far it has been great. You successfully resuscitated a woman with severe postpartum hemorrhage. You got ROSC on a young cardiac arrest patient, and just heard that he is awake and talking after having his LAD opened in the cath lab. You even managed to get the Cunningham technique to work on a dislocated shoulder for the first time in your career. Now, during a lull, you are joking with the nurses, and someone says the work “quiet”. The next minute, the triage nurses is running down the hallway with a limp, blue 3 week infant in her arms and 2 very scared parents in tow…

My approach

As I walk into the room, I always rapidly consider the pediatric assessment triangle.1 This assessment, completed in seconds, examines 3 essential aspects of the child’s presentation from the foot of the bed: appearance, work of breathing, and circulation to the skin.

Appearance

  • What is the tone? A newborn is normally slightly flexed, a 6 month old can sit and control their head, the toddler can cruise
  • Are they normally interactive? A 2 month old should have a social smile, a toddler is interested in who enters the room
  • What are the vocalizations?

Work of breathing

  • Carefully observe the respiratory rate with the child’s clothes off
  • Look for nasal flaring, grunting, or retractions
  • Listen for abnormal respiratory sounds

Circulation (skin)

  • Look for pallor, cyanosis, or mottling
  • Touch the skin to feel warmth and look at the cap refill

The combination of the three aspects of the pediatric assessment triangle help rapidly categorize sick infants into a few separate categories: respiratory distress, respiratory failure, shock, CNS or metabolic problems, and cardiopulmonary failure. Honestly, though, for the initial minutes of resuscitation, the management of all these categories is very similar and the categories are not mutually exclusive.


Respiratory distress: The work of breathing is abnormal, but appearance and circulation are normal
Respiratory failure: There is abnormal work of breathing AND abnormal appearance
CNS/metabolic problems: The appearance is abnormal BUT work of breathing and circulation are normal
Shock: Circulation to the skin is abnormal, plus or minus abnormal appearance.
Cardiopulmonary failure: All three are abnormal

Immediate actions

Call for help. The initial resuscitation of infants is the purview of emergency medicine, but I want my pediatricians involved as soon as possible in case this turns out to be a cardiac or metabolic disorder I have never heard of.

Take out the Broselow tape and pediatric resuscitation cart. Hopefully this is out before the child arrives. For the first 10 minutes, all of my drug doses and equipment sizes are entirely based off the Broselow length. The Broselow tape may not be perfectly accurate, and I will get an accurate weight when there is time, but the Broselow is good enough to get things started.2

Get the child on the monitor and check the vital signs. Don’t memorize the appropriate vital signs. I am not even going to list normal vitals in this post. Have a reference you can refer to (preferably evidence based) and just check the normal ranges every time you see a sick child. (See Flemming 2011 in the references for more evidence based reference ranges than are normally taught in PALS.)3 It is a good habit to check the oxygen saturation and blood pressure in both a preductal extremity (right arm) and a postductal limb (one of the legs). Realistically, you will probably come back to this once things have settled.

Apply oxygen. It is reasonable to routinely apply oxygen to all sick neonates, but tailoring oxygen therapy to the respiratory exam and oxygen saturation makes more sense.

Obtain vascular access. Don’t wait too long for an IO. I give my best nurse 2 attempts at an IV, and after that I place an IO.4 If the child appears to be in shock (abnormal circulation to the skin, heart rate, or blood pressure), give a bolus of 10ml/kg normal saline and then reassess. Repeat the bolus as needed.

Check a sugar (and treat as necessary).4,5 2.5mmol/L (45mg/dL) is the cutoff.If low, give dextrose 0.25-0.5 grams/kg. Usually this is recommended as 2-4 mL/kg of D10W, but if you have a good IV in a large vein 1-2mL/kg of D25W is also reasonable.Then start a glucose infusion (D10W with 0.2NS at 1.5 times maintenance). If you are struggling with vascular access, you can start with glucagon (0.03mg/kg), but by now you should have an IO in place.

Get an ECG to rule out arrhythmia.4 This is a step we frequently forget in children, but arrhythmias are relatively common and easy to miss. I get an ECG early in every pediatric resuscitation. If the ECG is difficult to read and your suspicion of an arrhythmia is high (eg heart rate >220) consider a double speed ecg, or empiric adenosine.

Treat for infection. Any neonate in significant distress should be considered septic and empiric antibiotics started. I start empiric meningitis coverage:4

  • Cefotaxime 50mg/kg
  • Ampicillin 100mg/kg
  • +/- Vancomycin 15mg/kg if streptococcal disease (meningitis) is strongly suspected
  • Acyclovir 20mg/kg should be given if the is a vesicular rash or a maternal history of genital herpes

Any child this sick is also getting a lumbar puncture. Unless everything is running perfectly, and I can get the lumbar puncture done within 15 minutes, I am going to give empiric antibiotics before the LP, and the results of the tap will just have to be determined in that context. (If the CSF has been sterilized, I am thrilled).

Specific diagnoses

The initial steps of monitors, oxygen, vascular access, glucose, fluid resuscitation, ECG and empiric treatment of infection are a relatively standard, but essential, part of resuscitation, whether adult or pediatric. Once those immediate actions have been completed, it is time to address some of the more pediatric specific diagnoses.

Congenital heart disease

My first thought is: could this be congenital heart disease? This is the most likely and most dangerous alternative diagnosis that requires a different management plan. Congenital heart disease can present in a myriad of ways, but there are two major presentations that will require prostaglandin E1 (PGE1): cyanosis and shock.

The ideal management of congenital heart disease involves an urgent echocardiogram and pediatric cardiologist assessment. Realistically, that is not an option for the vast majority of us. Therefore, my approach is based on one simple principle: in a crashing infant, I would much rather start PGE1 and find out it wasn’t required, than vice versa. The final diagnosis can be determined once they are safely in a pediatric ICU. Practically speaking, this means that I will give PGE1 to any infant in shock who does not respond to a usual fluid bolus or in respiratory distress who does not rapidly improve with 100% oxygen.If PGE1 is started, there is a high risk of apnea, and the child should be intubated when it is safe to do so.

  • Prostaglandin E1 0.05-0.1 mcg/kg/min6

For central cyanosis, the differential diagnosis is respiratory or cardiac disease. To differentiate between the two, you can use the hyperoxia test. Classically this test is performed by getting an ABG, then putting the infant on 100% oxygen for 10 minutes, and then repeating the ABG. You are looking for the partial pressure of oxygen to rise above 150 mmHg.6 However, its is not very realistic to get 2 arterial stabs on these critically ill infants. In practice the hyperoxia test can be done using the oxygen saturation. After 10 minutes of 100% oxygen, if the oxygen saturation is not ⩾ 95% (some sources say 85%), the cyanosis is probably from a shunt and you should presume congenital heart disease and start PGE1.4,6

Surgical emergencies

Next I consider surgical emergencies, as these infants need to be transferred out of my emergency department as soon as possible. If there is any history of green (bilious) vomit it is time to transfer to a pediatric surgeon.

Seizures

Seizures can be incredibly subtle in infants. Observe the child closely for ocular, facial, or subtle repetitive movement. If the child appears to be having seizures, follow your usual status epilepticus algorithm, but with 2 important caveats:

  • Hyponatremia is the second most common cause of new seizure in children (after febrile seizures). Ask specifically about formula and feeding. The treatment is hypertonic saline (2-3 mL/kg of 3% NaCl over 1 hour).5
  • Pyridoxine dependent seizures are rare, but have significant morbidity if not treated. I give pyridoxine (100mg IV push) to any seizing infant who does not respond to benzodiazepines.7

Metabolic disease

Metabolic disease can be incredibly complicated. Luckily, the emergency management is relatively simple. Four blood tests will cover the common pathways of the hundreds of different inborn errors: ammonia, glucose, ketones, lactate.8 To treat essentially every metabolic disease, you need to make the child NPO and give glucose (D10W with 0.5normal saline at 1.5x maintenance).5 Finally, it is important to search for any other concurrent problems, as metabolic crises are often triggered by other illnesses, such as sepsis.8

Therefore, at least until the labs are back, I make sure all sick infants are NPO and that they get some sugar with their IV fluids. When the labs are back, get a pediatric specialist on the phone (or in the department if possible) to guide further management.

Lab testing. A common question for sick children is: what labs should I order? For the most part, you +just need labs we are all familiar with: CBC, electrolytes, renal function, liver function, venous blood gas, and blood cultures drawn before antibiotics are started.8 The extra labs to consider are those for metabolic disease: ammonia, lactate, and ketones.

There are many other labs that the pediatricians may ultimately be interested in. Some, especially for metabolic disorders, are only accurate before treatment is started. There is no way we can remember or think of everything the pediatrics team will want to order. However, it is very reasonable to draw off one extra red top tube with the initial blood work, so it can be stored in the lab and tested later if needed.5

Endocrine disease

Although I generally think of metabolic and endocrine disorders in a similar category, I list endocrine disease separately here for one reason: to remind myself to check the genitalia. An empiric dose of hydrocortisone should be given to any child with ambiguous genitalia. (Once the labs are back, the combination of hyponatremia and hyperkalemia should also make you consider congenital adrenal hyperplasia).5 I would also empirically treat for CAH in any neonate with shock not responsive to fluid resuscitation and my first line vasopressor. (Sending blood for CAH before giving steroids is important, but again, just drawing an extra red top tube can really help.) The treatment is hydrocortisone 25mg IV, followed by a dose based on surface area that the pediatrician can sort out.5

Non-accidental trauma

Fight your denial. The last thing that any of us wants to be thinking about when trying to resuscitate a sick infant is the possibility of non-accidental trauma. Make it part of your algorithm so you don’t forget.

Ongoing Resuscitation

Sick infants require frequent reassessment to judge response to therapy. Giving too little fluid to a septic child is clearly a mistake, but the possibility of congenital heart disease means that giving too much fluid could also be a disaster. Give small boluses at a time, assessing the response to therapy. If the child improved with 10ml/kg, the diagnosis is more likely to be sepsis, and I would continue to provide fluids. If the child seems to be getting worse with fluids, I would move quickly to vasopressors.

  • Epinephrine 0.01-0.1 mcg/kg/min

Review the differential diagnosis

These initial steps should get the patient resuscitated and empirically treated for the most common causes of neonatal distress. Unfortunately, the differential diagnosis of a sick infant is very large, so when things have settled down, it is time to pull out your peripheral brain and review all of THE MISFIT diagnoses to make sure you aren’t missing anything.

THE MISFITS First10EM crashing infant.png

Notes

Some important medication doses
epinephrine 0.01-0.1 mcg/kg/min
etomidate 0.3mg/kg
fentanyl 1-2/mcg/kg/min
ketamine 1-2mg/kg IV
morphine 0.1mg/kg
phenylephrine 10-20mcg/kg bolus, 2-5mcg/kg/min
Prostaglandin E1 0.05-0.1 mcg/kg/min

There are 6 classic signs that make a murmur more likely to be pathologic. I doubt I will ever identify any of them: 6

  • Pansystolic, continuous, diastolic
  • Grade of 3/6 or greater murmur
  • Point of maximal intensity at left upper sternal border
  • Harsh quality
  • Early midsystolic click
  • Abnormal second heart sound6

Some important diagnoses to consider in addition to THE MISFITS6,8 are botulism, meningitis/ encephalitis, and acute hydrocephalus.

Having one diagnosis does not preclude another diagnosis. In fact, some diagnoses make a second diagnosis more likely. For example, children with inborn errors of metabolism can also get septic very quickly when faced with infection.

Other FOAMed Resources

The undifferentiated sick infant on Pediatric Emergency Playbook

Neonatal resuscitation on EMin5:

PV Card: Pediatric assessment triangle on ALiEM

The Toxic Neonate on ERCAST

Pyridoxine dependent seizures and Neonatal Seizures – not a benzo deficiency on Pediatric EM Morsels

References

  1. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatric emergency care. 26(4):312-5. 2010. PMID: 20386420
  2. Young KD, Korotzer NC. Weight Estimation Methods in Children: A Systematic Review. Annals of emergency medicine. 68(4):441-451.e10. 2016. PMID: 27105839
  3. Fleming S, Thompson M, Stevens R. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet (London, England). 377(9770):1011-8. 2011. PMID: 21411136 [free full text]
  4. Brown L et al. The Critically Ill Or Comatose Infant: An Organized Approach. Emergency Medicine Practice. 4(10):1-24. 2002.
  5. Claudius I, Fluharty C, Boles R. The emergency department approach to newborn and childhood metabolic crisis. Emergency medicine clinics of North America. 23(3):843-83, x. 2005. PMID: 15982549
  6. Strobel AM, Lu le N. The Critically Ill Infant with Congenital Heart Disease. Emergency medicine clinics of North America. 33(3):501-18. 2015. PMID: 26226862
  7. Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatric neurology. 38(6):377-90. 2008. PMID: 18486818
  8. Long D, Long B, Koyfman A. Inborn errors of metabolism: an emergency medicine approach. The American journal of emergency medicine. 34(2):317-8. 2016. PMID: 26643160

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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