A6 Admission Checklist .com



15 month old male brought in to ED by mom for tachypnea and decreased PO intake. He has had cough, runny nose and fever (Tmax 101) for past 2 days and today the child has refused to eat, more sleepy, and breathing fast, so mom came to ED. Sick contact at home, older sibling getting over URI. No recent travel. Vaccines UTD.

PMHx: born FT, no issues

PSHx: none

FHx: not significant

VS: T 38.4, HR 182, RR 40, BP: 90/50, O2 sat 98% RA

Gen: Tired appearing child

HEENT: normocephalic, atraumatic. PERRL, EOMI, TM clear non-erythematous, dry mucuous membranes

CV: S1S2 nml, no murmur, tachycardic, cap refill 2 seconds

Lungs: RR 40, mild subcostal retraction, CTA B/L, no crackles, no wheezing

Abd: soft, NT, ND

Ext: FROM, no deformities

Skin: no rash, dry, intact

Neuro: No focal neurological deficits

Wt: 8kg

Differentials?

- URI

- Viral syndrome

- Bronchiolitis

- Dehydration

- PNA

Intervention:

- ABCs

- Tylenol/motrin

- Fluids: 20mL/kg bolus (normal saline)

After NS bolus:

Patient still tachycardic to 180, RR 46 with crackles B/L, delayed cap refill (4-5sec). BP 92/46 ( compensated cardiogenic shock

What other PE exam would you do? Feel for liver ( hepatomegaly

CXR: shows cardiomegaly (will provide CXR)

Intervention:

- ECHO

- EKG

- Give supplemental O2 (increasing O2 supply)

- Labs: CBC, viral panel, cmp, troponin; BNP (to assess for cardiac failure)

- Call PICU and cardio

- Consider Lasix (fluid overload)

- Control fever (trying to reduce myocardial work)

- Fluids in cardiogenic shock ( still give fluids but in smaller increments: 5-10mL/kg

Ionotropes:

- Dopamine-Low dose increases renal and splanchnic blood flow, high dose increases HR and SVR.

- The ones in Red below are the ones you really want in Cardiogenic Shock as they boost contractility without increasing HR or afterload (they both will, in fact, reduce afterload). The one note about Milrinone is that it can drop BP a lot so if you’re already hypotensive, you may want to choose something else or add Epi along with it to support the BP.

- Dobutamine- Increases contractility, may reduce SVR, PVR.

- Milrinone-Inotropy and venodilation. Improve contractility and decrease after load

- Epinephrine- Increases HR,SVR and contractility. End point-adequate BP, acceptable tachycardia

- Norepinephrine-0.05-1.0mcg/kg/min. Increases SVR

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