October 31, 2019
Focus | Dehydration, Vomiting & Electrolytes
Thank you Dr. Todd Wylie for contributing to this week’s PEARL! 
Case Scenario:
EMS called to transport a one-year-old to the ED for vomiting and profuse diarrhea for 2 days. What additional specific questions should you ask?:
Fever subjective fever, no thermometer at home

Intake (feeding) and output (urination, stools) refusing to eat for 1 day but taking some oral liquids, decreased number of wet diapers

  • BE SPECIFIC: vomited how many times, time of last emesis, how many wet diapers today and time of last one, how many ounces of fluid and what type?

Activity level decreased activity, sleeping more than usual

Basics allergies, immunizations, PMH-including birth and social, daycare attendance, anyone at home sick?

  • NKDA, shots UTD, full term delivery, no recent illnesses, mother had a “virus” last week

EMS glucose = 70

Vital signs upon arrival to ED

Temp. – 100.5° F; HR – 148; BP – 89/57; Weight – 9.3 kg; Pulse Oximetry 97%

Brief exam fussy but consolable, tacky mucous membranes, capillary refill= 5 seconds, eyes sunken per mother
Diagnosis: No Brainer

DEHYDRATION– What %?
ANSWER: 6-9%
Key Points:
  • Common pediatric clinical presentation
  • Gastroenteritis most common cause of dehydration worldwide

In the United States:
  • 1.5 million outpatient visits annually
  • 200,000 annual hospitalizations
  • Approximately 300 deaths annually

Factors contributing to dehydration in small children and infants:
  • Larger surface area to body weight ratio
  • Greater resting metabolic rates
  • Higher rate of fluid turnover (roughly double that in adults)
  • Limited communication and ability to access fluids

Etiology of fluid loss:
  • Vomiting or diarrhea
  • Bleeding
  • Insensible losses, for example diabetes insipidus

Electrolyte and lab abnormalities - No single laboratory study identifies degree of dehydration

In moderate to severe dehydration or if placing IV, consider ordering:
  • Serum glucose, bicarbonate, potassium, and sodium
  • Blood urea nitrogen (BUN) and creatinine
  • Urine specific gravity or urinalysis
  • Remember some pediatric lab values vary by age
  • know the normal ranges for your lab
Table from our Pediatric ABC's and More Poster
Serum bicarbonate < 17 mEq/L somewhat predictive of dehydration; < 13mEq/L associated with significant dehydration

Urine specific gravity Immature concentrating ability of kidneys in neonates and young infants leads to poor correlation between urine specific gravity and degree of dehydration

Fluids: For severe dehydration and most moderate dehydration, give 20 ml/kg IV fluid boluses of NS or LR with reevaluation after each bolus
  • Consider caution or starting with only 10 ml/kg in the following circumstances:
  • Diabetic ketoacidosis
  • Suspected Congenital heart disease

After hydration improves calculate maintenance fluids by using length or weight based system or the formula below:
  • 4 ml/kg/hour for the first 10 kgs of body weight plus
  • 2 ml/kg/hour for the next 10 kgs of body weight plus
  • 1 ml/kg/hour for every kg > 20 kgs
  • For example, a 30 kg child would have a maintenance rate of 70 ml/kg/hr
 
Ondansetron (Zofran)
  • Relatively safe and effective for acute gastroenteritis
  • Facilitates oral rehydration
  • Reduces hospital admission rate (gastroenteritis)
  • It treats nausea and vomiting... not the underlying cause!

Dosing:
  • 2 mg ODT if < 15 kg and 4 mg ODT if > 15 kg; if over 30 kg can give adult dose of 8 mg
  • IV- 0.15 mg/kg, max 4 mg
Pediatric News
1) According to a new report, an estimated 339,000 Florida children were uninsured in 2018. This represents an increase of approximately 18% since 2016. Overall, Florida has the seventh highest rate of uninsured children in the nation. Our EDs and EMS agencies are the safety net! Read More

2) Prevent Child Injury has posted a new toolkit on stair safety. The messaging reminds parents and caregivers to protect children by carrying only the child when taking them up or down stairs, leaving one hand free to hold the railing. Toolkit materials include a customizable press release, a newsletter/blog article, social media posts, graphics, and a Pinterest board.  Read More

3) Florida PEDReady and Florida EMSC have a significant focus on rural EMS . Read this news report to find out why rural EMS is so important: What if you call 911 and no one comes? Inside the collapse of America's emergency medical services.
PEDReady Champions of the Week
Thanks to the EMLRC/FCEP team for supporting the PEDReady program and pediatric emergency education! Samantha League designs and disseminates our weekly newsletter and Melissa Keahey is the staff liaison for FCEP's pediatric committee.
Upcoming Pediatric Emergency Events
Webinar: Using Fatality Review to Understand Disasters
October 31, 2019 at 2:00 pm
Hosted by: EMSC IIC

This webinar will focus on common definitions of a disaster, best practices in fatality reviews when a disaster occurs, and available resources for children. Examples of how CDR and FIMR teams have used fatality review to gain a deeper understanding of disaster events will be shared. Changes to the National Fatality Review-Case Reporting System will also be discussed.
Handtevy Pre-Hospital Pediatric Instructor Course
November 5, 2019 | 8:00-5:00 pm | Pensacola, FL
Hosted by: Handtevy Pediatric Emergency Standards

This course uses the basic tenets of ACLS training as its foundation while focusing on the skills needed to rapidly and accurately treat sick and injured pediatric patients. It is intended to be used with the Handtevy Pediatric System.
NAEMT Principles of Ethics & Personal Leadership Course
November 6-7, 2019 | 8:30-4:30 pm | St. Augustine, FL
Hosted by: TraumaOne Flight Services

This 2-day (16-hour) course provides EMS and Mobile Healthcare (MHC) practitioners with the skills to effectively interact with patients and their families, other medical personnel, co-workers, supervisors and community residents. This course is appropriate for EMTs, paramedics, other MHC practitioners and emergency responders. Upon successful completion, students receive a certificate, wallet card
(good for 4 years) and 16 hours of CAPCE credit.

Pediatric Care After Resuscitation (PCAR) Course
Dec 2-3, 2019 | Jacksonville, FL

The mission of TCAR (Trauma Care After Resuscitation) Education Programs is to expand the knowledge base and clinical reasoning skills of nurses who work with injured patients anywhere along the trauma continuum of care, particularly in the post-resuscitation phase. 
Thanks for being a Pediatric Champion!
The Florida PEDReady Program
pedready@jax.ufl.edu | 904-244-8617