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IMMEDIATE MANAGEMENT OF SERIOUS & LIFE-THREATENING PROBLEMS

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Gastrointestinal (GI) emergencies in infants and children often present similarly. Key historical facts alert the emergency physician to these surgical conditions that require immediate interventions.

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PERFORM A BRIEF EXAMINATION

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Determine stability of the patient.

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  • Develop a general impression: Is the infant or child ill appearing?

  • Determine general appearance, work of breathing, and circulation to the skin:

    • General appearance includes tone, interaction, consolability, ability to gaze upon a face, and quality of cry or speech.

    • Work of breathing includes airway—is it patent and maintainable? And breathing—quality of airflow, associated sounds, use of accessory muscles, nasal flaring, and presence of grunting respirations?

    • Circulation to the skin—is the skin pale, mottled, or cyanotic?

  • Obtain vital signs including oxygen saturation and blood pressure.

  • Assess the abdomen: assess for signs and symptoms of an acute abdomen:

    • Abdominal skin color—pink, gray, blue.

    • Appearance—scaphoid, protuberant.

    • Assess for tenderness, guarding, and rigidity.

  • If instability is suspected, begin resuscitation immediately per standard PALS guidelines.

  • Treat shock:

    • Apply 100% oxygen via nonrebreathing mask or if the airway is not maintainable, prepare for rapid sequence intubation.

    • Insert two peripheral intravenous (IV) lines if possible, or an interosseous (IO) line to initiate therapy while definitive IV access is obtained.

    • Give crystalloid fluid bolus at 20 mL/kg IV or IO rapidly and repeat up to 3-4 boluses unless rales, respiratory distress, or hepatomegaly develops.

    • Obtain blood samples for point-of-care glucose, venous blood gas (VBG) or arterial blood gas (ABG), lactate, ionized calcium, a complete blood cell count (CBC) with differential, blood culture, serum electrolytes, tests of renal and liver function, amylase, lipase, type and crossmatch for packed red blood cells (PRBC), urine analysis (including dipstick chemical and microscopic analysis), and urine culture.

    • Treat hypoglycemia with dextrose (0.5-1 g/kg IV or IO). Use D25W (2-4 mL/kg) in children and adolescents; D10W (5-10 mL/kg) in infants and young children.

    • For fluid unresponsive shock, begin vasoactive drug therapy and titrate to correct poor perfusion or hypotension.

      • Normotensive: begin dopamine (5-20 mcg/kg per min IV/IO).

      • Hypotensive vasodilated (warm) shock: begin norepinephrine (0.1-2 mcg/kg per min IV/IO).

      • Hypotensive vasoconstricted (cold) shock: begin epinephrine (0.1-1 mcg/kg per min IV/IO).

    • Transfuse with PRBC to maintain hemoglobin (Hb > 10 g/dL).

    • Initiate antimicrobial emergency as soon as an intra-abdominal emergency is likely. Current recommendations for community-acquired infections in the pediatric patient are listed in Table 36–1.

    • Insert a nasogastric (NG) tube in infants or children with persistent vomiting, especially if vomitus is feculent or bilious; this strongly suggests an intestinal obstruction.

    • Consult surgery. Infants and children with abdominal pain or an abdominal emergency may require immediate surgical evaluation. Infants with bilious emesis, a rigid abdomen, or shock and a suspected acute abdominal process, consult surgery immediately.

    • Keep the child nothing by mouth (NPO) pending surgical evaluation.

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Table 36–1.Agents and regimens that may be used for the ...

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