Morning Report: 8/31/2012

Today’s Morning Report comes from our Save of the Month recipient Dr. Melton!

“Please evaluate for projectile vomiting”

A 17 day old baby boy with no significant birth history is sent in by his pediatrician for evaluation of projectile vomiting. Mom states that the vomiting began 4 days prior to presentation. Mom reports a great appetite but multiple episodes of vomiting that have become more forceful.

Pyloric Stenosis and Metabolic Derangements

Pyloric stenosis is caused by an increase in the musculature of the pylorus. Seen

in about 1 in 1000 live births. More common in first born males. Seen between

2 and 8 weeks of life (median, 5 weeks).

Symptoms:

Non-bilious projectile vomiting
Dehydration
Metabolic derangements: hyponatremia, hypokalemic, hypochloremic metabolic alkalosis

Exam:

General appearance on a spectrum from well appearing to lethargic
May find “olive shaped mass” in the RUQ.
May see abdominal peristaltic waves.
Evidence of dehydration: poor skin turgor, sunken eyes, sunken fontanelle

Everything is chaos: mom is crying, baby looks terrible, the nurse yells the baby is bradycardic! You assess disagree with the nurse but note that the baby has become more lethargic:

ABCs
IV, O2, monitor, fingerstick, Labs, ABG, UA, UCx, CXR, temperature
Resuscitation

Initial treatment:

20 cc/kg bolus NS
Monitor UOP

Hypoglycemia and Pediatrics

Plasma glucose level of <45 milligrams/dL in any symptomatic patient or <35 milligrams/dL in an asymptomatic neonate.

Hypoglycemia in the neonate or infant may result from inadequate oral intake, excess insulin, deficient hyperglycemic hormones, disorders of metabolism, acidurias, or systemic infection (sepsis). Infants of diabetic mothers are at risk for hypoglycemia due to excess fetal insulin level, premature infants or those small for gestational age are at risk due to inadequate glycogen stores.

The dose of dextrose is 0.5 to 1.0 gram/kg regardless of the route of administration. Newborns should receive 5 mL/kg of 10% dextrose (D10), whereas infants and children should receive 2 mL/kg of 25% dextrose.

The younger guys receive the less concentrated dextrose in order to prevent sclerosis of the peripheral veins.

Provide maintenance dextrose at a rate of 6 to 8 milligrams/kg/min with D10, which is 1.5 times the normal maintenance rate for infants and children.

Age	Dextrose bolus	Dextrose Maintenance	Other Modalities
Neonate	D10 5 mL/kg PO/NG/IV/IO	6 mL/kg/h D10	Glucagon, 0.3 milligram/kg IM Hydrocortisone, 25 grams PO/IM/IV/IO
Infant	D10 5 mL/kg PO/NG/IV/IO or D25 2 mL/kg	6 mL/kg/h D10	Glucagon, 0.3 milligram/kg IM Hydrocortisone, 25 grams PO/IM/IV/IO
Child	D25 2 mL/kg PO/NG/IV/IO	6 mL/kg/h D10 for the first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg	Glucagon, 0.3 milligram/kg/IM Hydrocortisone, 50 grams PO/IM/IV/IO
Adolescent	—	6 mL/kg/h D10 for the first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg	Glucagon, 0.3 milligram/kg IM Hydrocortisone, 100 grams PO/IM/IV/IO