The Harriet Lane Handbook: The Johns Hopkins Hospital [22 ed.] 0323674070, 9780323674072

Table of contents :
Cover
PEDIATRIC PARAMETERS AND EQUIPMENT
THE HARRIET LANE HANDBOOK
Copyright
Dedication
Preface
Content
1 - Emergency and Critical Care Management
I. APPROACH TO THE UNRESPONSIVE CHILD
A. Circulation1-­3,5-­10
B. Airway and Breathing1,7,11-­17
II. MANAGEMENT OF SHOCK3,5,7,11
A. Definition: Physiologic state characterized by inadequate oxygen and nutrient delivery to meet tissue demands
B. Etiology: Categorized into four basic types
C. Management
III. MANAGEMENT OF COMMON EMERGENCIES
A. Anaphylaxis18
B. Upper Airway Obstruction
C. Status Asthmaticus24-­28
D. Pulmonary Hypertensive Crisis11,29
E. Hypertensive Crisis11,30
F. Hypercyanotic Crisis (“Tet spell”)20,31
G. Altered Level of Consciousness20,32
H. Status Epilepticus33-­34
I. Increased Intracranial Pressure35-­37
IV. CRITICAL CARE REFERENCE DATA
REFERENCES
REFERENCES
2 - Traumatic Injuries
I. COMPONENTS OF THE TRAUMA ASSESSMENT
A. Primary Survey
B. Secondary Survey (Fig. 2.1)
II. HEAD AND NECK TRAUMA
A. Head Imaging
B. Cervical Spine and Neck Imaging
C. Specific Imaging Studies
III. CONCUSSION
A. Concussion Evaluation
B. Return-­to-­school and Return-­to-­play Guidelines (Table 2.1)
IV. THORACIC AND ABDOMINAL TRAUMA EVALUATION18
A. Physical Exam
B. Laboratory Studies to Consider
C. Imaging Studies to Consider
V. ORTHOPEDIC/LONG BONE TRAUMA
A. Physical Exam
B. Imaging
C. Fractures Unique to Children
D. Fractures Requiring Urgent Orthopedic Surgeon Consultation
E. Fractures That Are Appropriate to Manage Acutely With Outpatient Referral to Orthopedics (Table 2.2)
VI. DENTAL TRAUMA
A. Components of a Tooth (Fig. 2.3)
B. Differences Between Primary and Permanent Teeth (Fig. 2.4)
C. Dental Injuries
D. Anticipatory Guidance Following Dental Trauma
VII. OPHTHALMOLOGIC TRAUMA26
A. Chemical Injury to the Eye18
B. Ruptured Globe
C. Corneal Abrasion
D. Superglue to the Eye28
E. Eyelid Laceration
F. Orbital Floor Fractures
G. Other Instances Requiring Ophthalmologic Consultation
VIII. ANIMAL BITES
A. Wounds at the Highest Risk of Infection
B. Decision to Suture
C. Antibiotic Prophylaxis29
D. Tetanus Postexposure Prophylaxis: See Chapter 16
E. Rabies Postexposure Prophylaxis: See Chapter 16
IX. BURNS
A. Burns That Should Prompt Consideration of Elective Intubation
B. Estimation of the Surface Area of Burns
C. Estimation of the Depth of Burns (Table 2.5)
D. Fluid Resuscitation in Patients With Burns (Fig. 2.6)
E. Indications for Transfer to a Burn Center30
F. Management of Burns Not Referred to Burn Center
G. Other Special Considerations With Burns
H. Other Types of Burns
X. NONACCIDENTAL TRAUMA
A. Physical Abuse
B. Sexual Abuse
XI. RESOURCES
A. Acute Concussion Evaluation Forms for Emergency Department and Physician/Clinician Office: https://www.cdc.gov/headsup/provid...
B. Acute Concussion Evaluation Care Plans for Work and School: https://www.cdc.gov/headsup/providers/discharge-­materials.html
REFERENCES
REFERENCES
Color Plates
3 - Toxicology
I. INITIAL EVALUATION
A. History
B. Workup and Laboratory Investigation
C. Clinical Diagnostic Aids (Table EC 3.A)
II. TOXIDROMES
III. INGESTIONS AND ANTIDOTES
A. Decontamination
B. Enhanced Removal
C. Other Considerations
IV. ACETAMINOPHEN OVERDOSE7
A. Four Phases of Intoxication
B. Treatment Criteria
C. Antidote: N-­Acetylcysteine (See Formulary)
V. LEAD POISONING8
A. Definition
B. Sources of Exposure
C. Overview of Symptoms by Blood Lead Level
D. Management
VI. WEB RESOURCES
REFERENCES
REFERENCES
4 - Procedures
I. General Guidelines
A. Consent
B. Risks
C. Documentation
D. Attending to the Needs of a Fearful Child
II. Ultrasound for Procedures
A. Introduction to Ultrasound
B. Ultrasound Basics
III. Neurologic Procedures: Lumbar Puncture2,3
A. Indications
B. Complications
C. Cautions and Contraindications
D. Procedure
E. A video on lumbar punctures is available on the New England Journal of Medicine’s website
IV. Otolaryngologic Procedures
A. Cerumen Impaction Removal4,5
B. Foreign Body Removal from Ear6
C. Foreign Body Removal from Nose6,7
D. Management of Epistaxis6,8
V. Cardiovascular Procedures
A. Vagal Maneuvers for Supraventricular Tachycardia (SVT)9,10,11
B. Heelstick and Fingerstick12
C. Peripheral Intravenous Access
D. External Jugular Puncture and Catheterization (see Section XI, Online Content)
E. Radial Artery Puncture and Catheterization2,3
F. Posterior Tibial and Dorsalis Pedis Artery Puncture
G.Intraosseous (IO) Access2,3 (Fig. 4. 4)
H. Umbilical Artery and Umbilical Vein Catheterization2
VI. Pulmonary Procedures
A. Use of Metered-­Dose Inhalers and Spacer6
B. Needle Cricothyrotomy6,14
C. Needle Thoracostomy2,15
VII. Gastrointestinal Procedures
A. Nasogastric Tube Placement6,16
B. Gastrostomy Tube Replacement6,17
VIII. Genitourinary Procedures
A. Urinary Bladder Catheterization3,6,18
B. Suprapubic Bladder Aspiration2
IX. Musculoskeletal Procedures
A. Basic Splinting2
B.Selected Splints and Indications (Fig. 4. 8)
C. Radial Head Subluxation (Nursemaid’s Elbow) Reduction19
D. Finger/Toe Dislocation Reduction2
E. Knee Arthrocentesis2
F. Hematoma Blocks20
X. Skin/Dermatologic Procedures
A. Immunization and Medication Administration3
B. Basic Laceration Repair2
C. Incision and Drainage (I&D) of Abscess2
D. Soft Tissue Aspiration25
E. Tuberculin Skin Test Placement26
F. Tick Removal27
References
XI. Online Content
A. Ultrasound-­Guided Lumbar Puncture
B. External Jugular Puncture and Catheterization2
References
5 - Adolescent Medicine
I. ADOLESCENT HEALTH MAINTENANCE
II. SEXUAL HEALTH
REFERENCES
6 - Analgesia and Procedural Sedation
I. Pain Assessment
A. Infant1
B. Preschooler
C. School-­Age and Adolescent
II. Analgesics1
A. Safety
B. Nonopioid Analgesics
C.Opioids (Table 6. 2)
D. Local Anesthetics9–12
E. Nonpharmacologic Measures of Pain Relief13,14
III. Patient-­Controlled Analgesia (PCA)
A. Definition
B. Indications
C. Routes of Administration
IVor epidural
D.Agents (Table 6. 5)
E. Adjuvants
F. Side Effects of Opioid Patient-­Controlled Analgesia
IV. Opioid Tapering
A. Indications
B. Withdrawal
C. Recommendations for Tapering
D. Examples
V. Procedural Sedation1,9–12,19–21
A. Definitions
B. Preparation
C. Monitoring
D. Pharmacologic Agents
E. Discharge Criteria20
VI. Web Resources
References
References
7 - Cardiology
I. Physical Examination
A. Heart Rate
B. Blood Pressure
C. Heart Sounds
D. Systolic and Diastolic Sounds
E. Murmurs4
II. Electrocardiography
A. Basic Electrocardiography Principles
B. ECG Abnormalities
C.ECG Findings Secondary to Electrolyte Disturbances, Medications, and Systemic Illnesses (Table 7. 10)7,9
D. Long QT
E. Hyperkalemia
III. Congenital Heart Disease
A. Pulse Oximetry Screening for Critical Congenital Heart Disease
B.Common Syndromes Associated with Cardiac Lesions (Table 7. 11)
C. Acyanotic Lesions (Table 7.12)
D.Cyanotic Lesions (Table 7. 13)
IV. Acquired Heart Disease
A.Myocardial Infarction (MI) in Children (Box 7.4; Fig. 7. 8)
B. Endocarditis
C. Bacterial Endocarditis Prophylaxis
D. Myocardial Disease
E. Pericardial Disease
F. Kawasaki Disease19
G. Rheumatic Heart Disease
V. Imaging
VI. Procedures
A. Cardiac Surgery (Fig. 7.11, Table 7.14)
B. Cardiac Catheterization13,14
VII. Common Cardiac Complaints
A. Non-­Traumatic Chest Pain20
B. Syncope21
VIII. Exercise Recommendations for Patients With Congenital Heart Disease
IX. Lipid Monitoring Recommendations
A. Screening of Children and Adolescents23
B. Goals for Lipid Levels in Childhood23
X. Cardiovascular Screening
A. Sports24
B. Attention–Deficit/Hyperactivity Disorder (ADHD)27
XI. Web Resources
References
References
8 - Dermatology
I. Evaluation and Clinical Descriptions of Skin Findings
A. Primary Skin Lesions
B. Secondary Skin Lesions
C. Shapes and Arrangements
II. Vascular Anomalies1
A. Vascular Tumors
B. Vascular Malformations
III. Infections
A. Viral
B. Parasitic
C.Fungal (Figs. 8.12–8. 16, Color Plates)
D. Bacterial
IV.Hair Loss (Figs. 8.18–8. 20, Color Plates)
A.Telogen Effluvium (see Fig. 8. 18, Color Plates)
B.Alopecia Areata (see Fig. 8. 19, Color Plates)
C.Traction Alopecia (see Fig. 8. 20, Color Plates)
D. Trichotillomania and Hair Pulling
V. Acne Vulgaris
A. Pathogenetic Factors
B. Risk Factors
C. Clinical Presentation
D.Treatment14–16 (Table 8. 2)
VI.Common Neonatal Dermatologic Conditions (Fig. 8.21; Figs. 8.22–8. 30, Color Plates)
A.Erythema Toxicum Neonatorum (see Fig. 8. 22, Color Plates)
B.Transient Neonatal Pustular Melanosis (see Figs. 8.23–8. 24, Color Plates)
C.Miliaria (Heat Rash) (see Fig. 8. 25, Color Plates)
D.Milia (see Fig. 8. 26, Color Plates)
E.Neonatal Acne (see Fig. 8. 27, Color Plates)
F.Seborrheic Dermatitis (Cradle Cap) (see Figs. 8.28–8. 29, Color Plates)
G. Congenital Dermal Melanocytosis (formerly known as Mongolian Spots)
H.Diaper Dermatitis19 (see Fig. 8. 30, Color Plates)
VII.Autoimmune and Allergic Dermatologic Conditions (Figs. 8.31–8. 38, Color Plates)
A. Contact Dermatitis
B.Atopic Dermatitis (Eczema) (See Figs. 8.33–8. 37, Color Plates)
C.Papular Urticaria (See Fig. 8. 38, Color Plates)
D. Stevens-­Johnson Syndrome and Toxic Epidermal Necrolysis
E. Autoimmune Bullous Diseases: See Section X, Online Content
VIII. Nail Disorders28: see Section X, Online Content
IX. Disorders of Pigmentation: see Section X, Online Content
REFERENCES
X. Online Content
A. Autoimmune and Allergic Lesions
B. Nail Disorders28
C. Disorders of Pigmentation30
References
Color Plates
9 - Development, Behavior, and Developmental Disability
I. Developmental Definitions1,2
A. Developmental Streams
B. Developmental Quotient (DQ)
C. Abnormal Development
II. Guidelines for Normal Development and Behavior
A.Developmental Milestones (Table 9. 1)
B.Age-­Appropriate Behavioral Issues in Infancy and Early Childhood: See Table 9. 2
III. Developmental Screening and Evaluation of Developmental Disorders
A. Developmental Surveillance and Screening Guidelines
B.Commonly Used Developmental Screening and Assessment Tools: See Table 9. 3
C.Identification of Developmental “Red Flags”: See Table 9. 4
D. Evaluation of Abnormal Development
IV. Specific Disorders of Development
A. Overview
B. Intellectual Disability
C. Communication Disorders
D. Learning Disabilities4
E. Cerebral Palsy (CP)
F. Autism Spectrum Disorders
G. Attention Deficit/Hyperactivity Disorder: See Chapter 24
V. Longitudinal Care of Children With Developmental Disorders and Disabilities
A. Interdisciplinary Involvement
B. Relevant Laws and Regulation
VI. Transitions From Pediatric to Adult Care for Youth With Developmental Disabilities
A. The Need
B. The Role of the Pediatric Provider
C. Transition Domains
VII. Web Resources
References
References
10 - Endocrinology
I. Diabetes
A. Diagnosis of Diabetes Mellitus1-­3
B. Definition of Increased Risk (Prediabetes)
C. Interpreting Hemoglobin A1c1,2
D. Etiology: Distinguishing Between Types of Diabetes Mellitus1,2
E. Screening for Type 2 Diabetes Mellitus1,6
F. Additional Testing in New-­Onset Diabetes
G. Management of Diabetes6-­8
H. Diabetes-­Related Devices9,10
I. Monitoring6,8,9,11
J. Diabetic Emergencies12,13
II. Thyroid Gland14-­16
A. Thyroid Tests15,17,18
B. Hypothyroidism
C. Hyperthyroidism
III. Parathyroid Gland and Vitamin D22-­24
A. Parathyroid Hormone Function
B. Distinguishing Between Abnormalities Related to Parathyroid Hormone and Vitamin D
C. Vitamin D Supplementation
IV. Adrenal Gland25-­29
A. Adrenal Insufficiency
B. Adrenal Cortex Hormone Excess29
C. Adrenal Medulla Hormone Excess: Pheochromocytoma32-­34
V. Disorders of So dium and Water Regulation35
A.Distinguishing Between Disorders of Sodium and Water Regulation: See Table 10. 16
B. Correction of Hypo-­ and Hypernatremia: See Chapter 11
C. Conducting a Water Deprivation Test
D.Interpretation of Water Deprivation Test Results: See Table 10. 17
E. Differentiating Between Central Versus Nephrogenic Causes of Diabetes Insipidus
VI. Growth35-­37
A. Assessing Height
B. Short Stature
VII. Sexual Development39-­45
A. Puberty
B. Lab Evaluation
C. Polycystic Ovarian Syndrome48
D. Ambiguous Genitalia49
E. Cryptorchidism50
VIII. Neonatal Hypoglycemia Evaluation51,52
A. Definition
B. Treatment Goals
C. Management
D. Further Work-­up
E. Interpretation of Results
F. Hyperinsulinemia
IX. Additional Normal Values
X. Web Resources
A.Children with Diabetes (www.childrenwithdiabetes. com)
B.American Diabetes Association (www.diabetes. org)
C.International Society for Pediatric and Adolescent Diabetes (www.ispad. org)
D.Pediatric Endocrine Society (www.lwpes. org)
E.The Endocrine Society (www.endocrine. org)
F.American Thyroid Association (www.thyroid. org)
REFERENCES
A complete list of references can be found online at www.expertconsult.com
References
11 - Fluids and Electrolytes
I. Introduction
II. Fluid Resuscitation
A. Calculating Maintenance Fluid Volume
B. Calculating Fluid Loss
C. Maintenance Fluid Choice in Hospitalized Children
D. Volume Replacement Strategy7,12,13
III. Electrolyte Management
A. Serum Osmolality and Tonicity2,7,14
B. Sodium
C. Potassium
D. Calcium
E. Magnesium
F. Phosphate
IV. Algorithm for Evaluating Acid-­Base Disturbances7,17,18
A. Determine the pH
B. Calculate the anion gap (AG)
C. Calculate the delta gap (DG)20
D. Calculate the osmolal gap
E.Calculate expected compensatory response: (Table 11. 14)
F. Determine the likely etiology
G.If there is not appropriate compensation, consider an additional acid-­base derangement (Fig. 11. 2)
References
A complete list of references can be found online at www.expertconsult.com
References
12 - Gastroenterology
I. Gastrointestinal Emergencies
A. Gastrointestinal Bleeding
B. Acute Abdomen2
II. Conditions of the Gastrointestinal Tract
A. Vomiting
B. Gastrointestinal Reflux Disease3
C. Eosinophilic Esophagitis6,7
D. Celiac Disease9
E. Inflammatory Bowel Disease (EoE)10,11
F. Constipation17
G. Diarrhea18
III. Conditions of the Liver
A.Liver Laboratory Studies: Table 12. 6
B. Acute Liver Failure24,25
C. Nonalcoholic Fatty Liver Disease26
D. Hyperbilirubinemia27-­29
IV. Pancreatitis30-­32
A. Acute Pancreatitis33
B. Chronic Pancreatitis34,35
V. Web Resources
REFERENCES
References
13 - Genetics: Metabolism and Dysmorphology
I. METABOLISM1-­7
A. Clinical Presentation of Metabolic Disease (Box 13.1)
B. Evaluation
C. Categories of Metabolic Disorders
D. Management of Metabolic Crisis
E. Commonly Used Medications
II. NEWBORN METABOLIC SCREENING7
A. Timing
14 - Hematology
I. Anemia
A. Screening for Anemia
B. Definition of Anemia
C. Causes of Anemia
D. Evaluation of Anemia
E. Management of Anemia
II. Neutropenia
A. Definition of Neutropenia
B. Causes and Evaluation of Neutropenia11
C. Management of Neutropenia
III. Thrombocytopenia and Impaired Platelet Function
A. Definition of Thrombocytopenia
B. Bleeding Risk with Thrombocytopenia
C. Evaluation of Thrombocytopenia15,16
D. Causes of Thrombocytopenia and Impaired Platelet Function
E. Management of Thrombocytopenia
IV. Coagulation
A. Evaluation of Coagulation and Platelet Function
B. Definition of Abnormal Coagulation
C. Causes and Management of Coagulopathy
D. Causes of Hypercoagulability
E. Thrombus Management
V. Blood Component Replacement
A.Calculating Estimated Blood Volume (Table 14. 16)
C.Diagnosis and Management of Transfusion Reactions (Table 14. 18)
VI. Additional Resources
A.Medications to avoid with G6PD Deficiency: http://g6pddeficiency. org/wp/living-­with-­g6pd-­deficiency/drugs-­to-­avoid-­list
REFERENCES
VII. Online Content
A. Specific PRBC Types
B. Directed Donor Transfusions
References
15 - Immunology and Allergy
I. Allergic Rhinitis1–6
A. Epidemiology
B. Diagnosis
C. Differential Diagnosis
D. Treatment
II. Food Allergy7–12
A. Epidemiology
B. Manifestations of Food Allergy
C.Diagnosis of Food Allergy (Fig. 15. 1)
D. Differential Diagnosis
E. Treatment
F. Natural History
III. Drug Allergy13,14
A. Definition
B. Diagnosis
C.Management (Fig. 15. 2)
IV. Evaluation of Suspected Immunodeficiency
V. Immunoglobulin Therapy22–25
A. Intravenous Immunoglobulin (IVIG)
B. Intramuscular Immunoglobulin (IMIG)
C. Subcutaneous Immunoglobulin
D. Specific Immunoglobulins
E. Vaccination Timing
VI. Immunologic Reference Values
A.Serum IgG, IgM, IgA, and IgE Levels (Table 15. 3)
REFERENCES
References
16 - Immunoprophylaxis
I. Immunization Schedules
A. Immunizations for Children Ages 0 to 18
B. Nonroutine Vaccines Used in the United States3
II. Immunization Guidelines
A. Vaccine Informed Consent
B. Vaccine Administration
C. Live, Attenuated Vaccines
D. Timing and Spacing of Vaccine Doses
E. Contraindications and Precautions6
III.Postexposure Prophylaxis (Table 16. 5)
IV. Special Patient Populations7
A. Altered Immunocompetence8,9
B. Disease-­Specific Considerations
C. Preterm Infants
D. Pregnant Women
E. Immigration, Emigration, and Travel
V. Counseling and Communication about Vaccines16-­26
A. Vaccine Hesitancy
B. Countering Vaccine Hesitancy
VI. Web Resources27-­33
REFERENCES
VII. Online Content
A. Additional Vaccine Recommendations
B. The 3C Model: Key Barriers to Vaccine Use Worldwide16
C. Strategies to Address Vaccine Hesitancy18-­19,22-­26
D. Provider Resources for Vaccine Communication
References
17 - Microbiology and Infectious Disease
I. Common Neonatal and Pediatric Infections: Guidelines for Diagnosis and Initial Management
A.Congenital, Perinatal, and Neonatal Infections (Table 17. 1)
B.Pediatric Infections by System (Table 17. 2)
C.Pediatric Viral Illnesses (Table 17. 3)
D.Pediatric Tick-­Borne Diseases (Table 17. 4)
E.Tuberculosis: Diagnosis and Treatment (Boxes 17.1 and 17. 2)1,2
F. Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
II. Microbiology
A. Collection of Specimens for Blood Culture
B.Rapid Microbiologic Identification of Common Aerobic Bacteria (Fig. 17.4) and Anaerobic Bacteria (Fig. 17. 5)
III.Spectra of Activity for Commonly Used Antibiotics (Fig. 17. 6)
IV. Exposures to Blood Borne Pathogens and Prophylaxis
A. General Practice46
B. Disease-­Specific Post-Exposure Management
References
References
18 - Neonatology
I. Newborn resuscitation
A.Algorithm for Neonatal Resuscitation (Fig. 18. 1)
B.Endotracheal Tube Size and Depth of Insertion (Table 18. 1)
C. Vascular Access (See Chapter 4 for Umbilical Venous/Artery Catheter Placement)
II. Routine Newborn Care of a Term Infant
A. General Care for the Full-­Term Healthy Newborn with Uncomplicated Delivery
B. Prior to Discharge7
III. Newborn Assessment
A. Vital Signs and Birth Weight
B.APGAR Scores (Table 18. 2)
C. Gestational Age Estimation
D. Birth Trauma
E. Selected Anomalies, Syndromes, and Malformations (see Chapter 13 for genetic disorders)
IV. Fluids, Electrolytes, and Nutrition
A. Fluids
B. Glucose
C. Electrolytes, Minerals, and Vitamins
D. Nutrition
V. Cyanosis in the Newborn
A. Differential Diagnosis
B. Evaluation
VI. Respiratory Diseases
A. General Respiratory Considerations
B. Respiratory Distress Syndrome
C. Persistent Pulmonary Hypertension of the Newborn
D. Transient Tachypnea of the Newborn
E. Pneumothorax
VII. Apnea and Bradycardia
A. Apnea15
B. Bradycardia without Central Apnea
VIII. Cardiac Diseases
A. Patent Ductus Arteriosus
B. Cyanotic Heart Disease (See Chapter 7)
IX. Hematologic Diseases
A. Unconjugated Hyperbilirubinemia in the Newborn23
B. Conjugated Hyperbilirubinemia (See Chapter 12)
C. Polycythemia
X. Gastrointestinal Diseases
A. Necrotizing Enterocolitis
B. Bilious Emesis
C.Abdominal Wall Defects (Table EC 18. D)
D. Gastroesophageal Reflux Disease (See Chapter 12)
XI. Neurologic Diseases
A. Neonatal Hypoxic-­Ischemic Encephalopathy
B. Intraventricular Hemorrhage
C. Periventricular White Matter Injury
D. Neonatal Seizures (See Chapter 20)
E. Neonatal Abstinence Syndrome
F. Peripheral Nerve Injuries
XII. Urologic Disorders
A. Lower Urinary Tract Obstruction
B. Bladder Exstrophy-­Epispadias-­Cloacal Exstrophy Complex
XIII. Retinopathy of Prematurity34
A. Definition
B. Etiology
C. Diagnosis
D. Timing35
E. Classification
F. Management34-­35
XIV. Commonly Used Medications in the Neonatal Intensive Care Unit
XV. Web Resources
REFERENCES
XVI. Online Content
I. Prenatal Assessment of Fetal Health
A. Fetal Anomaly Screening
B. Fetal Health
C. Estimation of Gestational Age
References
19 - Nephrology
I.Urinalysis1: Table 19. 1
II. Kidney Function Tests
A. Tests of Glomerular Function
B. Tests of Kidney Tubular Function
III. Chronic Hypertension5-­7
A. Definition
B. Measurement of Blood Pressure in Children
C.Etiologies of Hypertension in Neonates, Infants, and Children (Table 19. 5)
D. Evaluation of Chronic Hypertension
E.Classification and Treatment of Hypertension (Table 19. 6)
F. Antihypertensive Drugs for Outpatient Management of Primary Hypertension in Children 1 to 17 Years of Age
IV. Urinary Tract Infections8-­13
A. History
B. Physical Examination
C. Risk Factors
D. Methods of Urine Collection
E. Diagnosis
F. Classification
G. Imaging
H. Treatment of Culture-­Positive Urinary Tract Infection
V. Proteinuria14–16
A. Definitions
B. Methods of Detection
C.Etiologies (Box 19. 1)
D. Evaluation15
E. Nephrotic Syndrome16
VI. Hematuria18
A. Definition
B. Etiologies: See Table 19.9
C.Evaluation (Fig. 19. 2)
D. Management (Fig. 19.3)
VII. Acute Kidney Injury19,20
A. Definition
B.Etiology (Table 19. 10)
C. Clinical Presentation
D. Acute Tubular Necrosis
E. Treatment Considerations
F. Complications
G. Radiographic Imaging Considerations in AKI/CKD
VIII. Chronic Kidney Disease23
A. Definition
B. Etiology
C. Clinical Manifestations (Table 19.12)
D. General Management
IX. Dialysis
A. Indications for Acute Dialysis
B. Techniques
C. Complications
X. Tubular Disorders
A.Renal Tubular Acidosis (Table 19. 13)26
B. Fanconi Syndrome
C. Nephrogenic Diabetes Insipidus
XI. Nephrolithiasis27-­30
A. Risk Factors
B. Presentation
C. Diagnostic Imaging
D. Management
E. Workup
F. Prevention
XII. Web Resources
A.International Pediatric Nephrology Association: www.ipna-­online. org
B. National Kidney Disease Education Program: https://www.niddk.nih.gov/health-­information/communication-­programs/nkdep
C. National Kidney Foundation: www.kidney.org
REFERENCES
References
20 - Neurology
I. NEUROLOGIC EXAMINATION
II. HEADACHES1–11
III. SEIZURES12–25
IV. HYDROCEPHALUS26–28
V. ATAXIA29,30
VI. STROKE31–33
VII. ENCEPHALOPATHY/ALTERED MENTAL STATUS34–37
VIII. NEUROMUSCULAR DISORDERS38–45
IX. WEB RESOURCES
REFERENCES
21 - Nutrition and Growth
I. ASSESSMENT OF GROWTH
A. Types of Growth Charts
B. Interpretation of Growth Charts11,12
C. General Guidelines Regarding Appropriate Growth13,14
II. MANAGEMENT OF OVERWEIGHT AND OBESE CHILDREN
A. AAP Recommendations for the Prevention of Obesity15-­17
B. Prevention and Management of Obesity in the Primary Care Setting (Table 21.1)
C. Conditions Associated with Obesity15
III. MALNUTRITION IN INFANTS AND CHILDREN
A. Defining Malnutrition16
B. Classifying the Degree to Which a Patient Is Malnourished (Table 21.2)17
C. Resources for Determining Z-­scores18
D. Differential Diagnosis of Malnutrition19
E. Physical Exam Findings Consistent with Malnutrition23-­25
F. Diagnostic Evaluation of Malnutrition26-­29
G. Red Flags That Suggest a Medical Cause of Malnutrition20
H. Approach to the Management of Malnourished Patients21,22 (Box 21.1)
IV. RE-­FEEDING SYNDROME
A. Patients at Risk of Developing Re-­Feeding Syndrome23
B. Management of Re-­Feeding Syndrome24
V. NUTRITIONAL NEEDS OF HEALTHY CHILDREN
A. Dietary Allowances for Carbohydrates and Protein (Table 21.3)
B. Fat Requirements (Table 21.4)
C. Vitamin Requirements (Tables 21.5 and 21.6)
D. Mineral Requirements (Table 21.7)
E. Fiber Requirements (Table 21.8)
VI. BREASTFEEDING AND THE USE OF HUMAN MILK
A. Benefits of Breast Milk31
B. Contraindications to Breastfeeding32,33 (Box 21.2)
C. Use of Milk Bank Donor Human Milk34
D. Safe Handling of Breast Milk35
E. Breastfeeding Challenges
VII. ENTERAL NUTRITION
A. Feeding the Healthy Infant
B. Available Formulas for Patients with Specific Clinical Conditions or for Those Requiring Special Diets (Tables 21.12 and 21.1...
C. Use of Enteral Tube Feeds37
D. Features of the Most Common Oral Rehydration Solutions (Table 21.14)
VIII. PARENTERAL NUTRITION
A. Indications for the Use of Parenteral Nutrition38
B. Starting and Advancing Parenteral Nutrition (Table 21.15)
C. Frequency of Monitoring Growth Parameters and Laboratory Studies in Patients on Parenteral Nutrition (Table 21.16)
D. Recommended Formulations of PN (Table 21.17)
IX. WEB RESOURCES
A. Professional and Government Organizations
B. Infant and Pediatric Formula Company Websites
C. Breastfeeding Resources
REFERENCES
REFERENCES
22 - Oncology
I. OVERVIEW OF PEDIATRIC MALIGNANCIES1-4
A. Epidemiology
B. Presenting Signs and Symptoms
II. PEDIATRIC HEMATOLOGIC MALIGNANCIES1-­2 (TABLE 22.1)
III. PEDIATRIC SOLID TUMOR MALIGNANCIES1-­2 (TABLE 22.2)
IV. PEDIATRIC CENTRAL NERVOUS SYSTEM (CNS) TUMORS1-­2,5-­8(TABLE 22.3)
A. Epidemiology
B. Clinical Presentation
C. Initial Workup
D. Management Principles
V. ONCOLOGIC EMERGENCIES2,9-­16
A. Fever and Neutropenia (Fig 22.1)
B. Hyperleukocytosis/Leukostasis
C. Tumor Lysis Syndrome
D. Spinal Cord Compression
E. Increased Intracranial Pressure (ICP)
F. Other Neurologic Emergencies: Cerebrovascular Accident (CVA), Seizures
G. Superior Vena Cava Syndrome/Superior Mediastinal Syndrome
H. Typhlitis (Neutropenic Enterocolitis)
I. Cytokine Release Syndrome
VI. COMMONLY USED CHEMOTHERAPEUTIC DRUGS AND ASSOCIATED ACUTE TOXICITIES (TABLE 22.4)
VII. COMMON CHEMOTHERAPY COMPLICATIONS AND SUPPORTIVE CARE1,11
A. Cytopenias: Anemia, Thrombocytopenia, Neutropenia
B. Mucositis
C. Nausea and Emesis
VIII. ANTIMICROBIAL PROPHYLAXIS IN ONCOLOGY PATIENTS (TABLE 22.6)17-­19
IX. HEMATOPOIETIC STEM CELL TRANSPLANTATION (HSCT)1,2,20
A. Goal
B. Preparative Regimens
C. Types of HSCT
D. Engraftment
X. COMPLICATIONS OF HSCT1,2,20-­22
A. Graft-­Versus-­Host Disease
B. Sinusoidal Obstructive Syndrome (SOS); Veno-­Occlusive Disease (VOD)
XI. CANCER SURVIVORSHIP3,23-­25
A. Understand the Diagnosis
B. Monitoring
C. Vaccinations in Oncology and HSCT Patients: see Chapter 16
XII. WEB RESOURCES
REFERENCES
XIII. ONLINE CONTENT
A. Complications of HSCT1,2,19-­21,25-­29
REFERENCES
23 - Palliative Care
I. INTRODUCTION TO HOSPICE AND PALLIATIVE MEDICINE
A. Definition of Palliative Care1,2
B. Definition of Hospice
C. Team Composition
II. COMMUNICATION AND DECISION MAKING
A. Decision-­Making Tools3
B. Structuring Family Meetings4
C. Breaking Bad News5
D. Other Tools for Difficult Conversations
III. CARE OF THE DYING CHILD
A. Limiting Interventions
B. Involving the Child in Conversations About Death8-­11
C. Supporting Patients Throughout the Dying Process
D. Pronouncing Death14
E. Explaining Autopsies15
F. Organ Donation
G. Completing Death Certificates14
H. Interacting with Loved Ones After a Child’s Death
IV. WEB RESOURCES
A. Center to Advance Palliative Care—capc.org
C. The American Academy of Hospice and Palliative Medicine—www.aahpm.org
REFERENCES
REFERENCES
24 - Psychiatry
I. OVERVIEW
A. Epidemiology and General Approach
B. Mental Status Exam
II. POSTPARTUM DEPRESSION
A. Epidemiology4: Prevalence in most studies is between 10% and 15%
B. Screening
C. Diagnosis
D. Treatment
III. COMMON PSYCHIATRIC CONDITIONS IN CHILDREN (2 TO 12 YEARS)
A. Attention-­Deficit/Hyperactivity Disorder
B. Anxiety Disorders
C. Oppositional Defiant Disorder (ODD)17
IV. COMMON PSYCHIATRIC CONDITIONS IN ADOLESCENTS
A. Depressive Disorders
B. Substance Use Disorders
C. Eating Disorders
V. PSYCHIATRIC EMERGENCIES
A. Suicide
B. Agitation31,32
VI. WEB RESOURCES
REFERENCES
REFERENCES
25 - Pulmonology and Sleep Medicine
I. EVALUATION OF PULMONARY GAS EXCHANGE
A. Pulse Oximetry1-­3
B. Capnography4,5
C. Blood Gases6-­8
D. Analysis of Acid-­Base Disturbances9-­11
II. PULMONARY FUNCTION TESTS (PFT)
A. Peak Expiratory Flow Rate (PEFR)12,13
B. Maximal Inspiratory and Expiratory Pressures14,15
C. Spirometry (for Children 6 Years of Age or Above)16,17
III. ASTHMA12,18
A. Definition
B. Clinical Presentation
C. Treatment
D. Prevention of Exacerbations
IV. BRONCHIOLITIS19-­23
A. Definition
B. Clinical Presentation
C. Treatment
V. BRONCHOPULMONARY DYSPLASIA (BPD)24-­27
A. Definition
B. Clinical Presentation
C. Diagnosis
D. Treatment
VI. CYSTIC FIBROSIS28-­37
A. Definition
B. Clinical Manifestations (Fig. 25.9)
C. Diagnosis
D. Treatment
VII. OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS)38-­42
A. Definition
B. Clinical Presentation
C. Diagnosis
D. Treatment
I.History
II.Physical examination
VIII. INFANT AND CHILD SLEEP43-­46
A. Sleep Duration
B. Sleep-­Related Infant Death
IX. BRIEF RESOLVED UNEXPLAINED EVENT (BRUE)47,48
A. Definition
B. Differential Diagnosis
C. Management
X. WEB RESOURCES
REFERENCES
XI. ONLINE CONTENT
A. Evaluation of Pulmonary Gas Exchange
B. Asthma
C. Childhood Sleep Disorders44,45
REFERENCES
26 - Radiology
I. GENERAL PEDIATRIC PRINCIPLES
II. CHOOSING THE RIGHT STUDY
III. HEAD
IV. NECK AND AIRWAY
V. CHEST
VI. HEART (SEE CHAPTER 7)
VII. ABDOMEN
27 - Rheumatology
I. BRIEF OVERVIEW OF CLINICAL CHARACTERISTICS OF RHEUMATOLOGIC DISEASES
A. Juvenile Idiopathic Arthritis (JIA)1–­5
B. Reactive Arthritis6–­8
C. Systemic Lupus Erythematosus (SLE)1,9–­11
D. Drug-­Induced Systemic Lupus Erythematosus1,6,9
E. Neonatal Systemic Lupus Erythematosus1,12
F. Vasculitis (Table 27.2)1,6,13–­23
G. Sarcoidosis6,14,24–­26
H. Scleroderma6,14,27
I. Sjögren Syndrome1,6,14,28
II. INTERPRETATION OF LABORATORY STUDIES USED IN THE DIAGNOSIS AND MONITORING OF RHEUMATOLOGIC DISEASES
A. Acute-­Phase Reactants
B. Autoantibodies (Table 27.3)14
C. Complement1,5
III. PRIMARY CARE MANAGEMENT OF RHEUMATOLOGIC DISEASES36,38,39
A. Vaccination
B. Weight Management
C. Bone and Skin Health
D. Reproductive Health
E. Other Aspects of Primary Care Coordination
F. Laboratory Monitoring
IV. WEB RESOURCES
REFERENCES
REFERENCES
28 - Blood Chemistry and Body Fluids
I. REFERENCE VALUES
II. EVALUATION OF BODY FLUIDS
A. Evaluation of Cerebrospinal Fluid
B. Evaluation of Urine
C. Evaluation of Transudate/Exudate
D. Evaluation of Synovial Fluid
III. CONVERSION FORMULAS
A. Temperature
B. Length and Weight
REFERENCES
REFERENCES
29 - Biostatistics and Evidence-Based Medicine
I. EVIDENCE-BASEDMEDICINE
A. Formulate the Clinical Question (PICO Process)
B. Search for the Evidence to Answer the Question
C. Critically Appraise the Evidence
D. Apply the Evidence to the Clinical Question
II. BIOSTATISTICS AND EPIDEMIOLOGY
A. Statistical Tests
B. Statistical Terminology
C. Types of Study Designs7 (see Table 29.2)
D. Measurement of Disease Occurrence and Treatment Effects2
E. Measurements of Test Performance2
III. WEB RESOURCES
A. Evidence-BasedResources
B. Biostatistics and Epidemiology Resources
REFERENCES
REFERENCES
31 - Drugs in Renal Failure
I. DOSE ADJUSTMENT METHODS
A. Maintenance Dose
B. Dialysis
II. ANTIMICROBIALS REQUIRING ADJUSTMENT IN RENAL FAILURE (TABLE 31.1)
III. NONANTIMICROBIALS REQUIRING ADJUSTMENT IN RENAL FAILURE (TABLE 31.2)
REFERENCES
REFERENCES
Pediatric BLS Health Care Providers
Pediatric Tachycardia
Pediatric Bradycardia
Pediatric Cardiac Arrest

Citation preview

PEDIATRIC PARAMETERS AND EQUIPMENT WT (kg) BAG VALVE MASK NASAL AIRWAY (Fr) ORAL AIRWAY BLADE ETT LMA GLIDESCOPE IV CATH (ga) CVL (Fr) NGT/OGT (Fr) CHEST TUBE (Fr) FOLEY (Fr)

Premie

Newborn

6 mo

1 yr

2-­3 yr

4-­6 yr

7-­10 yr

2.5-­3.5 Infant

3.5-­4 Infant

20-­25 Child

14-­18

14-­18

25-­35 40-­50 Child/small Adult adult 16-­20 18-­22

>50 Adult

12

10 Small child 14-­16

13-­16 Child

12

6-­8 Small child 14-­16

11-­15 yr >16 yr

Infant 50 mm MIL 0

Small 60 mm MIL 0

Small 60 mm MIL 1

2.5-­3.0 1 1 22-­24 3 5 10-­12

3.0-­3.5 1 1 or 2 22-­24 3-­4 5-­8 10-­12

3.5-­4.0 1.5 2 20-­24 4 8 12-­18

Small 60 mm MIL 1, MAC 2 4.0-­4.5 2 2 20-­24 4-­5 10 16-­20

Small 70 mm MIL 1, MAC 2 4.5-­5.0 2 3 18-­22 4-­5 10-­12 16-­24

Small 70-­80 mm MIL 2, MAC 3 5.0-­5.5 2.5 3 18-­22 5 12-­14 20-­28

Med 80-­90 mm MIL 2, MAC 3 5.5-­6.0 2.5-­3 3 18-­22 5 12-­14 20-­32

Med 90 mm MIL 2, MAC 3 6.0-­6.5 3 3 or 4 18-­20 7 14-­18 28-­38

Med 90 mm MIL 2, MAC 3 7.0-­8.0 4 3 or 4 16-­20 7 14-­18 28-­42

6

8

8

8

8

8

8

10

12

22-­36

ESTIMATED BLOOD PRESSURE BY AGE Measurement Systolic BP

50th % 90 + (age × 2)

MAP

55 + (age × 1.5)

5th % 60 (neonate); 70 (1 mo-­1 yr) 70 + (age × 2) (for 2-­10 yr) 10 yr) 40 + (age × 1.5)

NORMAL VITAL SIGNS BY AGE Premie

Heart Rate (beats/min) 120-­170

0-­3 mo 3-­6 mo 6-­12 mo 1-­3 yr 3-­6 yr 6-­12 yr >12 yr

110-­160 100-­150 90-­130 80-­125 70-­115 60-­100 60-­100

Age

Blood Pressure (mmHg) 55-­75/35-­45 (gestational age approximates normal MAP) 65-­85/45-­55 70-­90/50-­65 80-­100/55-­65 90-­105/55-­70 95-­110/60-­75 100-­120/60-­75 100-­120/70-­80

Respiratory Rate (breaths/min) 40-­70 30-­60 30-­45 25-­40 20-­30 20-­25 14-­22 12-­18

ENDOTRACHEAL TUBE FORMULAS Uncuffed ETT size: age (years)/4 + 4; Cuffed ETT size: age (years)/4 + 3 ETT depth (from lip to mid-­trachea): ETT internal diameter (size) × 3

GLASGOW COMA SCALE Activity

Score

Child/Adult

Score

Infant

Eye opening

4

Spontaneous

4

Spontaneous

3 To speech 3 To speech/sound 2 To pain 2 To painful stimuli 1 None 1 None Verbal 5 Oriented 5 Coos/babbles 4 Confused 4 Irritable cry 3 Inappropriate 3 Cries to pain 2 Incomprehensible 2 Moans to pain 1 None 1 None Motor 6 Obeys commands 6 Normal spontaneous movement 5 Localizes to pain 5 Withdraws to touch 4 Withdraws to pain 4 Withdraws to pain 3 Abnormal flexion 3 Abnormal flexion (decorticate) 2 Abnormal extension 2 Abnormal extension (decerebrate) 1 None 1 None (flaccid) Adapted from Hunt EA, Nelson-­McMillan K, McNamara L. The Johns Hopkins Children’s Center Kids Kard, 2016.

RESUSCITATION MEDICATIONS Adenosine Supraventricular tachycardia

0.1 mg/kg IV/IO RAPID BOLUS (over 1-­2 sec), Flush with 10 mL normal saline May repeat at 0.2 mg/kg IV/IO, then 0.3 mg/kg IV/IO after 2 min Max first dose 6 mg, max subsequent dose 12 mg Administer using a 3-­way stopcock attached to a 10 ml NS flush Amiodarone 5 mg/kg IV/IO Ventricular tachycardia No Pulse: Push Undiluted Ventricular fibrillation Pulse: Dilute and give over 20-­60 minutes Max first dose 300 mg, max subsequent dose 150 mg Only give max of 3 IV push doses Monitor for hypotension Strongly consider pretreating with IV calcium in patients with a pulse to prevent hypotension Atropine 0.02 mg/kg IV/IO/IM, 0.04–0.06 mg/kg ETT Bradycardia (increased Max single dose 0.5 mg vagal tone) Repeat in 5 minutes if needed (up to twice) to max total dose 1 mg Primary AV block Calcium chloride (10%) 20 mg/kg IV/IO Hypocalcemia Max dose 1 gram Calcium Gluconate 60 mg/kg IV/IO (10%) Max dose 3 grams Dextrose Weight-Based Dosing: 0.5–1 gram/kg Volume-Based Dosing (“Rule of 50”): 8 years age (d) Pharmacology: See Table 1.2 for rapid sequence intubation medications. (e)  Positioning: Place patient in “sniffing” position with neck slightly extended to align the airway. (i) Infants and toddlers may require towel roll beneath shoulders due to large occiput. (ii) Children and adolescents may require towel roll beneath neck. (2)  Procedure: Advanced airways should be placed by experienced healthcare providers with appropriate training. (a) Confirm placement by detecting EtCO2, observing chest wall movement, auscultating for symmetric breath sounds, and monitoring oxygen saturation. Evaluate placement via chest radiograph. (3)  Failure: Acute respiratory failure in an intubated patient may signify Displacement of the ETT, Obstruction, Pneumothorax, or Equipment failure (DOPE). d. Surgical airway: Consider needle or surgical cricothyrotomy if BVM, endotracheal intubation, and LMA fail. If available, consult emergently with difficult airway specialists (pediatric anesthesiologist, intensivist, and/or otolaryngologist). 3. Oxygenation and Ventilation a. Oxygen delivery systems: (1) Low-­flow systems (e.g., nasal cannula, simple face mask) do not meet the inspiratory flow demand of the patient. Delivery of set fraction of inspired oxygen (FiO2) is difficult due to room air mixing. (2) High-­flow systems (e.g., nonrebreather, oxygen hood) do meet the inspiratory flow demand of the patient. Measurable FiO2 is delivered.

1



Medication

Benefit

Indication

Dosing

Side Effects

Prevent bradycardia associated with laryngoscope insertion, decrease oral secretions Decrease oral secretions, may cause less tachycardia than atropine, preserves pupillary exam in trauma Blunts rise in ICP associated with laryngoscopy

Bradycardia in any patient, infants 5 years receiving a second dose of succinylcholine Hypersalivation

0.02 mg/kg IV/IO/IM (max 0.5 mg)

Tachycardia, pupil dilation

0.004–0.01 mg/kg IV/IM/IO (max 0.1 mg)

Tachycardia

Elevated ICP, shock, arrhythmia, and status asthmaticus

1 mg/kg IV/IO (max 100 mg)

Myocardial depression, altered mental status, seizures, muscle twitching

Etomidate (sedative)

Minimal cardiovascular side effects, minimally decreases ICP

0.3 mg/kg IV/IO

Fentanyl (analgesic, sedative) Ketamine (sedative, analgesic)

Minimal cardiovascular effect

Multitrauma patient at risk for increased ICP and hypotension Caution in patients with adrenal suppression; avoid in septic shock Shock

Status asthmaticus, shock and hypotensive patients Caution in patients at risk for elevated ICP or glaucoma history

1–2 mg/kg IV/IO (max 150 mg) 4–6 mg/kg IM

Suppresses adrenal corticosteroid synthesis, vomiting, myoclonus, lowers seizure threshold Chest wall rigidity, bradycardia, respiratory depression Vomiting, laryngospasm, hypersalivation, emergence reactions (hallucinations)

1. Adjuncts Atropine

Glycopyrrolate

Lidocaine

2. Induction Agents

Catecholamine release causes bronchodilation, abates bradycardia associated with laryngoscope insertion, increases HR and SVR, produces a “dissociative amnesia”

     

1–5 mCg/kg slow IV/IM push (max 100 mCg)

10  Part I  Pediatric Acute Care

ClinicalKey.com by Elsevier on May 16, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

TABLE 1.2 RAPID SEQUENCE INTUBATION MEDICATIONS11,15-­17,20

Minimal cardiovascular effect

Mild shock

0.05–0.3 mg/kg IV/IM/IO (max 10 mg)

Dose-­dependent respiratory depression, hypotension

Ultra-­short acting

Role in RSI unclear Avoid in shock or patients who require maintenance of CPP

1 mg/kg IV initial bolus, then 0.5 mg/kg boluses every 3 min as needed

Hypotension, myocardial depression, metabolic acidosis; may cause paradoxical hypertension in children

Role limited due to adverse events Contraindicated in neuromuscular disease, myopathies, spinal cord injury, crush injury, burns, renal insufficiency

IV: ≤2 years: 2 mg/kg >2 years: 1 mg/kg (30–60 sec onset, 4–6 min duration) IM: 3–4 mg/kg (3–4 min onset, 10–30 min duration) Max dose: 150 mg/dose IV/IM 1.2 mg/kg IV/IM/IO (30–60 sec onset, 30–40 min duration) Max dose: 100 mg

Hyperkalemia, trigger of malignant hyperthermia, masseter spasm, bradycardia, muscle fasciculations, increased intracranial, intraocular, and intragastric pressure

0.15–0.2 mg/kg IV/IO (1–3 min onset, 30–40 min duration) Max dose: 10 mg

Prolonged duration in hepatic failure

3. Neuromuscular blockade Succinylcholine (depolarizing)

Shortest acting neuromuscular blockade agent, reversible with acetylcholinesterase inhibitor

Rocuronium Minimal cardiovascular effect, reversible Caution in patients with difficult airway (nondepolarizing) with sugammadex

Vecuronium Minimal cardiovascular effect, reversible Caution in patients with difficult airway (nondepolarizing) with sugammadex

     

Prolonged duration in hepatic failure

CPP, Cerebral perfusion pressure; HR, heart rate; ICP, intracranial pressure; IM, intramuscular; IV, intravenous; IO, intraosseous; mCg, microgram; SVR, systemic vascular resistance; RSI, rapid sequence intubation.

1

Chapter 1  Emergency and Critical Care Management   11

ClinicalKey.com by Elsevier on May 16, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Midazolam (sedative, amnestic, anxiolytic) Propofol (sedative)

12  Part I  Pediatric Acute Care



















(3) High-­flow nasal cannula (HFNC): (a) High-­flow, noninvasive respiratory support provides a heated and humidified air-­oxygen mixture that may improve gas exchange by providing airway-­distending pressure. (b) Optimal and maximal flow rates are unknown. Consensus supports a maximum flow rate of up to 2 L/kg/min or 12 L/min for infants and toddlers, 30 L/min for children, and up to 50 L/min for adolescents and adults. b. Noninvasive positive pressure ventilation (NIPPV): (1)  CPAP: Delivery of a continuous, distending positive airway pressure independent of patient inspiratory effort. (2)  BiPAP: Pressure-­limited ventilatory mode in which the clinician sets an inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). (a) EPAP is started at 4 to 5 cmH2O and increased to a maximum of 8 to 12 cmH2O. (b) Set 4 to 6 cmH2O of pressure support, or the difference between IPAP and EPAP. (c) Consider setting a “backup rate,” or respiratory rate just shy of the spontaneous respiratory rate to be delivered in case of apnea. c. Mechanical Ventilation: (1)  Parameters: (a) Rate: Number of mechanical breaths delivered per minute. (b) FiO2: Fraction of oxygen in inspired gas. (c) PIP: Peak inspiratory pressure attained during respiratory cycle. (d) Positive end-­expiratory pressure (PEEP): Distending pressure that increases functional residual capacity (FRC), or volume of gas at the end of exhalation. (e) Mean airway pressure (Paw): Average airway pressure over entire respiratory cycle, which correlates to mean alveolar volume. (f) Tidal volume (VT): Volume of gas delivered during inspiration. (g) Time: May indicate a function of time spent in inspiration (Ti), in high pressure (Thigh), or in low pressure (Tlow). (2)  Modes of Ventilation: (a)  Controlled Ventilation: Ventilation is completely mechanical with no spontaneous ventilation efforts expected from the patient. (i) Pressure-­controlled ventilation (PCV): A preset respiratory rate and Ti delivers a pressure-­limited breath (the set pressure is maintained during inspiration). VT is determined by the preset pressure as well as lung compliance and resistance. (ii) Volume-­controlled ventilation (VCV): A preset respiratory rate and Ti delivers a preset VT.





















(b) Intermittent mandatory ventilation (IMV): Allows the patient to breathe spontaneously between a preset number of (mandatory) mechanical breaths. (i) Synchronized IMV (SIMV): If patient initiates spontaneous breath, mandatory breath is synchronized with patient effort rather than spaced evenly over each minute. (ii) If spontaneous breathing rate is less than mandatory rate, some mandatory breaths will be delivered in the absence of patient effort. (iii) Delivered breaths may be volume regulated or pressure limited. (c) Airway-­pressure-­release ventilation (APRV): Most of the respiratory cycle is spent at a high distending pressure (a functionally high CPAP phase) with intermittent, short release to a low pressure for a brief ventilation phase. Spontaneous breathing can be superimposed at any point in the cycle. (d) Support ventilation: Mechanical breaths support patient-­ initiated breaths, but no mandatory breaths are provided. (i) Pressure support (PS): Delivers a preset amount of pressure to assist spontaneous respiratory effort. (ii) Often used in combination with other modes of ventilation to support spontaneous breaths greater than preset respiratory rates. (e) High-­frequency oscillatory ventilation (HFOV): Gas flow pressurizes the system to the preset Paw while a piston moves backwards and forwards to force and withdraw a small VT (that approximates anatomic dead space) into the lungs at rates exceeding normal respiratory rates. (3)  Management: The three subdivisions of mechanical ventilatory support are the acute (lung recruitment), maintenance (lung recovery), and weaning phases. (a)  Acute: See Table 1.3 for ventilation parameter initial settings and titration effects. (b) Maintenance: To avoid volutrauma, barotrauma, or oxygen toxicity, maintain VT at 4-­6 mL/kg, PIP < 35 cmH2O, and FiO2 ≤ 60%. (c)  Weaning: (i) Assess daily for clinical signs of readiness, such as spontaneous breathing efforts. (ii) Standard indices indicating readiness include: FiO2 40 mmHg) is critical to overcome the resistance of increased ICP. a. Stabilize initially as per resuscitation guidelines. (1) Maintain normal oxygenation and ventilation to treat increased metabolic demand and avoid hypercarbia-­related cerebral vasodilation. (2) Consider hyperventilation (EtCO2 target between 25 and 30) for patients with active evidence of herniation. Prophylactic hyperventilation is otherwise not recommended. (3) Support MAP with adequate isotonic fluid resuscitation and vasoactive agents. b. Consultation with neurosurgical team is recommended and required immediately if evidence of herniation is present. c. Administer mannitol (0.25 to 1 g/kg) and/or hypertonic saline (5 to 10 mL/kg of 3% hypertonic saline) in case of acute neurologic deterioration or cerebral herniation. (1) Continuous infusions of 3% hypertonic saline (0.5 to 1.5 mL/kg/h) may be titrated as necessary to maintain ICP less than 20 mmHg. (2) Rapid osmotic diuresis from mannitol may cause hypovolemia and hypotension, especially in polytrauma patients. d. Request noncontrast head CT to evaluate for emergent surgical pathology. e. Treat acute seizure activity given the associated increased cerebral metabolic rate and subsequent increased cerebral blood flow. Consider prophylactic antiseizure therapy (e.g., phenytoin, levetiracetam), if transport or delayed definitive care is anticipated.

1

Chapter 1  Emergency and Critical Care Management   31

32  Part I  Pediatric Acute Care







f. Sedation and analgesia prevent increases in ICP related to pain and agitation, although benefit is balanced with risk of hypotension and alteration of neurologic exam. g. Avoid secondary brain injury by maintaining neuroprotective parameters: Maintain head midline and elevated at 30 degrees, normoglycemia, normonatremia, normothermia, and correct acidosis. h. If elevated ICP is refractory to medical management, consider draining an existing ventriculoperitoneal shunt or acute neurosurgical intervention (external ventricular drain or decompressive craniectomy). i. For elevated ICP refractory to medical and surgical management, consider barbiturate coma.  IV.  CRITICAL CARE REFERENCE DATA

1. Minute ventilation (VE):

VE =  Respiratory rate × Tidal volume  (VT )

2. Alveolar gas equation:

PA O2 =   [FiO2 (Patm − PH2 O)] − (Pa CO2 /R)



a. PAO2 = Alveolar partial pressure of oxygen b. FiO2 = Inspired fraction of oxygen (0.21 at room air) c. Patm = Atmospheric pressure (760 mmHg at sea level; adjust for high altitude) d. PH2O = Water vapor pressure (47 mmHg) e. PaCO2 = Arteriolar partial pressure of carbon dioxide (measured via arterial blood gas) f. R = Respiratory quotient (0.8; CO2 produced/O2 consumed) 3. Alveolar-­arterial oxygen gradient (A-­a gradient):



A−a gradient  =  PA O2 − Pa O2



a. PAO2 = Alveolar partial pressure of oxygen (estimated from alveolar gas equation) b. PaO2 = Arteriolar partial pressure of oxygen (measured via arterial blood gas) c. Normal gradient is 20 to 65 mmHg on 100% oxygen or 5 to 20 mmHg on room air d. The A-­a gradient is increased in hypoventilation, diffusion limitations, pulmonary blood-­flow shunts and ventilation/blood flow (V/Q) mismatch. 4. Oxygenation index (OI):

OI  =  Paw × FiO2 × 100 / Pa O2

a. Paw (mmHg) = Mean airway pressure b. OI >40 in hypoxemic respiratory failure is historically considered an indication for extracorporeal life support.

REFERENCES A complete list of references can be found online at www.expertconsult.com.

REFERENCES 1. Berg MD, Schexnayder SM, Chameides L, et al. Part 13: Pediatric basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S862–S875. 2. Atkins DL, Berger S, Duff JP, et al. Part 11: Pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S519–S525. 3. De Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 suppl 2):S526–S542. 4. Atkins DL, de Caen AR, Berger S, et al. 2017 American Heart Association focused update on pediatric basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2018;137:e1–e6. 5. Pediatric Advanced Life Support Provider Manual. Dallas: American Heart Association, Subcommittee on Pediatric Resuscitation; 2015. 6. Raymond TT, Cunnyngham CB, Thompson MT, et al. Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory inhospital pediatric cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Pediatr Crit Care Med. 2010;11(3):362–371. 7. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 suppl 3):S876–S908. 8. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128:417–435. 9. Berg RA, Sutton RM, Reeder RW, et al. Association between diastolic blood pressure during pediatric in-­hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784–1795. 10. Wells M, Goldstein LN, Bentley A. The accuracy of emergency weight estimation systems in children—a systematic review and meta-­analysis. Int J Emerg Med. 2017;10:29. 11. Nichols DG, Shaffner DH. Rogers’ Textbook of Pediatric Intensive Care. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2016. 12. Daugherty RJ, Nadkarni V, Brenn BR. Endotracheal tube size estimation for children with pathological short stature. Pediatr Emerg Care. 2006;22(11):710–717. 13. Mikalsen IB, Davis P, Øymar K. High flow nasal cannula in children: a literature review. Scand J Trauma Resusc Emerg Med. 2016;24:93. 14. Davis PJ, Cladis FP. Smith’s Anesthesia for Infants and Children. 6th ed. Philadelphia: Elsevier Inc; 2017. 15. Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: a review. Pediatr Emerg Care. 2004;20(5):339–344.

32.e1

32.e2  Part I  Pediatric Acute Care 16. Zelicof-­Paul A, Smith-­Lockridge A, Schnadower D, et al. Controversies in rapid sequence intubation in children. Curr Opin Pediatric. 2005;17:355–362. 17. Fuhrman BP, Zimmerman JJ. Fuhrman & Zimmerman’s Pediatric Critical Care. 5th ed. Philadelphia: Elsevier Inc; 2017. 18. Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4(2):13–37. 19. Leboulanger N, Garabedian EN. Airway management in pediatric head and neck infections. Infect Disord Drug Targets. 2012;12(4):256–260. 20. Shaw KN, Bachur RG. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2016. 21. Petrocheilou A, Tanou K, Kalampouka E, et al. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol. 2014;49(5):421–429. 22. Smith DK, McDermott AJ, Sullivan JF. Croup: diagnosis and management. Am Fam Physician. 2018;97(9):575–580. 23. Singh H, Parakh A. Tracheobronchial foreign body aspiration in children. Clin Pediatr (Phila). 2014;53(5):415–419. 24. National Asthma Education and Prevention Program. Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung and Blood Institute; 2007. 25. Jones BP, Fleming GM, Otillio JK, et al. Pediatric acute asthma exacerbations: evaluation and management from emergency department to intensive care unit. J Asthma. 53(6):607–617. 26. Dalabih AR, Bondi SA, Harris ZL, et al. Aminophylline infusion for status asthmaticus in the pediatric critical care unit setting is independently associated with increased length of stay and time for symptom improvement. Pulm Pharmacol Ther. 2014;27(1):57–61. 27. Wong JJ, Lee JH, Turner DA, et al. A review of the use of adjunctive therapies in severe acute asthma exacerbation in critically ill children. Expert Rev Respir Med. 2014;8(4):423–441. 28. Doymaz S, Schneider J, Sagy M. Early administration of terbutaline in severe pediatric asthma may reduce incidence of acute respiratory failure. Ann Allergy Asthma Immunol. 2014;112(3):207–210. 29. Abman SH, Hansmann G, Archer SL, et al. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation. 2015;132(21):2037–2099. 30. Baracco R, Mattoo TK. Pediatric hypertensive emergencies. Curr Hypertens Rep. 2014;16:456. 31. Park MK. Park’s Pediatric Cardiology for Practitioners. 6th ed. Philadelphia: Elsevier Inc; 2014. 32. Krmpotic K. A clinical approach to altered level of consciousness in the pediatric patient. Austin Pediatr. 2016;3(5):1046. 33. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3–23. 34. Glauser T, Shinnar S, Gloss D, et al. Evidence-­based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. 35. Pitfield AF, Carroll AB, Kissoon N. Emergency management of increased intracranial pressure. Pediatr Emerg Care. 2012;28(2):200–204.

Chapter 1  Emergency and Critical Care Management   32.e3

1

36. Kochanek P, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents-­ second edition. Pediatr Crit Care Med. 2012;13(suppl 1):S1–S82. 37. Stevens RD, Shoykhet M, Cadena R. Emergency neurological life support: intracranial hypertension and herniation. Neurocrit Care. 2015;23(suppl 2):S76–S82.

Chapter 2 Traumatic Injuries Nymisha Chilukuri, MD See additional content on Expert Consult

I.  COMPONENTS OF THE TRAUMA ASSESSMENT A.  Primary Survey 1. The primary survey includes assessment of ABCDE (airway, breathing, circulation, disability, exposure/exsanguination). This includes intravenous (IV) access, preferably two large-­bore catheters. 2. NOTE: The Advanced Trauma Life Support algorithm developed by the American College of Surgeons continues to support the ABC sequence in the primary survey. For nontraumatic cardiorespiratory arrest, the circulation, airway, and breathing (CAB) sequence is currently in use by the American Heart Association as part of the Pediatric Advanced Life Support algorithm (see Chapter 1). B. Secondary Survey (Fig. 2.1) 

II.  HEAD AND NECK TRAUMA A.  Head Imaging 1. The PECARN algorithm (Fig. 2.2) is often used to assess risk for clinically important traumatic brain injury.1 2. If signs of traumatic brain injury on computed tomography (CT), consider consultation by pediatric neurosurgery/trauma surgeon.  B.  Cervical Spine and Neck Imaging 1. There are currently no unified protocols or clinical guidelines for pediatric cervical spine clearance after blunt trauma. 2. Based on PECARN C-­Spine criteria,2 consider obtaining imaging if any of the following are present in a patient ≤16 years old: a. Altered mental status b. Focal neurologic deficits c. Complaint of neck pain d. Torticollis e. Substantial injury to the torso f. Predisposing condition g. High-­risk motor vehicle crash h. Diving accident 3. Note, many institutions alternatively use NEXUS criteria for clinical c-­ spine clearance. This is validated in children ≥8 years old3 and includes #1, 2, and 3 of PECARN c-­spine plus presence of intoxication or painful, distracting injury.4,5 33

Primary survey A - Airway B- Breathing C - Circulation D - Disability (neurological status) E - Exposure of patient

HEAD Head: Scalp laceration/hematoma, skull bone depression /deformity; raccoon eyes (periorbital ecchymoses suggesting orbital skull fracture) Face: Facial or nasal bone deformity/tenderness, mobile dentition, nasal septum hematoma Neurological status: Glasgow coma scale, sensory and motor evaluation in extremities Eyes: • Pupil size, symmetry, and reactivity; unilateral dilation suggesting CN III compression and possible herniation; hyphema Ears: • Hemotympanum, battle sign (ecchymosis behind pinna suggesting basillar skull fracture) • Cerebrospinal fluid leak CHEST Clavicle: Clavicle deformity, tenderness Heart and lungs: Breath sounds, heart sounds Chest wall: Symmetry, paradoxical movement, rib deformity/fracture, crepitus ABDOMEN/PELVIS • Tenderness, distention, ecchymosis • Shoulder pain suggesting referred subdiaphragmatic process • LUQ rib tenderness, flank pain, or flank ecchymosis suggesting splenic laceration • Rectal tone • Blood at urinary meatus suggests urethral injury; do not catheterize EXTREMITIES • Neurovascular status: Pulse, perfusion, pallor, paresthesias, paralysis, pain • Range of motion • Deformity, crepitus, pain • Compartment syndrome

FIGURE 2.1 Trauma primary and secondary survey.

NECK • Cervical spine tenderness, deformity, injury • Tracheal deviation • Crepitus BACK • Log-roll patient to evaluate spine for step-off along spinal column and rectal bone • Tenderness • Open or penetrating wound SKIN • Capillary refill, perfusion • Lacerations, abrasions, contusion

34  Part I  Pediatric Acute Care

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Secondary survey

GCS ≤14 OR Signs of altered mental status: • Agitation • Somnolence • Repetitive questioning • Slow response to verbal communication OR Palpable skull fracture

Yes CT 4.4% risk of ciTBI

No Scalp hematoma (excluding frontal) OR Loss of consciousness ≥5 seconds OR Severe mechanism of injury: • Fall >3 ft Yes • MVA with rejection, rollover, or fatality • Bike/pedestrian versus vehicle 0.9% without helmet risk • Struck by high-impact object of Not acting normally per parent ciTBI No

30 min)

Consider general anesthesia

Moderate

Severe aConsult

with neurologist prior to administering a benzodiazepine for sedation during EEG. BM, Bone marrow; CT, computed tomography; ECHO, echocardiogram; EEG, electroencephalogram; EMLA, eutectic mixture of local anesthetics; LP, lumbar puncture; LET, lidocaine, epinephrine, tetracaine; MRI, magnetic resonance imaging. Modified from Yaster M, Cote C, Krane E, et al. Pediatric Pain Management and Sedation Handbook. St. Louis: Mosby; 1997:551–552.

6

TABLE EC 6.A SUGGESTED ANALGESIA AND SEDATION PROTOCOLS

Drug Class

Duration of Action

Drug

Route

Onset (min)

Duration (hr)

Comments

Benzodiazepines

Short

Midazolam (Versed)

Diazepam (Valium)

Long

Lorazepam (Ativan)

Has rapid and predictable onset of action, short recovery time Causes amnesia Results in mild depression of hypoxic ventilatory drive Poor choice for procedural sedation Excellent for muscle relaxation or prolonged sedation Painful on IV injection Poor choice for procedural sedation Ideal for prolonged anxiolysis, seizure treatment

Short Intermediate

Methohexital Pentobarbital

1–3 5–10 10–30 1–3 7–15 30–60 1–5 10–20 30–60 5–10 1–10 5–15

1–2

Intermediate

IV IM/IN PO/PR IV (painful) PR PO IV IM PO PRb IV IM PO/PR

15–60

2–4

Barbiturates

aUse

0.25–1 2–3 2–3 3–4 3–6 3–6 1–1.5 1–4 2–4

PR form used as sedative for nonpainful procedure Predictable sedation and immobility for nonpainful procedures Minimal respiratory depression when used alone Associated with slow wake up and agitation

IV solution for PO, PR, and IN administration. Rectal diazepam gel (Diastat) is also available. bIV administration produces general anesthesia; only PR should be used for sedation. IM, Intramuscular; IN, intranasal; IV, intravenous; min, minute; PO, by mouth; PR, per rectum. Data from Yaster M, Cote C, Krane E, et al. Pediatric Pain Management and Sedation Handbook. St. Louis: Mosby; 1997:345–374; St Germain BA. The management of pain in the emergency department. Pediatr Clin North Am. 2000;47:651–679; and Cote CJ, Lerman J, Todres ID, et al. A Practice of Anesthesia for Infants and Children. Philadelphia: WB Saunders; 2001.

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TABLE 6.8 COMMONLY USED BENZODIAZEPINESa AND BARBITURATES1,4

Chapter 6  Analgesia and Procedural Sedation   143 BOX 6.2 NALOXONE (NARCAN) ADMINISTRATIONa Indications: Patients Requiring Naloxone (Narcan) Usually Meet All the Following Criteria • S  hallow respirations or respiratory rate 40 kg: Mix 0.4 mg (1 ampule) of naloxone with 9 mL of normal saline (final concentration 0.04 mg/mL = 40 mCg/mL) b.  If child 9 breaths/min. aNaloxone

administration for patients being treated for pain. Higher doses may be necessary for patients found in the community or those with signs of cardiopulmonary failure. Please see formulary for additional dosing. bRespiratory rates that require naloxone vary according to infant’s/child’s usual rate. IV, Intravenous; kg, kilogram; mCg, microgram; mg, milligram; mL, milliliter. Modified from McCaffery M, Pasero C. Pain: Clinical Manual. St. Louis: Mosby; 1999:269–270.

6

Procedure

144  Part II  Diagnostic and Therapeutic Information TABLE 6.9 EXAMPLES OF SEDATION PROTOCOLS Protocol/Doses

Comments

Ketamine × 1–3 doses Ketamine + midazolam + atropine (“ketazolam”)   Ketamine × 1–3 doses   Midazolam × 1 dose   Atropine × 1 dose Midazolam + fentanyl   Midazolam × 3 doses PRN

Lowest rates of adverse events when ketamine used alonea Atropine = antisialagogue Midazolam = counters emergence delirium Can be given IM or IV. If giving IM, combine all 3 agents in 1 syringe (using the smallest volume possible, preferably 10 mmHg consider pericardial effusion, tamponade, pericarditis, severe asthma, or restrictive cardiomyopathies. 4. Hypertension (HTN) a. See Chapter 1 for management of acute HTN. b. See Chapter 19 for screening, work-­up, and management of chronic HTN.  C.  Heart Sounds 1. S1: Associated with closure of mitral and tricuspid valves; heard best at the apex or left lower sternal border (LLSB). 2. S2: Associated with closure of pulmonary and aortic valves; heard best at the left upper sternal border (LUSB) and has normal physiologic splitting that increases with inspiration. 3. S3: Heard best at the apex or LLSB. 4. S4: Heard at the apex.  D.  Systolic and Diastolic Sounds See Box 7.1 for abnormal heart sounds.3  E. Murmurs4 Clinical characteristics are summarized in Table 7.3.3 145

Age (years) 1

2

3

SBP (mmHg) Height Percentile or Measured Height

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

DBP (mmHg) Height Percentile or Measured Height

5%

10%

25%

50%

75%

90%

95%

5%

10%

25%

50%

75%

90%

95%

29.7 75.4 84 98 101 113 33.4 84.9 87 101 104 116 35.8 91 88 102 106 118

30.2 76.6 85 99 102 114 34 86.3 87 101 105 117 36.4 92.4 89 103 106 118

30.9 78.6 86 99 102 114 34.9 88.6 88 102 106 118 37.3 94.9 89 104 107 119

31.8 80.8 86 100 103 115 35.9 91.1 89 103 106 118 38.4 97.6 90 104 108 120

32.7 83 87 101 104 116 36.9 93.7 90 104 107 119 39.6 100.5 91 105 109 121

33.4 84.9 88 102 105 117 37.8 96 91 105 108 120 40.6 103.1 92 106 110 122

33.9 86.1 88 102 105 117 38.4 97.4 91 106 109 121 41.2 104.6 93 107 110 122

29.7 75.4 41 54 59 71 33.4 84.9 45 58 62 74 35.8 91 48 60 64 76

30.2 76.6 42 55 59 71 34 86.3 46 58 63 75 36.4 92.4 48 61 65 77

30.9 78.6 42 56 60 72 34.9 88.6 47 59 63 75 37.3 94.9 49 61 65 77

31.8 80.8 43 56 60 72 35.9 91.1 48 60 64 76 38.4 97.6 50 62 66 78

32.7 83 44 57 61 73 36.9 93.7 49 61 65 77 39.6 100.5 51 63 67 79

33.4 84.9 45 58 62 74 37.8 96 50 62 66 78 40.6 103.1 53 64 68 80

33.9 86.1 46 58 62 74 38.4 97.4 51 62 66 78 41.2 104.6 53 65 69 81 Continued

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TABLE 7.1 BLOOD PRESSURE LEVELS FOR THE 50TH, 90TH, 95TH, AND 99TH PERCENTILES OF BLOOD PRESSURE FOR GIRLS AGED 1–17 YEARS BY PERCENTILES OF HEIGHT

4

5

6

7

Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 38.3 97.2 89 103 107 119 40.8 103.6 90 104 108 120 43.3 110 92 105 109 121 45.6 115.9 92 106 109 121

10% 38.9 98.8 90 104 108 120 41.5 105.3 91 105 109 121 44 111.8 92 106 109 121 46.4 117.8 93 106 110 122

25% 39.9 101.4 91 105 109 121 42.6 108.2 92 106 109 121 45.2 114.9 93 107 110 122 47.7 121.1 94 107 111 123

50% 41.1 104.5 92 106 109 121 43.9 111.5 93 107 110 122 46.6 118.4 94 108 111 123 49.2 124.9 95 109 112 124

75% 42.4 107.6 93 107 110 122 45.2 114.9 94 108 111 123 48.1 122.1 96 109 112 124 50.7 128.8 97 110 113 125

90% 43.5 110.5 94 108 111 123 46.5 118.1 95 109 112 124 49.4 125.6 97 110 113 125 52.1 132.5 98 111 114 126

95% 44.2 112.2 94 108 112 124 47.3 120 96 110 113 125 50.3 127.7 97 111 114 126 53 134.7 99 112 115 127

DBP (mmHg) Height Percentile or Measured Height 5% 38.3 97.2 50 62 66 78 40.8 103.6 52 64 68 80 43.4 110 54 67 70 82 45.6 115.9 55 68 72 84

10% 38.9 98.8 51 63 67 79 41.5 105.3 52 65 69 81 44 111.8 54 67 71 83 46.4 117.8 55 68 72 84

7

25% 39.9 101.4 51 64 68 80 42.6 108.2 53 66 70 82 45.2 114.9 55 68 72 84 47.7 121.1 56 69 73 85

50% 41.1 104.5 53 65 69 81 43.9 111.5 55 67 71 83 46.6 118.4 56 69 72 84 49.2 124.9 57 70 73 85

75% 42.4 107.6 54 66 70 82 45.2 114.9 56 68 72 84 48.1 122.1 57 70 73 85 50.7 128.8 58 71 74 86

90% 43.5 110.5 55 67 70 82 46.5 118.1 57 69 73 85 49.4 125.6 58 71 74 86 52.1 132.5 59 72 74 86

95% 44.2 112.2 55 67 71 83 47.3 120 57 70 73 85 50.3 127.7 59 71 74 86 53 134.7 60 72 75 87 Continued

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TABLE 7.1—CONT’D Age (years) BP Percentile

TABLE 7.1—CONT’D

8

9

10

11

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 47.6 121 93 107 110 122 49.3 125.3 95 108 112 124 51.1 129.7 96 109 113 125 53.4 135.6 98 111 115 127

10% 48.4 123 94 107 111 123 50.2 127.6 95 108 112 124 52 132.2 97 110 114 126 54.5 138.3 99 112 116 128

25% 49.8 126.5 95 108 112 124 51.7 131.3 97 109 113 125 53.7 136.3 98 111 114 126 56.2 142.8 101 113 117 129

50% 51.4 130.6 97 110 113 125 53.4 135.6 98 111 114 126 55.5 141 99 112 116 128 58.2 147.8 102 114 118 130

75% 53 134.7 98 111 115 127 55.1 140.1 99 112 116 128 57.4 145.8 101 113 117 129 60.2 152.8 104 116 120 132

90% 54.5 138.5 99 112 116 128 56.7 144.1 100 113 117 129 59.1 150.2 102 115 119 131 61.9 157.3 105 118 123 135

95% 55.5 140.9 100 113 117 129 57.7 146.6 101 114 118 130 60.2 152.8 103 116 120 132 63 160 106 120 124 136

DBP (mmHg) Height Percentile or Measured Height 5% 47.6 121 56 69 72 84 49.3 125.3 57 71 74 86 51.1 129.7 58 72 75 87 53.4 135.6 60 74 76 88

10% 48.4 123 56 70 73 85 50.2 127.6 58 71 74 86 52 132.2 59 73 75 87 54.5 138.3 60 74 77 89

25% 49.8 126.5 57 71 74 86 51.7 131.3 59 72 75 87 53.7 136.3 59 73 76 88 56.2 142.8 60 74 77 89

50% 51.4 130.6 59 72 74 87 53.4 135.6 60 73 75 87 55.5 141 60 73 76 88 58.2 147.8 61 74 77 89

75% 53 134.7 60 72 75 87 55.1 140.1 60 73 75 87 57.4 145.8 61 73 76 88 60.2 152.8 62 74 77 89

90% 54.5 138.5 61 73 75 87 56.7 144.1 61 73 75 87 59.1 150.2 61 73 76 88 61.9 157.3 63 75 77 89

95% 55.5 140.9 61 73 75 87 57.7 146.6 61 73 75 87 60.2 152.8 62 73 76 88 63 160 64 75 77 89 Continued

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Age (years)

12

13

14

15

Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 56.2 142.8 102 114 118 130 58.3 148.1 104 116 121 133 59.3 150.6 105 118 123 135 59.7 151.7 105 118 124 136

10% 57.3 145.5 102 115 119 131 59.3 150.6 105 117 122 134 60.2 153 106 118 123 135 60.6 154 106 119 124 136

25% 59 149.9 104 116 120 132 60.9 154.7 106 119 123 135 61.8 156.9 107 120 124 136 62.2 157.9 107 121 125 137

50% 60.9 154.8 105 118 122 134 62.7 159.2 107 121 124 136 63.5 161.3 108 122 125 137 63.9 162.3 108 122 126 138

75% 62.8 159.6 107 120 124 136 64.5 163.7 108 122 126 138 65.2 165.7 109 123 126 138 65.6 166.7 109 123 127 139

90% 64.5 163.8 108 122 125 137 66.1 167.8 108 123 126 138 66.8 169.7 109 123 127 139 67.2 170.6 109 123 127 139

95% 65.5 166.4 108 122 126 138 67 170.2 109 123 127 139 67.7 172.1 109 123 127 139 68.1 173 109 124 128 140

DBP (mmHg) Height Percentile or Measured Height 5% 56.2 142.8 61 75 78 90 58.3 148.1 62 75 79 91 59.3 150.6 63 76 80 92 59.7 151.7 64 76 80 92

10% 57.3 145.5 61 75 78 90 59.3 150.6 62 75 79 91 60.2 153 63 76 80 92 60.6 154 64 76 80 92

7

25% 59 149.9 61 75 78 90 60.9 154.7 63 75 79 91 61.8 156.9 64 76 80 92 62.2 157.9 64 76 80 92

50% 60.9 154.8 62 75 78 90 62.7 159.2 64 76 79 91 63.5 161.3 65 76 80 92 63.9 162.3 65 77 81 93

75% 62.8 159.6 64 76 79 91 64.5 163.7 65 76 80 92 65.2 165.7 66 77 81 93 65.6 166.7 66 77 82 94

90% 64.5 163.8 65 76 79 91 66.1 167.8 65 76 80 92 66.8 169.7 66 77 81 93 67.2 170.6 67 78 82 94

95% 65.5 166.4 65 76 79 91 67 170.2 66 76 81 93 67.7 172.1 66 77 82 94 68.1 173 67 78 82 94 Continued

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TABLE 7.1—CONT’D Age (years) BP Percentile

Age (years) 16

17

SBP (mmHg) Height Percentile or Measured Height

BP Percentile

DBP (mmHg) Height Percentile or Measured Height

Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th

5% 59.9 152.1 106 119 124 136 60.0 152.4 107 120 125

10% 60.8 154.5 107 120 125 137 60.9 154.7 108 121 125

25% 62.4 158.4 108 122 125 137 62.5 158.7 109 123 126

50% 64.1 162.8 109 123 127 139 64.2 163.0 110 124 127

75% 65.8 167.1 109 124 127 139 65.9 167.4 110 124 128

90% 67.3 171.1 110 124 128 140 67.4 171.3 110 125 128

95% 68.3 173.4 110 124 128 140 68.4 173.7 111 125 128

5% 59.9 152.1 64 76 80 92 60.0 152.4 64 76 80

10% 60.8 154.5 64 76 80 92 60.9 154.7 64 76 80

25% 62.4 158.4 65 76 80 92 62.5 158.7 65 77 80

50% 64.1 162.8 66 77 81 93 64.2 163.0 66 77 81

75% 65.8 167.1 66 78 82 94 65.9 167.4 66 78 82

90% 67.3 171.1 67 78 82 94 67.4 171.3 66 78 82

95% 68.3 173.4 67 78 82 94 68.4 173.7 67 78 82

95th + 12 mmHg

137

137

138

139

140

140

140

92

92

92

93

94

94

94

BP, Blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure. From Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;e20171904; https://doi.org/10.1542/peds.2017-­1904.

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TABLE 7.1—CONT’D

Age (years) 1

2

3

SBP (mmHg) Height Percentile or Measured Height

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

DBP (mmHg) Height Percentile or Measured Height

5%

10%

25%

50%

75%

90%

95%

5%

10%

25%

50%

75%

90%

95%

30.4 77.2 85 98 102 114 33.9 86.1 87 100 104 116 36.4 92.5 88 101 106 118

30.8 78.3 85 99 102 114 34.4 87.4 87 100 105 117 37 93.9 89 102 106 118

31.6 80.2 86 99 103 115 35.3 89.6 88 101 105 117 37.9 96.3 89 102 107 119

32.4 82.4 86 100 103 115 36.3 92.1 89 102 106 118 39 99 90 103 107 119

33.3 84.6 87 100 104 116 37.3 94.7 89 103 107 119 40.1 101.8 91 104 108 120

34.1 86.7 88 101 105 117 38.2 97.1 90 103 107 119 41.1 104.3 92 105 109 121

34.6 87.9 88 101 105 117 38.8 98.5 91 104 108 120 41.7 105.8 92 105 109 121

30.4 77.2 40 52 54 66 33.9 86.1 43 55 57 69 36.4 92.5 45 58 60 72

30.8 78.3 40 52 54 66 34.4 87.4 43 55 58 70 37 93.9 46 58 61 73

31.6 80.2 40 53 55 67 35.3 89.6 44 56 58 70 37.9 96.3 46 59 61 73

32.4 82.4 41 53 55 67 36.3 92.1 44 56 59 71 39 99 47 59 62 74

33.3 84.6 41 54 56 68 37.3 94.7 45 57 60 72 40.1 101.8 48 60 63 75

34.1 86.7 42 54 57 69 38.2 97.1 46 58 61 73 41.1 104.3 49 61 64 76

34.6 87.9 42 54 57 69 38.8 98.5 46 58 61 73 41.7 105.8 49 61 64 76 Continued

7

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TABLE 7.2 BLOOD PRESSURE LEVELS FOR THE 50TH, 90TH, 95TH, AND 99TH PERCENTILES OF BLOOD PRESSURE FOR BOYS AGED 1–17 YEARS BY PERCENTILES OF HEIGHT

TABLE 7.2—CONT’D

4

5

6

7

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 38.8 98.5 90 102 107 119 41.1 104.4 91 103 107 119 43.4 110.3 93 105 108 120 45.7 116.1 94 106 110 122

10% 39.4 100.2 90 103 107 119 41.8 106.2 92 104 108 120 44.2 112.2 93 105 109 121 46.5 118 94 107 110 122

25% 40.5 102.9 91 104 108 120 43.0 109.1 93 105 109 121 45.4 115.3 94 106 110 122 47.8 121.4 95 108 111 123

50% 41.7 105.9 92 105 108 120 44.3 112.4 94 106 109 121 46.8 118.9 95 107 111 123 49.3 125.1 97 109 112 124

75% 42.9 108.9 93 105 109 121 45.5 115.7 95 107 110 122 48.2 122.4 96 109 112 124 50.8 128.9 98 110 114 126

90% 43.9 111.5 94 106 110 122 46.7 118.6 96 108 111 123 49.4 125.6 97 110 113 125 52.1 132.4 98 111 115 127

95% 44.5 113.2 94 107 110 122 47.4 120.3 96 108 112 124 50.2 127.5 98 110 114 126 52.9 134.5 99 111 116 128

DBP (mmHg) Height Percentile or Measured Height 5% 38.8 98.5 48 60 63 75 41.1 104.4 51 63 66 78 43.4 110.3 54 66 69 81 45.7 116.1 56 68 71 83

10% 39.4 100.2 49 61 64 76 41.8 106.2 51 64 67 79 44.2 112.2 54 66 70 82 46.5 118 56 68 71 83

25% 40.5 102.9 49 62 65 77 43.0 109.1 52 65 68 80 45.4 115.3 55 67 70 82 47.8 121.4 57 69 72 84

50% 41.7 105.9 50 62 66 78 44.3 112.4 53 65 69 81 46.8 118.9 56 68 71 83 49.3 125.1 58 70 73 85

75% 42.9 108.9 51 63 67 79 45.5 115.7 54 66 70 82 48.2 122.4 57 68 72 84 50.8 128.9 58 70 73 85

90% 43.9 111.5 52 64 67 79 46.7 118.6 55 67 70 82 49.4 125.6 57 69 72 84 52.1 132.4 59 71 74 86

95% 44.5 113.2 52 64 68 80 47.4 120.3 55 67 71 83 50.2 127.5 58 69 73 85 52.9 134.5 59 71 74 86 Continued

152  Part II  Diagnostic and Therapeutic Information

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Age (years)

8

9

10

11

Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 47.8 121.4 95 107 111 123 49.6 126 96 107 112 124 51.3 130.2 97 108 112 124 53 134.7 99 110 114 126

10% 48.6 123.5 96 108 112 124 50.5 128.3 97 108 112 124 52.2 132.7 98 109 113 125 54 137.3 99 111 114 126

25% 50 127 97 109 112 124 52 132.1 98 109 113 125 53.8 136.7 99 111 114 126 55.7 141.5 101 112 116 128

50% 51.6 131 98 110 114 126 53.7 136.3 99 110 115 127 55.6 141.3 100 112 116 128 57.6 146.4 102 114 118 130

75% 53.2 135.1 99 111 115 127 55.4 140.7 100 112 116 128 57.4 145.9 101 113 118 130 59.6 151.3 103 116 120 132

90% 54.6 138.8 99 112 116 128 56.9 144.7 101 113 118 130 59.1 150.1 102 115 120 132 61.3 155.8 104 117 123 135

95% 55.5 141 100 112 117 129 57.9 147.1 101 114 119 131 60.1 152.7 103 116 121 133 62.4 158.6 106 118 124 136

DBP (mmHg) Height Percentile or Measured Height 5% 47.8 121.4 57 69 72 84 49.6 126 57 70 74 86 51.3 130.2 59 72 76 88 53 134.7 61 74 77 89

10% 48.6 123.5 57 70 73 85 50.5 128.3 58 71 74 86 52.2 132.7 60 73 76 88 54 137.3 61 74 78 90

7

25% 50 127 58 70 73 85 52 132.1 59 72 75 87 53.8 136.7 61 74 77 89 55.7 141.5 62 75 78 90

50% 51.6 131 59 71 74 86 53.7 136.3 60 73 76 88 55.6 141.3 62 74 77 89 57.6 146.4 63 75 78 90

75% 53.2 135.1 59 72 75 87 55.4 140.7 61 74 76 88 57.4 145.9 63 75 78 90 59.6 151.3 63 75 78 90

90% 54.6 138.8 60 72 75 87 56.9 144.7 62 74 77 89 59.1 150.1 63 75 78 90 61.3 155.8 63 76 78 90

95% 55.5 141 60 73 75 87 57.9 147.1 62 74 77 89 60.1 152.7 64 76 78 90 62.4 158.6 63 76 78 90 Continued

Chapter 7 Cardiology  153

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TABLE 7.2—CONT’D Age (years) BP Percentile

Age (years) 12

13

14

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 55.2 140.3 101 113 116 128 57.9 147 103 115 119 131 60.6 153.8 105 119 123 135

10% 56.3 143 101 114 117 129 59.1 150 104 116 120 132 61.8 156.9 106 120 125 137

25% 58.1 147.5 102 115 118 130 61 154.9 105 118 122 134 63.8 162 109 123 127 139

50% 60.1 152.7 104 117 121 133 63.1 160.3 108 121 125 137 65.9 167.5 111 126 130 142

75% 62.2 157.9 106 119 124 136 65.2 165.7 110 124 128 140 68.0 172.7 112 127 132 144

90% 64 162.6 108 121 126 138 67.1 170.5 111 126 130 142 69.8 177.4 113 128 133 145

95% 65.2 165.5 109 122 128 140 68.3 173.4 112 126 131 143 70.9 180.1 113 129 134 146

DBP (mmHg) Height Percentile or Measured Height 5% 55.2 140.3 61 75 78 90 57.9 147 61 74 78 90 60.6 153.8 60 74 77 89

10% 56.3 143 62 75 78 90 59.1 150 60 74 78 90 61.8 156.9 60 74 78 90

25% 58.1 147.5 62 75 78 90 61 154.9 61 74 78 90 63.8 162 62 75 79 91

50% 60.1 152.7 62 75 78 90 63.1 160.3 62 75 78 90 65.9 167.5 64 77 81 93

75% 62.2 157.9 62 75 78 90 65.2 165.7 63 76 80 92 68.0 172.7 65 78 82 94

90% 64 162.6 63 76 79 91 67.1 170.5 64 77 81 93 69.8 177.4 66 79 83 95

95% 65.2 165.5 63 76 79 91 68.3 173.4 65 77 81 93 70.9 180.1 67 80 84 96 Continued

154  Part II  Diagnostic and Therapeutic Information

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TABLE 7.2—CONT’D

Age (years) 15

16

17

BP Percentile Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg Height (in) Height (cm) 50th 90th 95th 95th + 12 mmHg

SBP (mmHg) Height Percentile or Measured Height 5% 62.6 159 108 123 127 139 63.8 162.1 111 126 130 142 64.5 163.8 114 128 132 144

10% 63.8 162 110 124 129 141 64.9 165 112 127 131 143 65.5 166.5 115 129 133 145

25% 65.7 166.9 112 126 131 143 66.8 169.6 114 128 133 145 67.3 170.9 116 130 134 146

50% 67.8 172.2 113 128 132 144 68.8 174.6 115 129 134 146 69.2 175.8 117 131 135 147

75% 69.8 177.2 114 129 134 146 70.7 179.5 115 131 135 147 71.1 180.7 117 132 137 149

90% 71.5 181.6 114 130 135 147 72.4 183.8 116 131 136 148 72.8 184.9 118 133 138 150

95% 72.5 184.2 114 130 135 147 73.4 186.4 116 132 137 149 73.8 187.5 118 134 138 150

DBP (mmHg) Height Percentile or Measured Height 5% 62.6 159 61 75 78 90 63.8 162.1 63 77 80 92 64.5 163.8 65 78 81 93

10% 63.8 162 62 76 79 91 64.9 165 64 78 81 93 65.5 166.5 66 79 82 94

25% 65.7 166.9 64 78 81 93 66.8 169.6 66 79 83 95 67.3 170.9 67 80 84 96

50% 67.8 172.2 65 79 83 95 70.7 174.6 67 80 84 96 69.2 175.8 68 81 85 97

75% 69.8 177.2 66 80 84 96 70.7 179.5 68 81 85 97 71.1 180.7 69 82 86 98

BP, Blood pressure; DBP, diastolic blood pressure; SBP, systolic blood pressure. From Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;e20171904; https://doi.org/10.1542/peds.2017-­1904.

7

90% 71.5 181.6 67 81 85 97 72.4 183.8 69 82 86 98 72.8 184.9 70 82 86 98

95% 72.5 184.2 68 81 85 97 73.4 186.4 69 82 86 98 73.8 187.5 70 83 87 99

Chapter 7 Cardiology  155

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TABLE 7.2—CONT’D

156  Part II  Diagnostic and Therapeutic Information BOX 7.1 SUMMARY OF ABNORMAL HEART SOUNDS • W  idely split S1: Ebstein anomaly, RBBB • Widely split and fixed S2: Right ventricular volume overload (e.g., ASD, PAPVR), pressure overload (e.g., PS), electrical delay in RV contraction (e.g., RBBB), early aortic closure (e.g., MR), occasionally heard in normal child • Narrowly split S2: Pulmonary hypertension, AS, delay in LV contraction (e.g., LBBB), occasionally heard in normal child • Single S2: Pulmonary hypertension, one semilunar valve (e.g., pulmonary atresia, aortic atresia, truncus arteriosus), P2 not audible (e.g., TGA, TOF, severe PS), severe AS, occasionally heard in normal child • Paradoxically split S2: Severe AS, LBBB, Wolff-­Parkinson-­White syndrome (type B) • Abnormal intensity of P2: Increased P2 (e.g., pulmonary hypertension), decreased P2 (e.g., severe PS, TOF, TS) • S3: Occasionally heard in healthy children or adults or may indicate dilated ventricles (e.g., large VSD, CHF) • S4: Always pathologic, indicative of decreased ventricular compliance • Ejection click: Heard with stenosis of the semilunar valves, dilated great arteries in the setting of pulmonary or systemic HTN, idiopathic dilation of the PA, TOF, persistent truncus arteriosus • Midsystolic click: Heard at the apex in mitral valve prolapse • Diastolic opening snap: Rare in children; associated with TS/MS AS, Aortic stenosis; ASD, atrial septal defect; CHF, congestive heart failure; LBBB, left bundle-­ branch block; LV, left ventricle; MR, mitral regurgitation; MS, mitral stenosis; PA, pulmonary artery; PAPVR, partial anomalous pulmonary venous return; PS, pulmonic stenosis; RBBB, right bundle-­ branch block; RV, right ventricular; TGA, transposition of the great arteries; TOF, tetralogy of fallot; TS, tricuspid stenosis; VSD, ventricular septal defect. Modified from Park MK. Pediatric Cardiology for Practitioners. 5th ed. St Louis: Elsevier; 2008:25.

1. Grading of heart murmurs: Intensified by states of higher cardiac output (e.g., anemia, anxiety, fever, exercise).3 a. Grade I: Barely audible b. Grade II: Murmur softer than heart sounds, but audible c. Grade III: Murmur moderately loud, equally loud as heart sounds, not accompanied by a thrill d. Grade IV: Murmur louder than heart sounds, associated with a thrill e. Grade V: Audible with a stethoscope barely on the chest f. Grade VI: Audible with a stethoscope off the chest 2. Benign heart murmurs4: a. Caused by a disturbance of the laminar flow of blood; frequently produced as the diameter of the blood’s pathway decreases and velocity increases. b. Present in >80% of children sometime during childhood, most commonly beginning at age 3 to 4 years. c. Accentuated in high-­output states, especially with fever and anemia. d. Normal electrocardiogram (ECG) and radiographic findings. NOTE: ECG and chest radiograph are not routinely used, nor are they cost-­effective screening tools for distinguishing benign from pathologic murmurs.

Chapter 7 Cardiology  157 TABLE 7.3 COMMON INNOCENT HEART MURMURS Description of Murmur

Classic vibratory murmur (Still’s murmur; systolic)

Age Group

Maximal at LMSB or between LLSB and apex Grade 2–3/6 in intensity Low-­frequency vibratory, twanging string, groaning, squeaking, or musical Pulmonary ejection Maximal at LUSB murmur (systolic) Early to midsystolic Grade 1–3/6 in intensity Blowing in quality Pulmonary flow murmur Maximal at LUSB of newborn (systolic) Transmits well to left and right chest, axilla, and back Grade 1–2/6 in intensity Venous hum Maximal at right (or left) supraclavicular and (continuous) infraclavicular areas Grade 1–3/6 in intensity Inaudible in supine position Intensity changes with rotation of head and disappears with compression of jugular vein

3–6 years; occasionally in infancy

Carotid bruit (systolic)

Any age

Right supraclavicular area over carotids Grade 2–3/6 in intensity Occasional thrill over carotid

8–14 years

Premature and full-­ term newborns Usually disappears by 3–6 months 3–6 years

LLSB, Left lower sternal border; LMSB, left middle sternal border; LUSB, left upper sternal border From Park MK. Pediatric Cardiology for Practitioners. 5th ed. St Louis: Elsevier; 2008:36.

3. A murmur is more likely to be pathologic when one or more of the following are present: Symptoms (e.g., chest pain, dyspnea with exertion, syncope with exertion); cyanosis; a systolic murmur that is loud (grade ≥3/6), harsh, pansystolic, or long in duration; diastolic murmur; abnormal heart sounds; presence of a click; abnormally strong or weak pulses.3,4 4. Systolic and diastolic heart murmurs (Box 7.2). 

II. ELECTROCARDIOGRAPHY A.  Basic Electrocardiography Principles 1. Lead placement (Fig. 7.1) 2. ECG complexes a. P wave: Represents atrial depolarization. b. QRS complex: Represents ventricular depolarization. c. T wave: Represents ventricular repolarization. d. U wave: May follow the T wave and represents late phases of ventricular repolarization. 3. Systematic approach for evaluating ECGs (Table 7.4 shows normal ECG parameters):3,5 a. Rate

7

Type (Timing)

158  Part II  Diagnostic and Therapeutic Information BOX 7.2 SYSTOLIC AND DIASTOLIC HEART MURMURS RUSB Aortic valve stenosis (supravalvular, subvalvular) Aortic regurgitation  LUSB Pulmonary valve stenosis Atrial septal defect Pulmonary ejection murmur, innocent Pulmonary flow murmur of newborn Pulmonary artery stenosis Aortic stenosis Coarctation of the aorta Patent ductus arteriosus Partial anomalous pulmonary venous return (PAPVR) Total anomalous pulmonary venous return (TAPVR) Pulmonary regurgitation  LLSB Ventricular septal defect, including atrioventricular septal defect Vibratory innocent murmur (Still’s murmur) HOCM (IHSS) Tricuspid regurgitation Tetralogy of Fallot Tricuspid stenosis  Apex Mitral regurgitation Vibratory innocent murmur (Still’s murmur) Mitral valve prolapse Aortic stenosis HOCM (IHSS) Mitral stenosis Murmurs listed by the location at which they are best heard. Diastolic murmurs are in italics. HOCM, Hypertrophic obstructive cardiomyopathy; IHSS, idiopathic hypertrophic subaortic stenosis; LLSB, left lower sternal border; LUSB, left upper sternal border; RUSB, right upper sternal border. From Park MK. Pediatric Cardiology for Practitioners. 5th ed. St Louis: Elsevier; 2008:30.

(1) Standardization: Paper speed is 25 mm/sec. One small square = 1 mm = 0.04 second. One large square = 5 mm = 0.2 second. Amplitude standard: 10 mm = 1 mV. (2) Calculation: HR (beats/min) = 60 divided by the average R-­R interval in seconds, or 1500 divided by the R-­R interval in millimeters. b. Rhythm (1) Sinus rhythm: Every QRS complex is preceded by a P wave, normal PR interval (although PR interval may be prolonged, as in first-­degree atrioventricular [AV] block), and normal P-­wave axis (upright P in leads I and aVF).

Chapter 7 Cardiology  159

90° aVR

aVL V6

0° I

180°

V5

A

aVF 90°

II

V4R

B

V4 V1

V2

V3

FIGURE 7.1 (A) Hexaxial reference system, (B) Horizontal reference system. (Modified from Park MK, Guntheroth WG. How to Read Pediatric ECGs. 4th ed. Philadelphia: Elsevier; 2006:3.)













(2) There is normal respiratory variation of the R-­R interval without morphologic changes of the P wave or QRS complex. c. Axis: The direction of the QRS in leads I and aVF should be observed, the quadrant determined, and comparison made with age-­ matched normal values (Fig. 7.2 and Table 7.4). d. Intervals (PR, QRS, QTc) (1) See Table 7.4 for normal PR and QRS intervals. (2) The QTc is calculated using the Bazett formula: QTc = QT (sec) measured/√R-­R (the average of three measurements taken from the same lead, usually lead II). (3) The QT interval is measured from the beginning of the QRS complex to the end of the T wave. Divide this value by the square root of the preceding R-­R interval to obtain the QTc. (4)  Normal values for QTc are: (a) 0.44 second is the 97th percentile for infants 3 to 4 days old.6 (b) ≤0.45 second in all males aged >1 week and in prepubescent females. (c) ≤0.46 second for postpubescent females. e. P-­wave size and shape: A normal P wave should be 98th percentile for age S in lead V6, >98th percentile for age Right ventricular strain (associated with inverted T wave in V1 with tall R wave)  Left Ventricular Hypertrophy (LVH) Criteria Left ventricular strain (associated with inverted T wave in leads V6, I, and/or aVF)  Left axis deviation (LAD) for patient’s age Volume overload (associated with Q wave >5 mm and tall T waves in V5 or V6) Increased QRS voltage in left leads (with normal QRS duration): R in lead V6 (and I, aVL, V5), >98th percentile for age S in lead V1, >98th percentile for age

C.  ECG Findings Secondary to Electrolyte Disturbances, Medications, and Systemic Illnesses (Table 7.10)7,9 D. Long QT 1. Diagnosis: a. In general, QTc is similar in males and females from birth until late adolescence (0.37 to 0.44 second). b. In adults, prolonged QTc is generally >0.45 second. c. In ∼10% of cases, patients may have a normal QTc. Patients may also have a family history of long QT associated with unexplained syncope, seizure, or cardiac arrest, without prolongation of QTc on ECG. d. Treadmill exercise testing may prolong the QTc and will sometimes induce arrhythmias. 2. Complications: Associated with ventricular arrhythmias (torsades de pointes), syncope, and sudden death. 3. Management: a. Congenital long QT: β-­blockers and/or defibrillators; rarely requires cardiac sympathetic denervation or cardiac pacemakers. b. Acquired long QT: Treatment of arrhythmias, discontinuation of precipitating drugs, and correction of metabolic abnormalities.  E. Hyperkalemia: ECG changes dependent on the serum potassium (K+) level; however, the ECG may be normal with serum K+ levels between 2.5 and 6 mEq/L. 1. Serum K+ 6 mEq/L: Tall T wave.

7

Supplemental Criteria

Name/Description

Cause

Treatment

Hypovolemia, shock, anemia, sepsis, fever, anxiety, CHF, PE, myocardial disease, drugs (e.g., β-­ agonists, albuterol, caffeine, atropine)

Address underlying cause

Normal (especially in athletic individuals), increased ICP, hypoxia, hyperkalemia, hypercalcemia, vagal stimulation, hypothyroidism, hypothermia, drugs (e.g., opioids, digoxin, β-­blockers), long QT

Address underlying cause; if symptomatic, refer to inside back cover for bradycardia algorithm

SINUS TACHYCARDIA Normal sinus rhythm with HR >95th percentile for age (usually infants: 30 sec) or non-­sustained

166  Part II  Diagnostic and Therapeutic Information

RR

2XRR p1

Premature atrial contraction (PAC)

Atrial flutter

Atrial fibrillation

FIGURE 7.5 Supraventricular Arrhythmias.  p1, Premature atrial contraction. (From Park MK, Guntheroth WG. How to Read Pediatric ECGs. 4th ed. Philadelphia: Elsevier; 2006:129.)

TABLE 7.7 VENTRICULAR ARRHYTHMIAS Name/Description

Cause

Treatment

PREMATURE VENTRICULAR CONTRACTION (PVC) Ectopic ventricular focus causing Myocarditis, myocardial injury, None; more worrisome if early depolarization. Abnormally cardiomyopathy, long QT, associated with underlywide QRS complex appears congenital and acquired ing heart disease or prematurely, usually with full heart disease, drugs syncope, if worse with compensatory pause. May be (catecholamines, theophylactivity, or if they are unifocal or multifocal line, caffeine, anesthetics), multiform (especially couBigeminy: Alternating normal and MVP, anxiety, hypokalemia, plets); address underlying abnormal QRS complexes. hypoxia, hypomagnesemia; cause; rule out structural Trigeminy: Two normal QRS comcan be normal variant heart disease plexes followed by an abnormal one Couplet: Two consecutive PVCs VENTRICULAR TACHYCARDIA Series of three or more PVCs at rapid See causes of PVCs (70% have Refer to front of book for rate (120–250 beats/min), with underlying cause) tachycardia with poor wide QRS complex and dissociated, perfusion and tachycardia retrograde, or no P wave with adequate perfusion algorithms VENTRICULAR FIBRILLATION Depolarization of ventricles in unco- Myocarditis, MI, postoperative ordinated asynchronous pattern, state, digitalis or quinidine yielding abnormal QRS complexes toxicity, catecholamines, of varying size and morphology severe hypoxia, electrolyte with irregular, rapid rate; rare in disturbances, long QT children. MI, Myocardial infarction; MVP, mitral valve prolapse.

Requires immediate defibrillation; refer to front of book for asystole and pulseless arrest algorithm

Chapter 7 Cardiology  167

RR

2XRR

Premature ventricular contraction (PVC) PVC p

p

p

p

p

Ventricular tachycardia

FIGURE 7.6 Ventricular Arrhythmias.  p, P wave; PVC, premature ventricular contraction; RR, R-­R interval. (From Park MK, Guntheroth WG. How to Read Pediatric ECGs. 4th ed. Philadelphia: Elsevier; 2006:138.)

TABLE 7.8 NONVENTRICULAR CONDUCTION DISTURBANCES Name/Descriptiona

Cause

Treatment

FIRST-­DEGREE HEART BLOCK Abnormal but asymptomatic Acute rheumatic fever, tick-­borne (e.g., No specific treatment delay in conduction through AV Lyme) disease, connective tissue except to address node, yielding prolongation of disease, congenital heart disease, the underlying PR interval cardiomyopathy, digitalis toxicity, cause postoperative state, normal children SECOND-­DEGREE HEART BLOCK: MOBITZ TYPE I (WENCKEBACH) Progressive lengthening of PR Myocarditis, cardiomyopathy, congenital Address underlying interval until a QRS complex is heart disease, postoperative state, MI, cause, or none not conducted; common finding toxicity (digitalis, β-­blocker), normal needed in asymptomatic teenagers children, Lyme disease, lupus SECOND-­DEGREE HEART BLOCK: MOBITZ TYPE II Loss of conduction to ventricle without lengthening of the PR interval; may progress to complete heart block

Same as for Mobitz type I

Address underlying cause; may need pacemaker

THIRD-­DEGREE (COMPLETE) HEART BLOCK Complete dissociation of atrial Congenital due to maternal lupus or and ventricular conduction, other connective tissue disease with atrial rate faster than ventricular rate; P wave and PP interval regular; RR interval regular and much slower aHigh-­degree

If bradycardic and symptomatic, consider pacing; refer to back of the book for bradycardia algorithm

AV block: Conduction of atrial impulse at regular intervals, yielding 2:1 block (two atrial impulses for each ventricular response), 3:1 block, etc. AV, Atrioventricular; MI, myocardial infarction.

7

Ventricular fibrillation

168  Part II  Diagnostic and Therapeutic Information

p

First-degree AV block

Second-degree AV block Mobitz type I p (Wenckebach phenomenon) p Mobitz type II 2:1 AV block

p

p

p

p

p

p p

p p

p p

p

p

p

p

p

p

p

p p

p

p

R R R R p Complete (third-degree) p p p p p p p p p AV block FIGURE 7.7 Conduction Blocks.  p, P wave; R, QRS complex. (From Park MK, Guntheroth WG. How to Read Pediatric ECGs. 4th ed. Philadelphia: Elsevier; 2006:141.)

TABLE 7.9 VENTRICULAR CONDUCTION DISTURBANCES Name/Description

Criteria

Causes/Treatment

RIGHT BUNDLE-­BRANCH BLOCK (RBBB) Delayed right bundle conduction prolongs RV depolarization time, leading to wide QRS

1. Prolonged or wide QRS with ASD, surgery with right terminal slurred R′ (m-­shaped ventriculotomy, RSR′ or RR′) in V1, V2, aVR occasionally seen in 2. Wide and slurred S wave in normal children leads I and V6

LEFT BUNDLE-­BRANCH BLOCK (LBBB) Delayed left bundle conduction pro- 1. Wide negative QRS complex in Hypertension, longs septal and LV depolarization lead V1 with loss of septal R ischemic or valvular time, leading to wide QRS with wave heart disease, loss of usual septal signal; there 2. Wide R or RR′ complex in lead cardiomyopathy is still a predominance of left V6 with loss of septal Q wave ventricle forces; rare in children. WOLFF-­PARKINSON-­WHITE (WPW) Atrial impulse transmitted via 1. Shortened PR interval anomalous conduction pathway 2. Delta wave to ventricles, bypassing AV 3. Wide QRS node and normal ventricular conduction system; leads to early and prolonged depolarization of ventricles; bypass pathway is a predisposing condition for SVT

Acute management of SVT if necessary, as previously described; consider ablation of accessory pathway if recurrent SVT; all patients need cardiology referral

ASD, Atrial septal defect; LV, left ventricle; RV, right ventricle; SVT, supraventricular tachycardia.

Short QT Long QT-­U

Prolonged QRS

ST-­T Changes

X

X

Sinus Tachycardia

Sinus Bradycardia

AV Block

Ventricular Tachycardia

X

X

X

X X X

X

T

X

T T

X

X T

Miscellaneous

CHEMISTRY Hyperkalemia Hypokalemia Hypercalcemia Hypocalcemia Hypermagnesemia Hypomagnesemia DRUGS Digitalis Phenothiazines Phenytoin Propranolol Tricyclic antidepressants Verapamil MISCELLANEOUS CNS injury

X

Low-­voltage P waves; peaked T waves

X

X X

X

X X

X T

X X T

X

T

T

X

T

X

X

X

X

X

7

T

Chapter 7 Cardiology  169

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TABLE 7.10 SYSTEMIC EFFECTS ON ELECTROCARDIOGRAM

Short QT Long QT-­U Friedreich ataxia Duchenne muscular dystrophy Myotonic dystrophy Collagen vascular disease Hypothyroidism Hyperthyroidism Lyme disease Holt-­Oram, maternal lupus

Prolonged QRS

X

ST-­T Changes X

Sinus Tachycardia X X

X X

X

X

X

Sinus Bradycardia

AV Block

Ventricular Tachycardia

X X

X

X

X X X

Miscellaneous Atrial flutter Atrial flutter

Low voltage X X X

CNS, Central nervous system; T, present only with drug toxicity; X, present. Data from Garson A Jr. The Electrocardiogram in Infants and Children: A Systematic Approach. Philadelphia: Lea & Febiger; 1983:172; and Walsh EP. Cardiac arrhythmias. In: Fyler DC, Nadas A, eds. Pediatric Cardiology. Philadelphia: Hanley & Belfus; 1992:141–143.

170  Part II  Diagnostic and Therapeutic Information

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TABLE 7.10—CONT’D

Chapter 7 Cardiology  171

Syndrome

Dominant Cardiac Defect

CHARGE DiGeorge Trisomy 21 Marfan Loeys-­Dietz Noonan Turner Williams FAS IDM VATER/VACTERL

TOF, truncus arteriosus, aortic arch abnormalities Aortic arch anomalies, TOF, truncus arteriosus, VSD, PDA Atrioventricular septal defect, VSD Aortic root dilation, mitral valve prolapse Aortic root dilation with higher risk of rupture at smaller dimensions Supravalvular pulmonic stenosis, LVH COA, bicuspid aortic valve, aortic root dilation as a teenager Supravalvular aortic stenosis, pulmonary artery stenosis Occasional: VSD, PDA, ASD, TOF TGA, VSD, COA, cardiomyopathy VSD

VCFS

Truncus arteriosus, TOF, pulmonary atresia with VSD, TGA, interrupted aortic arch

ASD, Atrial septal defect; CHARGE, a syndrome of associated defects including Coloboma of the eye, Heart anomaly, choanal Atresia, Retardation, and Genital and Ear anomalies; COA, coarctation of aorta; FAS, fetal alcohol syndrome; IDM, infant of diabetic mother; LVH, left ventricular hypertrophy; PDA, patent ductus arteriosus; TGA, transposition of the great arteries; TOF, tetralogy of Fallot; VATER/VACTERL, association of Vertebral anomalies, Anal atresia, Cardiac anomalies, Tracheoesophageal fistula, Renal/radial anomalies, Limb defects; VCFS, velocardiofacial syndrome; VSD, ventricular septal defect. From Park MK. Pediatric Cardiology for Practitioners. 5th ed. St Louis: Elsevier; 2008:10–12.

3. Serum K+ >7.5 mEq/L: Long PR interval, wide QRS, tall T wave. 4. Serum K+ >9 mEq/L: Absent P wave, sinusoidal. 

III.  CONGENITAL HEART DISEASE A.  Pulse Oximetry Screening for Critical Congenital Heart Disease 1. To be done as late as possible, but before discharge from nursery, preferably >24 hours of life, due to decreased false-­positive rate. Recommended to use the right hand and 1 foot, either in parallel or direct sequence. 2. The screening result would be considered positive if: a. Any oxygen saturation measure 5% between upper and lower extremities is also suggestive of coarctation

Chest Radiograph Findings Usually normal

Marked cardiomegaly and pulmonary venous congestion Rib notching from collateral circulation usually not seen in children younger than 5 years because collaterals not yet established

AR, Aortic regurgitation; ASD, atrial septal defect; BP, blood pressure; BVH, biventricular hypertrophy; CDG, congenital disorders of glycosylation; CHD, congenital heart disease; CHF, congestive heart failure; HTN, hypertension; LAE, left atrial enlargement; LICS, left intercostal space; LLSB, left lower sternal border; LUSB, left upper sternal border; LVH, left ventricular hypertrophy; MR, mitral regurgitation; PVM, pulmonary vascular markings; RAD, right axis deviation; RAE, right atrial enlargement; RBBB, right bundle-­branch block; RICS, right intercostal space; RUSB, right upper sternal border; RVH, right ventricular hypertrophy; SEM, systolic ejection murmur; VLBW, very low birth weight (i.e., 150 indicates pulmonary rather than cardiac disease. Note: Pulse oximetry is not useful for following changes in oxygenation once saturation has reached 100% (approximately a Pao2 of >90 mmHg).12–17 See Table EC 7.A for interpretation of oxygen challenge test (hyperoxia test). 

IV.  ACQUIRED HEART DISEASE A.  Myocardial Infarction (MI) in Children (Box 7.4; Fig. 7.8) B. Endocarditis 1. Common causative organisms: Approximately 70% of endocarditis is caused by streptococcal species (Streptococcus viridans, enterococci), 20% by staphylococcal species (Staphylococcus aureus, Staphylococcus epidermidis), and 10% by other organisms (Haemophilus influenzae, gram-­negative bacteria, fungi). 2. Presentation: Heart murmur, recurrent fever, splenomegaly, petechiae, fatigue, Osler nodes (tender nodules at the fingertips), Janeway lesions (painless hemorrhagic areas on the palms or soles), splinter hemorrhages, Roth spots (retinal hemorrhages). 3. Diagnosis—Duke’s Criteria: a. Pathologic criteria: (1) Direct evidence of endocarditis based upon histologic findings. (2) Gram stain positive or cultures of specimens. b. Clinical criteria: 1 major criterion and 1 minor OR 3 minor criteria: (1) Major: Persistently positive blood cultures (2 sets 1 hour apart), positive echocardiogram for vegetations, new regurgitant murmur, single positive blood culture for Coxiella burnetii. (2) Minor: Fever, predisposing valvular condition (prosthetic heart valve, valve lesion OR intravenous drug user [IVDU]), vascular phenomenon (e.g., emboli), immunologic phenomenon (e.g., Roth’s spots, Osler’s nodes), positive blood cultures that do not meet major criteria. 4. Management: Daily blood cultures while febrile; support heart failure symptoms with diuretics, digoxin, etc.  C.  Bacterial Endocarditis Prophylaxis See Box 7.5 for cardiac conditions that meet criteria for prophylaxis.18 1. All dental procedures that involve treatment of gingival tissue, the periapical region of the teeth, or oral mucosal perforation. 2. Invasive procedures that involve incision or biopsy of respiratory mucosa, such as tonsillectomy and adenoidectomy. 3. Not recommended for genitourinary or gastrointestinal tract procedures; solely for bacterial endocarditis prevention. 4. Treatment: Amoxicillin is preferred PO; ampicillin if unable to take PO; cephalexin if allergic to penicillins.28 

FiO2 = 0.21 PaO2 (% Saturation)

FiO2 = 1.00 PaO2 (% Saturation)

PaCO2

Normal Pulmonary disease Neurologic disease Methemoglobinemia Cardiac disease •Separate circulationa •Restricted PBFb •Complete mixing without restricted PBFc Persistent pulmonary hypertension PFO (no R to L shunt)

70 (95) 50 (85) 50 (85) 70 (85)

>200 (100) >150 (100) >150 (100) >200 (85)

35 50 50 35