The Critically Ill Or Comatose Infant: An Organized Approach

Table of Contents

 

1. Abstract
2. Critical Appraisal Of The Literature
3. Epidemiology, Etiology, And Pathophysiology
   1. Shock States
   2. Brain Dysfunction
   3. Respiratory Failure
   4. Cellular Hypoxia
4. Differential Diagnosis
   1. Infectious And Respiratory Causes
      1. Bacterial Tracheitis
      2. Bronchiolitis/Asthma
      3. Infant Botulism
      4. Meningitis/Encephalitis
   2. Cardiac Causes
      1. Arrhythmias
      2. Myocarditis
      3. Supraventricular Tachycardia
      4. Ductus Arteriosus Dependent Lesions
   3. Genitourinary Causes
   4. Gastrointestinal Causes
      1. Appendicitis
      2. Intussusception
      3. Bowel Obstruction
      4. Dehydration
   5. Endocrinologic/Metabolic Causes
      1. Congenital Adrenal Hyperplasia
      2. Hypoglycemia
      3. Diabetic Ketoacidosis
   6. Neurologic Causes
   7. Traumatic Causes
   8. Toxicologic Causes
5. Prehospital Care
6. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. General Appearance
   3. Vital Signs
   4. Head Examination
   5. Neck Examination
   6. Chest Examination
   7. Abdomen Examination
   8. Skin Examination
   9. Neurologic Examination
   10. Monitoring
7. Interventions
   1. Intubation
   2. Fluid Administration And Blood Pressure Support
   3. Treatment Of Hypoglycemia
   4. Antibiotics
   5. Management Of Bronchiolitis
8. Diagnostic Studies
   1. Bedside Tests
   2. Laboratory Tests
   3. Radiology Tests
9. Special Circumstances
   1. Ventriculoperitoneal Shunts
   2. Sickle Cell Disease
   3. Known Inborn Errors Of Metabolism
   4. Transplant Recipients
   5. Technology-Dependent Children
   6. Neonatal Intensive Care Unit Graduates/Bronchopulmonary Dysplasia
   7. Chemotherapy Patients
   8. Congenital Heart Disease
10. Common Pitfalls/Medicolegal Issues
11. Disposition
12. Summary
13. Risk Management
14. Cost- And Time-Effective Strategies
15. Clinical Pathway: Managing The Critically Ill Neonate (First Several Weeks Of Life)
16. Clinical Pathway: Managing The Critically Ill Neonate (First Several Weeks Of Life) (continued)
17. Clinical Pathway: Managing The Critically Ill Older Infant (A Few Weeks To About 18 Months Of Age)
18. Clinical Pathway: Managing The Critically Ill Older Infant (A Few Weeks To About 18 Months Of Age) (continued)
19. Tables
    1. Some Clinical Features Of The Critically Ill Appearance In Infants
    2. Differential Diagnosis Of The Critically Ill-Appearing Or Comatose Emergency Infant In The ED.
    3. Selected Pediatric Toxicologic Substances And Their Presenting Symptoms
    4. Selected Treatment Recommendations And Their Underlying Rationale For Critically Ill Or Comatose Infants
    5. Common Diagnostic Tests Used In Evaluating The Critically lll Or Comatose Infant
    6. General Principles For The Care Of The Technology Dependent Critically ill Child
    7. Avoiding Medical Malpractice Axioms You Can Trust
20. References

Abstract

The crashing infant is a challenge in any setting. From the largest specialty children's center to the smallest rural ED, a dying baby creates havoc. Even when you think you're prepared, things appear chaotic. Procedures go wrong; rarely used equipment seems to disappear. IV access becomes impossible for even the most experienced hands; your mind freezes when trying to calculate drug doses. The right decisions must come quickly or a baby will die.

Even if a children's center is down the street, parents might panic and bring an ill infant to the closest facility; therefore, every emergency physician and every ED must prepare for this scenario. Critically ill children arrive in all kinds of EDs, at all times throughout the day and night.¹

This article will help the emergency physician stay organized and minimize the chaos that can ensue when caring for critically ill infants (up to about 18 months of age). Emergencies pertaining to full cardiopulmonary arrest (e.g., sudden infant death syndrome), precipitous deliveries, known trauma, or emergencies occurring in otherwise well infants (e.g., the management of fever in the well-appearing infant, generalized [tonic-clonic] status epilepticus, and apparent life-threatening events) are beyond the scope of this article.

Critical Appraisal Of The Literature

The literature on critically ill infants primarily focuses on the final diagnoses and not the initial presentation. In addition, because many of the related conditions are relatively rare, there are few randomized, controlled trials covering them, not to mention that there are potential ethical conflicts in conducting such trials in critically ill children.² Further confounding the issue is that the critically ill state is not as well studied or defined as, for example, full cardiopulmonary arrest.^3,4 There are some good systematic reviews regarding individual conditions such as bronchiolitis.⁵ However, in the case of unusual diseases, we are left with small case series or reviews that extend over years or even decades.^6,7

Epidemiology, Etiology, And Pathophysiology

Many diverse conditions can cause critical illness in infants, and the progression from a relatively well appearance to arrest may be rapid or relatively gradual. Many of these critically ill infants have common signs and symptoms regardless of etiology. (See Table 1.) Determining the underlying etiology can help tailor care to the individual patient. The major causes of the critically ill or comatose state include shock states, brain dysfunction, respiratory failure, cellular hypoxia, and intussusception. Unfortunately, one precipitant can ultimately cause another; a child with pneumonia may also be hypoxic, hypoglycemic, and develop shock and respiratory failure as the disease process progresses. Therefore, the inter-related etiologies in the critically ill infant make identifying multiple causes an important exercise. Causes of critical illness can occur in surprising combinations, as seen in a case report describing a child with primary hypoglycemia presenting in acute respiratory failure.¹⁶

Shock States

Shock is a physiologic state in which there is inadequate tissue perfusion to meet metabolic demand.¹⁷ Compensatory mechanisms preferentially maintain blood flow to the heart and brain, often leaving the skin cold and clammy. As the shock state worsens, the patient will progress from tachycardia and normal blood pressure to tachycardia and hypotension, then to bradycardia, and finally full arrest. (See Table 1.) The most common forms of shock in young children are hypovolemic (broadly defined) and cardiogenic.

Pump failure can be due to congenital/genetic causes or acquired (usually infectious) causes.¹⁸ Acquired cardiomyopathies are more common in older children and adolescents than infants.¹⁹

Risk Management

1. "It was a cold night, so I thought that was the reason for his low temperature."

Oral and axillary temperatures may be misleading, but if the rectal temperature is low, the child is in trouble. Sepsis and hypoglycemia are two common medical emergencies that may account for a low rectal temperature.

2. "She's not diabetic, so I didn't even think about hypoglycemia. Besides, she wasn't sweaty or shaky."

Hypoglycemia occurs frequently in critically ill infants and children. Infection, toxins, drugs, and other physiologic stressors may precipitate hypoglycemia. In one small study, hypoglycemia was the presenting symptom in a number of patients with sepsis from various sources.¹⁰⁰

3. "Intussusception? The child was lethargic—who would have thought of intussusception?"

Intussusception is a tough diagnosis to make in an infant who is only showing lethargy. The absence of fever and the presence of blood in the stool provide important clues. Acting quickly to rule out and treat intussusception may save bowel.¹⁵⁴

4. "The family seemed so normal. Child abuse just wasn't a consideration."

Occult trauma could be the cause of lethargy or shock. Children younger than 12 months are particularly likely to have intracranial injury in the absence of visible trauma.¹⁵⁵

5. "It couldn't be an ingestion—she can't even walk yet!"

Infants frequently explore the world by putting things in their mouths. An amazing array of objects can be aspirated or ingested. Amounts as small as one pill found in Grandma's purse can be toxic. (See Table 3.)

6. "I didn't know what VP shunt failure would look like."

Ventriculoperitoneal shunt failure can present with symptoms just like sepsis or meningitis.¹⁵⁶ Lethargy and vomiting in such a child mandates a CT. Shunt series are frequently requested by the neurosurgical consultant.

7. "There was bilious vomiting, but I thought it was just gastroenteritis and dehydration."

In the neonate, bilious vomiting is the hallmark of malrotation with midgut volvulus.⁶ This dreaded "death vomit" signals a surgical emergency.

8. "Except for the tachycardia, his vital signs looked pretty good, so I didn't think we would need an IV."

Infants have the capacity to maintain their blood pressure until late in their illness. When they crash, all reserves have been exhausted, and the results can be frighteningly dramatic. Obtain IV or intraosseous access early in the illappearing infant.

9. "I usually like the consultant to order the antibiotics in the infant—and only after the spinal tap."

There are no overwhelming data proving that the timing of antibiotics in the ED makes a crucial difference in the outcome of the septic child.¹⁵⁷ That said, early antibiotics seem like a good idea. Malpractice cases are won or lost depending on how close physicians approach the mythical "30 minutes after arrival" goal for antibiotics in the septic child.

10. "I didn't think about him being born prematurely when she said he was 2 months old."

Management of the infant changes based on the age of the child. When the baby is born prematurely, remember to adjust the age based on the date for a full-term birth. If a child was born eight weeks premature (at 32 weeks' gestation) and is now 10 weeks old, in many ways he or she is physiologically similar to a 2-week-old.

Tables

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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