The Emergency Department Approach to Newborn and Childhood Metabolic Crisis

Pediatric Cardiac Arrest and Resuscitation

Pediatric cardiac arrest in the emergency department is rare. We emphasize the importance of preparedness for pediatric cardiac arrest and offer strategies for the optimal recognition and care of patients in cardiac arrest and peri-arrest. This article focuses on both prevention of arrest and the key elements of pediatric resuscitation that have been shown to improve outcomes for children in cardiac arrest. Finally, we review changes to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that were published in 2020.

Hypo and Hyper: Common Pediatric Endocrine and Metabolic Emergencies

The presentation of endocrine and metabolic emergencies represents one of the more challenging clinical scenarios faced by pediatricians and emergency providers. In this review, the authors attempt to describe some of the more common entities that a provider may see and provide a guide for the recognition and management of these difficult-to-assess and often very ill children.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

Neonatal endocrine emergencies: a primer for the emergency physician

The resuscitation principles of securing the airway and stabilizing hemodynamics remain the same in any neonatal emergency. However, stabilizing endocrine disorders may prove especially challenging. Several organ systems are affected simultaneously and the clinical presentation can be subtle. Although not all-inclusive, the implementation of newborn screening tests has significantly reduced morbidity and mortality in neonates. Implementing routine screening tests worldwide and improving the accuracy of present tests remains the challenge for healthcare providers. With further study of these disorders and best treatment practices we can provide neonates presenting to the emergency department with the best possible outcomes.

Effectiveness of a clinical pathway for the emergency treatment of patients with inborn errors of metabolism

OBJECTIVE

The goal was to measure the effectiveness of a clinical pathway for the emergency department care of patients with inborn errors of metabolism.

METHODS

Two years after the implementation of a multidisciplinary clinical pathway for patients with inborn errors of metabolism in our urban, academic, pediatric emergency department, we compared measures of timeliness and effectiveness for patients treated before the pathway with the same measures for patients treated after implementation of the pathway. Measures of timeliness included time to room, time to doctor, time to glucose infusion, and total emergency department length of stay. Measures of clinical effectiveness included the proportion of patients receiving adequate glucose infusions, proportion of patients admitted, inpatient length of stay, and proportion of patients requiring PICU admission.

RESULTS

A total of 214 emergency department visits for patients with inborn errors of metabolism were analyzed, 90 before and 124 after initiation of the pathway. All measures of timeliness of care except total emergency department length of stay demonstrated significant improvement in comparisons of values before and after initiation of the pathway. Measures of clinical effectiveness also demonstrated significant improvements after initiation of the pathway. There was improvement in the proportion of patients who received adequate glucose infusions, with a decrease in the proportion of patients who required admission to the PICU. Emergency department length of stay, inpatient length of stay, and the proportion of patients admitted to the hospital were not affected.

CONCLUSIONS

Most measures of timeliness and 2 measures of effectiveness showed improvement after implementation of an emergency department pathway for patients with inborn errors of metabolism. Therefore, a clinical pathway can improve the emergency care of patients with inborn errors of metabolism.

Profound hypokalemia: unusual presentation and management in a 12-year-old boy

Hypokalemia is a frequent electrolyte abnormality that rarely requires more than oral supplementation to correct. We describe a case of profound hypokalemia and cardiac arrhythmia requiring unusually large amounts of "bolused" potassium to restore to normal sinus rhythm. Our patient presented with significant dehydration and electrolyte abnormalities after several days of emesis. Most alarming of these findings was a serum potassium level of 1.2 mEq/L. The electrocardiogram showed changes consistent with hypokalemia that rapidly degraded into pulseless ventricular tachycardia. Potassium chloride of 140 mEq was hand-pushed during the resuscitation with return of spontaneous rhythm. The patient was discharge 11 days later in his prearrest state.

The crying infant

Infants with the chief complaint of crying can present a diagnostic dilemma to the health care provider. This article discusses the differential diagnosis and management of the crying infant.