Pediatric emergency medicine trisk 2769 2769

pressures minimized. Depending on the diagnosis, there may be other clinical
indicators such as fever, vomiting, and sepsis that may affect fluid management.
In severely ill or complex patients, the measurement of central venous pressure
may provide a more precise guide for monitoring fluid status.
Sedation is an important adjunct to efficient assisted ventilation to reduce
anxiety and increase tolerance to the presence of a tracheal tube and assisted
ventilation. Morphine sulfate dosed 0.1 to 0.2 mg/kg every 1 to 2 hours or as a
continuous infusion of 0.1 mg/kg/hr is often used. This is frequently combined
with a benzodiazepine, such as midazolam 0.1 to 0.2 mg/kg every 1 to 2 hours or
as a continuous infusion. Dexmedetomidine is increasingly being used in critical
care units and some EDs. It provides anxiolysis and sedation without adverse
impact on respiratory drive, airway protection, and hemodynamic stability.
Muscle relaxants may help optimally ventilate intubated children with severe
respiratory failure, such as those with stiff lungs (e.g., severe interstitial
pneumonia) or stiff chest wall (e.g., status epilepticus), by improving compliance
and reducing oxygen consumption. Depolarizing agents may include repeated
doses of rocuronium at 1 to 1.2 mg/kg/dose. Alternatively, vecuronium bromide
can be administered starting at 0.1 mg/kg every 1 to 2 hours or as a drip at 0.1 to
0.2 mg/kg/hr.
Clinical Indications for Discharge or Admission
Patients with acute respiratory failure require hospitalization. If resuscitation
efforts restore adequate oxygenation and ventilation and a stable trajectory has
been established, admission to the inpatient floor for continued evaluation and
management may be appropriate. The level of inpatient care required for patients
on HFNC and noninvasive ventilation varies by institution. However, most
patients with respiratory failure will require intensive care unit (ICU) admission,
and prompt communication with the critical care team at one’s institution or an
appropriate transfer facility should be an early priority in management (see
Chapter 11 Interfacility Transport and Stabilization ).

ASTHMA

CLINICAL PEARLS AND PITFALLS