We have all been there: evaluating the child that presents to our department and is sick—really sick. It may be the 7-day-old with breathing problems or the 5-year-old with vomiting and fever, with every patient bringing their own broad differential and varying approach. In that instant when we start our resuscitation or evaluation, we often remember the words or advice given to us by a mentor or colleague, helping us learn and treat based on their experiences—sometimes successes and sometimes not. That is Dr. Horeczko’s goal with the Playbook: to give pearls and advice on some common (and not so common) pediatric presentations that he has gleaned along the way in an effort to help others.

(click for larger image) Figure 1. Pediatric Assessment Triangle
© Pediatric Emergency Playbook

He starts with Adam, the 7-day-old with breathing problems. The differential diagnosis for such a complaint in this age group is vast, and the first question we often ask ourselves is, is the patient sick? We spend our time teaching students, residents, and fellows the difference between sick and not sick. The Playbook provides some rapid-assessment tools, using both visual graphics (see Figures 1 and 2) and verbal mnemonics to help easily distinguish between sick and not sick. For example, using the mnemonic “TICLS” can help you quickly assess a pediatric patient with undifferentiated illness in a matter of seconds and can give you valuable information:

T = Tone
I = Interactiveness
C = Consolability
L = Look/gaze
S = Speech/cry

The Playbook also refers to the Pediatric Assessment Triangle (PAT), a global assessment tool that takes into account what is done in the first 20–30 seconds that you are in a patient’s room (see Figure 1). It helps to distinguish the difference between potential respiratory, cardiovascular, and metabolic etiologies of disease.

The Playbook then discusses a differential diagnosis for the sick infant: “THE MISFITS.”

T = Trauma
H = Heart disease or Hypovolemia
E = Endocrine emergencies
M = Metabolic
I = Inborn errors of metabolism
S = Seizures
F = Formula problems
I = Intestinal disasters
T = Toxins
S = Sepsis

Sepsis is deliberately saved for last as it’s common practice to treat the sick infant with antibiotics, but this encourages you not to forget other key categories of potential pathology.

The Playbook takes special time to review a specific subset of patients who will present in this age group, and those are the ones whose ductus arteriosus is closing. These patients will often present in cardiopulmonary failure, pending arrest. As the ductus closes, patients with cardiac lesions, dependent upon that route for supplemental blood flow, will decompensate. Examples of these lesions include critical coarctation of the aorta, truncus arteriosus, transposition of the great arteries, tricuspid atresia, tetralogy of Fallot, and total anomalous pulmonary venous return. To help with the diagnosis, the hyperoxia test can be performed. Place the child on a non-rebreather mask and, after several minutes, perform an arterial blood gas (ABG) test. Ideally, you obtain a preductal ABG in the right upper extremity and compare that with one on the lower extremity, but this may not be practical. In a normal circulatory system, the pO2 should be high, in the hundreds, and certainly over 250 torr. This effectively excludes congenital heart disease as an etiology. If the pO2 on supplemental oxygen is less than 100, then this is extremely predictive of hemodynamically significant congenital heart disease.