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Pediatric Pearls – Peds Card Codes

Sylvia Del Castillo, MD, Ilene Claudius, MD, and Solomon Behar, MD
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19:17
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:54

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EM:RAP 2017 March Written Summary 580 KB - PDF

Your patient is diaphoretic, shocky and has a median sternotomy scar. No problem you think. But wait, one more thing, they’re also an infant.

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Donnie s. -

Excellent review. as I am at a low volume ED for pediatrics. My question surrounds TPA vs Heparin in the clotted shunt. In the case presented heparin was chosen over TPA for reasons explained, but in our ED we transfer children which may take minutes to hours sometimes. Would the outcome be better for the patient if TPA was given vs heparin? Also if heparin is given, have we addressed the clotted shunt that we feel the patient has medically legally? Would not we expect resolution of symptoms if the clot is lysed by the TPA to allow blood flow?

ilene c. -

That is a great question. Unfortunately, I lack a great answer. There is so little written on either that (regardless of what you do), you are not covered by evidence or formal recommendations. There definitely is not a comparison between the 2. In general , there is little written on systemic tPA (or any thrombolytic) in children for any cause. I found 2 case reports of tiny infants getting tPA for a shunt clot, both of which are successful and I pasted one below for dosing. I think if the family is well informed, it might be reasonable to discuss risk/benefit of both options and include them in the decision making (and document well). If not and the surgeon is not reachable, I'd go with heparin if they are mottled and looking crappy but alive and tPA if they are clearly going to die imminently- my general approach in absentia of data!
Abstract (Ries): A 10 day old infant with pulmonary atresia, ventricular septal defect, and collateral pulmonary blood supply through a left sided ductus arteriosus developed complete shunt thrombosis four days after the creation of a modified Blalock-Taussig shunt. Recombinant tissue plasminogen activator was given locally into the proximal end of the shunt as two bolus injections of 0.1 mg/kg and two bolus injections of 0.2 mg/kg over 10 minutes, followed by a continuous infusion of 1.4 mg/kg/day for 16 hours and 0.7 mg/kg/day for 18 hours with systemic low dose heparin 5 IU/kg/h. This resulted in complete clot dissolution and reperfusion without haemorrhagic complications and without laboratory signs of systemic fibrinolytic activation.

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Crashing Slowly Full episode audio for MD edition 238:10 min - 332 MB - M4AEM:RAP 2017 March German Edition Deutsche 73:21 min - 101 MB - MP3EM:RAP 2017 March Spanish Edition Español 89:05 min - 122 MB - MP3EM:RAP 2017 March Aussie Edition Australian 16:33 min - 23 MB - MP3EM:RAP 2017 March French Edition Français 25:15 min - 35 MB - MP3EM:RAP 2017 March Canadian Edition Canadian 28:50 min - 40 MB - MP3EM:RAP 2017 March Board Review Answers 262 KB - PDFEM:RAP 2017 March Board Review Questions 218 KB - PDFEM:RAP 2017 March MP3 Files 316 MB - ZIPEM:RAP 2017 March Written Summary 580 KB - PDF

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