Download B2B Emergency Review

Pediatrics Review
Emergency
Gina Neto, MD FRCPC
Division of Emergency Medicine
Objectives
• Review pediatric resuscitation guidelines
• Recognize pediatric conditions that present to the
emergency
• Describe management of pediatric emergency
cases
Pediatric Resuscitation
• Pediatric Airway
• Larger head
• Bigger tongue
• Narrowest part is subglottic
area
• Epiglottis is more floppy
• Larynx is more anterior and
cephalad
• Chest wall more compliant
Pediatric Resuscitation
• Airway Management
• Position, suctioning
• Nasal/Oral airway
• Endotracheal intubation
 Cuffed tube size: age/4 + 3 (+/- 0.5mm)
• Medications
Atropine (consider if< 6 yrs)
Paralytic - Succinylcholine, Rocuronium
Ketamine, Midazolam/Fentanyl, Propofol
Pediatric Resuscitation
• Bradycardia
• Non-Cardiac causes (6 H’s, 5 T’s)
 Hypoxia (Most Common)
 Hypovolemia, Hypo/Hyperkalemia, Hypoglycemia,
Hypothermia
Toxins, Tamponade, Thrombosis, Trauma (ICP)
• Cardiac causes - AV block, sick sinus
• Epinephrine 0.01 mg/kg (repeat every 5 min)
• Consider Atropine 0.02 mg/kg
Pediatric Resuscitation
• Tachycardia
• Narrow
• Wide
• Stable or Unstable
• Know what is normal for age
Pediatric Resuscitation
• Sinus Tachycardia
• Rate usually < 220/min
• Variable rate
• Look for causes
 Pain, fever, dehydration, resp distress, poor perfusion
• SVT
• Rate usually > 220/min infants, > 160 teens
• Rate is fixed
Pediatric Resuscitation
• SVT
• Vagal maneuvers
 Ice to face, Valsalva
• Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg
• If Unstable:
• Synchronized Cardioversion 0.5-1 J/kg
 If not effective increase to 2 J/kg
Pediatric Resuscitation
• Tachycardia with Wide QRS
• Stable
• Consider Adenosine
• Amiodarone 5 mg/kg
• Consult Cardiology
• Unstable with pulse
• Cardioversion 0.5 - 1 J/kg 1st dose, then 2 J/kg
Pediatric Resuscitation
• Tachycardia with Wide QRS and No Pulse or
Ventricular Fibrillation
• CPR
 Start at 16:2 compressions/breath
• Defibrillation 2 J/kg
 Then 4 J/kg
 Increase subsequent shocks to max of 10 J/kg
• Epinephrine 0.01 mg/kg every 3-5 min
• Amiodarone 5 mg/kg
Case
• 10 yr old boy with asthma, difficulty breathing
today. Cough and runny nose for 3 days.
• T 36.5, RR 40, HR 130, O2 Sat 89%.
• Suprasternal and scalene retractions, decreased
air entry, expiratory wheeze.
• Describe your management.
Asthma
• Mild Asthma:
• Salbutamol MDI x 3 doses prn
• Moderate Asthma:
• Salbutamol MDI x 3 doses then prn
• Steroids
 Dexamethasone 0.15-0.3 mg/kg PO (max 12)
 Prednisone 1-2 mg/kg PO (max 60 mg)
Asthma
• Severe Asthma:
• Salbutamol via nebulization with
• Ipratropium 250 mcg x 3 doses q20 min
• Steroids
 Dexamethasone 0.15-0.3 mg/kg PO (max 12)
 Prednisone 1-2 mg/kg PO (max 60 mg)
Asthma
• If not improving within 60 min or signs of
impending respiratory failure:
• Magnesium Sulfate 50 mg/kg/dose IV (max 2g)
• Give over 20-30 min
• May cause severe hypotension
• IV NS 20 bolus ml/kg
• Methylprednisolone 1-2 mg/kg IV
Case
• 2 mo male with 2 day hx rhinorrhea, poor feeding
and cough. Few hrs resp distress.
• RR 60 HR 120 T 37C. Pink, well hydrated.
• Chest - inspiratory crackles, exp wheezes.
• Diagnosis?
• Treatment?
Bronchiolitis
• RSV - Respiratory Syncytial Virus most common
• Parainfluenza, Influenza A, Adenovirus, Human
metapneumovirus
• Peak in winter
• More serious illness
• < 2 months
• Hx of prematurity < 35 weeks
• Congenital heart disease
Bronchiolitis
• Treatment
• Supportive care – suctioning, hydration
• ? Nebulized Epinephrine – short term relief
• ? Dexamethasone
 1 mg/kg on Day 1 then 0.6 mg/kg for another 5 days
• ? Nebulized Hypertonic Saline
Case
• 2 yr old girl awoke tonight with respiratory distress.
Harsh, “barky” cough.
• HR 100 RR 28 T 37
• Mild distress. Stridor at rest.
• Diagnosis?
• Treatment?
Croup
•
•
•
•
•
Parainfluenza most common
Hoarse voice, barky cough, stridor
Peak fall and spring
Infants and toddlers
Treatment
• Dexamethasone (0.6 mg/kg)
• Nebulized Epinephrine if in respiratory distress
• Consider Nebulized Budesonide
Steeple
Sign
Case
• 18 month female with fever x 2 days. Difficulty
swallowing.
• HR130 RR28 T39C
• Exam normal except won’t move neck fully.
• What diagnostic test should be performed?
Retropharyngeal Abscess
• < 6yrs
• Complication of bacterial pharyngitis
• Infection of posterior pharyngeal
nodes – regress by school age
• Grp A strep, oral anaerobes and S.
aureus
• Treatment
• IV Clindamycin and Cefuroxime
• Consult ENT
Retropharyngeal Soft Tissues *
Age (yrs)
Maximum (mm)
0-1
1.5 x C2
1-3
0.5 x C2
3-6
0.4 x C2
6-14
0.3 x C2
*
Retrotracheal Soft Tissues *
Age (yrs)
Maximum (mm)
0-1
2.0 x C5
1-2
1.5 x C5
2-3
1.2 x C5
3-6
1.2 x C5
6-14
1.2 x C5
*
Case
• 5 yr old male fever x 6 hrs. Refusing to eat or
drink. Voice muffled, drooling.
• Not immunized.
•
•
•
•
HR 140 RR 20 T 39.5
Very quiet, doesn't move.
Slight noise on inspiration.
Chest clear, exam normal.
Epiglottitis
• Rarely seen
• Strep pneumoniae
• H. influenzae uncommon due
to vaccine
• Do not disturb patient
• Consult Anesthesia, intubate
• IV Ceftriaxone and Clindamycin
Case
• 2 yo male with sudden onset noisy and abnormal
breathing
• Was playing on floor before developing difficulty
breathing
• VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
• Mild wheezing with mild inspiratory stridor
What
investigation
would you
do next?
Expiratory
CXR
Inspiratory
Expiratory
Foreign Body Aspiration
• Highest risk between 1 -3 yrs old
 Immature dentition, poor food control
 More common with food than toys
• peanuts, grapes, hard candies, sliced hot dogs
• Acute respiratory distress (resolved or ongoing)
• Witnessed choking
• Cough, Stridor, Wheeze, Drooling
• Uncommonly…. Cyanosis and resp arrest
Case
• 1 month old girl fever today. Cough and runny
nose. Slightly decreased feeding.
• Looks well, alert and interactive
• T 38.9o HR 176 RR 42 BP 100/50
• Font flat, neck supple, exam non remarkable
• What is your approach to this case?
Fever < 1 month
• Etiology is organisms from birth canal
 Group B Streptococcus , Escherichia coli (Gram neg),
Listeria monocytogenes
• Highest rate of bacterial infection of any age group
• <2 weeks - 25%
• 0-4 weeks - 13%
• Septic Work Up
• Admission, IV antibiotics
Fever 1-3 months
• May still see birth canal organisms, but also:
 Streptococcus pneumoniae , Neisseria meningitidis,
Haemophilus influenzae type b (uncommon)
• Overall rate of bacterial infection is ~8%
Bacteremia 2%
Meningitis 0.8%
UTI 5%
• “Low Risk Infant” rate of bacterial infection is 1%
 Bacteremia 0.5%
Low Risk Criteria “Rochester” for Febrile Infants
• Well appearing infants 1-3 mos are low risk for serious
bacterial infection if:
 Previously healthy
•
•
•
•
Born at term (> 37 weeks)
No hyperbilirubinemia
No hospitalizations
No chronic or underlying diseases
 No evidence of focal bacterial infection
 Laboratory parameters:
• WBC count 5-15/mm3
• Urinalysis WBC count < 5/hpf
• Stool WBC count < 5/hpf (if infant has diarrhea)
Fever 3-36 months
• Viral infections cause of fever in >90%
• 6% of children seen in the ED have a specific,
recognizable viral syndrome
 e.g. croup, bronchiolitis, roseola, varicella, coxsackie
• UTI in ~5%
• Bacteremia very low rates now (< 0.2%)
• 5% in 1980’s, HIB vaccine 1987
• 2% in 1990’s, Pneumococcal vaccine 2000
Case
• 2 year old boy with generalized tonic clonic
movements. Duration 5 min.
•
•
•
•
T 39.2o HR 110 RR 24 BP 110/60
Awake now, normal neurological exam.
Right TM bulging, neck supple, no rash.
Past med history unremarkable.
• Approach?
Febrile Seizure
• Simple Febrile Seizure
• T>38.5
• 6 mo-5 yr
• Generalized seizure, < 15 min
• One seizure within 24 hours
• Neurologically normal before and after
• Occur in ~ 5% of children
• Recurrence in 30%
Febrile Seizure
• Risk of epilepsy is 1%
• ~ same as general population
• Higher risk (2.4%) if:
• Multiple febrile seizures
• < 12 mos at the time of first febrile seizure
• Family history of epilepsy
Seizure Management
• ABC's
• IV access
• Seizure treatment
• 1st Line - Benzodiazepines
• Lorazepam or Diazepam (Rectal or IV)
• Midazolam (Intranasal or Buccal)
• 2nd Line
 Phenytoin, Fosphenytoin
 Phenobarbitol
Seizure Management
• Seizure treatment
• 3rd Line




Midazolam infusion
Propofol
Thiopental
Other: Levitiracetam, Topiramate, Valproic Acid
• Observe until child returns to normal
• After simple febrile seizure no neurological
investigations indicated (eg CT, EEG)
Case
• 9 month old female with fever x 2 days. Vomiting x
20 today. Diarrhea x 10 today. Voiding scant
amounts.
•
•
•
•
HR 120 RR 36 BP 100/50 T 38.5
Cap refill 2 sec, pink, decreased skin turgor.
Font sunken, eyes sunken.
Abdo + GU normal.
Case
• What is the degree of dehydration of this child?
• Management?
Gastroenteritis
• Oral Rehydration
• 5 ml/kg/hr divided every 5-10 min
• Consider Ondansetron (0.15 mg/kg)
• Early refeeding (including milk) within 12 hrs of last
emesis
• Rule out UTI
Fluids and Electrolytes
• Maintenance (D5NS)
 4ml/kg/hr for first 10 kg
 2ml/kg/hr for second 10 kg
 1 ml/kg/hr for rest of weight in kg
• Deficit (NS)
• If moderate to severe dehydration give NS bolus
 20 ml/kg over 15-60 min
• Replace remaining deficit over 24 hours (if normal Na)
 First half over 8hrs, second half over 16 hrs
• Ongoing Losses
• Diarrhea, Vomiting, Insensible losses with fever
Case
• 15 month old male with intermittent sudden severe
abdo pain x 24 hrs. Vomiting x 3. Diarrhea with
blood and mucus.
• HR130 RR24 T37
• Tender abdomen with fullness in RUQ
• Diagnosis?
• Investigations?
Intussusception
• 1-3 years
• Boys 2:1
• Classic Triad (10-30%)
• Vomiting
• Crampy abdominal pain
• “Red currant jelly” stools
• Lethargy is common
Intussusception
• 75% are ileo-colic
• Lead point
• Peyer's Patches
preceding viral infection
•
•
•
•
Meckel diverticulum
Polyps
Hematoma (Henoch Schonlein Purpura)
Lymphoma
Intussusception
• Plain AXR
• May be normal
• May have signs of bowel
obstruction
• Paucity of air in RLQ
• No air in Cecum on
Lateral Decubitus
• Target Sign
• Crescent Sign
Intussusception
• Air Contrast Enema
• Success rate >80%
• Recurrence 10-15%
Case
• 4 week old boy with vomiting for past week.
Initially one emesis per day now emesis with every
feed. Forceful. No bile.
• No fever. No diarrhea.
• Looks well. Mild dehydration.
• Abdomen soft, non tender, BS present.
• DDx?
Case
• Na 140 K 3.0 Cl 90 BUN 24 CR 50
• WBC 8.5 Hgb 120 Plts 360
• Venous gas
pH 7.50, PCO2 44, HCO3 30
Pyloric Stenosis
• Most common surgical condition < 2 mos
• 4-6 wks of age
• Ratio male to female is 4:1
• Increased in first born males
• Occurs in 5% of siblings and 25% if mother was
affected
Pyloric Stenosis
• Nonbilious vomiting
• Emesis increases in force and frequency and
eventually becomes projectile
• Classic findings:
• Hypertrophied pylorus palpable “olive” in
epigastric area
• Peristaltic waves progressing from LUQ to the
epigastrium
Pyloric Stenosis
• Laboratory abnormalities:
• Hypokalemia
• Hypochloremia
• Metabolic alkalosis
• Ultrasound
• Thickened pylorus
Case
• 1 month old with bilious vomiting. Multiple
episodes of yellow green vomiting since this
morning. Progressive lethargy and irritability.
• Looks unwell, irritable cry.
• Abdomen distended.
• Weak pulses, cap refill>5 sec.
• DDx? Management?
Volvulus
• Twisting of a loop of bowel
around its mesenteric
attachment.
• 80% present by the first month
40% present in the first
week
Rarely can be seen in older
children.
Volvulus
• Sudden onset of bilious vomiting
in a neonate.
• Acute abdomen with shock
• May have more gradual course
with episodic vomiting
Volvulus
• Evidence of small bowel
obstruction
• Dilated loops
• Air fluid levels
• Paucity of distal air
Volvulus
• Upper GI series
• “corkscrew”
appearance of the
duodenum and
jejunum
Case
2 yr old boy with fever for 6 days.
Red eyes but no discharge.
Generalized rash.
Erythema of the palms of hands
and soles of feet.
• Red, swollen lips.
• Enlarged cervical lymph nodes.
•
•
•
•
Kawasaki Disease
• Usually < 4 yrs old, peak between 1-2 yrs
• Fever for > 5 days and 4 of the following:
 Bilateral non-purulent conjunctivitis
 Polymorphous skin eruption
 Changes of peripheral extremities
• Initial stage: reddened palms and soles
• Convalescent stage: desquamation of fingertips and toes
 Changes of lips and oral cavity
 Cervical lymphadenopathy ( >1.5 cm)
Kawasaki Disease
• Subacute phase - Days 11-21
• Desquamation of extremities
• Arthritis
• Convalescent phase - > Day 21
• 25% develop coronary artery aneurysms if untreated
• Other manifestations:
• Uveitis, Pericarditis, Hepatitis, Gallbladder hydrops
• Sterile pyuria, Aseptic meningitis
Kawasaki Disease
• Treatment
• IV Immunoglobulin
• Reduces incidence of coronary aneurysms to 3% if given
within 10 days of onset of illness
• Defervescence with 48 hrs
• ASA
• High dose during acute phase then lower dose for 3 mos
Case
• 3 yr old girl with rash starting
today.
• Recent URTI.
• Swollen ankles and knees.
Painful walking.
• Diagnosis?
Henoch-Schonlein Purpura
• Systemic vasculitis – IGA mediated
• 75% are 2-11 yrs
• Clinical Features
 Rash (non thrombocytopenic
purpura) 100%
 Arthritis (ankles, knees) - 68%
 Abdominal pain - 53%
 Nephritis - 38% (ESRD in ~1%)
• Intussusception (2-3%)
Case
• 1 yr old boy with
mouth lesions for two
days
• What are the two most
likely causes?
Herpetic Gingivostomatitis
• Herpes Simplex
• Severe primary infection
• HSV1 (80%), HSV2 (20%)
• Fever, irritability, poor intake
• Ulcers on mucous membranes
• Treatment
• Acyclovir
• Pain control, IV hydration
Hand, Foot and Mouth Disease
• Coxsackievirus, usually A16
• Summer
• Ulcers on tonsilar pillars
• can have generalized stomatitis
• Vesicles on hands and feet
• URTI, pharyngitis
• Vomiting and diarrhea
• Generalized maculopapular rash
Case
• 5 yr old girl with itchy
rash
• Varicella Zoster
• This child
to the ED
later with
fever and
comes back
three days
worsening
pain...
Diagnosis?
Necrotizing Fasciitis
• Invasive group A
streptococcal infection
• IV Penicillin and
Clindamycin
• Consult ID, surgery
• MRI
Case
• 3 yr old girl fever for 3
days, unwell
• Rash spreading over
entire body with skin
peeling
Diagnosis?
Staphylococcal Scalded Skin Syndrome
Exotoxin causes separation of epidermis
< 2yr
Fever, toxic appearance, generalized erythema
Exfoliation of skin, accentuated in flexor surfaces
• skin lifts to touch (Nikolsky’s sign)
• Perioral crusting, “honey coloured” lesions
•
•
•
•
• Fluid resuscitation
• IV Cloxacillin, Cefazolin or Clindamycin
Case
• 10 yr old boy with fever
• Unwell today
• Rapidly progressing rash
since this morning
Meningococcemia
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•
•
•
•
Usually < 5 yrs, Adolescents outbreaks
Fever, toxic appearance
Petechiae, purpura
DIC, shock
High mortality (25-80%)
• Resuscitation
• IV Ceftriaxone
• Treat household contacts
Septic Shock
• How are you going to resuscitate this child?
• First intervention?
• Next?
• Next?
• Next?
Septic Shock
• Leading cause of death in infants and children
6 million deaths per year worldwide
• Etiology of sepsis
•
•
•
•
Streptococcus pneumonia
Escherichia coli
Neisseria meningitidis
Other: Group A strep, other Gram neg bacilli, Staph.
aureus, Enterococcus
• IV Antibiotics: Ceftriaxone and Vancomycin
Septic Shock
• Hypotension is DECOMPENSATED SHOCK
• Most children have “cold shock”
 Decreased cardiac output and increased systemic
vascular resistance
 Poor perfusion, cool extremities, delayed cap refill
• Adolescents more likely to have “warm shock”
Low systemic vascular resistance
Bounding pulses, wide pulse pressure
Catecholamine Resistant Shock
Administer Hydrocortisone 2 mg/kg
Sepsis – Goal Directed Therapy
• Normal perfusion
o Cap Refill < 2 sec
o Normal pulses with no diff between central and
peripheral pulses
•
•
•
•
•
•
Urine output > 1 ml/kg/hr
Normal level of consciousness
Normal mean arterial pressure (MAP)
Normal lactate
Normal central venous pressure (CVP)
Central venous O2 saturation (ScvO2) > 70%
Case
• 6 month old with
swollen L leg
• Parents state 3 yr old
brother fell onto baby
• Approach to this case?
Child Abuse
• Suspect if history vague, inconsistent with injury or
child’s development
Bruises
• Can not date bruises by color
• “If they don’t cruise they don’t bruise”
• Toddlers don’t bruise buttocks, inner arms/legs, neck or
trunk
• Patterned marks – linear, hand prints
• Bites – adult if > 3 cm
Child Abuse
Fractures
• Metaphyseal (corner, bucket handle)
 Shearing force from shaking
 Usually < 1yr
• Posterior ribs
• Femur in non-ambulatory child
• Multiple fractures, different ages
• Low risk – clavicle, tibia in toddler
Child Abuse
Head trauma
• Direct contact injuries
 Scalp hematoma
 Depressed skull fracture
 Epidural hematoma
• Rotational acceleration injuries
 Subdural hemorrhages
 Retinal hemorrhages
Child Abuse
• Admit all children < 2 yrs
• Skeletal survey for < 2 yrs (consider for 2-5 yrs)
• CT head if < 1 yr
• Opthalmologic exam
Ideally within 24 hours (must be <72 hrs)
• Mandatory reporting to child welfare agency
Case
• 2 yr old at grandmother’s house
• Took unknown amount of pills that he found in her
purse 30 minutes ago
• No symptoms
• What is your approach?
Poisoning in Children
• Young children
Exploratory ingestion
Ingest small amount of a single substance
• Can grasp single pill at 1 yr
• Can’t hold handful of pills until > 15 mos
• Child preparations have small opening – spills out
• Adolescents
Ingest large amounts of one or more substances
Suicidal gesture
Poisoning in Children
• Common ingestions
• Household products
• Cough/cold
• Vitamins
• Antibiotics
• Acetaminophen and Ibuprofen
• Antidepressants
Poisoning in Children
• For most medications, ingestion of a few pills by a
small child is not harmful
• Single pills that can cause harm:
• Oral hypoglycemics
• Calcium channel blockers
• Tricyclic antidepressants
• High Dose Opioids
Approach to Unknown Ingestion
• History
• Attempt to identify possible drug ingested
• Friends, parents, paramedics, police
• Physical Exam
• Look for toxidrome signs
• Neurologic impairment
• Skin marks, Breath odour
• Look for signs of trauma, head injury
Approach to Unknown Ingestion
• Management
• ABC’s
• Check Glucose
• Cardiac Monitoring
• Gastric decontamination – Charcoal, WBI
• Antidotes
• Benzodiazepines for agitation, seizures
• NaHCO3 for arrhythmias
Approach to Unknown Ingestion
• Diagnostic testing
• CBC, lytes, BUN/Cr, glucose, gas, osmolality
Anion gap, Osmolar gap
• Specific serum drug levels (Acet, ASA, Alcohols)
• ECG
• Abd Xray for radio-opaque toxins





C - Calcium, Condoms
H - Heavy metals
I - Iron
P - Phenothiazines, Potassium
S - Slow-release preparations
Toxidromes
• Anticholinergic
o Mad as a hatter - Agitation and hallucinations
o Blind as a bat - Dilated pupils
o Hot as hell - Fever, Flushed
o Dry as a bone - MM, skin; Urine retention;
Decreased GI motility
o Tachycardia. Hypertension
o e.g. Tricyclic Antidepressants, Dimenhydrinate
Toxidromes
• Cholinergic
o SLUDGE
o Salivation, Lacrimation, Urination, Defecation, GI
cramps, Emesis
o Pulmonary edema
o Bradycardia
o Agitation, confusion. seizures
• e.g. Pesticides
Toxidromes
• Sympathomimetic
o Agitation and hallucinations
o Dilated pupils
o Fever, Tachycardia, Hypertension
o Diaphoretic
o Increased bowel sounds
o e.g. Cocaine, Amphetamines
Toxidromes
• Opioid
o Coma
o Respiratory depression
o Hypotension
o Miosis
o e.g. Heroin, Fentanyl, Oxycodone
Summary
• Review of pediatric emergency cases:
o
o
o
o
o
o
o
o
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Resuscitation
Respiratory emergencies
Fever in infant, 3-36 months
Febrile seizures, Status epilepticus
GI presentations
Rashes associated with serious illness
Sepsis
Child abuse
Poisoning
Questions ?