Pediatrics Review

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Pediatrics Review

• Emergency

Gina Neto, MD FRCPC Division of Emergency
Medicine Childrens Hospital of Eastern Ontario
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Case 1

• 2 month old male
• 2 day hx rhinorrhea, poor feeding
• 1 day hx cough
• Few hrs resp distress
• RR60 HR120 T37C
• Pink well hydrated smiling
• Chest - inspiratory crackles, exp wheezes
• Diagnosis?

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Bronchiolitis

• RSV - Respiratory syncytial virus most common
• parainfluenza, influenza A, adenovirus
• Peak in winter
• Infants more serious illness
• Treatment
• Nebulized Epinephrine short term relief
• ? Dexamethasone
• 1 mg/kg on Day 1
• 0.6 mg/kg for another 5 days

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Case 2

• 2 yr old girl
• Congestion x 2 days
• Awoke tonight with respiratory distress
• Loud noise on breathing in, harsh barky cough
• Improved on the way to hospital
• HR100 RR28 T37
• Minimal distress
• Stridor, mild indrawing
• Diagnosis?

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Croup

• Parainfluenza type III
• Hoarse voice, barky cough, inspiratory stridor
• Peak fall and spring
• Infants and toddlers
• Treatment
• Dexamethasone (0.6 mg/kg)
• Nebulized Epinephrine if in respiratory distress
• Consider Nebulized Budesonide

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Croup

• Steeple Sign

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Case 3

• 18 month female
• Fever x 2 days
• Difficulty swallowing
• HR130 RR28 T39C
• Exam normal except wont move neck fully
• What diagnostic test should be performed?

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Case 3

• Retropharyngeal Abscess
• Complication of bacterial pharyngitis
• Group A hemolytic strep, oral anaerobes and S.
  aureus
• Treatment
• IV Clindamycin and Cefuroxime
• Consult ENT

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Retropharyngeal Soft Tissues
Age (yrs) Maximum (mm)
0-1 1.5 x C5
1-3 0.5 x C5
3-6 0.4 x C5
6-14 0.3 x C5

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

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Case 4

• 5 yr old male
• Febrile x 6 hrs
• Refusing to eat or drink
• Voice muffled, drooling
• Not immunized
• Very quiet, doesn't move HR140 RR20 T39.5
• Slight noise on inspiration
• Chest clear, exam normal

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Case 4

• Epiglottitis
• Rarely seen
• Strep pneumoniae
• H. influenzae uncommon due to vaccine
• Do not disturb patient
• Consult anesthesia, intubate
• IV cefuroxime

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Case

• 17 month old male with a one-hour history of
  noisy and abnormal breathing
• Improved now, but at the time, parents thought
  he was quite distressed. Coughing and having
  trouble breathing at home.
• VS T36.8, P200 (crying), R28 (crying), O2 sat 99
  
• Alert, no cyanosis, no drooling, no dyspnea
• Chest Mild wheezing with mild inspiratory stridor

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Soft Tissues Neck Lateral View
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CXR (PA) What investigation would you do
next?
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Expiratory CXR
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Inspiratory Expiratory
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Foreign Body Aspiration

• Highest risk between 1 -3 years old
• Immature dentition no molars, poor food
  control)
• More common with food than toys
• peanuts, grapes, hard candies, sliced hot dogs
• Acute respiratory distress (now resolved or
  ongoing)
• witnessed choking period
• cough, gag
• stridor, wheeze
• drooling
• muffled voice
• Uncommonly Cyanosis and resp arrest

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Case 5

• 9 month old female
• Fever x 2 days
• Vomiting (no blood, no bile) x 20 today
• Diarrhea (no blood) 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

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Case 5

• What is the degree of dehydration of this child?
• Management?

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Dehydration
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Gastroenteritis

• 10 Dehydration
• Rule out UTI
• ORT with rehydration solution (Pedialyte,
  Gastrolyte)
• 5 ml every 2 min
• continue until appears hydrated
• Consider Ondansetron (0.15 mg/kg)
• Early refeeding ( including milk) within 12 hrs

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Fluids and Electrolytes

• Maintenance
• 4cc/kg/hr for first 10 kg
• 2cc/kg/hr for second 10 kg
• 1 cc/kg/hr for rest of weight in kg
• D5WNS
• Deficit
• If severely dehydrated give FLUID BOLUS, 20 cc/kg
  over 15-60 min
• NS
• Deficit fluid - first half over 8hrs, second
  half over 16 hrs
• Ongoing Losses
• Diarrhea, vomiting, polyuria, NG losses
• Insensible losses with fever
• ADD MAINTENANCE DEFICIT ONGOING LOSSES

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Case 6

• 15 month old male
• Intermittent sudden severe abdo pain x 24 hrs
• crampy abd pain every 30 minutes
• Vomiting (no blood, no bile) x 3
• Diarrhea with blood and mucus
• HR130 RR24 T37
• Tender abdomen with fullness in RUQ
• Diagnosis?
• Investigations?

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Intussusception

• 1-3 years
• Boys 21
• Classic Triad (10-30)
• Vomiting
• Crampy abdominal pain
• Red currant jelly stools
• Lethargy is common
• 75 are ileo-colic
• Lead point
• ? Peyer's Patches - preceding viral infection
• Other Meckel diverticulum, polyps, hematoma
  (HSP), lymphoma

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Intussusception

• Plain AXR
• May be normal
• May have sxs bowel obstruction
• Paucity of air in RLQ
• No air in Cecum on Lateral Decub

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Intussusception

• Target Sign

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Intussusception

• Crescent Sign

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Intussusception
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Intussusception

• Air Contrast Enema
• Success rate gt80
• Recurrence 10-15

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Case 7

• 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.
• Born at 39 weeks gestation. Spontaneous vaginal
  delivery.
• Looks well. Mild dehydration.
• Abdomen soft, non tender, BS present.
• DDx?

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Case 7

• 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

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Pyloric Stenosis

• Most common surgical condition in first two
  months of life.
• Usually 4-6 weeks of age
• Ratio male to female is 41.
• Increased in first born males
• Occurs in 5 of siblings and 25 if mother was
  affected
• Symptoms of gastric outlet obstruction
• Nonbilious vomiting
• Emesis increases in frequency and eventually
  becomes projectile

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Pyloric Stenosis

• Classically
• hypertrophied pylorus is palpable as an olive
  in the epigastric area
• peristaltic waves may be seen progressing from
  LUQ to the epigastrium
• Laboratory abnormalities
• hypokalemic, hypochloremic, metabolic alkalosis

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Case 8

• 1 month old with bilious vomiting
• Multiple episodes of yellow green vomiting since
  this morning.
• Progressive lethargy and irritability. Poor
  feeding.
• Looks unwell, irritable cry.
• Abdomen distended.
• Weak pulses, cap refillgt5 sec.
• DDx? Management?

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Volvulus

• Twisting of a loop of bowel around its mesenteric
  attachment.
• Sudden onset of bilious vomiting in a neonate.
• Acute abdomen with shock
• may have a gradual course with episodic vomiting
• 80 present by the first month
• 40 present in the first week
• Rarely can be seen in older children.

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Volvulus

• Evidence of small bowel obstruction
• dilated loops, air fluid levels, paucity of
  distal air

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Volvulus

• Upper GI series
• corkscrew appearance of the duodenum and
  jejunum

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Case 9

• 1 month old girl
• 12 hr history of fever, 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?

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Low Risk Criteria (Rochester) for Febrile Infants

• Well appearing infants 1-3 months are low risk
  for serious bacterial infection if the following
  criteria are met
• Previously healthy
• Born at term (gt 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 lt 5/hpf
• Stool WBC count lt 5/hpf (if infant has diarrhea)

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Case 10

• 2 year old boy
• Sudden onset 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?

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Febrile Seizure

• ABC's, IV access
• Seizure treatment
• IV/PR lorazepam or diazepam
• phenytoin, phenobarbitol
• Simple Febrile Seizure
• Tgt38.5
• lt20min, generalized seizure
• 6mo-6yr
• neurologically normal before and after
• Observe in the ED until child returns to normal
  neuro status

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Case 11

• 2 yr old boy with persistent fever for 6 days
• Red eyes but no discharge.
• Generalized rash, with erythema of the palms of
  his hands and soles of his feet
• Red, swollen lips and enlarged cervical lymph
  nodes

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Kawasaki Disease

• Usually lt 4 yrs old, peak between 1-2 yrs
• Unknown etiology, ? infectious
• Fever for gt 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 ( gt1.5 cm)

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Kawasaki Disease

• Subacute phase - Days 11-21
• Resolving acute symptoms
• Desquamation of extremities
• Arthritis
• Convalescent phase - gt Day 21
• 25 develop coronary artery aneurysms
• Myocardial infarction
• Other manifestations
• Uveitis
• Pericarditis
• Hepatitis, Gallbladder hydrops
• Sterile pyuria, Aseptic meningitis

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Kawasaki Disease

• Investigations
• CBC thrombocytosis
• ESR elevated
• CXR, ECG
• Echocardiogram
• 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

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Case 12

• 3 year old boy
• Found eating acetaminophen from open container on
  kitchen counter
• Bottle contained 60 x 160mg tabs and only 10
  found on the floor
• No distress HR90 RR24 T37 BP 110/BO
• Exam normal
• Management?

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Poisoning in Children

• Present at 2 ages
• Young children
• exploratory ingestion
• ingest small amount of a single substance
• Adolescents
• ingest large amounts of one or more substances
• suicidal gesture

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Acute Ingestion

• ABCs
• Gastric Decontamination
• Charcoal
• Not to be used routinely for all ingestions
• Greatest benefit is within 1 hr of ingestion
• 89 decrease if within 30 min
• 37 decrease at 1 hr
• Substances not adsorbed by charcoal alcohols,
  iron, lithium
• Whole Bowel Irrigation
• For substances not adsorbed by charcoal and
  sustained release preparations
• GoLytely by NG at a rate of 500 ml -2 L/hr

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Acute Ingestion

• Acetaminophen Poisoning
• Most Common ingestion
• Toxic dose 150 mg/kg or gt7.5 g
• Clinical findings
• lt24 hrs - vomiting, may be asymptomatic
• 24-72 hrs - liver enzyme abnormalities
• 72-96 hrs - liver failure, multi-system organ
  failure
• 4 days - recovery or death
• Do acetaminophen level at 4 hours, plot on
  nomogram

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Rumack-Matthew Nomogram
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Acetaminophen - Metabolism
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N-Acetylcysteine

• Mechanisms of action
• Precursor for glutathione
• Increases sulfation metabolism
• Directly reduces NAPQI to APAP
• Directly conjugates NAPQI
• Late effect - proposed mechanisms
• Modulates inflammatory response
• antioxidant, free radical scavenger
• effect on leukocyte function
• Improves oxygen delivery
• Reservoir for glutathione

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12 yr old girl baseball hit finger...
Type II
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Salter-Harris Classification
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10 yr old boy fall onto hand...
Type I
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16 yr old hockey player collided with another
player and fell...
Type IV
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14 yr old boy running and twisted ankle...
Type III
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11 yr old fell off garage...
Type V
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3 yr old girl with rash starting todayRecent
URTISwollen ankles and knees. Painful
walking.Diagnosis?
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Henoch-Schonlein Purpura

• Systemic vasculitis IGA mediated
• 75 of cases between 2-11 years of age
• Clinical Features
• 100 - rash (non thrombocytopenic purpura)
• 68 - arthritis
• 53 - abdominal pain
• 38 - nephritis (ESRD in 1)
• Intussusception (2-3)

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1 yr old boy with mouth lesions for two days...

• What are the two most likely causes for this
  condition?

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Herpes Simplex
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Coxsackie
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5 yr old girl itchy rash for two days...

• Varicella Zoster
• This child comes back to the ED three days later
  with worsening fever and pain...

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Diagnosis?

• Necrotizing Fasciitis
• Invasive group A streptococcal infection
• IV Penicillin and Clindamycin
• Consult ID, surgery
• MRI

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• Questions ?