Common Paediatric Emergency Referrals

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Common Paediatric Emergency Referrals

• Mark Anderson
• Consultant Paediatrician
• Great North Childrens Hospital

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Case 1
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Archie, 18 months

• Unwell for 2 days with runny nose and cough
• Felt hot
• Difficulty breathing wheezy today

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Archie, 18 months

• Examination
• Coryzal
• Mild subcostal recession
• Quiet wheeze throughout chest

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Differential diagnosis?
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Differential diagnosis

• Viral induced wheeze (VIW) episodic wheeze
• 1st presentation asthma multi-trigger wheeze
• (Bronchiolitis)

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How to differentiate VIW from asthma?
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How to differentiate VIW from asthma?

• Can be difficult!
• Asthma more likely if
• Multiple triggers for wheeze
• Interval symptoms
• Personal or family history of atopy
• Absence of virus (!)

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Specific Therapy?
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Specific therapy

• Inhaled bronchodilator
• Salbutamol
• Ipratropium bromide
• ?Steroids

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Steroids in preschool VIW

• Little evidence for efficacy
• 120 children aged 1-5y given prednisolone or
  placebo
• No effect on parental reported respiratory
  symptom score at 7 days
• 700 preschool children given prednisolone or
  placebo
• No effect on duration of hospitalisation
• No effect on respiratory symptom score in first
  24 hours

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Steroids in preschool VIW

• Short burst therapy probably should be reserved
  for clinical features suggestive of atopic asthma
• History of multi-trigger wheeze
• Severe eczema
• Family history of atopy

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What determines need for admission?
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What determines need for admission?

• Oxygen requirement (SpO2 lt93)
• Respiratory effort
• Hydration concerns
• Social complications

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Take home points

• Preschool wheeze appears to have multiple
  phenotypes
• Short burst oral steroids no longer the
  cornerstone of management for all preschool
  wheeze
• Questions?

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Case 2
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Micah, 2 years

• Unwell for 2 days with runny nose and cough
• Feels hot
• Mum noticed lump in neck

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What do you want to know?
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What do you want to know?

• Well/unwell
• Location
• Size
• Heat
• Other lymphadenopathy
• Spleen/liver

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Micah, 2 years

• 4-5cm diameter firm swelling in upper cervical
  chain
• Non-fluctuant
• A few other small lymph nodes
• No swallowing issues
• Well otherwise

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Plan of action?
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Plan of action?

• Do nothing?
• Investigations?
• Oral antibiotics?
• Intravenous antibiotics?

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Causes of acute cervical lymphadenopathy

• Reactive
• Infection
• Bacterial
• Atypical mycobacterium
• TB
• Other

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Plan(s) of action

• Fluctuant node
• Incision drainage/excision
• Well
• Oral antibiotics for 7-10 days review in 48-72h
• Unwell
• IV antibiotics
• Investigations probably only indicated for
  persistent adenitis (gt2 weeks)

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Take home points

• Acute adenitis
• If collection suspected, needs ID
• Oral antibiotics review appropriate for the
  majority of well children
• Questions?

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Case 3
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Bethany, 6 years

• Awoke complaining of left hip and thigh pain
• Previously fit and well apart from an upper
  respiratory tract infection 7 days previously

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What else do you want to know?
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What else do you want to know?

• Characteristics of the pain
• Systemic features
• Recent travel or systemic illness
• Medication history
• (Trauma)

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Bethany, 6 years

• Refused to weight bear
• Became very distressed at attempted examination
• Temperature 38.7
• Flushed tachycardic

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Differential diagnosis of the limping child?
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Differential diagnosis of the limping child

• Transient synovitis/ reactive arthritis
• Septic arthritis/osteomyelitis
• Perthes disease
• Slipped Upper Femoral Epiphysis
• JIA
• Malignancy
• Abdominal/testicular pathology
• Discitis, Lyme disease, NAI

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Red flags

• Severe unremitting pain
• Complete non-weight bearing
• Pseudoparalysis
• Night pain
• Fever
• Back pain
• Features of malignancy

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Bethany, 6 years

• Differential diagnosis
• Septic arthritis
• Reactive arthritis

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Investigations?
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Investigations

• White cell count 11.5 x 109/L
• CRP 30mg/L
• ESR 15 mm/h
• Plain X-ray normal
• Urgent ultrasound hip effusion

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Kochers clinical prediction rule

• Factors
• Fever gt38
• Unable to weight bear
• ESRgt40mm/hr in the first hour
• Serum WCC gt12x106/L
• Probability of septic arthritis
• No factors present lt0.2
• 2 factors present 40
• 3 factors present 93
• 4 factors present gt99

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Bethany, 6 years

• Presumptive diagnosis septic arthritis
• Joint aspiration wash out
• Gran stain negative
• gt50,000 white cells/mm3 on microscopy
• IV antibiotics for 2 weeks, oral for 4 weeks

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Take home points

• Limping is a common presentation
• Limping is not a diagnosis
• Not all children need excessive investigation
• All children need clear follow up plans

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Thank you!