Download - Pediatrics Review Emergency
Pediatrics ReviewEmergency
Gina Neto, MD FRCPCDivision of Emergency Medicine
• Review pediatric resuscitation guidelines
• Recognize pediatric conditions that present to the emergency
• Describe management of pediatric emergency cases
Objectives
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
• 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, RocuroniumKetamine, Midazolam/Fentanyl, Propofol
Pediatric Resuscitation
• Bradycardia• Non-Cardiac causes (6 H’s, 5 T’s)
Hypoxia (Most Common) Hypovolemia, Hypo/Hyperkalemia,
Hypoglycemia, HypothermiaToxins, 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
Pediatric Resuscitation• Tachycardia• Narrow• Wide• Stable or Unstable
• Know what is normal for age
• 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
Pediatric Resuscitation
• 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.
Case
• 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
Asthma
• 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?
Case
• 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 • Nebulized Epinephrine – short term relief
• ? Dexamethasone 1 mg/kg on Day 1 0.6 mg/kg for another 5 days
• ? Nebulized Hypertonic Saline
Bronchiolitis
• 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?
Case
• 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
Croup
Steeple Sign
• 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?
Case
• < 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 Abscess
Age (yrs) Maximum (mm)0-1 1.5 x C21-3 0.5 x C23-6 0.4 x C26-14 0.3 x C2
Retropharyngeal Soft Tissues *
Age (yrs) Maximum (mm)0-1 2.0 x C51-2 1.5 x C52-3 1.2 x C53-6 1.2 x C56-14 1.2 x C5
Retrotracheal Soft Tissues *
*
*
• 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.
Case
• Rarely seen • Strep pneumoniae• H. influenzae uncommon
due to vaccine
• Do not disturb patient• Consult Anesthesia,
intubate • IV Ceftriaxone and
Clindamycin
Epiglottitis
• 17 mo 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
Case
What investigation would you do next?
ExpiratoryCXR
Inspiratory Expiratory
• 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
Foreign Body Aspiration
• 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?
Case
• 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 month
• 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%
Fever 1-3 months
• 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)
Low Risk Criteria “Rochester” for Febrile Infants
• 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
Fever 3-36 months
• 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?
Case
• 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
Febrile Seizure
• 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 Thiopental Propofol Paraldehyde
• Observe in the ED until child returns to normal
• After simple febrile seizure no neurological investigations indicated (eg CT, EEG)
Seizure Management
• 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?
Case
• ORT with rehydration solution (eg Pedialyte)• 5 ml/kg/hr divided every 5 min, continue
until appears hydrated
• Consider Ondansetron (0.15 mg/kg)
• Early refeeding (including milk) within 12 hrs
• Rule out UTI
Gastroenteritis
• Maintenance (D5NS)4ml/kg/hr for first 10 kg2ml/kg/hr for second 10 kg1 ml/kg/hr for rest of weight in kg
• Deficit (NS)• If severely dehydrated give NS bolus
20 ml/kg over 15-60 min • Replace over 24 hours
First half over 8hrs, second half over 16 hrs• Ongoing Losses• Diarrhea, Vomiting, Insensible losses with fever
Fluids and Electrolytes
• 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?
Case
• 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
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
• Air Contrast Enema
• Success rate >80%• Recurrence 10-15%
Intussusception
• 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
Case
• 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 frequency and
eventually becomes projectile
• Classic findings:• Hypertrophied pylorus palpable “olive” in
epigastric area• Peristaltic waves progressing from LUQ to
the epigastrium
Pyloric Stenosis
Pyloric Stenosis
• Laboratory abnormalities:• Hypokalemia• Hypochloremia• Metabolic alkalosis
• Ultrasound• Thickened pylorus
• 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?
Case
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
• 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
Volvulus
• 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.
Case
• 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
Kawasaki Disease
• 3 yr old girl with rash starting today.
• Recent URTI.
• Swollen ankles and knees. Painful walking.
• Diagnosis?
Case
• 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%)
Henoch-Schonlein Purpura
Case• 1 yr old boy with
mouth lesions for two days
• What are the two most likely causes?
• Herpes Simplex• Severe primary
infection• HSV1 (80%), HSV2
(20%)
• Fever, irritability, poor intake
• Ulcers on mucous membranes
• Treatment• Acyclovir• Pain control, IV
hydration
Herpetic Gingivostomatitis
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 comes back to the ED three days later with worsening fever and 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?
• 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
Staphylococcal Scalded Skin Syndrome
• 10 yr old boy with fever
• Unwell today• Rapidly progressing
rash since this morning
Case
• Usually < 5 yrs, Adolescents outbreaks• Fever, toxic appearance• Petechiae, purpura• DIC, shock• High mortality (25-80%)
• Resuscitation• IV Ceftriaxone• Treat household contacts
Meningococcemia
• 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
• Sepsis if systemic inflammatory response signs (SIRS) and signs of infection• Fever, or HR, RR, or WBC
• Severe sepsis if signs of organ dysfunction or tissue hypoperfusion
• Septic Shock if cardiovascular dysfunction
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 resistanceBounding pulses, wide pulse pressure
Septic Shock
• 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?
Case
• Young childrenExploratory ingestionIngest 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
• AdolescentsIngest large amounts of one or more
substancesSuicidal gesture
Poisoning in Children
• Activated Charcoal• 1 g/kg• Greatest benefit is within 1 hr of ingestion
At 30 min 89% decreaseAt 1 hr 37% decrease
• Not useful forAlcoholsHydrocarbonsAnions or Cations (Iron, Lithium)Acids or Alkali
GI Decontamination
• Whole Bowel Irrigation• PegLyte
0.5-2 L per hour via NG
• For substances not adsorbed by charcoal and sustained release preparationsIronLithiumEC ASA
GI Decontamination
• Common ingestions• Household products• Cough/cold, vitamins, antibiotics• Acetaminophen and Ibuprofen• Antidepressants
• Pills that are harmful if single dose taken• Oral hypoglycemics, calcium channel
blockers, tricyclic antidepressants
Poisoning in Children
• Clinical Effects• 0-24 hrs
GI irritation, may be asymptomatic
• 24-48 hrsSigns of liver involvement begin
• 72-96 hrs Fulminant hepatic failureRenal failure
Acetaminophen
Acetaminophen
Acetaminophen• > 4 hr Acetaminophen
level• Plot on nomogram
• N-AcetylcysteinePrecursor for glutathione Increases sulfation
metabolismDirectly reduces NAPQI to
APAPDirectly conjugates NAPQI
Salicylates• Clinical Effects• GI upset - N&V, Gastritis • Tinnitus – often the first symptom• CNS – Confusion, Lethargy, Cerebral
edema• Hyperpnea – Early have respiratory
alkalosis• Hyperthermia• Renal and Liver toxicity – rare• Impaired platelet function
Salicylates• Mechanism of Action• Uncoupling of oxidative phosphorylation
HyperthermiaGlycogenolysis, LipolysisHyperglycemia initially then hypoglycemia
from impaired gluconeogenesis• Inhibits Kreb’s cycle
Anaerobic metabolismLactic acidosis
• Urine alkalinization• Ion trapping – ASA is weak acid
• Hemodialysis• If signs of multiorgan failure
Salicylates
• Low incidence of toxicity, most asymptomatic
• Reversibly blocks cycloxygenase, prostaglandins
• Clinical Effects• GI upset, bleeding• Renal failure• Bronchospasm• Massive overdoses > 400 mg/kg
metabolic acidosis, seizures, coma, hypotension
Ibuprofen
• Triad of clinical effects:• Cardiovascular
Prolonged QRS, QT, PR, ArrhythmiasHypotension
• CNSComa, Seizures
• Anticholinergic symptoms
Tricyclic Antidepressants
Tricyclic Antidepressants• Mechanisms of toxicity
• Blockade of fast Na+ channels
• Type 1A “quinidine-like effects”
• Membrane stabilizing effects• Inhibition of GABA
reuptake• Blockade of alpha 1
receptors• Anticholinergic effects
• NaHCO3• 1-2 meq/Kg then infusion
D5W + 150 meq NaHCO3/L at 1.5 x maintenance
• Benzodiazepines• Sedation, seizures
• Lipid therapy• May be helpful, case reports
Tricyclic Antidepressants
• Much safer than TCA’s
• Clinical Effects:• N&V• Sedation• QT prolongation• Seizures
• Serotonin Syndrome
SSRI’s
• Serotonin SyndromeAgitation, HypervigilanceMyoclonus, Muscle rigiditySeizuresDiaphoresis, shiveringHyperthermia, Autonomic dysfunction – HR, BPDiarrhea
• Treatment• Benzodiazepines, Active cooling
SSRI’s
• Review of pediatric emergency cases: Resuscitation Asthma, Bronchiolitis, Croup, Upper airway Fever in infant, 3-36 months Febrile seizures, Status epilepticus Gastroenteritis, Pyloric stenosis,
Intussusception Rashes associated with serious illness Sepsis Poisoning
Summary
Questions ?