Common Pediatric ED Presentations Flashcards
Modified GCS for infants
Eye Opening 4 – spontaneously 3 – to speech 2 – to pain 1 – no response
Verbal Response 5 – coos, babbles 4 – irritable cry 3 – cries to pain 2 – moans to pain 1 no response
Motor Response 6 – normal, spontaneous movement 5 – withdraws to touch 4 – withdraws to pain 3 – decorticate flexion 2 – decerebrate extension 1 – no response
Modified GCS for children <4 years
Eye Opening 4 – spontaneously 3 – to speech 2 – to pain 1 – no response
Verbal Response
5 – oriented, social, speaks, interacts
4 – confused speech, disoriented, consolable
3 – inappropriate words, not consolable/aware
2 – incomprehensible, agitated, restless, not aware
1 – no response
Motor Response 6 – normal, spontaneous movement 5 – localizes to pain 4 – withdraws to pain 3 – decorticate flexion 2 – decerebrate extension 1 – no response
Trauma or suspected trauma patient <1 year of age with large, boggy scalp hematomainvestigations
Requires u/s or CT
Respiratory distresss in children presentation
- infants not able to feed, older children not able to speak in full sentences
- anxious, irritable, lethargic – may indicate hypoxia
- tachypnea >60 (>40 if preschool age, >30 if school age), retractions, tracheal tug
- pulsus paradoxus
- wheezing, grunting, vomiting
Croup presentation
0.5-4 years
Prodrome of days
Low grade fever
Steeple sign
Prainfluenza
Barky cough, drooling
Perform oral exam
Bacterial tracheitis presentation
5-10 years
hours to days prodrome
high fever
exudates in trachea on radiograph
S. aureus/GAS
Barky cough, no drooling, appears toxic, intubation/ICU, antibiotics
complete oral exam
Epiglottitis presentation
2-8 years
minutes to hours prodrome
high fever
thumb sign on radiograph
H influenzae type B
4 D’s: drooling, dyspnea, dysphagia, dysphonia + tripod sitting
No barky cough, but drooling, appears toxic, intubation ICU/antibiotics
DO NOT PERFORM oral exam, consult ENT
Croup management
■ dexamethasone x 1 dose
■ if moderate-severe, add nebulized epinephrine (racemic has limited availability)
■ consider bacterial tracheitis/epiglottitis if unresponsive to croup therapy
■ humidified O2 should not be given (no evidence for efficacy)
Croup pathophysiology
usually laryngotracheitis caused by parainfluenza viruses
Bacterial tracheitis management
■ airway maintenance - usually require intubation, ENT consult, ICU
■ start antibiotics (e.g. cloxacillin), pending C&S
Epiglottitis management
do not examine oropharynx or agitate patient
immediate anesthesia, ENT call - intubate
then IV fluids, antibiotics, blood cultures
Asthma exacerbation management
■ supplemental O2 if saturation <90% or PaO2 <60%
■ bronchodilator therapy: salbutamol (Ventolin®) 0.15 mg/kg x3 by masks q20min
■ give corticosteroid therapy as soon as possible after arrival (prednisolone 2 mg/kg, dexamethasone 0.6 mg/kg, 2 doses 24 h apart)
■ if severe, add 250-500 µg ipratropium (Atrovent®) to first 3 doses salbutamol if critically ill, not responding to inhaled bronchodilators or steroids: give IV bolus, then infusion of MgSO4
■ IV β2-agonists if critically ill and not responding to above
How to manage the febrile infant
• for fever >38°C without obvious focus
■ <28 d
◆ admit
◆ full septic workup (CBC and differential, blood C&S, urine C&S, LP ± stool C&S, CXR if indicated)
◆ treat empirically with broad spectrum IV antibiotics
■ 28-90 d
◆ as above unless infant meets Rochester criteria, partial septic workup (CBC and differential, blood C&S, urine C&S, CXR if indicated)
■ >90 d
◆ toxic: admit, treat, full septic workup
◆ non-toxic and no focus: investigate as indicated by history and physical
What is Rochester Criteria for Febrile Infants Age 28-90 days old
Rochester Criteria for Febrile Infants Age 28-90 Days Old
• Nontoxic looking
• Previously well (>37 wk gestational age, home with mother, no hyperbilirubinemia, no prior antibiotics or hospitalizations, no chronic/underlying illness)
• No skin, soft tissue, bone, joint, or ear infection on physical exam
• WBC 5,000-15,000,
bands <1,500,
urine <10 WBC/HPF,
stool <5 WBC/HPF
Febrile seizures demographic
- children aged 6 mo-6 yr with fever or history of recent fever
- typical vs. atypical febrile seizures
- normal neurological exam afterward and relatively well-looking after seizure
- no evidence of intracranial infection or history of previous non-febrile seizures
- often positive family history of febrile seizures
Febrile seizure investigations and management
• if it is a febrile seizure: treat fever and look for source of fever
• if not a febrile seizure: treat seizure and look for source of seizure
■ note: may also have fever but may not meet criteria for febrile seizure
• ± EEG (especially if first seizure), head U/S (if fontanelle open)
Typical febrile seizure
<15 min duration
Generalized seizure
Frequency 1 in 24 h
Atypical febrile seizure
> 15 mins
Focal features
> 1 in 24 h
Red flags for pediatric abdominal pain
• Significant weight loss or growth ret rdation (need growth chart)
Fever
- Joint pain with objective physical findings
- Rash
- Rectal bleeding
- Rebound tenderness and radiation of pain to back, shoulders, or legs
- Pain wakes from sleep
- Severe diarrhea and encopresis
- Trauma or suspected trauma patient <1 yr of age with a large, boggy scalp hematoma requires U/S or CT
Meningitis sepsis neonatal pathogens and treatment
GBS,
E. coli,
Listeria,
Gram-negative bacilli
Ampicillin + cefotaxime
Meningitis sepsis 1-3 months pathogens and treatment
GBS, E. coli, Listeria, Gram-negative bacilli S. pneumoniae H. influenze type b Meningococcus
Ampicillin + cefotaxime + vancomycin
Meningitis sepsis >3 months pathogens and treatment
S. pneumoniae
H. influenze type b ( >5 years)
Meningococcus
Ceftriaxone + vancomycin
Otitis media pathogens and treatment
S. pneuonia
H. influenzae type B
M. catarrhalis
1st line - Amoxicillin 80-90 mg/kg/d
2nd line - clarithromycin 15 mg/kg/d bid (for penicillin allergy)
Treatment failure - 90 mg/kg/d amoxicillin and 6.4 mg/kg/d clavulanate divided into BID dosage
Strep pharyngitis pathogens and treatment
Group A β-hemolytic Streptococcus
penicillin/amoxicillin or erythromycin (penicillin allergy)
UTI pathogens and treatment
E. coli, Proteus, H. influenzae, Pseudomonas, S. saprophyticus, Enterococcus, GBS
Oral: cephalexin (older children) IV: ampicillin and aminoglycoside
Pneumonia 1-3 months pathogens and treatment
Viral, S. pneumoniae, C. trachomatis, B. pertussis, S. aureus, H. influenzae
cefuroxime ± macrolide (erythromycin) OR ampicillin ± macrolide
PNA 3 mo-5 year pathogens and treatment
Viral, S pneumoniae, S. aureus, H. influenzae, Mycoplasma pneumoniae
ampicillin/amoxicillin or cefuroxime
PNA >5 years pathogens and treatment
Viral, S pneumoniae, S. aureus, H. influenzae, Mycoplasma pneumoniae
ampicillin/amoxicillin + macrolide or cefuroxime + macrolide
Injury patterns associated with child abuse
■ HI: torn frenulum, dental injuries, bilateral black eyes, traumatic hair loss, diffuse severe CNS injury, retinal hemorrhage
■ Shaken Baby Syndrome: diffuse brain injury, subdural/SAH, retinal hemorrhage, minimal/no evidence of external trauma, associated bony fractures
■ skin injuries: bites, bruises/burns in shape of an object, glove/stocking distribution of burns, bruises of various ages, bruises in protected areas
■ bone injuries: rib fractures without major trauma, femur fractures age <1 yr, spiral fractures of long bones in non-ambulatory children, metaphyseal fractures in infants, multiple fractures of various ages, complex/multiple skull fractures
■ GU/GI injuries: chronic abdominal/perineal pain, injury to genitals/rectum, STI/pregnancy, recurrent vomiting or diarrhea
Investigations with suspected child abuse/neglect
consider skeletal survey x-rays (especially in non-ambulatory child), ophthalmology consult, CT head
What should you do if suspected/known child abuse/neglect
obligation to report any suspected/known case of child abuse or neglect to CAS yourself (do not delegate)
document injuries
