Emergency Medicine - Pediatrics Flashcards
Fracture of distal radius
Buckle fx, aka torus fx?
Are fractures or sprains more common in kids? Why?
Fractures, because kids ligaments are stronger than their bones
Salter-Harris classication of fractures
S - straight across, type I
A - above growth plate, type II
L - lower or beLow growth plate, type III
T - two or through growth plate, type IV
ER - ERasure of growth place or cRush, type V
(I think)
What’s the proper hand alignment
When hand is flexed, all finger tips should point toward scaphoid and digits may overlap when flexed
Most common pediatric elbow fracture
Supracondylar fx
How do you treat gartland types I, II, III fractures?
Supracondylar fractures. Tx type I with elbow split, type II get ortho consult for open vs closed reduction with percutaneous pin placement, type III ortho consult
3yo limping and refusing to walk with normal exam and some pain when twist LE and tap heel? Tx?
Toddlers fx, spiral or oblique fx through distal 1/3 of tibia, nondisplaced, often unwitnessed fall or minor trauma, tx with short or long leg cast x3-4wks, ortho f/u in 1wk
12moM with barky cough and congestion at night, crying, upset with hoarse voice, inspiratory stridor, and clear lungs? Cause? Tests? Tx?
Croup. ALWAYS viral (RIPAM). Clinical dx, but CXR shows steeple sign (subglottic narrowing). Tx with cold mist/hot shower, DEXAMETHASONE, racemic Epi nebulized if audible stridor at rest
Causes of croup
Always viral. RIPAM: RSV, influenza, parainfluenza (>60%), adenovirus, mycoplasma
Reasons to admit patient with croup
If DX is questionable, continued audible stridor, toxic appearance, dehydration and V, very young (?, <3mo)
7yoM with cough, SOB, HX of wheezing, breathless with one word answers, inspiratory and expiratory wheeze, subcostal and intercostal retractions
Asthma
Describe mild asthma
Incr RR, No/mild accessory muscle use or retractions, moderate often end-expiratory wheeze
Describe moderate asthma
Incr RR, Moderate accessory muscle use and retractions, loud wheeze throughout exhalation
Describe severe asthma
Incr/Decr RR, Severe accessory muscle use or retractions, inspiratory and expiratory wheeze
Indications for X-ray in diagnosis of asthma in child. What do you see on CXR?
If exam is asymmetric, minimal improvement, chest pain, severe exacerbation or first time wheeze. See hyperinflation, peri bronchial thickening, atelectasis.
What labs do you need to get with asthma?
Labs not required. ABG is severe exacerbation. K if continuous beta agonists (push K into the cell).
Reasons to admit kid with asthma
O2 requirement, persistent resp distress with need for tx < every 4hrs, high risk, ED visit within last 24hrs
7wk old with fever, decr PO, fast breathing, cold Sx for a few days, diffuse wheezing and retractions
Bronchiolitis
Tx of asthma
Bronchodilators, corticosteroids, supportive O2, hydration, ABx if concerned for bacterial inf (PNA)
26moF with fever, V, RLQ and pain for 1d, T38.9, HR138, RR48, 92%RA, tachyon epic with diffuse crackles and diffuse abdominal pain R>L
PNA
Cause of PNA in neonates
Group B Strep, GN enterics
Cause of PNA in 2wk to 2mo old
Chlamydia, viruses, S. Pneumo, S. Aureus, H.flu
Cause of PNA in 2mo to 3yrs
Viruses, S. Pneumo, S. Aureus, H.flu
Cause of PNA in 3yrs to 19 hrs
Viruses, S. Pneumo, mycoplasma pneumo
20moM coughing with fast breathing, active and playful, RR42, O2 sat 95%, mild R-sided wheezes and decr breath sounds
Foreign body aspiration
Where is FBA most common?
Slightly more common on R
CXR of kid with FBA
Foreign body, hyperinflation, infiltrates
33 day old infant M with fever. Per mother, has been slightly cranky but no other sx. Brother has a cold. in ED, alert, vigorous, T 38.4, normal exam.
febrile infant (0-56d) with T>38C. Do Septic workup: CBC with diff, BCx, UA, UCx, LP, CXR if URI Sx, Stool Cx if Sx. Since pt 29-56d old, decide if high or low risk, admit and give Abx if high risk. withhold Abx if low risk.
Philadelphia Criteria after septic workup.
If 0-28d, admit, immediate Abx, acylovir admit, immediate Abx. if 29-56d, low risk if PMHx nl, well appearing and nl labs -> option 1 outpt mgmt, 24hr f/u, withhold ABx or option 2 inpt obs, withhold ABx.
11mo F with fever for 2 days. No other Sx. PE reveals a well-appearing, interactive infant. T 40.20C, but remainder of exam is normal.
2-36mo febrile young infant. T>/= 39C. if well appearing, <12mo Cath urine dipstick, UCx and tx if urine positive.
2-36mo causes of fever >39C
occult bacteremia - Hflu B, Strep pneumo; fever without source - well appearing, no source, no tx; occult UTI - Ecoli, GN enterics, enterococci
tx of occult UTI in 2-36mo
for GN enterics: cefixime, TMP-SMX, cephalexin
9yo F with fever and sore throat for 3d. +V, -D, URI Sx, dyspnea, or dysuria. PE: T=40°C, well-appearing, + exudative, erythematous pharynx and anterior cervical adenopathy. What if she had dysuria? or tachypnea and crackles?
> 3yo, VIRAL -> no testing/tx needed, but use Sx as guide: pharyngitis do rapid strep test. Dysuria do UA, UCx. Tachypnea/crackles do CXR.
A previously healthy 22 day old girl presents with a chief complaint of “feeling warm”. No vomiting, diarrhea, cough, or irritability. Alert, well-appearing, 38.6º
< 4 weeks old: admit, presumptive antibiotics
5-8 weeks old: may consider outpatient therapy without antibiotics, if low risk (philadelphia) criteria are met
Philadelphia criteria
Age: 29-56 days; Fever: > 38.2° Low-risk Criteria: on PE no infection and well-appearing Labs: CSF < 8 (or 10?) wbc/hpf CSF profile wnl and negative Gram stain WBC < 15,000 Band/neutrophil < 0.2 UA < 10 wbc/hpf CXR: no infiltrate Social: Good observer and car and phone
A 47 day old presents with T = 38.6°. She is slightly fussy but consoles easily and has a normal exam. LP?
febrile young infants 29-56 days old who meet all other low risk criteria are highly unlikely to have bacterial meningitis. It is reasonable to omit the LP in this setting.
A 38 day old presents with coughing and “trouble breathing”
On PE, T = 38.3º. He is well-appearing and noted to be wheezing.
For <29 days old, RSV infection doesn’t significantly alter rate of SBI
For 29-60 days old, Those with clinical bronchiolitis (with or without documented RSV inf) are at significantly lower risk for SBI compared to others. There is a clinically important rate of UTI among FYI with RSV and/or bronchiolitis
An 11 day old presents with poor feeding, fussiness, and a tactile fever
On PE, T = 38.7º. He is irritable and slightly dehydrated. Plan? Cause of fever?
Full sepsis work-up, initiate antibiotics, and hospitalize. Ecoli, CGS, listeria (<21d with severe inf.
when should we consider HSV inf in febrile infant? TX?
< 21 days old, Mum had active primary HSV at delivery, on PE: Vesicles, Seizure (27%), Lab studies show CSF pleocytosis (especially if CSF RBCs also), Increased liver enzymes
Consider empiric testing and acyclovir (60 mg/kg/day tid) if one of these criteria
cause of fever 0-21d, tx
GBS, enterococcus, GNegs, HSV. Amp, cefotaxime, acyclovir
cause of fever in 22-28d? Tx?
GBS, enterococcus, GNegs. Amp, cefotaxime, +Vanc if Gpos bugs in CSF or if septic.
cause of fever in 29-56d? tx?
late GBS or pneumococcus. Cefotaxime.
risks for occult UTI in 2-36mo
caucasian > latino > AA; /=39C; fever for >/=2d; no source of fever; uncircumcised
what is considered a positive UA for occult UTI testing in 2-36mo with fever?
urine dipstick positive if +nitrites +/- moderate leukesterase or microscopic UA has >10-15 WBC/hpf. always send UCx bc of false negatives
