Pediatric Emergencies Flashcards
Meningitis
Etiology
Types
Meningitis: inflammation/infection of the meninges: brain covering
Types
bacterial: sever and life threatening
viral: acute, self limitng
sterile: meninginal inflammtion in the absence of a soruce of infection that is pyogenic bacteria: thus sterile can be fungal or neoplastic
Those under 2 months are at the highest risk because they are not yet vaccinated with the meningioccogeal vaccine
Meningitis
Symptoms : infants v older kids
Infants
- URI like symptoms: fever, lethargy/irritability
- poor feeding
- bulding fontelle: increased ICP
- vomiting/dirrahea
- respiratroy distress & seizure (most severe presentation)
if meningococcal = will see the Pururitc rash along with the symptoms above
the “meningenal symptoms: of nuchal rigitity, photophobic are not seen in those under 2 years
Older Kids
- the classic triad: fever, neck stiffness & HA
- meningeal signs: photophobia, nausea/vomitng & confusion
- lethargy and AMS
if meningococcal = will see the Pururitc rash along with the symptoms above
Exam findings
- kernig: knees bent; if + pain when you passively extend
- bruskinki: if passive flex of neck elicts bending of knees = +
- nuchal rigity: passive flexiong ofneck, if resistance thats +
Meningitis
Evaluation/Diagnosis
Evaluation: this is a medical emergency
-assess if they got HiB and Pneumococcal vaccine
LABS
- CBC, ESR/CRP, CMP
- cultures
- PT/INR, PTT
- lactate: if need to assess sepsis
LUMBAR PUNCTURE needs to be done to assess CSF
- should be done on all that you suspect meningitis: except those who have evidence of increased ICP(bulding fontelle, papilledma : need CT (but do NOT delyat abx and culutres to get CT)
contraindicated if: infection over the sitre, hemodynamically unstable, respiratory distress
LP; send CSF for cell count and diff, glucose and protein concentrations and gram stain/culutre (and HSV to rule out)
LP: CSF Analysis and how it guides your decision making
what bugs are we working with
Bacterial CSF
- turbid color
- elevated opening pressure
- increased WBC >1,000
- increased protein >200
- DECREASED GLUCOSEbecause they’re eating it all
Viral
- clear color
- normal OP
- increased WBC not as high as baterial: under 300 with LYMPHOCYTES
- increased protein
- normal glucose
Bugs
- HSV will be those < 1 month
- entervirus will be those > 1 month
- 0-1 month = GBS
- 1-3 months = GBS, strepococcus pneumonaie & nisseria meningitis
Meningitis
Treatment by age
0-1 month
1+ months
when dou you steroids
viral???
Treatment
0-1 month: you’re worried about GBS, listera and e. coli
IV ampucillin + IV gentamycin
OR
IV ampucillin + broad spectrum cephalsporin (cefotaxime)
ADD: IV vanco if you suspect strep pneumo.
those 1+ months: youre worried about covierng meningocccous and pneumococcus
IV ceftriaxone and IV vancomycin
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culutre: then tailore ABX.
for strep penumo and h. flu : ADD DEXTAMETHASONE (steroid)
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Viral
- supprotive care + fluids
- if known HSV or HSV encephalitis = acyclovir IV
Complications of Meningitis
post-exposure prophylaxis
- increased ICP
- DIC
- cardiopulmonary arrest
- sepsis/septic shock
- long term: hearing loss, learning delays
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Post-expsoure prophylaxis
everyone needs to be given abx. (under 24 hours from identfying)
- those who had 8+ hours of contact
- those with are household members
- preferred: ceftriaxone because 1 dose, but can do rifampin
Reye Syndrome
Etiology
presentation
Etiology
- USING ASPRIN IN KIDS TO TREAT A FEVER CREATES THIS!!!!
- a progessive encephalitis with hepatic dysfunction
- presentation: usually a URI that was treated, resolved then acutely worsens over the next few days
- commonly the URI was influ A/B or varicella
Presentation
- initially, nonstop vomiting and confusion
- seizures & coma due to increased ICP
- hyperventiliation
- hepaltomegaly without jaudice
- can be fatal
Reye’s Syndrome
workup : labs and imaging
Workup
LP: do CSF analysis will be normal cells, normal protein but low glucose
- LFTS: elevated (AST, ALT, bili)
- increased PT
- hypoglycemia
Imaging
- abd. US or CT: steatosis of the liver
Treatment
supportive: IV fluids with dextrose prevent hypoglycemia and seizure
- seizure treatment/prophlaxis (Keppra)
decrease ICP
- elevate HOB
- IV mannitol
- fever control (febrile seizure risk)
Kawasaki Disease
Etiology
Etiology
- a mucocutaneous lymph node syndrome: widespread inflmmation of the medium sized vessels: arteries in the mucucutanoues areas of the body
- a vasculitis: 2nd mc in peds
- most commony cause of acquired cornary artery disease in pediatrics
- typically under 5 years old
Kawasaki’s Disease
Symptoms
penumonic & describtion of each symptom
Symptoms : WARM and CREAM
Warm = fever that is lasting 5+ days
with 4 of the following symptoms
C : conjuntivitis
R: rash
E: extremities
A: adenopathy
M: mucositis
Conjunctivitis
- bilateral injection without exudates: spares limbus
Rash
- morbilliform, macular red rash
- starts in the perineal region: spreads from there check diaper
Extremities
- red, swollen desquamous: peeling of the palsma nd soles
- beau’s lines: transverse nail grooves
Adenopathy
- cervical usually
Mucositis
- Strawberry tongue
- cracked, chapped lips
Rash and mucositis are almost always seen
Kawasaki’s Disease
incomplete v complete
Incomplete
- need to still consider KD in kids under 6montsh with an unexplained fever in teh absence of otehr symptoms: because the downside of cornary artery disease is so bad
Incomplete = thoe with unexplained fever for 5+ days and only 2-3 of the CREAM symptoms
Kawasaki’s Disease
Workup
labs
imaging
treatment
Workup- Labs
- CBC, ESR/CRP, LFTS, UA = not needed but can help
- nonspecific inflammation is what you’ll find
Workup-Imaging
- echo needs to be done ASAP to assess thehealth of the heart in that moment and have a baseline for comparison
Treatmen t
IV immunoglobulin = reduces risk of cornary complications
- delay immunizations for 11 months
ASPRIN: singificantly reduces inflammation and throbosis (eduate on reyes)
Steroids : reduce inflammation
advanced stages: warfarin or LMWH
refractory: pulse dose steroids + influximab
Kawasaki’s Disease
Long Term Following
Long Term
- Echo: 2-6 weeks post diagnosis
- send to peds cardiologist
HSP: Henoch Schonlein Purpura
etiology
Clinical Presentation general
Etiology
- most commony systemic vasculitis in kids
- an IgA vasculitis: small vessels: IgA complexes deposit in the vascular walls
- most are preceeded by a URI: streptococcus: the immune rxn triggers
Clinical Presentation
- purpura, arthritis, abd pain, kidney disease: usually develops over days/weeks
often the purpura and arthritis preceed the rest
Clinical PResenation of HSP
specifics about each symptoms
Palpable purpura: without cogaulopathy or platlet issues
- lower extremities/dependent areas (butt)
- nonpainful
- +/- edema
arthritis/arthralgia
- transient, migratory: 1-4 joints
- lower Extremities joints : hips, knees and ankles
- periarticualr swelling without effusions
- limitied ROM
Abd pain
- colicky, +/- GI bleeding
- n/v
- intussusception of the small bowel (not the illoceccal = surg. emerg)
- often + FOB, but its due to GI inflammation and ucosal injury
kidney disease
- seen often in th eolders kids with HSP
- hematuria +/- red blood cell casts, mild proteinuria
- nephrotic range protein with elevated CR, HTN
some pt. can have scrotal involvement = edema/pain
HSP
Diagnosis and Treatment/management
Diagnosis
Clinical presence of the purpura+ 2 other characteristics
often, labs arent necessary
- elevated IgA
- CBC,BMP, UA = nonspecific
- PT, PTT, INR = normal
an unusual presentation: can prompt a biopsy of the skin/kidney = leukocytoclastic vasculitis with increased IgA deposition
Treatment
- spontanous resolution
- supportive hydration ,rest and pain control
- pain contorl : tylenol or NSAIDS (no nsaids if GI bleed)
- if severe: steroids
- PCP and nephorlogy follow up
Forgein Body Inhalation
etiology
what are they inhaling
where is ti going
Etiology
- FBA is the most commony cause of morbidity/mortality i kids under 2
- small airway + increased curiosity + fine motor skills = disaster!
what are they inhaling - infants
- PEANUTS
- popcorn,
- toy pieces
- hardware
what are they inahling - older
- coins
- paperclips
- pins
- pen caps
- jewlery
where does it go
- majority are in the brochi: Right > left
FB Inhalation
presentation
Presentation
depends on
- amoutn of abstruction
- location of object
- age
- type of object
- time since
those with…
- severe respiratory distress, cyanosis AMS = respiratory emergency = rigpi bronch. remove and intubate
Commonly
- wheezing, coughing & dimisihed breath sounds
- tachypnea
- stridor
- vairiations in aeration by region
if it gets stuck in : laryngotracheal higher up = more acuter respiratory distress
- stridor
- wheeze
- salivation
- dyspnea
- vioce changes
if it gets stuck further down, large bronchi
- cough + wheeze
- hemoptysis
- choking, cyanosis
- SOB, decreased BS
- fever possible
- they are less liekly to be in acute distress after the initail choking
FB inhalation
witnessed?
Evaluation & management
Witnessed Event
- have a high sensitivity fo aspiration if they has respiratry symptoms and teh event was witnessed
- presenting after days: think PNA, abcess, etc.
Evaluation
- if they’re actively obstructed: chocking, etc. = back blows to the infant or heimlich to odler kids no blind sweeps
Stable + suspected + symptoms
- plain AP + lateral Xray
if XRAY + for the FB: consutl ENT to get rigid bronch.
if XRAY - for the FB but you have sus: depedns on radiolucent of the object, probably gonna bronch them anyway
if a lower airway obstruction: presenting later
- atlectaisis, medistainl shift, PNA, hyperinflated lung
- look for FB on XARY and rigid bronch.
- if its been there for a few weeks: give abx. + steroids then rigid broch
FB Ingestion
what coud be ingested
what is ingested
button batteries: EMERGENCY
- coins
- magnent s
- marbles
- buttons
- pins
Risk Factors for retention
most will spontaneously pass on theri own UNLESS…
- younger age
- congenital malformation
- GERD/ eosinophili esophagitis
- neuromuscular disease
normal areas of physiological narrowing: aortic arch , and LES
FB Ingestion
Clinical Presentaion & Evaluation
Presentation = depends on location of the FB
esophagus: refusing to eat, chest pain dysphaga, drooling or respiratory issues
stomach: asymptomatic unless obstruction: vomting, distention
intestines: abcess or perofrmation
Evaluation
- get AP and Lateral Xray of neck, chest and abd.
- always need to establish coin v button battery
- BB: step off, halo sign and belved edge
FB Ingestion
Management
Management
urgent removal for..
- airway compromise
- near/complete esophageal obstruction
- inability to tolerate secretions
Smoot, Round object + no respiratory issues + pt. can swallow
- observe, it will pass spontaneously
Stomach
- can see it in stool
FB in esophagus = removal with endoscopic within 24 hours
Button battery = URGENT endoscopic removal
- risk of thermal burns
things with a heavy, blunted end will pass on own
Things with two shapr ends = endoscopic removal because performation risk
objects > 5 cm = remove: wont pass lig of triex.
magnents = remove if more than 1
Burns
overview
Evaluation
Burns
- calculated via the TBSA
- partial and full thickness = included in the TBSA calcuation
- Lund and Brwoder Chart used to estimate
- alwasy considere abuse and nonaccidental trauma (weird hx., patterns, delayed presentation)
Evaluation of Burn
ABCs
- upper airway = intubate
- inhaled smoke can interfer with the oxygenation process
- circumferential burns = impact chest wall complicant
chemical burn = need irrigation
flame = carbon monoxide expsoure
electrical = cardaic concerns
obtain their weight!!!!
Types of burns: thckness
Thicknesses
superfisical thickness
- painful, wont blister
- sunburn
- “first”
Partial Thickness
- blisters
- superfisical partial burn
- “second”
- scar
- painful
- blisters and weeps
Intermedicate thickness
- deeper than partial
- more scarring
- less painful because youre starting to destory the nerves
Full thickness
- “third”
- dry, no sensation
- may need graft, contractures can occur
Fourth degree
- into the bone or muscle
Labs and Imaging
Burns
Labs
- CBC, CMP
- Ck and UA (look for rhabdomyosis)
- VBG, carboxyhem, serum lactacte: look for cyanide and CO
Imaing
- depends on MOA and PE
- c spine
- ct head, cehst or abd.
- CXR: respiratory
Management of BUrns
fire related: give O2
signs of airway injury; RSI intubation with blood pressure preserer: ketamine
vascualra ccess: somewhere not burend
tetnus vaccine!!!!
pain control with morphine or fetanly
Fluid Resusitation
- Parkland Formula for burns > 10%
- 4mL x (TBSA%) x (weight in kg)
- 1/2 this given in first 8 hours
- seoncd 1.2 given over 16 hours
- LR is fluid of choice
- if under 5= give dextrose to prevent hypoglycemia
How is fluid monitored in a burn pt
Fluid Monitoring
Urine output!
1-2ml/kg per hour = those under 30 kg
0.5-1ml/kg per hour = those ove 30 kg
heartrate is a better indicator of hypovolemia
metabolic acidosis on BMP: low bicarb
Classify
minor
moderate
severe burns
Minor Burns
- those < 5% TBSA
- superfisical thickness
- undeer 5% partial thickness
- can be D/c from ED
Moderate Burns
- 5-15% TBSA
- burns to head, face, hands, feet, perineum, eyes, across joints
- these usually need trauma consult
Major BUrns
- those > 15% TBSA
- 15% TBSA of partial thickness or 5% total thickness
- significant electrical burn
- inhalation injuries
- transfer to burn center
Treatmentof Minor Burns
Minor
- cool, room temp sterile water
- NO ice directly to it
- pain control: tylenol or NSAIDS
- wash with mild soap and water
- debreid with saline-soaked gauze
- superfisical burns do not need dressing: but int ehED typically bacitracin and silver foam with normal gauze
Treatmentof Partial/Full thickness Burns
Initial wound mangement clean with mild soap/water
- debreidment with saline soaked gauze
Dressing
- partial = moist environment with antimicrobial (bacitrainc or siler products)
- full = trasnfer to burn center with sterile DRY dressing
Dehydration
Classifications
critical
acute
urgernt
nonurgent
Critical
- pre-exisitng metabolic derangement
- hypoperfusion
- AMS
- VERY SICK
Acute
- tachycardic
- abd pain
- shrunken fontelle/eyes
- prolong cap. refill
- DM
Urgent
- decreased activiy
- oligouria
Dehydration
define
etiology
Define
- water loss only = cells pulling water into the cells :results in hypernatremia
- hypovolemia = loss of water and salt = volume deletion that reduces cirualtion and compromises tissue function
Etiology
- excessive fluid losses: GI illness (diarrhea,vomiting) , skin burns/fever, urinary losses (DI)
- inadequate fluid intake
- third spacing: edema, liver failure, malnutrtion
Dehydration
Assessment
Assesssment: 10 point or 4 point scale
assess the following on PE
- appearance
- tachycardic/tachypena
- dry muscus membranes
- sucken eyes
- cap refill under 2?
- skin elasticity
- urine output
- hypotension - hypovolemia
- sunken fontelle
Labs
- all pts: POC glucose and betahydroxy. (loking for ketosis)
- BMP: sodium typically ok
- eleavted BUN
- decreased bicarb
- UA and dipstick : osmolaitiy assessment
Dehydration
management
Management
Zofran: for everyone!!! (check QT prolpngation)
Oral rehydartion
- preferred oral if possible
- small amoutns via spoon/syringe
- anything they will drink
lab derangements, inabiltiy to tolerate ORT with ongoing losses = IV rehydartion deemed necessary
failure of ORT: 1+ episode of vomting after zofran or refusal of PO fluids for 30+ minutes
IV rehydartion
- IV NS bolus
- hypoglycemic without ketosis: D10W
- hypoglycemic with ketosis: D5NS over 60 minutes
Dehydartion
criteria for discharge
Criteria
- must pee
- must tolerate PO
- VS improved
- clinical improvement: cap refill and mucos membranes
- ongoing losses? electrolyte abnormaolie s= admit fo rcontinuous IV rehydartion
