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
