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Emergency Medicine 2 > Pediatric Emergencies > Flashcards

Pediatric Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

emergency pediatrics

A
  • •Most kids are healthy – they are mostly born perfect – they will “hide” an illness from you
  • •Young resilient bodies compensate well, until illness advances.
  • •Clinical deterioration occurs quickly in infants and small children.
  • •Have vital sign tables handy
  • Be attentive to weight-based dosing of medicines
  • Pediatric fluid resussitation
    • Boluses of 20ml/kg in shock
    • Boluses of 10ml/kg in dehydration (not in shock)
    • Re-assess after each bolus – doing too much fluid resuscitation can kill a child
  • He says he would follow this formula up until aroun ~40kg… not exact science
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2
Q

IV sites

A
  • Intraosseous
  • Don’t lose a lot of time trying to get an IV line in a baby to avoid IO
  • If by the time you’re ready to put the IO in the nurse doesn’t get the IV, DO THE IO FOR A CRITICALLY ILL BABY
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3
Q

how to miss an important pediatric illness

A
  • High prevalence of self-resolving minor illness creates “wellness bias.”
  • Pressure to be “productive” and see high numbers of patients in a short time.
  • Desire to avoid unnecessary or expensive tests.
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4
Q

Fever/sepsis/occult bacteremia

A
  • Temp greater than 38C (100.4 F) = “fever”
  • Temp less than 39C (102.2 F) correlates to a low risk for bacteremia.
  • Most pediatric fevers have an obvious source
  • Return at any hour if you are concerned that the kid is getting worse
  • Toxic appearing: PALE, maybe cyanotic, maybe a little bit rubrous. Kids with darker skin may be harder to tell
    • Ask the parent!
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5
Q

Fever

A
  • Common sources of pediatric fever
    • Otitis Media
    • Pharyngitis-URI
    • Pneumonia
    • Acute Gastro-enteritis
  • Treat and release non-toxic toddlers and children with identified source of infection
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6
Q

toxic appearance?

A
  • Pale, Lethagic, Limp
  • Poor perfusion
    • Cyanosis, mottled skin
  • Respiratory distress
    • Tachypnea, shallow breathing
  • Altered Mental Status
    • Poor eye contact, feeding, failure to respond to caregivers.
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7
Q

occult bacteremia

A
  • Infants and toddlers
    • H. influenzae type b
    • N. meningitidis
    • S. pneumoniae
  • Older children
    • N. meningitidis
    • Group A beta hemolytic Strep.
  • No consistantly present findings on history or exam, except for fever.
  • Response to antipyretics has no diagnostic value.
  • Temp <39C correlates with a low likelyhood of positive blood cultures.
  • Ear thermometer and axillary temp is unreliable in infants and toddlers. Get a rectal temp.
  • Approach to fever is dependant on patients age.
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8
Q

neonates, age 0-28 days with fever 38c or more

A
  • Admit them all. Let the pediatrician sort them out.
    • CBC
    • Blood cultures
    • Urinalysis
    • Urine culture
    • Lumbar puncture
    • Parenteral antibiotics
  • In hospital workup.
    • Chest X-Ray
      • Cough
      • Tachypnea
      • O2 sat less than 95%
  • Stool studies if diarrhea
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9
Q

fever, age 28-90 days

A
  • CBC
  • Urinalysis, gram stain if available
  • Urine culture
  • Blood culture
  • Consider:
    • Lumbar puncture, (some authors say all patients in this category)
    • Chest x-ray
    • Stool studies
    • Fecal leucocyte count and stool culture
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10
Q

fever without a source: who can go home?

A
  • Rochester Criteria for bacteremia risk in infants 28-90 days old, with fever
    • Overall risk of occult bacteremia in well appearing febrile infant: 7-9%
    • If all Rochester Criteria met, risk is less than 1%
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11
Q

rochester criteria

A
  • History
    • Term birth, not hospitalized longer than mother
    • No prior prior acute illness or hospitalizations
    • No chronic illness
    • No hyperbilirubenemia
    • No prior antibiotics
  • lExam
    • Non-toxic appearance - “well appearing”
    • No skeletal, skin, soft tissue, or ear infections
  • Lab
    • WBC 5-15k; bands less than 1.5k
    • Urine less that 10wbc/hpf, or neg leukocyte esterase/nitrate or negative gram stain of unspun urine
    • Fecal smear less than 5wbc/hpf
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12
Q

management of fever without source: 28-90 days old

A
  • Toxic appearing or high risk or unreliable caregivers
    • admit for septic work-up and parenteral abx
  • If reliable caregivers and access to follow-up in office or ED
    • Blood culture
    • Urine culture
    • Consider LP and ceftriaxone 50mg/kg IV
    • Re-evaluate in 24 hours
    • Admit positive blood culture or febrile UTI
    • Treat afebrile UTI as outpatient.
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13
Q

fever 3-36 months

A
  • Found a source? - treat it and discharge
  • Fever without source
    • Occult UTI
      • 2% of FWS in children under 5yrs
      • 6-8% of girls; 2-3% of boys under 12mo
      • Higher temp correlates with increased likely hood of UTI
      • Untreated UTI can lead to kidney damage and renal failure in adulthood
  • Fever without source
    • Occult Pneumonia
      • Positive x-ray in 3% of infants or young children without tachypnea, respiratory distress, rales or decreased breath sounds (pulse oximetry not studied)
      • Heptavalent pneumococcal vaccine reduces likelyhood of pneumonia
      • Positive x-ray in 26% of children with temp >39C or wbc>20k
    • Generally speaking, kids with PNA will be tachypnic!!
  • Fever without source
    • Occult Bacteremia
      • FWS with temp 39.5 (103.1f)
      • Positive blood culture in <1% if WBC <15k
      • Positive blood culture in 10% if WBC > 15k
      • 3% of cases of Pneumococcal bacteremia progress to menningitis
      • Heptavalent pneumococcal vaccine, Prevnar, is effective in preventing invasive pneumococcal disease.
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14
Q

Management of FWS 3-36

A
  • Toxic appearance
    • Admit
    • Septic work-up
    • IV antibiotics
  • Non toxic, Temp <39c
    • No tests
    • Acetaminofen
    • Return if fever persists >48 hours or if condition deteriorates.
  • Nontoxic with temp> 39 C
    • Evaluate urine for all females < 12 months old; uncircumcised males < 12 months old; circumcised males < 6 months old.
    • If UTI is found: culture urine, treat with antibiotics and and follow up in 48 hours.
  • Nontoxic with temp> 39 C
    • Chest x-ray if O2 sat < 95%, tachypnea, rales, temperature ≥39.5°C and WBC count ≥20,000
  • If patient not documented to have recieved conjugate pneumococcal vaccine:
    • Draw CBC
    • If WBC > 15k or ANC > 10k, or temp>39.5, then send blood culture and treat with Ceftriaxone
  • If O2 sat < 95%, tachypnea, rales, temperature ≥39.5°C
    • Draw CBC, blood culture and obtain chest x-ray
    • Treat pneumonia or WBC > 20 k with Ceftriaxone
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15
Q

febrile seizures

A
  • Generalized seizure, less than 15 minutes duration associated with fever spike
  • 2.4% risk of epilepsy by age 25, double average risk
  • Control and prevent febrile seizures by controlling fever
  • Don’t worry about simple febrile seizures
  • Worry about what else causes fever, and seizures
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16
Q

meningitis

A

Invasive infection of the subarachnoid space, usually by hematogenous spread from the upper respiratiory tract, or direct inoculation from sinusitis, mastoidits or otitis media or skull fracture

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17
Q

bacterial meningitis history

A
  • History
    • The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
    • Neonatal meningitis associated with maternal infection or pyrexia at delivery
    • Younger than 3 months, nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high pitched cry, or seizures
    • Meningismus and a bulging fontanel may be observed but are not needed for diagnosis
    • Paradoxical irritability – normally if you try to comfort a kid they feel a little better but if you try to comfort or carress the baby they will cry more and its because their nervous system is on fire!!
  • After age 3 months, more typical symptoms
    • Fever
    • Vomiting
    • Irritability
    • lethargy, or any change in behavior
  • After age 2-3 years
    • headache
    • stiff neck
    • photophobia
    • Course may be brief and fulminant ( N. meningitidis) or gradual
18
Q

bacterial meningitis exam

A
  • Exam
    • Young infants
      • specific findings are rare
      • May be febrile or hypothermic
      • Bulging fontanelle, diastasis of skull sutures, nuchal rigidity are late signs.
  • Exam
    • Toddlers and children
      • Meningeal signs
      • headache
      • nuchal rigidity
      • positive Kernig or Brudzinski’s sign
      • Focal neurological signs
      • Seizures in 30% of cases
      • Obtundation or coma in 15-20%
      • Petechial-purpuric rash
19
Q

bacterial meningitis lab and imaging

A
  • Lab
    • Complete blood count (CBC) with differential
    • Blood cultures
    • Coagulation studies
    • Serum glucose
    • Erythrocyte sedimentation rate (ESR)
    • Electrolytes
    • Serum and urine osmolalities
    • Bacterial antigen studies can be performed on urine and serum. They are mostly useful in cases of pretreated meningitis
  • Imaging
    • Head CT
      • Focal neurological signs
      • To rule out other pathology
      • Does not rule out increased intracranial pressure
20
Q

bacterial meningitis procedures

A
  • Lumbar Puncture
    • Measure opening pressure
    • Cell count
    • Gram stain
    • Culture and sensitivity
    • Glucose
    • Protein and antigen
    • Acid-fast bacillus
    • Fungal stains
21
Q

epiglottitis

A
  • Age: historically, mean age 36 months (increasing since Hib vaccine)
  • Age range 1-6 years
  • Mortality near zero in centers with established protocols for management
  • Mortality 9-18% if diagnosis delayed
  • History
    • Acute onset of fever and sore throat
    • Dysphagia
    • Distress
    • Drooling
    • Cough is rare
  • Exam
    • Toxic appearing
    • Sniffing position
    • Muffled voice
    • Stridor
    • Lymphadenopathy
  • Hold further evaluation!
  • Humidified O2 by nasal canula or mask, held by parent.
  • Assemble a team capable of securing the airway
    • Fiberoptic naso-tracheal intubation, in the OR
    • Rapid Sequence Intubation, orotracheal, in the ER
    • Needle crico-thyrotomy if intubation fails
    • Long slow breaths if bag valve mask used prior to intubation
  • Exam of Retropharanyx
    • DON’T LOOK!
  • Oximetry, hypoxia and cyanosis are late signs.
  • Imaging
  • Disposition
  • Intubate in OR
  • Admit to ICU
  • IV abx
  • Steroids not proven
22
Q

Croup (AKA laryngotracheobronchitis)

A
  • Mean age:18 months
  • Age range: usually 3 months- 3years
  • Mortality: rare
  • History
    • Gradual onset of URI symptoms
    • Rhinorrhea
    • Cough, barking like a seal
    • Fever
    • Stridor, often resolves by time of ED presentation.
  • Exam
    • Generally non toxic
    • May be playful and cooperative or restless and anxious
    • Stridor: inspiratory > expiratory
    • subglottic swelling, “steeple sign”
  • Treatment
    • Cool mist
    • Racemic epinephrine
    • Dexamethasone 0.6mg kg IM or PO (same efficacy), some authors recomend repeat dose in 6 hrs.
    • Nebulized Budesonide
  • Consultation/Admission, consider Intubation if:
    • Hypoxia, cyanosis
    • Retractions unrelieved by initial treatment
    • Diminished breath sounds, diminished stridor
    • Change in mental status
  • Tobacco/irritant free environment
  • Vaporizer
  • Cool night air
  • Antipyrexia
23
Q

retropharyngeal abscess

A
  • Bacterial infection of retropharyngeal space leads to abscess formation and airway obstruction
  • Can progress to mediastinitis (50% mortality), pericarditis, jugular vein thrombosis, carotid artery erosion, sepsis.
  • Overall mortality 1%
  • History
    • Sore throat
    • Odynophagia
    • Fever
    • Neck stiffness
    • Neck swelling (97% in infants)
    • Cough (33% in in infants)
  • Exam findings:
    • Neck mass (91%)
    • Cervical adenopathy (83%)
    • Fever (86%)
    • Neck stiffness (59%)
    • Retropharyngeal bulge (43% - do not palpate in children)
    • Agitation (43%)
    • Lethargy (42%)
    • Drooling (22%)
    • Torticollis (18%)
    • Respiratory distress (4%)
    • Stridor (3%)
  • Lab studies, not very helpfull
  • 18% will have normal white count
  • Up to 82% of blood cultures will be negative
  • Admission/Consultation
  • IV abx
  • Intubate if respiratory distress
  • ENT will decide wether to I&D (in OR) or not
24
Q

esophageal foreing bodies

A
  • Coins that fail to pass into the stomach can be removed by a foley catheter under fluroscopy, or by endoscopy
  • Button batteries lodged in the esophagus must be removed emergently
  • Any esophageal foreign body can lead to airway obstruction.
25
Q

tracheobronchial foreign bodies

A
  • 50% show air trapping
  • 12% atelectasis
  • 18% signs of infection
  • 24% normal
  • Suspected Respiratory Foreign bodies may need CT or bronchoscopy to confirm the diagnosis
26
Q

signs of respiratory distress

A
  • Grunting
  • Flaring
  • Severe tachypnea
  • Retractions
  • Low O2 saturation
  • Severe distress not responsive to supplemental O2?
    • Get help and prepare to intubate
27
Q

pneumonia

A
  • Neonates
    • grunting, flaring, tachypnea, and retractions
    • lethargy, poor feeding, or irritability
    • Cough is rare
    • Fever may be absent (may be hypothermic)
    • Beta Strep likely if within 24 hours of birth
    • Chlamydia pneumonia with conjuntivitis in 2nd or 3rd week
  • Infants
    • Cough
    • Preceding URI
    • grunting, flaring, tachypnea, retractions
    • lethargy; poor feeding; or irritability
    • Bacterial, usually feberile
  • Toddlers and Small Children
    • Cough
    • Preceding URI
    • Vomiting (post-tussive emesis)
    • Abdominal pain
    • Fever
  • Older Children
    • Atypical pathogens, Mycoplasma, more common
    • May have other constitutional symptoms such as headache and pleuritic chest pain
28
Q

pneumonia exam, labs, admission criteria, outpatient therapy

A
  • Shirt off, Lights on.
  • Observe respiratory effort and count respiratory rate
  • Auscultation
    • Attempt while sleeping or feeding
    • Warm the stethescope
    • Crackles (rales)
    • Focal wheezes
    • Focal diminished breath sounds
  • Labs
    • CBC non specific, consider for more severely ill patients
    • Blood culture on all admitted patients
    • Sputum gram stain and culture difficult to obtain.
  • Chest x-ray
  • Admission criteria
    • Age under 6 months
    • Immunocompromised
    • Chronic illness, (cystic fibrosis)
    • Toxic appearing
    • Failed outpatient treatment
  • Outpatient therapy
    • Antibiotics
    • Sanford Guide or local antibiogram
29
Q

bronchiolitis history

A
  • History
    • Preceding URI
    • Fever
    • Increased work of breathing
      • Wheezing
      • Cyanosis
      • Grunting
      • Noisy breathing
    • Vomiting, especially post-tussive
    • Irritability
    • Poor feeding or anorexia
30
Q

bronchiolitis exam

A
  • Tachypnea, up to 50-60 breaths per minute (most common physical sign)
  • Tachycardia
  • Fever, usually in the range of 38.5- 39°C
  • Mild conjunctivitis or pharyngitis
  • Diffuse expiratory wheezing
  • Nasal flaring, intercostal retractions
  • Cyanosis
  • Inspiratory crackles
  • Otitis media
  • Apnea, especially in infants younger than 6 weeks
  • Palpable liver and spleen from hyperinflation of the lungs and consequent depression of the diaphragm
31
Q

bronchiolitis labs and imaging

A
  • Lab
    • CBC: seldom useful
    • Urine specific gravity: possible dehydration.
    • Serum chemistries: gauging severity of dehydration.
    • ABG may be needed in the severely ill patients
    • Specific viral test for RSV helps confirm diagnosis but not essential.
  • Chest x-ray
    • Hyperinflation and patchy infiltrates may be seen. These findings are nonspecific and may be observed in asthma, viral or atypical pneumonia, and aspiration.
    • Focal atelectasis
    • Air trapping
    • Flattened diaphragm
    • Increased anteroposterior diameter
    • Peribronchial cuffing
    • Chest radiographs may also reveal evidence of alternative diagnoses, such as lobar pneumonia, congestive heart failure, or foreign body aspiration.
32
Q

bronchiolitis treatment and admission criteria

A
  • Treatment
    • Pulse oximetry monitoring
    • Respiratory support
    • O2, cool mist
    • Nasal suction
    • Supportive care
    • Comfort
    • Hydration
    • Antipyrexia, analgesia
  • Admission Criteria
    • Oxygen saturation less than 94% after therapy. Some say less than 92%
    • Respiratory distress (eg. respiratory rate >60/min or retractions at rest)
    • Apnea or risk of apnea
    • Age younger than 2 months or history of prematurity
    • Underlying cardiopulmonary disease or immunosuppression
33
Q

pyloric stenosis

A
  • History
    • Occurs by 3rd week of life
    • Projectile vomiting after feeding
    • Hungry
    • Failure to gain weight
    • Progresses to dehydration
  • hypochloremic, hypokalemic metabolic alkalosis.
  • Exam
    • Signs of dehydration (hyprochloremic hypolalemic metabolic alkalosis.)
    • Palpable “olive” near lateral edge of right rectus, inferior to liver, is diagnostic
    • Ultrasound if “olive” not palpated (20% false negative)
    • Barium swallow
34
Q

Intussusception

A
  • Most common cause of intestinal obstruction age 3mo-6yrs
  • male:female = 4:1
  • Episodic abdominal pain, increasing severity and frequency
  • Currant jelly stools in 50%
35
Q

Midgut volvulus

A
  • Acute onset of billius vomiting, distension, pain.
  • 50% in 1st month; 90% in first year
  • Plain films may see “coffee bean sign” or “birds beak”, likely need ct or crontrast study
  • Surgery is needed emergently as bowel becomes ischemic, necrotic and perforates.
36
Q

Infantile colic

A
  • Infant that feeds normally has episodes of crying and drawing up legs.
  • Parents will attribute to abdomen but pt without vomiting or diarrhea
  • Usually resolves by 10 weeks. Look for other causes: abuse, constipation,volvulus,corneal abrasion, hair tournequet, GERD or anal fissures.
37
Q

Causes for child still crying

A
  • “IT CRIES”
    • Infection - any kind (look for fever, infectious sx)
    • Trauma - including abuse (know your infant milestones)
    • Cardiac - SVT, sweating with feeds, FTT, poor feeding
    • Reflux & Reaction to meds
    • Immunization site & Intussisception
    • Eyes - corneal abrasions (do fluorescein staining)
    • Strangulation/Surgical causes - hair tourniquets, torsion, intussisception (check the fingers/toes, take off the diaper)
38
Q

pediatric orthopedics

A
  • Lower threshold for ordering x- rays than adults
  • When splinting, immobilize the joint above and below.
  • Consider child abuse, injured tot may need skelital survey, aka babygram
  • Torus fracture
  • greenstick fracture
39
Q

Nursemaid’s elbow

A
  • Nursemaid’s Elbow, AKA subluxation of the radial head
    • Caused by distraction of the arm in extension
    • Most common 1-4 years old
    • Child presents in no distress
    • Refuses to use injured arm
    • Held in pronation, and extension
    • No deformity or significant tenderness
  • Imaging is not needed if history and exam is typical
  • X ray tech likely to reduce while positioning for film
40
Q

Slipped capital femoral epiphysis

A
  • Slipped Capital Femoral Epiphysis
    • Age 12-15 in boys, 10-13 in girls
    • Often associated with obesity
    • Presents with hip and groin pain, knee pain
    • Abnormal gait, external rotation
    • Unable to press thigh against abdomen
    • X-rays
      • AP and frog leg views
  • Management
    • Admission
    • Consultation
    • Absolute non-weight bearing
    • Surgery
41
Q

transient tenosynovitis of the hip

A
  • Acute or gradual onset of abnormal gait
  • Under 10 years old
  • Hip, thigh and knee pain
  • Tenderness over anterior hip
  • X-rays normal or show hip joint effusion
  • Normal or slightly high wbc and esr
  • Supportive treatment and re eval in 2 weeks
42
Q

other causes of hip pain

A
  • Septic joint
    • Esr>20, CRP >2mg/dl, wbc>12
    • Non weight bearing
    • Fever
  • Juvenile Rheumatoid Arthritis
  • Lupus
  • Legg Calve Perthe disease
  • Leukemia
  • Many, many causes of bone and joint pain

Emergency Medicine 2 (8 decks)

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