Pediatric Emergencies 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
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
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.
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!
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
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.
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.
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%
- Chest X-Ray
- Stool studies if diarrhea
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
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%
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
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.
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
- Occult UTI
- 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!!
- Occult Pneumonia
- 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.
- Occult Bacteremia
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
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
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
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.
- Young infants
- 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
- Toddlers and children
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
- Head CT
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
tracheobronchial foreign bodies
* 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
signs of respiratory distress
* Grunting
* Flaring
* Severe tachypnea
* Retractions
* Low O2 saturation
* Severe distress not responsive to supplemental O2?
* Get help and prepare to intubate
27
pneumonia
* 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
pneumonia exam, labs, admission criteria, outpatient therapy
* 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
bronchiolitis history
* History
* Preceding URI
* Fever
* Increased work of breathing
* Wheezing
* Cyanosis
* Grunting
* Noisy breathing
* Vomiting, especially post-tussive
* Irritability
* Poor feeding or anorexia
30
bronchiolitis exam
* 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
bronchiolitis labs and imaging
* 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
bronchiolitis treatment and admission criteria
* 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
pyloric stenosis
* 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
Intussusception
* 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
Midgut volvulus
* 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
Infantile colic
* 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
Causes for child still crying
* “IT CRIES"
* **I**nfection - any kind (look for fever, infectious sx)
* **T**rauma - including abuse (know your infant milestones)
* **C**ardiac - SVT, sweating with feeds, FTT, poor feeding
* **R**eflux & Reaction to meds
* **I**mmunization site & Intussisception
* **E**yes - corneal abrasions (do fluorescein staining)
* **S**trangulation/Surgical causes - hair tourniquets, torsion, intussisception (check the fingers/toes, take off the diaper)
38
pediatric orthopedics
* 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
Nursemaid's elbow
* 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
Slipped capital femoral epiphysis
* 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
transient tenosynovitis of the hip
* 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
other causes of hip pain
* 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
