Peds ER Flashcards
CPS criteria for AOM?
To properly diagnose AOM, there must be fluid behind the tympanic membrane (a middle ear effusion) and specific signs and symptoms of middle ear inflammation (indicating that this fluid is pus
Signs of a middle ear effusion:
An immobile tympanic membrane (as demonstrated by pneumatic insufflation, tympanogram or acoustic reflectometry) or presence of liquid in the external ear canal as a result of tympanic membrane rupture (acute otorrhea)
+/- Opacification of the tympanic membrane (not secondary to scarring)
+/- Loss of the bony landmarks behind the tympanic membrane (specifically loss of the short or lateral process of the malleus)
+/- A visible air fluid level behind the tympanic membrane
Signs of middle ear inflammation:
Bulging tympanic membrane with marked discoloration (hemorrhagic, red, gray or yellow)
Acute onset of symptoms:
Rapid onset of ear pain (otalgia), or unexplained irritability in a preverbal child
Organisms for AOM?
The most common pathogens in the post-pneumococcal vaccine era are Streptococcus pneumoniae (31%) and nontypeable Haemophilus influenzae (56%) and Moraxella catarrlis (16%)
Management of AOM?
Treatment of pain is essential for all children diagnosed with AOM. Topical analgesics such as benzocaine-antipyrene are recommended for routine use, unless there is a known perforation of the TM. Acetaminophen 15 milligrams/kilogram or ibuprofen 10 milligrams/kilogram can be used.
Consider the use of a wait-and-see prescription for the treatment of uncomplicated AOM. Parents are given a prescription and told to wait and see for 48 to 72 hours, and if the child is not better or becomes worse, to fill the prescription. Contraindications to the use of a wait-and-see prescription are: age < 6 months, an immunocompromised state, ill-appearance, recent use of antibiotics or the diagnosis of another bacterial infection. If any of these conditions are met, the child should be prescribed an immediate antibiotic.
Amoxicillin 40-50 milligrams/kilogram/dose PO given twice daily (or 30 milligrams/kilogram/dose three times daily) times daily remains the first drug of choice for uncomplicated AOM.
Second line antibiotics include amoxicillin/clavulanate 40–50 milligrams/ kilogram/dose given twice daily. Cefpodoxime 5 milligrams/kilogram/dose PO twice daily, cefuroxime axetil 15 milligrams/kilogram/dose twice daily, cefdinir 7 milligrams/kilogram/dose PO once or twice daily, and ceftriaxone 50 milligrams/kilogram/dose IM for 3 daily doses are alternatives. For patients allergic to the previously mentioned antibiotics, azithromycin 10 milligrams/kilogram/dose PO on the first day followed by 5 milligrams/kilogram/dose PO for 4 more days can be used.
Infants younger than 60 days with AOM are at risk for infection with group B Streptococcus, Staphylococcus aureus, and gram-negative bacilli and should undergo evaluation and treatment for presumed sepsis.
In uncomplicated AOM, symptoms resolve within 48 to 72 hours; however, the middle ear effusion may persist as long as 8 to 12 weeks. Routine follow-up is not necessary unless the symptoms persist or worsen.
If mastoiditis is suspected, obtain a CT scan of the mastoid. If the diagnosis is confirmed, obtain consultation with an otolaryngologist and start parenteral antibiotics.
Common organisms for otitis externa?
It is commonly caused by Pseudomonas aeruginosa, Staphylococcus epidermidis, and Staphylococcus aureus, which often coexist.
Clinical features of otitis externa?
Peak seasons for OE are spring and summer, and the peak age is 9 to 19 years. Symptoms include earache, itching, and, less commonly, fever. Signs include erythema, edema of EAC, white exudate on EAC and TM, pain with motion of the tragus or auricle, and periauricular or cervical adenopathy.
Treatment of otitis externa?
Cleaning the ear canal with a small tuft of cotton attached to a wire applicator is the first step. Place a wick in the canal if significant edema obstructs the EAC.
Treat mild OE with acidifying agents alone, such as 2% acetic acid (VoSol). Consider oral analgesics, such as ibuprofen at 10 milligrams/kilogram/dose every 6 hours. Fluoroquinolone otic drops are now considered the preferred agents over neomycin containing drops. Ciprofloxacin with hydrocortisone, 0.2% and 1% suspension (Cipro HC), 3 drops twice daily or ofloxacin 0.3% solution 10 drops twice daily can be used. Ofloxacin is used when TM rupture is found or suspected. Oral antibiotics are indicated if auricular cellulitis is present.
Follow-up should be advised if improvement does not occur within 48 hours; otherwise routine follow-up is not recommended. Malignant OE is characterized by systemic symptoms and auricular cellulitis. This condition can result in serious complications and requires hospitalization with parenteral antibiotics.
Major pathogens of acute bacterial sinusitis?
The major pathogens in childhood are Streptococcus pneumoniae, Moraxella catarrhalis, and nontypeable Haemophilus influenzae.
Clinical features of acute bacterial sinusitis?
Two major types of sinusitis may be differentiated on clinical grounds: acute severe sinusitis and mild subacute sinusitis. Acute severe sinusitis is associated with elevated temperature, headaches, and localized swelling and tenderness or erythema in the facial area corresponding to the sinuses. Such localized findings are seen most often in older adolescents. Mild subacute sinusitis is manifest in childhood as a protracted upper respiratory infection associated with purulent nasal discharge persisting in excess of 2 weeks. Fever is infrequent. Chronic sinusitis may be confused with allergies or upper respiratory infections.
Management of acute bacterial sinusitis?
Patients with mild symptoms suggestive of a viral infection can be observed for 7 to 10 days, with no antibiotics prescribed. Suspect acute bacterial sinusitis if symptoms persist or are severe: fever > 39°C, purulent nasal drainage for > 3 days and ill-appearance.
For children with mild to moderate sinusitis, treat with amoxicillin (40–50 milligrams/kilogram/dose PO twice daily) for 10 to 14 days. For children who present with severe symptoms, are in day care or have recently been treated with antibiotics, prescribe oral second- and third-generation cephalosporins such as cefprozil (7.5 to 15 milligrams/kilogram PO twice a day), cefuroxime (15 milligrams/kilogram PO twice a day), and cefpodoxime (5 milligrams/kilogram PO twice a day). Intranasal steroids have shown modest benefits and are recommended if antibiotics do not result in improvement in the first 3 to 4 days of treatment.
Modified Centor Criteria?
The patients are judged on four criteria, with one point added for each positive criterion:
History of fever
Tonsillar exudates
Tender anterior cervical adenopathy
Absence of cough
The Modified Centor Criteria add the patient’s age to the criteria:
Age 44 subtract 1 point
The point system is important in that it dictates management. Guidelines for management state:
0 or 1 points - No antibiotic or throat culture necessary (Risk of strep. infection <10%) 2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2) 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%)
The presence of all four variables indicates a 40 - 60% positive predictive value for a culture of the throat to test positive for Group A Streptococcus bacteria. The absence of all four variables indicates a negative predictive value of greater than 80%.The high negative predictive value suggests that the Centor Criteria can be more effectively used for ruling out strep throat than for diagnosing strep throat.
Clinical features of Herpangina, hand, foot, and mouth disease (HFM)?
Herpangina causes a vesicular enanthem of the tonsils and soft palate, affecting children 6 months to 10 years of age during late summer and early fall. The vesicles are painful and can be associated with fever and dysphagia. HFM disease usually begins as macules which progress to vesicles of the palate, buccal mucosa, gingiva, and tongue. Similar lesions may present on the palms of hands, soles of feet, and buttocks. Herpes simplex gingivostomatitis often presents with abrupt onset of fever, irritability, and decreased oral intake with edematous and friable gingiva. Vesicular lesions often with ulcerations are seen in the anterior oral cavity.
Treatment is supportive. Parental fluids PRN if child cannot tolerate orally.
Clinical features of GAS pharyngitis?
Peak seasons for GABHS are late winter or early spring, the peak age is 5 to 15 years, and it is rare before the age of 2. Symptoms (sudden onset) include sore throat, fever, headache, abdominal pain, enlarged anterior cervical nodes, palatal petechiae, and hypertrophy of the tonsils. With GABHS there is usually the absence of cough, coryza, laryngitis, stridor, conjunctivitis, and diarrhea. A scarlatinaform rash associated with pharyngitis almost always indicates GABHS and is commonly referred to as scarlet fever.
Clinical features of EBV?
Ebstein Barr Virus (EBV) is a herpes virus and often presents much like streptococcal pharyngitis. Common symptoms are fever, sore throat, and malaise. Cervical adenopathy may be prominent and often is posterior and anterior. Hepatosplenomegaly may be present. EBV should be suspected in the child with pharyngitis nonresponsive to antibiotics in the presence of a negative throat culture.
Clinical features of gonococcal pharyngitis?
Gonococcal pharyngitis in children and nonsexually active adolescents should alert one to the possibility of sexual abuse. Gonococcal pharyngitis may be associated with infection elsewhere including proctitis, vaginitis, urethritis, or arthritis.
Diagnosis of EBV pharyngitis?
Diagnosis of EBV is often clinical. A heterophile antibody (monospot) can aid in the diagnosis. The monospot may be insensitive in children < 2 years of age and is often negative in the first week of illness. If obtained, the white blood cell count may show a lymphocytosis with a preponderance of atypical lymphocytes.
Diagnosis of gonococcal pharyngitis?
Diagnosis of gonococcal pharyngitis is made by culture on Thayer-Martin medium. Vaginal, cervical, urethral, and rectal cultures also should be obtained if gonococcal pharyngitis is suspected.
Diagnosis of GAS pharyngitis?
Centor criteria –> rapid. If rapid negative then send to culture.
Treatment of GAS pharyngitis?
Antibiotics for the treatment of GABHS pharyngitis should be reserved for patients with a positive rapid antigen test or culture. Antibiotic choices for GABHS include penicillin V (children 250 milligrams PO twice daily, adolescent/adult 500 milligrams PO twice daily); benzathine penicillin G 1.2 million units IM (600,000 units IM for patients weighing less than 27 kg); and erythromycin ethylsuccinate 10 to 20 milligrams/kilogram/dose PO given twice daily for 10 days. Antipyretics and analgesics should be routinely prescribed until symptoms resolve.
Reality: amox
Treatment of gonococcal pharyngitis?
Treat gonococcal pharyngitis with ceftriaxone 250 milligrams IM. When gonococcal pharyngitis is suspected, empiric treatment of chlamydia is recommended with azithromycin 1 gram PO given in the emergency department. Appropriate follow-up should be encouraged for treatment failure and symptomatic contacts. Follow-up for suspected gonococcal pharyngitis should include local reporting agencies and social service investigations.
Treatment of EBV pharyngitis?
EBV is usually self-limited and requires only supportive treatment including antipyretics, fluids, and rest. A dose of dexamethasone 0.5 milligrams/kilogram PO to a maximum of 10 milligrams once may be given for more severe disease presentations
Clinical features, DDx and Dx of cervical lymphadenitis?
Cervical Lymphadenitis
Acute, unilateral cervical lymphadenitis is commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Bilateral cervical lymphadenitis is often caused by viral entities such as EBV and adenovirus. Chronic cervical lymphadenitis is less common but may be caused by Bartonella henselae (also called occuloglandular fever) or Mycobacterium species.
Clinical Features
Acute cervical lymphadenitis presents with tender, 2 to 6 cm nodes often with overlying erythema. Bilateral cervical lymphadenitis presents with small, rubbery lymph nodes and usually self-resolves. Bartonella results from the scratch of a kitten with ipsilateral cervical lymphadenitis and often concurrent conjunctivitis.
Diagnosis and Differential
Most cases are diagnosed clinically, although culture may guide effective antimicrobial treatment. Differential may also include sialoadenitis (infection of the salivary glands), which is usually caused by Staphyloccocus aureus or Streptococcus pyogenes, as well as gram-negative and anaerobic bacteria.
Treatment of cervical lymphadenitis?
Either amoxicillin plus clavulanic acid, 30 to 40 milligrams/kilogram/dose given twice daily or clindamycin 10 to 15 milligrams/kilogram/dose given three times daily are recommended first line antibiotics for the treatment of acute cervical lymphadenitis.
The presence of a fluctuant mass may require incision and drainage in addition to antimicrobial therapy.
Most cases of acute bilateral cervical lymphadenitis resolve without antibiotics, as they often represent viral infection or reactive enlargement. Chronic cases of lymphadenitis are often treated surgically, with directed antimicrobial therapy in some cases depending on clinical diagnosis.
Normal vegetative functions in a neonate?
Bottle-fed infants generally take 6 to 9 feedings (2 to 4 oz) in a 24-hours period, with a relatively stable pattern developing by the end of the first month of life. Breast-fed infants generally prefer feedings every 1 to 3 hours. Infants typically lose up to 12% of their birth weight during the first 3 to 7 days of life. After this time, infants are expected to gain about 1 oz/d (20 to 30 grams) during the first 3 months of life. The number, color, and consistency of stool in the same infant changes from day to day and differs among infants. Normal breast-fed infants may go 5 to 7 days without stooling or have 6 to 7 stools per day. Color has no significance unless blood is present or the stool is acholic (ie, white).
A normal respiratory rate for a neonate is from 30 to 60 breaths/min. Periodic breathing (alternating episodes of rapid breathing with brief (< 5 to 10 seconds) pauses in respiration) is usually normal. Normal newborns awaken at variable intervals that can range from about 20 minutes to 6 hours. Neonates and young infants tend to have no differentiation between day and night until approximately 3 months of age.
DDx inconsolability
Corneal abrasion Hair tourniquet (finger, toe, penis) Stomatitis Intracranial hemorrhage Fracture (nonaccidental trauma) Nasal obstruction/congestion Inborn error of metabolism Acute infection (sepsis, urinary tract infection, meningitis) Congenital heart disease (including supraventricular tachycardia) Abdominal emergency (incarcerated hernia, volvulus, intussusception) Testicular torsion Encephalitis (herpes)
Colic
Intestinal colic is the most common cause of excessive (but not inconsolable) crying. The cause is unknown. The incidence is about 13% of all neonates. The formal definition includes crying for at least 3 hours per day for at least 3 days per week over a 3-week period. Intestinal colic seldom lasts beyond age 3 months. No effective treatment has been identified. In general, the initial diagnosis of colic is not made in the emergency department and it is a diagnosis of exclusion.
Fever in a neonate - management
Fever in the neonate (age 28 days or younger) is defined as the history of documented fever by a parent or presence of a rectal temperature of 38°C (100.4°F) or higher in the ED. Fever in the neonate must be taken seriously, and at this point in time the proper management includes a complete septic work-up, administration of parenteral antibiotics, and admission.
Blood in stool - neonate
Although bacterial infection may cause bloody diarrhea, this is rare in neonates. The most common causes of blood in the stool in infants younger than 6 months are cow’s milk intolerance and anal fissures. Breast-fed infants may have heme-positive stool from swallowed maternal blood due to bleeding nipples. Necrotizing enterocolitis may present as bloody diarrhea and usually presents with other signs of sepsis (eg, jaundice, lethargy, fever, poor feeding, or abdominal distention). Abdominal radiography may demonstrate pneumatosis intestinalis or free air.
Constipation in neonate - when is it
- DDx
- management
Infrequent bowel movements in neonates do not necessarily mean that the infant is constipated. Stool patterns can be quite variable and breast-fed infants may go 1 week without passing stool and then pass a normal stool. Inquire about the passage of meconium in the first 24 to 48 hours of life; infants without normal stooling in the first 2 days of life may have anatomic anomalies (eg, intestinal stenosis or atresias), cystic fibrosis, Hirschsprung disease, or meconium ileus or plug. Constipation that develops later in the first month of life suggests Hirschsprung disease, hypothyroidism, anal stenosis, or anterior anus. Rarely, botulism can present with constipation that precedes neurologic symptoms (cranial nerve deficits, hypotonia, weak cry). Laxatives and enemas are contraindicated in neonates.
Clinical signs of sepsis in infant?
Clinical signs may be vague and subtle in the young infant, including lethargy, poor feeding, irritability, or hypotonia. Fever is common; however, very young infants may be hypothermic. Tachypnea and tachycardia are usually present as a result of fever but also may be secondary to hypoxia and metabolic acidosis. Sepsis can rapidly progress to shock, manifest as prolonged capillary refill, decreased peripheral pulses, altered mental status, and decreased urinary output. Hypotension is usually a very late sign of septic shock in children and, in conjunction with respiratory failure and bradycardia, indicates a grave prognosis
Clinical features and diagnosis of meningitis in children
Meningitis may present with the subtle signs that accompany less serious infections, such as otitis media or sinusitis. Irritability, inconsolability, hypotonia, and lethargy are most common in infants. Older children may complain of headache, photophobia, nausea, and vomiting and exhibit the classic signs of meningismus with complaints of neck pain. Occasionally, meningitis presents as a rapidly progressive, fulminant disease characterized by shock, seizures, or coma, or with febrile status epilepticus
Diagnosis is made by lumbar puncture and analysis of the cerebrospinal fluid (CSF). The CSF should be examined for white blood cells, glucose, and protein and undergo Gram stain and culture. Herpes encephalitis should be considered in the seizing neonate and any child with CSF pleocytosis. In the presence of immunocompromise, infections with opportunistic or unusual organisms should be considered. Cranial computed tomography should be performed before lumbar puncture in the presence of focal neurologic signs or increased intracranial pressure..
Initial antibiotics for neonate with sepsis/meningitis?
Ampicillin, 100 milligrams/kilogram
plus
Cefotaxime, 50 milligrams/kilogram
HSc uses amp and gent
DDx stridor in child
Laryngomalacia, due to a developmentally weak larynx, accounts for 60% of stridor in the neonatal period, but is self-limited and rarely requires treatment. Common causes of stridor in children > 6 months of age discussed here include viral croup, epiglottitis, bacterial tracheitis, airway foreign body, retropharyngeal abscess, and peritonsillar abscess. Other etiologies include Ludwig’s angina and oropharyngeal trauma
Clinical features of croup (laryngotracheobronchitis)
Viral croup is responsible for most cases of stridor after the neonatal period. It is usually a benign, self-limited disease caused by edema and inflammation of the subglottic area. Children ages 6 months to 3 years are most commonly affected, with a peak at an age of 12 to 24 months.
Croup occurs mainly in late fall and early winter, typically, beginning with a 1- to 5-day prodrome of cough and coryza, followed by a 3- to 4-day period of classic barking cough, though cough and stridor may be abrupt in onset. Symptoms peak on days 3 to 4 and are often perceived as more severe at night. Physical examination classically shows a biphasic stridor, although the inspiratory component usually is much greater.
Diagnosis and DDx of croup
The diagnosis of croup is clinical: a barking, seal-like cough and history or finding of stridor in the appropriate setting is diagnostic. The differential diagnosis includes epiglottitis, bacterial tracheitis, or foreign body aspiration. Radiographs are not necessary, unless other causes are being considered. Lateral neck and chest radiographs may demonstrate the normally squared shoulders of the subglottic tracheal air shadow as a pencil tip, hourglass, or “steeple sign” though this sign is neither sensitive nor specific for croup.
Management of croup?
Patients with significant stridor should be kept in a position of comfort with minimal disturbance; monitor pulse oximetry and provide oxygen as needed.
Administer dexamethasone 0.15 to 0.6 milligrams/kilogram (10 milligrams max) PO or IM (may use the IV formulation orally). Nebulized budesonide (2 milligrams) may be clinically useful in moderate to severe cases. Even patients with very mild croup symptoms benefit from steroids, therefore most ED patients diagnosed with croup should be treated with corticosteroids.
Nebulized racemic epinephrine, 0.05 mL/kg/dose up to 0.5 mL of a 2.25% solution, should be used to treat moderate to severe cases (significant stridor at rest). Alternatively L-epineprhine (1:1000), 0.5 mL/kg (to a maximum of 5 mL) can be used. Children with stridor associated only with agitation do not need epinephrine.
Although intubation should be performed when clinically indicated, aggressive treatment with epinephrine results in less than a 1% intubation rate. When necessary, consider a smaller endotracheal tube than estimated by age to avoid trauma to the inflamed mucosa.
Helium plus oxygen (Heliox), typically in a 70:30 mixture, may prevent the need for intubation in the most severe cases. Heliox can be effectively given with a maximum oxygen concentration of 40%, therefore, patients requiring higher FiO2 are not candidates for Heliox.
Children with persistent stridor at rest, tachypnea, retractions, and hypoxia or those who require more than two treatments of epinephrine should be admitted to the hospital.
Discharge criteria include the following: at least 3 hours since the last dose of epinephrine, nontoxic appearance, no clinical signs of dehydration, room air oxygen saturation greater than 90%, parents able to recognize changes in the patient’s condition, and no social concerns with access to telephone and relatively short transit time to the hospital.
Clinical features, dx and ddx of epiglottitis
Epiglottitis is life threatening and can occur at any age. Historically caused by Haemophilus influenza, vaccination has decreased the occurrence of epiglottitis and shifted the median age of presentation toward older children and adults. In immunized children, most cases are caused by strep and staph species.
Clinical Features
Classically, there is abrupt onset of high fever, sore throat, and drooling. Symptoms may progress rapidly to stridor and respiratory distress. Cough may be absent and the voice muffled. The patient is toxic in appearance and may assume a tripod or sniffing position to maintain the airway. The presentation in older children and adults can be subtler. The only complaint may be severe sore throat, with or without stridor. The diagnosis is suggested by severe sore throat, normal-appearing oropharynx, and a striking tenderness with gentle movement of the hyoid.
Diagnosis and Differential
Radiographs are usually unnecessary to make the diagnosis in patients with a classic presentation. If the diagnosis is uncertain, then lateral neck films should be taken at the bedside in extension and during inspiration with a minimum of disturbance. If it is necessary for the patient to be moved to the radiology suite, a physician trained in airway management should be present at all times. The epiglottis is normally tall and thin, but in epiglottitis, it is very swollen and appears squat and fat like a thumbprint (called the “thumb sign”) at the base of the hypopharynx. False negative radiographic evaluations do occur, and, if suspicion remains, gentle direct visualization of the epiglottis is necessary to exclude the diagnosis. Blood cultures are positive in up to 90% of patients, whereas cultures from the epiglottis are less sensitive.
