Pneumonia

Question 1

A 5 year old girl presents to the ED with a 3 day history of fever and frequent most cough. She is tired and has been off her food. From a distance you can see that she is tachypnoeic, with suprasternal and subcostal recessions.

Answer 1

Impression
Given 3 day hx of infective respiratory symptoms, am provisionally concerned about a pneumonia in this patient also considering her age. Concerned about complications including systemic infective progression.

DDx to consider;
- infective: Bronchitis, URTI, viral vs bacterial pneumonia
- non-infective: CP, chronic lung disease, Congenital heart disease, asthma exacerbation, FBI (unlikely given time course of presentation)

Goals
- call for senior help conduct A to E initially to ensure HD stable and no respiratory intervention required
- use thorough Hx/Ex/Ix to assess severity of presentation, guide disposition
- start empirical ABx therapy

Question 2

Pneumonia - Assessment

Answer 2

Assessment
Given tachyponoeic and increased WOB, would call for senior help and begin a primary survey
A - patent, maintaining
B - RR, SP02, Assess WOB, resp exam; wheeze, stridor, crops (consolidation), percussion and air entry findings. administer supplemental 02 if low sats
C - HR/BP monitoring, assess for HD instability. Gain IVC access if severe pneumonia for bloods and IV ABx administration. Take VBG, cultures given febrile, additional bloods (FBC, CRP, UEC, LFT).

Question 3

Pneumonia - History

Answer 3

History
- PC: time course, duration, progression
- sx: fever, chills, rigors, cough, productive? wheeze chest tightness, baseline respiratory function, haemoptysis, preceding URTI sx?
- associated sx: vomiting, nausea, diarrhoea, etc
- oral intake, irritability, behavioural disturbance, inputs vs outputs
- PMHx: lung disease, heart disease, asthma, etc
Paeds Hx
- developmental milestones, vaccinations, Blue book for growth, pregnancy and birth details/complications
- immunocompromised?

Question 4

Pneumonia - Examination

Answer 4

Examination
- General appearance + vitals
- Resp exam: percuss for dullness, auscultate for creps, reduced air entry, wheeze, etc.
- AVPU/GCS

Assess severity
- mild: no WOB, minimal tachypnoea
- mod: increased WOB, tachyponiea/tachycardia, sats 90-95%
- Severe: marked WOB, marked tachypnoea, SP02<90%, altered mental state

Question 5

Pneumonia - Investigations

Answer 5

Investigations
Diagnostic
- CXR: looking for lobar pattern in typical bacterial pneumonia, diffuse interstitial pattern if viral or other atypical
- Sputum MCS - isolate causative pathogen, directed ABx therapy

Other
- Bedside: septic work up
- Bloods: as per A to E, cultures as febrile

Question 6

Pneumonia - Management

Answer 6

Management
Disposition
- admit if mod-sev, or if not tolerating orals/ poor fluids and oral nutrition

Definitive
- start empirical ABx; refer to local guidelines is both age and severity dependent;
o mild: Amoxicillin
o Mod: IV ben pen
o Sev: IV ceftriaxone/cefotaxime + fluclox
- switch to directed therapy once sensitivities return, add azithromycin if concerned about atypicals, review local protocols

Supportive
- supplemental 02
- antipyretics, analgesia
- fluid and electrolyte balance
- parental education, reassurance