Pediatric Emergencies

the 411 for ED Residents

Amy Buoncristiani, MDContra Costa Regional Medical CenterDepartment of Emergency Medicine

Topics Covered

• Upper Airway Emergencies

• Fever without Source

• Asthma

Pediatric Upper Airway Emergencies

DDx of stridor and fever: • Croup• Tracheitis• Retropharyngeal abscess• Epiglottitis

Croup aka viral laryngotracheobronchitis

Sx: Rhinorrhea, fever, barking cough, stridor, tachypnea, retractions, hypoxia

Dx: Clinical plus/minus lateral soft tissue neck to exclude epiglottitis in severe stridor

Path: parainfluenza mostly ; others adeno, influenza, rsv, mycoplasma

Peak: fall and winter

Age: 6 mos – 4 years

Evidence Based Croup Management

• Dexamethasone 0.6 mg/kg po (iv form) or IM x 1– Give to any severity of Croup– Reduces symptoms in 6 hrs– Fewer visits/hospitalizations– Decreased ED time and decreased use of Epi

• Racemic Epinephrine– For stridor at rest or severe Upper Airway obstxn– Dose 0.5 mL (0.05-0.1 ml/kg) – Observe 3-4 hrs and can d/c if no stridor at rest, good MS

*Cool Mist not considered helpful, but used for comfort

Tracheitis - watch for it!

• Due to Hib immunization and steroid treatment, tracheitis now exceeds epiglottitis and croup as the most common life-threatening infection of the upper respiratory tract in children

• Mortality high• Staph aureus most common

Tracheitis

• Sx: – Has features of epiglottitis and viral croup– Starts with viral upper respiratory symptoms, low

grade F, cough– Then rapid onset of high fever, respiratory

distress, variable stridor, and appears toxic. – Unlike patients with epiglottitis, these children

typically have a cough, are comfortable lying flat, and do not drool

TracheitisManagement

• Airway support • Contact ENT for endoscopic diagnosis and

intubation• Bug Juice: Vancomycin, Ampicillin-Sulbactam• Contact CHO ICU for transfer/transport

Retropharyngeal Infections:Abscess and Cellulitis

RP Space is potential space between pharynx and prevertebral fascia

Etiology: spread of infection from pharyngitis, tonsillitis, sinusitis, or cervical lymphadenitis

Age: < 6 years, peak age 3

RP Infections

Sx: feverneck and throat pain neck swellingdecreased movement of neck

(extension) drooling

decreased po intakeStridor and resp distress less common

RPI Management

Dx: CT of the neck soft tissues the standard if your attending insists, you may wind up ordering first a:lateral neck film that may (or may not)

show expansion of the prevertebral space = > 1 vertebral body width>7 mm at C2, and > 14 mm at C7

Tx: Broad Spectrum antibioticstransfer to CHO

Retropharyngeal AbscessImage and Clinical

Epiglottitis

Epidemiology: Rapid decline since 1990 Rise in Adults since that time Most likely caused by Staph and Strep now H. Influenza epiglottitis still rarely occurs in

vaccinated children

Epiglottitis Dx & Management

• Suspect in child with rapid progression of fever, stridor, drooling, throat pain, but young children may have more subtle course

• Lateral Neck film may show ‘thumbprint’• Contact ENT to take child to OR for direct

laryngoscopy and intubation• Broad Spectrum Antibiotics, no good evidence

for other Rx. Some try steroids, racemic Epi while considering DDx

Lateral Soft Tissue Neck ImagingEpiglottis

Normal Abby Normal

PediatricFever Management in ED

Initial and Basic Care:• Children under 36 months require a rectal

temperature• Triage nurse usually gives child given tylenol (15

mg/kg) or motrin (10mg/kg)• Ask nurse to start Oral Rehydration Therapy

(ORT) which is pedialyte administered by caregiver 5 ml every 5 min by syringe and recording this on sheet for Staff to review

Febrile Child Triage

• Infants < 3 months with – either a history of T> 100.4 by caregiver or – nurse identified T>100.4 or 38– are made a Triage Level 1 to facilitate physician

exam and ordering work up in under 30 minutes

• Any febrile child who is toxic – Triage Level 1 and needs to be seen by physician

within 10 minutes of triage

Fever Without a Source (FWS)

• Source not found in 20% febrile kids

• But, several percent have a Serious Bacterial Infection (SBI) or UTI

• Guidelines are AGE based due to differences in pathogens and immune function

Sources of Fever• Any obvious site of infection: – Pneumonia– bacterial diarrhea– cellulitis– overt otitis media (>1 month old)– abscess– clinical croup– Varicella

Sources of Fever

Viral sources– A positive rapid RSV, Influenza, Parainfluenza,

adenovirus test places child at much lower risk of SBI/UTI

– Still Strongly consider check for UTI in F < 24 mo and UCB < 6 mos

Despite positive test, or ‘source’:

**ALL NEONATES < 1 MONTH GET FULL SEPSIS WORKUP**

Pneumococcal Vaccine and Our Approach to Fever

• Heptavalent PNC Vaccine = Prevnar or PCV-7 added to immunization schedule in August 2000

• Infants receive at 2, 4, 6 and 12 – 15 mo

• Efficacy against IPD from vaccine serotypes is 97.3 % and from all types 89.1%

Pneumococcal Vaccine and Our New Approach to Fever

• Since IPD is responsible for majority of non UTI Serious Bacterial Infections in infants > 3 mo, the risk of SBI in vaccinated children is <1 % regardless of WBC count

– (translation: non toxic child over 3 months, don’t absolutely need CBC anymore!)

• IPD SBI’s still exist, so CLOSE FOLLOW UP

• ***Vaccine doesn’t change management of diagnosing UTI***

Facts about Fever in Neonates< 1 month old

• Incidence SBI/UTI = 4-12 %• UTI associated with up to 20 % bacteremia• Clinical exam unreliable • Even if viral test positive, UTI, or other

infection found, need to still do full sepsis work up because of high rate and risk of bacteremia and meningitis from source of infection, and high rate of concomitant SBI in virally infected neonates

FWS Management< 1 month

All get:• Cath UA and Culture• CBC, Blood Culture x 1• Lumbar Puncture for– Cell count, Gram Stain, Culture, HSV PCR if

pleiocytosis or infant ill appearing• IV Amp and Gent• Transfer to John Muir WC (CCHP-MediCal) or

CHO (straight MediCal) and depending on home town

FWS Epidemiology in 1 – 3 month old T> 38C, 100.4F

• UTI Prevalence High: UCBoys>girls>Cboys

• CBC helps place infant at low or high risk

• Rate of SBI (not UTI) in – Low risk infants = WBC between 5 and 15K= 1-3%– High risk infants WBC>15, <5 =20 %!

FWS Management in 1 – 3 month old T> 38

• Cath UA and Culture• CBC • Blood Culture• IM or IV Ceftriaxone if WBC >15, strongly

consider if <5• LP if irritable, lethargic, and strongly consider if

antibiotics are to be given.• Follow up in 24 hours, admit if unreliable

Risk Stratifying for FWS 3 – 36 months Unvaccinated = < 2 doses Prevnar

• Rate of Bacteremia 2.6 – 6 % in unvaccinated child regardless of WBC

• But, 2 large RCT’s tell us that WBC can be used to stratify into high and low risk groups when T>39.5– WBC > 15K Rate Bacteremia = 10% – WBC < 15 Rate Bacteremia = 1%

Pneumococcal Vaccinated 3-36 mo with fever > 39.5

A child is considered vaccinated if has at least 2 doses of pneumococcal vaccine, second dose more than 2 weeks before presentation

Risk of SBI drops to < 1% in this group, thus CBC or Blood Culture unlikely to change management in well appearing child

Pneumococcal Vaccine doesn’t protect against UTI

Prevalence of UTIand Risk Stratification

3-36 mo group:

Girls 6-8% in < 12 monthsGirls 5-10 % < 24 months

High Risk Girls = < 24 months

Boys< 6 mos: 2.7 % (mostly Uncirc)Circ Boys > 3 mo rate UTI very low <<1%

High risk boys are Uncirc = < 6 months old

Management for UTIof Febrile T > 39 and 3-36 months

High Risk Infants = F<24 mo, UCB<6 mo:All get Cath UA and Culture

Consider Screening Low Risk, especially if F> 48 hr (F > 24 mo, UCB to 12 mo, CB to 6 mo)

Options: 1. Cath UA and send Culture

or 2. Bag UA (don’t culture), but if LE/Nitrite +,

send Cath UA and culture

Management for SBIT > 39.5 (103.1), child 3-36 months

If child is NOT pneumococcal vaccinated CBC and Blood Culture, Treat IM/IV Ceftriaxone if WBC > 15

DO LP on any child with fever of any degree who is lethargic, irritable, ill appearing

Treatment of Febrile 3-36 mo child

UTI:– Oral as good as IV for UTI– First dose in ED– IM/IV Ceftriaxone– Oral Keflex, Cefixime

Unvaccinated with T > 39.5 (103.1) and WBC>15:– IM/IV Ceftriaxone

Any toxic appearing child:– IV amp + gent + vanco (if pneumococcal suspected)

Questions to ask about Febrile Children 3-36 mo

• Is the child toxic?• Is there a fever source?• Is the boy circumcised?• How many and when was most recent

Prevnar?• What is the likelihood of good follow up?

Final Notes

• Use your clinical judgment with children, and treat them not as a child, but as a little patient.

• If it is the right thing to do, then do it, even if it is invasive, or takes monitoring or more time, i.e., LP’s, IV pain meds when indicated

• Arrange closer follow up for children than others: 24 hr return is common in ED with febrile children FWS

Overview of ED Pediatric Asthma Management

Inhaled Beta AgonistsSupplemental Oxygen prn, Moniter prnCorticosteroidsSystemic Medications for Status AsthmaticusStep Up Home therapy in Persistent AsthmaticsEducationDisposition decision

Albuterol

Evidence:

– Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses

– Nebulized albuterol for severe disease, infants or when there is strong parent preference

Albuterol Dosing in ED

MDI+ Spacer: 1-8 puffs every 20 minutes x 3Spacers: Face Mask style for 1 – 10 years oldAlbuterol MDI 8 puffs = 2.5 mg UD nebulized

Albuterol Dosing in ED

Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h

>5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h

Nebulized Continuous: 5-10 mg/hr

calculate and caution <1 yr old0.3-0.5mg/kg/hr

Overview of ED Pediatric Asthma Management

Inhaled Beta AgonistsSupplemental Oxygen prn, Moniter prnCorticosteroidsSystemic Medications for Status AsthmaticusStep Up Home therapy in Persistent AsthmaticsEducationDisposition decision

Albuterol

Evidence:

– Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses

– Nebulized albuterol for severe disease, infants or when there is strong parent preference

Albuterol Dosing in ED

MDI+ Spacer: 1-8 puffs every 20 minutes x 3Spacers: Face Mask style for 1 – 10 years oldAlbuterol MDI 8 puffs = 2.5 mg UD nebulized

Albuterol Dosing in ED

Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h

>5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h

Nebulized Continuous: 5-10 mg/hr

calculate and caution <1 yr old0.3-0.5mg/kg/hr

AtroventAnticholinergic

Nebulizer solution (0.25 mg/mL)

• < 20 kg : 0.25 mg = ½ UD

• < 20 kg : 0.5 mg = 1 UD every 20 minutes for 3 doses, then as needed q6h

Corticosteroids in ED

• Short bursts of steroids beneficial in acute asthma and reduce hospitalizations, duration

• Strongly consider corticosteroids for every asthma exacerbation or viral reactive airways.

• Down side is negligible and Benefits are evidence based.

The New FavoriteCorticosteroid

Oral Dexamethasone (T ½ 36-72 hr)

–May give tasteless IV form orally!!–0.6 mg/kg/day for 2 doses. –Give 2nd dose 24-36 hrs after the first. –May send home family with syringe of the

correct second dose of the IV form–Or Rx oral tablet form and crush in pudding

or jam

Adjunct Meds in Status Asthmaticus

Evidence: Magnesium is first line systemic bronchodilator

RCTs and Metas have established safety and efficacy in kids, reduces hospitalization

Single dose: 25-75 mg/kg (max 2 g) IV over 20 minutes

Adverse: flushing and nausea

Injectable Beta 2 Agonists: Terbutaline and Epinephrine

No proven benefit, but used when faced with

impending respiratory failure and possible intubation

Terbutaline

0.01 mg/kg SC every 20 minutes for 3 doses then every 2–6 hours as needed

Max dose 0.25 mg, or adult dose

Epinephrine 1:1000 =1 mg/mL

Dose Child and Adult: 0.01 mg/kg SC

Max dose 0.5 mg every 20 minutes x 3 doses

Step up Home Therapy

Send home patients with inhaled corticosteroids, who have persistent or not well controlled asthma**Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbationsJournal of Allergy and Clinical Immunology - Volume 124, Issue 2 Suppl (August 2009)

What is Uncontrolled Asthma?Rule of 2’s

More than 2 daytime/exercise symptoms/week or

>2 episodes of albuterol use/week, or >2 nighttime awakenings per MONTH or > 2 steroid courses or hospitalizations in last

YEAR