pediatrics review 2015 dr. andrea boone, md, frcpc alberta children’s hospital foothills medical...
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Pediatrics Review 2015
Dr. Andrea Boone, MD, FRCPCAlberta Children’s HospitalFoothills Medical CentreUniversity of Calgary
Disclosures
I have no financial disclosures or academic conflicts.
Objectives
Pediatric emergenices…in 50 minutes!
Review key pediatric emergencies – from neonates to adolescents
Evidence base reviews of select emergencies
Fever: Neonate (0-28 days)
Full septic work up: CBC + diff, Blood culture, Urine culture, lumbar puncture
Empiric antibiotics: Ampicillin/cefotaxime or Ampicillin/Gentamicin To cover typical bugs causing neonatal sepsis:
Group B Strep E. Coli Listeria monocytogenes Chlamydia trachomatis N. gonorrhea
Add acyclovir Herpetic skin lesions Seizure Maternal history genital HSV Abnormal LFTs
Philadelphia Rochester Boston
Age 29-60d <60days 28-89d
Temp >38.2C >38C >38C
History Not specified Term infantNo perinatal AbxNo underlying diseaseNot hospitalized longer than the mother
No immunizations < 48hNo antimicrobial < 48hNot dehydrated
Physical Exam
Well-appearingUnremarkable exam
Well-appearingNo ear, soft tissue or bone infection
Well-appearingNo ear, soft tissue, or bone infection
Labs (defineLower risk)
WBC<15,000Band-neutrophil ratio<0.2UA <10 WBC/hpfUrine gm stain: negativeCSF<8 wbc/hpfCSF gm stain: negativeCXR: no infiltrateStool: no RBC, no WBC
WBC 5,000-15,000Absolute band <1500/mm3UA<10 WBC/hpfStool smear <5WBC/hpf
WBC <20,000CSF<10/mm3UA<10wbc/hpfCSF < 10 WBC/hpfCXR: no infiltrate
Fever: Infant (29-90 days)
Fever: Infant (29-90 days)
Designed to detect low risk patients that could be managed as outpatients
Boston criticized for higher WBC cut off resulting in high rate of SBI (~5%) in patients identified as low risk; requires empiric antibiotics
Philadelphia requires LP, but no empiric antibiotics
Rochester criteria, no LP, no empiric antibiotics, rate of SBI in low risk infants < 1 %
Fever: Infant (29-90 days)
Approach – partial septic work-up: Well appearing, >37 wks, no identifiable soft
tissue infection/source, not hospitalized longer than mom
Low risk infants: WBC: 5000-15000, < 1500 bands Urine cath R&M: WBC < 10 /hpf Stool analysis, only if diarrhea: < 5 /hpf
Discharge with 24 hour follow up pending cultures. No empiric antibiotics. If plan for empiric antibiotics (ceftriaxone 50
mg/kg), do LP.
UTIs in Children > 2 months
Check urine in 2-36 months with unexplained fever Urine collection:
Not toilet trained, < 2 y/o Urine cath or suprapubic aspirate for U/A, C&S Bag specimen – screen only. If positive, need cath for C&S
(not exam answer….do cath on exam) Toilet trained
Mid stream/clean catch urine for R/M, C&S Risk factors for UTI:
Uncircumcised male < 12 mo, circumcised < 6 mo GU abnormalities Female < 24 months, fever > 39 C without focus
UTIs in Children > 2 months
Management: Antibiotics geared towards local susceptibility
patterns and usual bugs E. Coli, Klebsiella, Serratia, Enterbacter, Citrobacter
Common choices cefixime, septra, clavulin
PO vs IV for uncomplicated febrile UTI > 2 months PO acceptable provided HD stable, not toxic,
tolerating po, normal GU anatomy, with close follow up available
UTIs in Children > 2 months
Indications for ED Imaging: Not clinically improving within 48 hours:
Renal Bladder US (RBUS) for ?abscess ?hydronephrosis to suggest obstruction/high grade VUR
Indications for f/u imaging with family MD: 1st episode febrile UTI – RBUS indicated 2nd episode febrile UTI - VCUG indicated
Case
2 yr old boy wakes up at 3 AM with difficulty breathing
URTI sxs for 3 days. Hoarse voice and barky cough.
T 39, RR 48, HR 140, O2 sat 95% Moderate distress. Stridor at rest. Indrawing.
Management? Differential diagnosis?
Croup
Parainfluenza most common RSV, influenza, adenovirus
Hoarse voice, barky cough, stridor Young children, Peak fall and spring Neck soft tissue xray if atypical, severe, not
improving
Dexamethasone (0.6 mg/kg) for all, effect by 6 hrs Nebulized Epinephrine effect by 30 min Consider Nebulized Budesonide 2 mg if severe Difficult airway!!!
Croup: Westley Croup Score
Mild 0-3, Moderate 4-7, Severe >8
Respiratory failure if >12
Mild (0-2) No stridor No to minimal indrawing
Moderate (3-5) Stridor/indrawing at rest No distress/agitation
Severe (6-11) Stridor/indrawing at rest Agitation/distressed
Resp. failure > 12 Lethargy/cyanotic
Retropharyngeal Abscess
Complication of Pharyngitis, Head & Neck infections, Penetrating trauma
Grp A strep, oral anaerobes and S. aureus < 6 yrs
Retropharnygeal lymph nodes regress
Stridor, sore throat, muffled voice Neck pain and stiffness Fever, unwell appearance
Retropharyngeal Soft Tissues *
Age (yrs) Maximum (mm)
0-1 1.5 x C2
1-3 0.5 x C2
3-6 0.4 x C2
6-14 0.3 x C2
Age (yrs) Maximum (mm)
0-1 2.0 x C5
1-2 1.5 x C5
2-3 1.2 x C5
3-6 1.2 x C5
6-14 1.2 x C5
Retrotracheal Soft Tissues *
*
*
Retropharyngeal Abscess
Complications Airway compromise Erosion into carotid artery Aspiration pneumonia Mediastinitis Lateral pharyngeal space rupture Extension into spine
IV Ceftriaxone and Clindamycin Consult ENT Consider CT
Epiglottitis
Involves all supraglottic tissues GAS, Strep pneumoniae
H.influenza rare
Rapid onset of severe sore throat, stridor, drooling, sniffing/tripod position
Do not disturb patient Consult Anesthesia, ENT- Intubate in OR IV Ceftriaxone and Clindamycin
Bacterial Tracheitis
Toxic, unwell appearing Severe Croup sxs – non responsive to treatment Mortality 4% Staphylococcus aureus
Also S. pneumo, H.influenza, M.catarrhalis, C.diphtheriae
ICU admission Consult anesthesia if need intubation IV Ceftriaxone and Clindamycin (or Clox, or
Vanco)
Foreign Body Aspiration
Highest risk between 1 -3 yrs old Immature dentition, poor food control More common with food than toys
peanuts, grapes, hard candies, sliced hot dogs
Acute respiratory distress (resolved or ongoing) Witnessed choking Cough, Stridor, Wheeze, Drooling Uncommonly…. Cyanosis and resp arrest
Inspiratory Expiratory
Respiratory Emergencies - Bronchiolitis
Bronchiolitis < 2 y/o, most common < 12 y/o “first episode wheeze”, clinically variable
presentation, viral URTI to severe LRTI Typically coryza, cough, variable WOB with
crackles/wheeze on exam RSV most common cause
human metapneumovirus, influenza, parainfluenza, adenovirus
Higher risk – preterm < 35 wks, < 2 months of age, Congenital heart disease, immunodeficiency
Respiratory Emergencies - Bronchiolitis
Investigations: Routine labs not helpful, including NP swab CXR not helpful, misleading, leads to
inappropriate antibiotics Fever + bronchiolitis
Neonate – full septic work up, rate of SBI still high
1-3 months – rate of UTI 5%, do urine cath C&W; rate of bacteremia <1%; meningitis rare
VBG/ABG – only in impending respiratory failure
Respiratory Emergencies - Bronchiolitis
Management: Supportive care is the mainstay Epinephrine – short term response, may trial Nasal suctioning – superficial/frequent; short term
response Salbutamol – not recommended Hypertonic saline nebs – not recommended; some
evidence to support use in inpatient, need to give with epi as bronchoconstrictor
Epi + dexamethasone (Plint et al. NEJM 2009) CanBest – one study, approached significance in reduction
in admissions, controversy re large steroid doses; not routinely recommended
Respiratory Emergencies - Bronchiolitis
Indications for admission: Persistent sats < 90% room air Dehydration requiring NG/IV fluids Significant WOB High risk infants History of apnea at home or in department Family not coping
Pertussis
Most commonly < 6 months 3 clinical stages:
Catarrhal – mild URTI symptoms, 1-2 weeks Paroxysmal – staccoto cough, post-tussive emesis,
apnea, classic whoop often absent < 3 y/o; 2-4 wks Convalescent – gradual resolution
Diagnosis – clinical, suspect if prolonged cough contact, NP swab for C&S, PCR; CXR often normal
Management admit if < young age, apnea, increased WOB Erythomycin to reduce spread of infection
Congestive Heart Failure
Left to Right shunts Presentation at 1 month Decreasing pulmonary vascular resistance 1st month of life
Increased blood flow into lungs
Symptoms Irritability, Diaphoresis Poor feeding (early fatigue), Failure to thrive
Signs Tachypnea, Tachycardia, Respiratory distress Enlarged liver Gallop/murmur
Congestive Heart Failure
VSD most common Other: ASD, PDA
Diagnosis Pansystolic Murmur, Hyperactive precordium ECG – LVH CXR – cardiomegaly, vascular redistribution
ED Management ABC’s, Glucose Furosemide 1mg/kg CPAP
Congenital Heart Disease - Age of presentation
Cardiac Emergencies: A Case
EMS call enroute with blue baby, 6 wk male On arrival ++crying, RR 60 Sats 55% on 100%
NRBM, HR 180, BP 72/48, T 37.2 R glucose 5.1 CR 4 sec, mottled Clear lungs. Single S2. + systolic murmur No hepatomeglay. Benign abdo Further history – term baby, poor feeding since
birth, poor weight gain, known murmur
Cardiac Emergencies: A Case
Tetralogy of Fallot
Right ventricular outflow tract obstruction (RVOTO)
Right ventricular hypertrophy(RVH)
Overriding aorta Ventricular
septal defect (VSD)
Cardiac Emergencies: Tet Spell
Pathophysiology: Worsening right to left shunt secondary to
sudden decrease in SVR Metabolic acidosis increases hyperpnea/preloadPrecipitants: Crying, exercise (feeding), tachycardia,
defecation, hypovolemiaManagement principles: Increase SVR, abort hyperpnea, correct
hypoxia, correct acidosis
Cardiac Emergencies: Tet Spell
Management: 100% Oxygen - pulmonary vasodilation Knees to chest/squat – increases SVR Soothe child – stops crying/hyperpnea
cycle/drops venous return Fluid bolus 10-20 cc/kg – improve RV filling Morphine 0.1 mg/kg IV – anxiolysis Propranolol 0.1 mg/kg IV – reduces RVOTO spasm Refractory cases – HCO3/ketamine/phenylephrine
2 yr old boy with fever for 6 days. Red eyes but no discharge. Generalized rash. Erythema of the palms of hands
and soles of feet. Red, swollen lips. Enlarged cervical lymph nodes.
Diagnosis? Complications?
Case
Kawasaki Disease
Usually < 4 yrs old peak 1-2 yrs
Fever for >/= 5 days and 4 of: Bilateral non-purulent conjunctivitis Rash Changes of peripheral extremities
• Initial stage: reddened palms and soles, edema• Convalescent stage: desquamation of fingertips and
toes Changes of lips and oral cavity Cervical lymphadenopathy ( >1.5 cm)
Kawasaki Disease
Subacute phase - Days 11-21 Desquamation of extremities Arthritis
Convalescent phase - > Day 21 If untreated ~ 25% coronary artery aneurysms
Other manifestations: Uveitis, Pericarditis, Myocarditis Hepatitis, Gallbladder hydrops Aseptic meningitis
Incomplete Kawasaki’s Disease
Incomplete(Atypical) 5 d fever
2 -3 criteria
AAP Kawasaki statement Newburger et al. Pediatrics, 2004
Kawasaki Disease
Supplemental Lab Criteria ESR >40 CRP >3 WBC > 15 000/mm Anemia Platelets after 7 days > 450 Elevation of ALT Albumin < 3 Urine >10 WBC/hpf
Kawasaki Disease
Treatment
IV Immunoglobulin (2 g/kg) Reduces coronary aneurysms to 3% if given
within 10 days of onset of illness Defervescence with 48 hrs
ASA During acute phase high dose (80-100
mg/kg/day) then low dose (3-5 mg/kg/day) for 6-8 weeks
Stop if normal ECHO
Neonatal Jaundice
Most common neonatal presentation in 1st week of life
Unconjugated vs conjugated
Acute bilirubin encephalopathy Early: High pitched cry, lethargy, hypotonia Late: Hypertonia, seizures, coma, death
Chronic bilirubin encephalopathy Athetoid cerebral palsy, seizure d/o, deafness
HYPERBILIRUBINEMIA
Conjugated Unconjugated
Hemolysis
Non-hemolytic•Breast feeding associated•Breast milk•Sepsis•Hypothyroid•Bruising/cephalohematoma•Polycythemia•Hypoxia/Acidosis•Intestinal obstruction•Gilbert syndrome•Lucey Driscoll•Crigler Najjar (I, II)
Blood group•ABO•Rh•minor
Membrane•HS•Poikilocytosis•Elliptocytosis
Enzyme•G6PD•Pyruvate kinase
Non-immune
Immune
Neonatal Jaundice
Key components of assessment: Septic risk factors?
PPROM, GBS +, intrapartum fever, prior neonate with GBS
Septic behaviour? Poor feeding, irritability, lethargy, vomiting,
colour change, difficulty breathing, decreased urine output
Unwell appearing neonate? Pallor, mottling, irritability, lethargy, high
pitched cry, abnormal vital signs, weight loss > 10% of birth weight
Neonatal Jaundice
Investigations: Total serum bilirubin (TSB) + direct
(conjugated) bilirubin CBC, Blood group, DAT (direct antibody
test=Coombs test) Consider: Septic work up – blood culture,
urine culture, lytes, creat, VBG ~8% of jaundice requiring treatment have
UTIs (even in absence of symptoms/signs of infection) – so check urine if meet treatment threshold
Neonatal Jaundice
Risk Factors:• Isoimmune
hemolysis• G6PD• Asphyxia• Resp distress• Lethargy• Temp
instability• Sepsis• Acidosis
Neonatal Jaundice
Management: Start intensive phototherapy Consider IV fluids Keep baby warm Consider IV antibiotics if concerning for
sepsis Check exchange transfusion chart!
Case
3 week old boy vomiting every feed for 24 hours.
Vomit is yellow/green. No diarrhea. Dry diaper since this morning.
HR 180, RR 40, T 37.2 R. Irritable and restless. Eyes sunken. Mouth dry. Cap refill 5 sec. Abd distended and diffusely tender.
What is your approach to this infant? Differential diagnosis?
Volvulus
Malrotation with midgut volvulus Short small bowel mesentery, ligament of Treitz poorly fixed Twisting of the bowel around the superior mesenteric artery
Sudden onset of bilious vomiting, usually 1st month of life
Acute abdomen with shock Bowel ischemia and necrosis, GI bleeding
ABC’s, Fluid resuscitation, Glucose, NG tube Plain AXR – cannot rule out Upper GI series – definitive test Emergent surgery
Pyloric Stenosis
4-6 weeks of age Male to female 4:1, first born males 5% of siblings and 25% if mother was affected
Symptoms of gastric outlet obstruction Non-bilious vomiting Emesis increases in frequency and eventually becomes
projectile Peristaltic wave, palpable mass in epigastrium “olive”
Labs – hypochloremic hypokalemic metabolic alkalosis Ultrasound Rehydration, correction of metabolics prior to surgery
Case
1 yr boy with vomiting and diarrhea since last night.
This morning he had three loose stools with blood. He cries intermittently in cycles of 10 to 20 minutes.
T36.5, HR 118, RR 40, BP 100/50. Pale and lethargic. Abd soft, mild tenderness. Mass palpable in RLQ.
Investigations? Diff Dx?
Intussusception
Usually invagination of ileum into cecum (75%)
6 months to 3 yrs Males to female 3:2
90% are idiopathic Post viral illness – hypertrophy of Peyer
patches Pathologic causes - Meckel diverticulum,
polyps, hematoma (Henoch-Schonlein Purpura), lymphoma/leukemia, cystic fibrosis
Intussusception
Classic triad present in 10-30% Intermittent, crampy abdominal pain Vomiting “Currant jelly" stools
Late sign, indicates intestinal edema and mucosal bleeding
Lethargy in 25%
Ultrasound (Sens 97-100%, Spec 88-100%)
AXR (Sens 45%, Spec 21%)
Lack of air in RLQ, obstruction Target sign, Crescent sign
Intussusception
Plain AXR: Paucity of air in RLQ Absent liver edge Obstruction Target sign
RUQ mass, sometimes looks like a target
Crescent sign Intussceptum lead
point protruding into gas filled pocket
Management:
Air Contrast Enema• Success rate 95%• Bowel perforation in 1-3%
Recurrence rate 10-15%• 50% within first 24 hrs• Other 50% within 10 mos
Admit for observation
Case
4 yr old with bruising to both legs today
Pain with walking, swollen ankles.
Abdominal pain with blood in stool.
Diagnosis? Complications?
Henoch-Schonlein Purpura
IGA mediated vasculitis 2-11 yrs
Rash 100% Palpable petechiae/purpura, can be urticarial,
buttock/leg Arthritis 70%
Ankles > knees >wrists > elbows Abdominal pain 50%
Intussusception 2% Nephritis 40% (ESRD in ~1%)
Henoch-Schonlein Purpura
Investigations CBC, PT PTT, Lytes, BUN, CR; Urinalysis
Prot, Alb, Immunoglobulins Strep testing – Throat swab, ASOT
Weekly U/A and BP until sxs resolve then monthly for 6 mos
Treatment NSAID’s for pain relief Consider steroids for abdominal, testicular, CNS
involvement Controversial for renal complications
Nephrology consult if hypertension, nephrotic sx’s
Case
4 yr old with 2 week history of polyuria and polydipsia
Very sleepy today. Complaining of headache.
Normal vital signs. Tired but arousable. Dry MM. Eyes sunken. Normal cap refill.
Blood sugar at triage “HIGH”
Initial Management?
Diabetic Ketoacidosis
DKA Diagnostic criteria: pH<7.30 and/or HCO3<15 mmol/L random serum glucose > 11.1 mmol/L + urine ketones
Symptoms Polyuria/Polydipsia, Wt loss Abdominal pain, Fatigue
Signs Kussmaul respirations Ketotic breath “Look dry”; usually mild-mod dehydration CNS changes – headache, confusion, irritability, lethargy
Diabetic Ketoacidosis
Cerebral edema in 0.7-3.0% Patient risk factors
Age < 2 years New onset DM, Longer duration of Sx More severe dehydration – high urea, K+, hct Greater acidosis - Low initial pC02, pH < 7.1
Treatment risk factors Rapid administration of hypotonic fluids IV bolus of insulin Early insulin infusion Failure of serum Na to rise during treatment Use of NaHCO3
Wolfsdorf J et al. Pediatric Diabetes 2014
Diabetic Ketoacidosis
Fluid bolus only if hypotensive 10 ml/kg over 30-60 min
Calculate fluids based on 10% dehydration replaced over 48 hrs; do not exceed 2x maintenance
NS + 40 meq KCl/L (if voiding and K<5)
Diabetic Ketoacidosis
Start Insulin infusion 1-2 hrs after IV fluids Insulin 0.05 – 0.1 units/kg/hr
No Insulin bolus No Bicarbonate Monitor hourly VS, neurovitals, glucose
Gas, lytes, osm, urine ketones q2-4h
Diabetic Ketoacidosis
Cerebral Edema For headache alone
Raise head of the bed to 30o
Decrease fluids to maintenance
If altered LOC (GCS<10) 3% Saline 5 cc/kg over 20 min OR Mannitol 0.5 gm/kg iv over 20 min Prepare for intubation STAT CT scan
Febrile Seizure
Simple Febrile Seizure T>38.5 6 mo-5 yr Generalized seizure, < 15 min One seizure within 24 hours Neurologically normal before and after
Occur in ~ 5% of children Recurrence in 30%
Management – as per fever management.
Febrile Seizure
Risk of epilepsy is 1% Epilepsy in general population 1%
Higher risk (2.4%) if: Complex febrile seizures
2 or more in 24 hr Prolonged > 15 min focal
< 12 mos at the time of first febrile seizure Family history of epilepsy
Seizure Management
ABC’s, Check Glucose Extended lytes Anticonvulsant levels
Phenytoin, Phenobarbitol, Valproic acid, Carbamazepine
Septic work up? Imaging? Consider ingestion
Anion gap, Osm gap, ASA, Acet, Toxic alcohols
1st line - Benzodiazepines 2nd line – Fosphenytoin or phenytoin, Phenobarb 3rd line - Midazolam infusion
Other – Thiopental, Pentobarbitol, Paraldehyde, Propofol, Valproic acid, Topiramate, Levetiracetam
Status EpilepticusCPS GuidelinesPaediatr Child Health 2011;16(2):91-7
Minor Head Injury: CATCH
CATCH - Canadian Assessment of Tomography for Childhood Head Injury
Inclusion criteria Witnessed loss of consciousness or disorientation Definite amnesia Persistent vomiting (two or more distinct
episodes of vomiting 15 minutes apart) Persistent irritability in the ED if < 2 yrs GCS > 13 in the ED Injury within the past 24 hours.
Osmond et al, CMAJ 2010
Minor Head Injury: CATCH
Osmond et al, CMAJ 2010
Minor Head Injury: CATCH
Subsequent multi-centre validation of CATCH rule Sensitivity of 87% with 4 high risk factors Sensitivity of 98% with 7 high and medium risk
factors Required 38% of patients to undergo CT Main criticism:
increased rate of CT likely due to inclusion of all MVCs and boggy hematoma
Poor sensitivity with high risk criteria – missed 4 ciTBI EDH
Improved sensitivity with 7 criteria but still missed 1 EDH
Osmond et al.CJEM. Vol 14. S1, 2012
Minor Head Injury: PECARN
Identification of children at very low risk of clinically-important traumatic brain injuries:
Inclusion criteria Any child with injury < 24 hours GCS 14-15
Looks at who does not need a CT rather than who needs a CT
Kupperman et al, Lancet 2009
Minor Head Injury: PECARN < 2 y/o
Kupperman et al, Lancet 2009
Minor Head Injury: PECARN > 2 y/o
Kupperman et al, Lancet 2009
Minor Head Injury
Optimal clinical decision rule not yet established
PECARN vs CATCH vs CHALICE Single site external validation comparing
physician judgment to 3 decision rules Physician judgment and PECARN only rules to
identify all clinically important TBIs Both CATCH and CHALICE missed clinically
important TBIs CATCH had lowest specificity (Sens 91%, Spec
44%
Annals of EM. 64 (2). Aug 2014
Child Abuse
Suspect if history vague, changing, inconsistent with degree of injury or child’s development
Bruises Can not date bruises by color “If they don’t cruise they don’t bruise”
Uncommon for toddlers to bruise buttocks, genitalia, inner arms or legs, neck or trunk
Patterned marks – linear, hand prints Bites – adult if > 3 cm
Child Abuse
Fractures Metaphyseal (corner, bucket handle)
shearing force from shaking usually < 1yr
Posterior ribs Femoral in non-ambulatory child Scapular, sternal, spinous process Multiple fractures, different ages
Low risk – clavicle, tibia in toddler
Child Abuse
Skull fractures Multiple, occipital, wide
Retinal hemorrhages Multiple layers with peripheral extension
most specific for abuse Bilateral, flame shaped
uncommon in accidental trauma (<1.5%)
Child Abuse
Admit all children < 2 yrs
Skeletal survey for < 2 yrs (consider for 2-5 yrs)
CT head if < 1 yr Opthalmologic exam
Ideally within 24 hours (must be <72 hrs)
Arrange clinical photography of marks/bruises
Mandatory reporting to child welfare agency
Questions?
Thank you!