Pediatrics ReviewEmergency

Gina Neto, MD FRCPCDivision of Emergency Medicine

• Review pediatric resuscitation guidelines

• Recognize pediatric conditions that present to the emergency

• Describe management of pediatric emergency cases

Objectives

Pediatric Resuscitation• Pediatric Airway• Larger head• Bigger tongue• Narrowest part is

subglottic area• Epiglottis is more floppy• Larynx is more anterior

and cephalad• Chest wall more

compliant

• Airway Management• Position, suctioning• Nasal/Oral airway• Endotracheal intubation

Cuffed tube size: age/4 + 3 (+/- 0.5mm)• Medications

Atropine (consider if< 6 yrs)Paralytic - Succinylcholine, RocuroniumKetamine, Midazolam/Fentanyl, Propofol

Pediatric Resuscitation

• Bradycardia• Non-Cardiac causes (6 H’s, 5 T’s)

Hypoxia (Most Common) Hypovolemia, Hypo/Hyperkalemia,

Hypoglycemia, HypothermiaToxins, Tamponade, Thrombosis, Trauma (ICP)

• Cardiac causes - AV block, sick sinus

• Epinephrine 0.01 mg/kg (repeat every 5 min)• Consider Atropine 0.02 mg/kg

Pediatric Resuscitation

Pediatric Resuscitation• Tachycardia• Narrow• Wide• Stable or Unstable

• Know what is normal for age

• Sinus Tachycardia• Rate usually < 220/min• Variable rate• Look for causes

Pain, fever, dehydration, resp distress, poor perfusion

• SVT• Rate usually > 220/min infants, > 160

teens• Rate is fixed

Pediatric Resuscitation

• SVT• Vagal maneuvers

Ice to face, Valsalva

• Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg

• If Unstable:• Synchronized Cardioversion 0.5-1 J/kg

If not effective increase to 2 J/kg

Pediatric Resuscitation

• Tachycardia with Wide QRS• Stable• Consider Adenosine• Amiodarone 5 mg/kg• Consult Cardiology

• Unstable with pulse• Cardioversion 0.5 - 1 J/kg 1st dose, then 2

J/kg

Pediatric Resuscitation

• Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation• CPR

Start at 16:2 compressions/breath• Defibrillation 2 J/kg

Then 4 J/kg Increase subsequent shocks to max of 10 J/kg

• Epinephrine 0.01 mg/kg every 3-5 min• Amiodarone 5 mg/kg

Pediatric Resuscitation

• 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days.

• T 36.5, RR 40, HR 130, O2 Sat 89%.• Suprasternal and scalene retractions,

decreased air entry, expiratory wheeze.

• Describe your management.

Case

• Mild Asthma:• Salbutamol MDI x 3 doses prn

• Moderate Asthma:• Salbutamol MDI x 3 doses then prn• Steroids

Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma

• Severe Asthma:• Salbutamol via nebulization with• Ipratropium 250 mcg x 3 doses q20 min• Steroids

Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma

• If not improving within 60 min or signs of impending respiratory failure:• Magnesium Sulfate 50 mg/kg/dose IV

(max 2g)• Give over 20-30 min• May cause severe hypotension• IV NS 20 bolus ml/kg

• Methylprednisolone 1-2 mg/kg IV

Asthma

• 2 mo male with 2 day hx rhinorrhea, poor feeding and cough. Few hrs resp distress.

• RR 60 HR 120 T 37C. Pink, well hydrated.• Chest - inspiratory crackles, exp wheezes.

• Diagnosis?• Treatment?

Case

• RSV - Respiratory Syncytial Virus most common• Parainfluenza, Influenza A, Adenovirus,

Human metapneumovirus• Peak in winter• More serious illness• < 2 months• Hx of prematurity < 35 weeks• Congenital heart disease

Bronchiolitis

• Treatment • Nebulized Epinephrine – short term relief

• ? Dexamethasone 1 mg/kg on Day 1 0.6 mg/kg for another 5 days

• ? Nebulized Hypertonic Saline

Bronchiolitis

• 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough.

• HR 100 RR 28 T 37 • Mild distress. Stridor at rest.

• Diagnosis? • Treatment?

Case

• Parainfluenza most common• Hoarse voice, barky cough, stridor • Peak fall and spring• Infants and toddlers • Treatment• Dexamethasone (0.6 mg/kg)• Nebulized Epinephrine if in respiratory

distress• Consider Nebulized Budesonide

Croup

Steeple Sign

• 18 month female with fever x 2 days. Difficulty swallowing.

• HR130 RR28 T39C• Exam normal except won’t move neck fully.

• What diagnostic test should be performed?

Case

• < 6yrs• Complication of bacterial

pharyngitis• Infection of posterior

pharyngeal nodes – regress by school age

• Grp A strep, oral anaerobes and S. aureus

• Treatment• IV Clindamycin and

Cefuroxime• Consult ENT

Retropharyngeal Abscess

Age (yrs) Maximum (mm)0-1 1.5 x C21-3 0.5 x C23-6 0.4 x C26-14 0.3 x C2

Retropharyngeal Soft Tissues *

Age (yrs) Maximum (mm)0-1 2.0 x C51-2 1.5 x C52-3 1.2 x C53-6 1.2 x C56-14 1.2 x C5

Retrotracheal Soft Tissues *

*

*

• 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling.

• Not immunized.

• HR 140 RR 20 T 39.5 • Very quiet, doesn't move. • Slight noise on inspiration. • Chest clear, exam normal.

Case

• Rarely seen • Strep pneumoniae• H. influenzae uncommon

due to vaccine

• Do not disturb patient• Consult Anesthesia,

intubate • IV Ceftriaxone and

Clindamycin

Epiglottitis

• 17 mo male with sudden onset noisy and abnormal breathing

• Was playing on floor before developing difficulty breathing

• VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

• Mild wheezing with mild inspiratory stridor

Case

What investigation would you do next?

ExpiratoryCXR

Inspiratory Expiratory

• 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

Foreign Body Aspiration

• 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding.

• Looks well, alert and interactive• T 38.9o HR 176 RR 42 BP 100/50 • Font flat, neck supple, exam non remarkable

• What is your approach to this case?

Case

• Etiology is organisms from birth canal Group B Streptococcus , Escherichia coli

(Gram neg), Listeria monocytogenes • Highest rate of bacterial infection of any age

group• <2 weeks - 25%• 0-4 weeks - 13%

• Septic Work Up• Admission, IV antibiotics

Fever < 1 month

• May still see birth canal organisms, but also: Streptococcus pneumoniae , Neisseria

meningitidis, Haemophilus influenzae type b (uncommon)

• Overall rate of bacterial infection is ~8%Bacteremia 2%Meningitis 0.8%UTI 5%

• “Low Risk Infant” rate of bacterial infection is 1%

Bacteremia 0.5%

Fever 1-3 months

• Well appearing infants 1-3 mos are low risk for serious bacterial infection if:

Previously healthy• Born at term (> 37 weeks)• No hyperbilirubinemia• No hospitalizations • No chronic or underlying diseases

No evidence of focal bacterial infection Laboratory parameters:

• WBC count 5-15/mm3

• Urinalysis WBC count < 5/hpf• Stool WBC count < 5/hpf (if infant has diarrhea)

Low Risk Criteria “Rochester” for Febrile Infants

• Viral infections cause of fever in >90%• 6% of children seen in the ED have a

specific, recognizable viral syndrome e.g. croup, bronchiolitis, roseola, varicella,

coxsackie• UTI in ~5% • Bacteremia very low rates now (< 0.2%)• 5% in 1980’s, HIB vaccine 1987• 2% in 1990’s, Pneumococcal vaccine 2000

Fever 3-36 months

• 2 year old boy with generalized tonic clonic movements. Duration 5 min.

• T 39.2o HR 110 RR 24 BP 110/60 • Awake now, normal neurological exam.• Right TM bulging, neck supple, no rash. • Past med history unremarkable.

• Approach?

Case

• 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%

Febrile Seizure

• Risk of epilepsy is 1% • ~ same as general population

• Higher risk (2.4%) if:• Multiple febrile seizures• < 12 mos at the time of first febrile seizure• Family history of epilepsy

Febrile Seizure

• ABC's• IV access• Seizure treatment• 1st Line - Benzodiazepines

• Lorazepam or Diazepam (Rectal or IV)• Midazolam (Intranasal or Buccal)

• 2nd Line Phenytoin, Fosphenytoin Phenobarbitol

Seizure Management

• Seizure treatment• 3rd Line

Midazolam infusion Thiopental Propofol Paraldehyde

• Observe in the ED until child returns to normal

• After simple febrile seizure no neurological investigations indicated (eg CT, EEG)

Seizure Management

• 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea x 10 today. Voiding scant amounts.

• HR 120 RR 36 BP 100/50 T 38.5• Cap refill 2 sec, pink, decreased skin turgor.• Font sunken, eyes sunken.• Abdo + GU normal.

Case

• What is the degree of dehydration of this child?

• Management?

Case

• ORT with rehydration solution (eg Pedialyte)• 5 ml/kg/hr divided every 5 min, continue

until appears hydrated

• Consider Ondansetron (0.15 mg/kg)

• Early refeeding (including milk) within 12 hrs

• Rule out UTI

Gastroenteritis

• Maintenance (D5NS)4ml/kg/hr for first 10 kg2ml/kg/hr for second 10 kg1 ml/kg/hr for rest of weight in kg

• Deficit (NS)• If severely dehydrated give NS bolus

20 ml/kg over 15-60 min • Replace over 24 hours

First half over 8hrs, second half over 16 hrs• Ongoing Losses• Diarrhea, Vomiting, Insensible losses with fever

Fluids and Electrolytes

• 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus.

• HR130 RR24 T37 • Tender abdomen with fullness in RUQ

• Diagnosis?• Investigations?

Case

• 1-3 years• Boys 2:1

• Classic Triad (10-30%)• Vomiting• Crampy abdominal pain• “Red currant jelly” stools

• Lethargy is common

Intussusception

• 75% are ileo-colic• Lead point• Peyer's Patches

preceding viral infection• Meckel diverticulum• Polyps• Hematoma (Henoch Schonlein Purpura)• Lymphoma

Intussusception

Intussusception

• Plain AXR• May be normal

• May have signs of bowel obstruction

• Paucity of air in RLQ • No air in Cecum on

Lateral Decubitus

• Target Sign

• Crescent Sign

• Air Contrast Enema

• Success rate >80%• Recurrence 10-15%

Intussusception

• 4 week old boy with vomiting for past week. Initially one emesis per day now emesis with every feed. Forceful. No bile.

• No fever. No diarrhea.

• Looks well. Mild dehydration. • Abdomen soft, non tender, BS present.

• DDx?

Case

• Na 140 K 3.0 Cl 90 BUN 24 CR 50

• WBC 8.5 Hgb 120 Plts 360

• Venous gas pH 7.50, PCO2 44, HCO3 30

Case

• Most common surgical condition < 2 mos

• 4-6 wks of age• Ratio male to female is 4:1• Increased in first born males

• Occurs in 5% of siblings and 25% if mother was affected

Pyloric Stenosis

• Nonbilious vomiting• Emesis increases in frequency and

eventually becomes projectile

• Classic findings:• Hypertrophied pylorus palpable “olive” in

epigastric area• Peristaltic waves progressing from LUQ to

the epigastrium

Pyloric Stenosis

Pyloric Stenosis

• Laboratory abnormalities:• Hypokalemia• Hypochloremia• Metabolic alkalosis

• Ultrasound• Thickened pylorus

• 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability.

• Looks unwell, irritable cry.• Abdomen distended.• Weak pulses, cap refill>5 sec.

• DDx? Management?

Case

Volvulus• Twisting of a loop of bowel

around its mesenteric attachment.

• 80% present by the first month

40% present in the first week

Rarely can be seen in older children.

Volvulus• Sudden onset of bilious

vomiting in a neonate.

• Acute abdomen with shock

• May have more gradual course with episodic vomiting

• Evidence of small bowel obstruction • Dilated loops• Air fluid levels• Paucity of distal air

Volvulus

• Upper GI series • “corkscrew”

appearance of the duodenum and jejunum

Volvulus

• 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.

Case

• Usually < 4 yrs old, peak between 1-2 yrs• Fever for > 5 days and 4 of the following:

Bilateral non-purulent conjunctivitis Polymorphous skin eruption Changes of peripheral extremities

• Initial stage: reddened palms and soles• 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• 25% develop coronary artery aneurysms if

untreated

• Other manifestations:• Uveitis, Pericarditis, Hepatitis, Gallbladder

hydrops• Sterile pyuria, Aseptic meningitis

Kawasaki Disease

• Treatment

• IV Immunoglobulin• Reduces incidence of coronary aneurysms to 3%

if given within 10 days of onset of illness• Defervescence with 48 hrs

• ASA• High dose during acute phase then lower dose for

3 mos

Kawasaki Disease

• 3 yr old girl with rash starting today.

• Recent URTI.

• Swollen ankles and knees. Painful walking.

• Diagnosis?

Case

• Systemic vasculitis – IGA mediated

• 75% are 2-11 yrs • Clinical Features

Rash (non thrombocytopenic purpura) 100%

Arthritis (ankles, knees) - 68% Abdominal pain - 53% Nephritis - 38% (ESRD in ~1%)

• Intussusception (2-3%)

Henoch-Schonlein Purpura

Case• 1 yr old boy with

mouth lesions for two days

• What are the two most likely causes?

• Herpes Simplex• Severe primary

infection• HSV1 (80%), HSV2

(20%)

• Fever, irritability, poor intake

• Ulcers on mucous membranes

• Treatment• Acyclovir• Pain control, IV

hydration

Herpetic Gingivostomatitis

Hand, Foot and Mouth Disease• Coxsackievirus, usually A16• Summer• Ulcers on tonsilar pillars• can have generalized

stomatitis• Vesicles on hands and feet

• URTI, pharyngitis• Vomiting and diarrhea• Generalized maculopapular rash

Case• 5 yr old girl with

itchy rash

• Varicella Zoster

• This child comes back to the ED three days later with worsening fever and pain...

Diagnosis?Necrotizing

Fasciitis

• Invasive group A streptococcal infection

• IV Penicillin and Clindamycin

• Consult ID, surgery• MRI

Case• 3 yr old girl fever for

3 days, unwell

• Rash spreading over entire body with skin peeling

Diagnosis?

• Exotoxin causes separation of epidermis• < 2yr• Fever, toxic appearance, generalized

erythema• Exfoliation of skin, accentuated in flexor

surfaces• skin lifts to touch (Nikolsky’s sign)

• Perioral crusting, “honey coloured” lesions• Fluid resuscitation• IV Cloxacillin, Cefazolin or Clindamycin

Staphylococcal Scalded Skin Syndrome

• 10 yr old boy with fever

• Unwell today• Rapidly progressing

rash since this morning

Case

• Usually < 5 yrs, Adolescents outbreaks• Fever, toxic appearance• Petechiae, purpura• DIC, shock• High mortality (25-80%)

• Resuscitation• IV Ceftriaxone• Treat household contacts

Meningococcemia

• How are you going to resuscitate this child?

• First intervention?

• Next?• Next?• Next?

Septic Shock

• Leading cause of death in infants and children

6 million deaths per year worldwide

• Etiology of sepsis• Streptococcus pneumonia• Escherichia coli • Neisseria meningitidis• Other: Group A strep, other Gram neg bacilli,

Staph. aureus, Enterococcus• IV Antibiotics: Ceftriaxone and Vancomycin

Septic Shock

• Sepsis if systemic inflammatory response signs (SIRS) and signs of infection• Fever, or HR, RR, or WBC

• Severe sepsis if signs of organ dysfunction or tissue hypoperfusion

• Septic Shock if cardiovascular dysfunction

Septic Shock

• Hypotension is DECOMPENSATED SHOCK • Most children have “cold shock”

Decreased cardiac output and increased systemic vascular resistance

Poor perfusion, cool extremities, delayed cap refill

•  Adolescents more likely to have “warm shock”

Low systemic vascular resistanceBounding pulses, wide pulse pressure

Septic Shock

• 2 yr old at grandmother’s house• Took unknown amount of pills that he found

in her purse 30 minutes ago

• No symptoms

• What is your approach?

Case

• Young childrenExploratory ingestionIngest small amount of a single substance

• Can grasp single pill at 1 yr • Can’t hold handful of pills until > 15 mos• Child preparations have small opening – spills out

• AdolescentsIngest large amounts of one or more

substancesSuicidal gesture

Poisoning in Children

• Activated Charcoal• 1 g/kg• Greatest benefit is within 1 hr of ingestion

At 30 min 89% decreaseAt 1 hr 37% decrease

• Not useful forAlcoholsHydrocarbonsAnions or Cations (Iron, Lithium)Acids or Alkali

GI Decontamination

• Whole Bowel Irrigation• PegLyte

0.5-2 L per hour via NG

• For substances not adsorbed by charcoal and sustained release preparationsIronLithiumEC ASA

GI Decontamination

• Common ingestions• Household products• Cough/cold, vitamins, antibiotics• Acetaminophen and Ibuprofen• Antidepressants

• Pills that are harmful if single dose taken• Oral hypoglycemics, calcium channel

blockers, tricyclic antidepressants

Poisoning in Children

• Clinical Effects• 0-24 hrs

GI irritation, may be asymptomatic

• 24-48 hrsSigns of liver involvement begin

• 72-96 hrs Fulminant hepatic failureRenal failure

Acetaminophen

Acetaminophen

Acetaminophen• > 4 hr Acetaminophen

level• Plot on nomogram

• N-AcetylcysteinePrecursor for glutathione Increases sulfation

metabolismDirectly reduces NAPQI to

APAPDirectly conjugates NAPQI

Salicylates• Clinical Effects• GI upset - N&V, Gastritis • Tinnitus – often the first symptom• CNS – Confusion, Lethargy, Cerebral

edema• Hyperpnea – Early have respiratory

alkalosis• Hyperthermia• Renal and Liver toxicity – rare• Impaired platelet function

Salicylates• Mechanism of Action• Uncoupling of oxidative phosphorylation

HyperthermiaGlycogenolysis, LipolysisHyperglycemia initially then hypoglycemia

from impaired gluconeogenesis• Inhibits Kreb’s cycle

Anaerobic metabolismLactic acidosis

• Urine alkalinization• Ion trapping – ASA is weak acid

• Hemodialysis• If signs of multiorgan failure

Salicylates

• Low incidence of toxicity, most asymptomatic

• Reversibly blocks cycloxygenase, prostaglandins

• Clinical Effects• GI upset, bleeding• Renal failure• Bronchospasm• Massive overdoses > 400 mg/kg

metabolic acidosis, seizures, coma, hypotension

Ibuprofen

• Triad of clinical effects:• Cardiovascular

Prolonged QRS, QT, PR, ArrhythmiasHypotension

• CNSComa, Seizures

• Anticholinergic symptoms

Tricyclic Antidepressants

Tricyclic Antidepressants• Mechanisms of toxicity

• Blockade of fast Na+ channels

• Type 1A “quinidine-like effects”

• Membrane stabilizing effects• Inhibition of GABA

reuptake• Blockade of alpha 1

receptors• Anticholinergic effects

• NaHCO3• 1-2 meq/Kg then infusion

D5W + 150 meq NaHCO3/L at 1.5 x maintenance

• Benzodiazepines• Sedation, seizures

• Lipid therapy• May be helpful, case reports

Tricyclic Antidepressants

• Much safer than TCA’s

• Clinical Effects:• N&V• Sedation• QT prolongation• Seizures

• Serotonin Syndrome

SSRI’s

• Serotonin SyndromeAgitation, HypervigilanceMyoclonus, Muscle rigiditySeizuresDiaphoresis, shiveringHyperthermia, Autonomic dysfunction – HR, BPDiarrhea

• Treatment• Benzodiazepines, Active cooling

SSRI’s

• Review of pediatric emergency cases: Resuscitation Asthma, Bronchiolitis, Croup, Upper airway Fever in infant, 3-36 months Febrile seizures, Status epilepticus Gastroenteritis, Pyloric stenosis,

Intussusception Rashes associated with serious illness Sepsis Poisoning

Summary

Questions ?