Pediatrics Review

Gina Neto, MD FRCPCPediatric Emergency Medicine

Objectives

• Pediatric Emergency in 45 min!

• Recognize and manage acute pediatric presentations from newborn to older children

• Describe evidence based management of selected pediatric conditions

Case

• 4 day old girl presents to the ED with jaundice.• Today is sleepy and has to be woken for feeds.

• Born at term, SVD. No complications. BW 3.5 kg.

• T 37.2, HR 140, RR 36, BP 90/50. Wt 3.1 kg• No distress. Sleeping but arouses easily.• Skin jaundiced, sclera icteric.

Case

• Further history

Baby is breastfeeding every 3 hrs but falling asleep, stays on breast for 30 min.

No urine output since last evening.

GBS neg, SROM 1 hr before delivery. Asian ethnicity. Mom is O pos.

Case

• Assessment?• Initial management?

Jaundice is a medical emergency!• Start phototherapy immediately

> 10% wt loss– dehydration vs poor weight gain• IV fluids

Sleepy vs Lethargic• ? Needs septic work up

Neonatal Jaundice

• Most common medical presentation in 1st week of life• Unconjugated vs Conjugated

• Physiologic jaundice 3rd day of life RBC mass, Immature liver conjugation, Increased

enterohepatic circulation• Poor feeding and dehydration

“Not Enough Breastfeeding Jaundice” Increased enterohepatic circulation, Decreased bilirubin

clearance

Neonatal Jaundice

• Breast milk jaundice Starts Day 5-7, Well baby May last for several weeks

• ? Component in milk that inhibits conjugation• Blood destruction

Immune (Hemolysis)• ABO incompatibility, Rh Disease

Non-Immune • Blood Disorders (G6PD, Spherocytosis)• Hematoma, Polycythemia

• Sepsis• Other (Gilbert, Crigler-Najjar, Hypothyroidism)

Neonatal Jaundice

• Conjugated hyperbilirubinemia is always pathologic

Liver Disease• Biliary obstruction (atresia, choledochal cyst)• Hepatitis

Sepsis STORCH infection

• Syphilis, Toxoplasmosis, Rubella, CMV, HSV, Hep B Metabolic disorders

• Galactosemia, Tyrosinemia

Neonatal Jaundice

• Bilirubin Induced Encephalopathy Basal ganglia involvement

Early • High-pitched cry, lethargy, hypotonia

Late• Hypertonia, extensor rigidity, seizures, coma, death

Long term• Athetoid cerebral palsy, deafness

Neonatal Jaundice

• Labs Bilirubin – total and conjugated  STAT ! CBC, Blood group, Direct antibody test (Coombs)     Consider Septic Workup, Lytes, BUN, Cr, Glu, VBG

• Start phototherapy immediately• Converts unconjugated bilirubin into water soluble isomers

• If treatment needed: Consider IV hydration, Keep baby warm Catheter Urine (~8% will have a UTI)

Neonatal Jaundice

Remember to also plot on Exchange Transfusion Graph if in treatment range

Case

• 5 day old boy presents with vomiting and lethargy

• Over the past 24 hrs the baby has become increasingly sleepy and difficult to feed.

• Vomited several times. • No wet diapers since last night.

• Born at term. SVD. No complications. BW 3.5 kg

Case

• T 35.2oC, HR 200, RR 60, BP 90/50. • O2 sat 96%• Lethargic, mottled infant

• Chest - clear, mild intercostal indrawing• CV - normal HS, cap refill 5 sec• Abd - slightly distended

Case

• What is the physiologic status of the infant?

Shock• Compensated or decompensated?

• Initial management?• ABC’s

O2 IV fluids

• Check glucose• Warm the baby!!

Septic Appearing Newborn

“THE MISFITS” (Causes of Shock in the Newborn)

• Trauma Non-accidental

• Heart Duct dependent lesions

• Coarctation of aorta, Hypoplastic left heart, Aortic stenosis Arrythmias – SVT

• Endocrine Congenital Adrenal Hyperplasia Thyrotoxicosis

Septic Appearing Newborn

“THE MISFITS” (Causes of Shock in the Newborn)

• Metabolic - Hypoglycemia, Hyponatremia• Inborn errors of metabolism• Sepsis• Formula errors• Intestinal catastrophes - Volvulus, Necrotizing

Enterocolitis• Toxins• Seizures

Sepsis

• Risk factors Prematurity PROM >18 hrs Fever in mother or infant at delivery Multiple births Previous sibling with GBS infection

• Pathogens Group B Strep 30%, E. coli 30-40%, Other Gram neg 15-20% Gram pos (including Listeria monocytogenes) 10% Viral (HSV, HZV, RSV, Coxsackie), Chlamydia

Sepsis

• ABC’s, Fluid Resuscitation, Glucose• “Septic work up”

CBC, Blood C&S Cath urine R&M, C&S LP - if stable CXR - if resp sx's Viral serology

• Treatment Ampicillin & Gentamycin or Cefotaxime If suspect herpes – Add Acyclovir

Congenital Adrenal Hyperplasia

• Most common is 21 hydroxylase deficiency (95%) Aldosterone and cortisol deficiency Excess production of testosterone

• Girls - Ambiguous genitalia• Boys - Adrenal crisis/shock at ~1 week

• Management: Correct fluid and electrolyte imbalances

• Low Glu, Low Na, High K Hydrocortisone Fludrocortisone

Cardiogenic Shock

• Acyanotic duct dependent lesions Critical left heart obstruction Poor systemic blood flow Acidosis and shock

• Hypoplastic left heart syndrome• Coarctation of the aorta• Aortic stenosis• Total anomalous pulmonary venous return

PDA Closure

• Increased O2 sat with first breath contraction of ductus arteriosus• physiologic closure at ~12 hrs• anatomic closure at 2-3 wks

• Duct dependent lesions • No pulmonary blood flow cyanosis• No systemic blood flow shock

Cardiogenic Shock

• Acyanotic duct dependent lesions

• ABC’s Fluid resuscitation Consider Intubation Maintain relative hypoxia and hypercarbia

• Start Prostaglandin E1

Infusion at 0.05-0.1 g/kg/min Complications:

• Apnea in ~15%, Hypotension, Fever, Seizures Improvement within 15-30 min

Case

• 3 day old girl brought to the ED with a history of progressive cyanosis and irritablity

• T 36.3oC, HR 160, RR 48, BP 94/40. O2 sat 74%• Irritable, cyanotic infant• Chest clear. S1 S2, soft systolic murmur, normal

pulses, cap refill 3 sec

• What is your approach to this infant?• Differential diagnosis?

Cyanotic Newborn

Cyanotic heart lesions

• Decreased pulmonary blood flow Tetralogy of Fallot (TOF) Pulmonary atresia or stenosis

• Desaturated blood shunted to systemic circulation Transposition of great vessels (TGA) Truncus arteriosus Tricuspid atresia Total anomalous pulmonary venous return (TAPVR)

Cyanotic Newborn

• Non Cardiac Causes Upper airway obstruction

• Choanal atresia Pulmonary disease

• Pneumonia• Diaphragmatic hernia• Persistent pulmonary hypertension

Neurologic• Hemorrhage, hydrocephalus, infection• Neuromuscular disorders

Polycythemia Methemoglobinemia

Cyanotic Newborn

• Management

• ABC’s, Glucose• 100% oxygen test

Poor response to oxygen suggests cyanotic cardiac lesion

Use only diagnostically O2 promotes closure of PDA• Maintain relative hypercarbia and hypoxia

pCO2 45-50, O2 sat <90%• Start Prostaglandin E1

Infusion at 0.05-0.1 g/kg/min

Case

• 1 month old boy with 2 day history of irritability and poor feeding. Difficulty breathing today.

• No fever or URTI sx’s. Born at term, healthy.

• T 37.5oC, HR 160, RR 80, BP 85/50. O2 sat 92%• Mild respiratory distress, indrawing, bilateral crackles• S1 S2, III/VI systolic murmur, normal pulses• Liver at 5 cm below CM

• What is the most likely diagnosis?

Case

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

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 CPAP

Congenital Heart Disease - Age of presentation

Case

• 3 week old boy vomiting every feed for 24 hours.• Vomit is yellow. 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

• 40% present in first week, 80% present by 1 month• Malrotation

• Short small bowel mesentery, ligament of Treitz poorly fixed• Twisting of the bowel around the superior mesenteric artery

• Sudden onset of bilious vomiting• Acute abdomen with shock

Bowel ischemia and necrosis, GI bleeding

• ABC’s, Fluid resuscitation, Glucose• Upper GI series• 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 – low K, low Cl, metabolic alkalosis • Ultrasound

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

• Target sign

Intussusception

• Crescent Sign

Intussusception

Intussusception

• 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

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

• 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

• 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• 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

Kawasaki Disease

Incomplete(Atypical)• Fever >5 d

with 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

Case

• 4 month old with difficulty breathing x 2 days.• Cough and congestion. Poor Feeding.

• Moderate distress. T 37. RR 80. HR 160. Sat 94%• Crackles and wheezes bilaterally. Indrawing.

• Management?

Bronchiolitis

• Respiratory Syncytial Virus most common Parainfluenza, Influenza, Adenovirus, Human metapneumovirus

• Peak in winter• More serious illness

• < 2 months• Hx of prematurity < 35 weeks• Congenital heart disease

• Bronchiolitis with fever < 3 mos• Bacteremia rare, UTI in 5%

Bronchiolitis

• Nebulized Epinephrine - short term relief

• Dexamethasone • Synergistic effect with Epi – time dependent effect• 1 mg/kg on Day 1 then 0.6 mg/kg for 3-5 days

• Nebulized Hypertonic Saline• Benefit in inpatient studies, May be helpful in ED• Causes bronchoconstriction – Give with Epi

• No benefit of Salbutamol, CXR not helpful

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 commonRSV, 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 if severe• Difficult airway!!!

• Mild 0-3, Moderate 4-7, Severe >8 • Respiratory failure if >12        

Croup

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, 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%• Streptococcus, Staphylococcus aureus

Also 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

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

• pH<7.30 and/or HCO3<15 mmol/L Ketonuria

• 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 < 5 years New onset DM, Longer duration of Sx High initial urea, 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

Diabetic Ketoacidosis

• Diabetic ketoacidosis in children and adolescents with diabetes. Wolfsdorf J et al. Pediatric Diabetes 2009

Diabetic Ketoacidosis

• Fluid bolus only if hypotensive 10 ml/kg over 30-60 min

• Calculate fluids based on 10% dehydration replaced over 48 hrs

• NS + 40 meq KCl/L (if voiding and K<5)

Diabetic Ketoacidosis

• Start Insulin infusion 1-2 hrs after IV fluids Insulin 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

Case

• 2 yr old with generalized tonic clonic seizure.

• Noted to be seizing at home. Ambulance called, ongoing seizure on arrival.

• T 40, HR 120, RR 36, Sat 98%

• Management?• Definition of febrile seizure?

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%

Febrile Seizure

• Risk of epilepsy is 1% • Epilepsy in general population 1%

• Higher risk (2.4%) if:• Multiple febrile seizures• < 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 - 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

Case

• 6 month old with swollen L leg

• Parents state 3 yr old brother fell onto baby

• Approach to this case?

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

Head trauma• Direct contact injuries

scalp hematoma, subgaleal hematoma depressed skull fracture epidural hematoma

• Rotational acceleration injuries subdural hemorrhages cerebral edema retinal hemorrhages

Child Abuse

Retinal hemorrhages• Multiple layers with peripheral extension

most specific for abuse• Bilateral, flame shaped

uncommon in accidental trauma (<1.5%)• Other causes

40% of normal newborns Glutaric aciduria II (retinal and subdural hemorrhages) CPR – prolonged duration, coagulopathy Infectious – CMV, malaria, endocarditis

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

Case

• 4 yr old boy fall from play structure

• Vomited twice• Headache initially, now resolved• Normal exam in ED

• Does he need a CT?

Minor Head Injury

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

Minor Head Injury

Identification of children at very low risk of clinically-important brain injuries

• Inclusion criteria Any child with injury < 24 hours

• Looks at who does not need a CT rather than who needs a CT

Kupperman et al, Lancet 2009

Minor Head Injury

• < 2 yrs

Minor Head Injury

• > 2 yrs

Summary

• Quick tour through key PEM cases

• Neonatal presentations• Pediatric cardiac emergencies• Abdominal emergencies• Bronchiolitis, Upper airway infections• DKA• Febrile Seizure• Child Abuse• Minor head injury

Questions ?