Pedpourri – Pediatric Disorders II Christopher S. Amato, MD, FACEP, FAAP

Emergency Medical Associates Goryeb Children’s / Morristown Medical Center

Director, Pediatric Emergency Medicine Fellowship Editor, ACEP PEER VIII, Pediatric EM

1

Case

7 male, diarrhea, fever x 2 days VS: WNL, looks well abd: soft, +/-diffuse tenderness, no peritoneal

sign Bloods, urine: non contributory Dx: ?Gastroenteritis

Case cont’d

Presents again next day, same symptoms exam: no change no bloods drawn seen by Gen Surg.

D/C with Gastroenteritis

Case cont’d

Presents 3rd time, abd pain increased rebound OR: perforated appendix

Case

24 months, male, crying, “bloated” no v/d, last bm 2 days ago vs: wnl, happy, looks well abd: no mass, nontender, +BS Abd. Series: stool+++ Dx: Constipation

Case cont’d

Presents next day lethargic pale, not responding, tachypneic protuberant abd 7.10/30/5 OR: intussusception

Which 2 diagnosis are found on emergency discharge records most frequently for missed

pediatric abdominal catastrophes in court cases?

Gastroenteritis Constipation

KIDS: VERBAL vs. NON-VERBAL

Differences? Similarities?

PRESENTATION:THE SPECTRUM

Stoic

H

Denies pain Fear of further medical attention

Histrionic Exaggerates pain

?missed diagnosis

1/3 of kids presenting with Abdominal Pain get no

specific diagnosis!!! (not good)

Abdominal Emergencies

Vomiting +/- abd pain – DDx 0 to 2 years

Appendicitis Colic Gastroenteritis Hernia, Incarcerated Hirschsprung’s Intussusception Malrotation/volvulus Testicular torsion

NEC Lactose intolerance Pyloric stenosis Toxins Neurogenic causes UTI CAH/adrenal crisis Inborn errors

Case

5 week old male infant with chief complaint of vomiting ◦ Has had almost daily emesis since birth ◦ Usually dribbles out of mouth ◦ Now more forceful and occurring with every feed ◦ No respiratory symptoms

◦ Now appears weak, eyes sunken

Radiology

Case Discussion: Hypertrophic Pyloric Stenosis (HPS) (1 of 2)

Background HPS: The most common surgical cause

of vomiting in infants. Hypertrophy of the circular musculature

surrounding the pylorus leads to obstruction of the gastric outlet.

Case Discussion: Hypertrophic Pyloric Stenosis (HPS) (2 of 2)

Background Infants with HPS present with nonbilious

projectile vomiting in the second to fourth weeks of life. Symptoms rarely occur before 2 weeks or

later than 4 to 6 months of age.

Your First Clue: HPS

• Male infant • Nonbilious, projectile emesis • Hungry appearing • Visible peristaltic waves • Palpable olive-shaped pylorus in

midepigastric region

Peristaltic Wave

Peristaltic Wave

Radiology Until recently, upper GI was the

"gold standard" for diagnosis of pyloric stenosis.

Positive upper GI signs for HPS are “string sign" (single streak of barium in lumen of elongated pylorus).

Ultrasonography

Indicative of pyloric stenosis

Length ≥ 1.6 cm wall thickness ≥ 0.4 cm Diameter ≥ 1.4 cm are

Management

ABCs Naso- or orogastric tube decompression Correct dehydration, metabolic and electrolyte

abnormalities with intravenous fluids. Ensure adequate urine output. Consult a pediatric surgeon. Surgery delayed until electrolytes stable

Case Progression/Outcome

Electrolytes: hypochloremic, hypokalemic, metabolic

alkalosis. Fluid resuscitation and gastric decompression

were initiated. A pediatric surgeon was consulted. Patient underwent a pyloromyotomy 2 days after

admission and was discharged 3 days later.

Case

18-month old infant ◦ Vomiting x 1 day, multiple times, nondescript ◦ Abdominal pain, nondescript, appears intermittent ◦ Lethargy afterwards ◦ Draws legs up into abdomen with discomfort

Radiology

Discussion: Intussusception

Intussusception is an invagination of the proximal portion of the bowel into an adjacent distal bowel segment.

Second most common cause of intestinal

obstruction in infants Approximately 80% to 90% involve

invagination of the ileum into colon (ileo-colic).

Background (1 of 2)

Peak age of occurrence is between 5 and 9 months, with most cases occurring from 3 months to 2 years.

10% to 25% occur in children older than 2

years.

Your First Clue: Intussusception (1 of 2)

Classic triad Intermittent colicky abdominal pain

(85%-90%) Vomiting (65%-80%) Emesis may be nonbilious, but may

become bilious or feculent. Bloody Stool with mucoid "currant jelly" stools---late finding

Your First Clue: Intussusception (2 of 2)

Only 20% have all three 70% have two of three

Radiology: Meniscus or Crescent Sign

Ultrasonography

Radiology: Barium or Air Contrast Enema

Management

ABCs Fluid resuscitation

Obtain surgical consultation. Perform barium or air contrast enema. Surgical reduction for: Signs of peritonitis Shock Pathologic lead point Unable to reduce with barium or air contrast enema

Case Progression/Outcome

After fluid resuscitation, Air contrast enema. Intussusception was

found and reduced. Lethargy quickly disappeared, and the

infant took oral fluids. The infant was discharged after

observation in ED.

Intussusception

Risk of recurrence Typically in the first 24 hours. Enema reduction 5-10% Surgical reduction 1-4%

Disposition Data shows safety with discharge from ED

36

WHAT if X-RAY Looked like this???

Malrotation with Midgut Volvulus

Malrotation is abnormal fixation of bowel mesentery

Volvulus is twisting of loop of bowel around mesenteric attachment Obstruction, ischemia, necrosis

Normal

Malrotation

Ladd bands

Midgut Volvulus

Malrotation with Midgut Volvulus

Usually presents in first year of life 75% < 1 mo; 90% <1yo Rarely may not present until childhood

Abdominal pain - nonspecific Bilious vomiting Abdominal distension and hematochezia

may be present Mortality up to 60%

Malrotation with Midgut Volvulus - Radiography

Plain films Normal to obvious SBO “Double-bubble” sign –

distension of stomach and first part of duodenum

UGI Study of choice “Apple core”, “corkscrew”, or

“coiled spring” sign Surgical consult prior to obtaining

UGI

Malrotation with Midgut Volvulus

Treatment IV hydration Correction of electrolytes NG tube Antibiotics Surgical correction

Acute Gastroenteritis

Gastroenteritis – Etiology

Bacterial: 10 – 20%

Shigella Salmonella E. coli Campylobacter Yersinia Vibrio cholera

Viral: 60%

Rotavirus Norwalk and Norwalk-

like (calicivirus) Adenovirus Astrovirus Coxsackie Echovirus

Treatment – Viral

Focus on oral hydration Antidiarrheals not recommended Antiemetics generally not needed ◦ Phenergan black box warning <2 years ◦ Ondansetron becoming more popular Good safety and efficacy profile

(AAP, Pediatrics 1996; Ramsook, Ann Emerg Med 2002. Freedman, N Engl J Med

2006)

Signs of Dehydration Summary

PE: ◦ Abnormal Cap refill

◦ Abnormal Skin turgor

◦ Abnormal Respiratory Pattern

Protective: Normal urine Output, Nl HCO3

ORT for mild/moderate dehydration vs. IV

End Tidal CO2 for HCO3 >37 torr

After hydration give Glucose fluid

Ondansetron helpful with vomiting

Dehydration in Children ORT vs IVRT in Current Practice

ORT IVRT

*Based on a national random survey of emergency physicians (N=176) selected from the American Academy of Pediatrics (AAP) Section on Emergency Medicine mailing list.3

1. AAP Practice Parameter Committee. Pediatrics. 1996;97:424-435. 2. World Health Organization. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. 4th rev. Geneva, Switzerland: WHO Press; 2005; 3. Ozuah PO et al. Pediatrics. 2002;259-261; 4. Conners GP et al. Pediatr Emerg Care. 2000;16:335-338. 5. Humphrey GB et al. Pediatrics. 1992;90:87-91. 6. Cummings EA et al. Pain. 1996;68:25-31; 7. Frey AM. J Intraven Nurs. 1998;21:160-165; 8. Black KJL et al. Pediatr Emerg Care. 2005;21:707-711

Treatment Guidelines ORT is preferred in mild-to-moderate dehydration1

Use IVRT in severe dehydration or in children who cannot tolerate ORT1,2

Clinical Practice Realities

Use in Mild Dehydration*

71% always or almost always3 2% always or almost always3

Use in Moderate Dehydration*

15% always or almost always3 49% always or almost always3

Possible Contributing Factors Ongoing perception that ORT ineffective and takes too much time4

Parents expect an IV4

Catheter placement is one of the leading sources of pain and anxiety in children5,6

Often requires multiple attempts7-8

Is there another option?

SubCutaneous Hydration

Subcutaneous fluid administration for achieving hydration, to increase the dispersion and absorption of other injected drugs, and in subcutaneous urography for improving resaborption of radiopaque agents

Background

Subcutaneous (SubQ) administration of fluids was common from 1900 to 1950

IV route first developed in the 50s SubQ fluids safe and effective in mild to moderate

dehydration1

IV access may be difficult in dehydrated children and the elderly

Recombinant human hyaluronidase (rHuPH20) is FDA approved in subcutaneous fluid administration for

achieving hydration

1. Allen CH, Etzwiler LS, Miller MK, et al. Pediatrics. 2009;124:e858-e867.

Summary

ORAL HYDRATION THERAPY IS YOUR FRIEND!!! ◦ 5ml / 5 minutes and increase as tolerated

Alternatives? ◦ Nasogastric hydration ◦ Subcutaneous Hydration

GI – bloody diarrhea

Hemolytic uremic syndrome most common cause of ARF in children ◦Micronagiopathic hemolytic anemia ◦ Renal failure ◦ Thrombocytopenia ◦ Risk of seizures and hypertension

◦ Treatment of E.coli is risk for development

Inflammatory Bowel Disease

Crohn’s Disease ◦ Skip lesions ◦ Mouth to anus ◦ Cobblestoning ◦ Extra-intestinal manifestations

Ulcerative colitis ◦ Continuous from distal colon to proximal ◦ Significant risk of oncologic deterioration/conversion

Case

12 year male complains of abdominal pain ◦ Lasted 3 hours ◦ Obviously uncomfortable

◦ On exam, lower abdominal tenderness

◦ Further evaluation reveals…

Testicular Torsion

Salvage rate ◦ Less than 6 hours: 80-100% ◦ After 24 hours: <10%

Presence of a cremasteric reflex is possible Horizontal lie Vomiting Ultrasound with color flow

Colic / Crying – Differential

Infection: meningitis, otitis media, UTI Corneal abrasion / foreign body Intestinal obstruction Fracture Child abuse/increased intracranial pressure Incarcerated hernia Testicular torsion Hair tourniquet

Colic Criteria

Unexplained Crying for >3 hours for >3 days/week in >3 weeks

… In an otherwise healthy child.

“Neonatal bilious emesis is a surgical emergency until proven otherwise”

DIFFERENTIAL DIAGNOSIS

Infants: ◦ #1.inguinal hernia ◦ #2 intussusception

Case

3month old male presents with vomiting x1 hour ◦ can’t keep anything down

PE: small, protuberant abdomen, (+) tympanic belly

V.S. T 37.3, P 175, RR 50 PMHx: ex 33 weeker

Inguinal Hernia

INCARCERATED INGUINAL HERNIA

Most common in first year of life 30% of infant hernias present with incarceration

most manually reducible Dx by physical examination alone If abdomen distended or septic

obtain KUB to R/O free air

HERNIA REDUCTION POINTERS

Trendelenburg promotes spontaneous reduction ? Ice packs to limit edema Incarcerated bowel may be compromised

Temperature concerns Frog leg position to relax abdominal wall Quiet, calm environment limit fussiness /crying Sugar coated pacifier Keep NPO (tell parents!!)

HERNIA REDUCTION Transfix hernia, grasp testicle within scrotum Hand presses incarcerated mass through

inguinal canal Conscious sedation helpful Emergent surgery if hernia not completely

reduced, or postreduction obstruction, nonviable bowel, sepsis

If successful reduction, admit and repair when edema subsides in ≅ 24 hrs

Case Study: “Abdominal Pain”

8-year-old boy presents with 1 day of abdominal pain, fever, nausea, and vomiting.

Patient was previously healthy, although

several family members are ill. Boy is alert, has no retractions or tachypnea,

and color is normal.

Initial Assessment and Detailed Physical Examination

Initial assessment: –ABCDEs: Normal

Detailed physical examination: –Normal except for abdominal exam, which shows

tenderness in RLQ, voluntary guarding, and no rebound

–Pain had migrated from peri-umbilical area to RLQ

Management Priorities

Stop oral intake. Obtain vascular access. Begin fluid resuscitation with 20 mL/kg (500 mL)

NS.

Obtain blood and urine for laboratory analysis.

Administer pain medications. Consider antibiotics. Obtain surgical consultation.

Diagnostic Studies (1 of 2)

Laboratory There is no single specific laboratory

test that will diagnose appendicitis and rule out other causes for a child's illness. WBC is often normal.

Clinical Features: Your First Clue

Classic presentation in <50% of cases ◦ Periumbilical pain ◦ Anorexia, nausea, and vomiting ◦ Right lower quadrant pain ◦ Fever

Peritoneal irritation ◦ Percussion tenderness and rebound

Often a delay in diagnosis

Radiology: Plain Films

A fecalith is seen in 10% of cases.

May see evidence of bowel obstruction

Ultrasonography

Graded compression ultrasonography is particularly useful in the child with equivocal clinical signs.

No radiation exposure and accurate in experienced hands

Often nondiagnostic

CT Scan of Abdomen and Pelvis

High sensitivity and specificity rate Requires contrast Radiation exposure

Many institutions have elected to perform ultrasonography first.

Perform CT scan if highly suspicious of appendicitis and ultrasonography is non-diagnostic.

Case Progression/Outcome

Laboratory results showed a slightly elevated WBC.

Patient underwent ultrasonography, which showed a swollen appendix.

He was taken to the operating room. A non-perforated but inflamed appendix was removed.

TAKE HOME MESSAGE

rely on history very few physical findings (50% normal abd. exam)

TAKE HOME AND BRING TO WORK MESSAGE

HISTORY!!!! IF IN DOUBT RE-EXAMINE IF STILL UNSURE RE-EXAMINE LATER

AIRWAY / HEAD / ENT 79

Airway

Children’s airways different: Smaller = Increased resistance

More anterior/superior

Large, floppy glottis

Larger occiput = Affects patency

Large

Loss of tone with sleep, sedation, or CNS dysfunction

Frequent cause of upper airway obstruction

Anatomical differences in the airway- Tongue

Nose is responsible for 50% of total airway resistance at all ages

Infant: blockage of nose = respiratory distress due to

obligate nasal breather

Anatomical differences in the airway- Nose

Poiseuille’s Law

If radius is halved, resistance increases 16fold

R = 8 n l Π r4

Diagram of the Effect of Edema on the Cross-Sectional

Airway Diameter (R = radius)

Adult Airway Area = Π R2 = Π 102 = 100 Π mm2 (Normal) If have 1 mm Edema Area = Π 92 = 81 Π mm2

Or 81% of normal

Full Term Newborn Area = Π R2 = Π 32 = 9 Π mm2 (Normal) If have 1 mm Edema Area = Π 22 = 4 Π mm2

Or 44% of normal

1mm = 20% loss

1mm = 50% loss

20 mm

6 mm

W h e re ’s th e n o i se ?

ILBSET (I’ll Be Set)

Stridor Anatomy

Inspiratory Larynx

Bilateral (I/E) Subglottic

Expiratory Tracheomalacia

Signs of Respiratory Distress

Retractions Access muscles Wheezing Sweating Prolonged expiration Pulsus paradoxus Apnea Cyanosis

Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation

C AT E G O R I Z AT I O N O F R E S P I R AT O R Y E M E R G E N C I E S

Airway obstruction: ◦ Upper - stridor ◦ Lower – wheezing ◦ (where is the noise?)

Alveolar or interstitial conditions: ◦ Rales

Pediatrics ET tube

Internal Diameter mm: ◦ Uncuffed: (Age/4)+4 ◦ Cuffed ( > 1yr old): (Age/4) +3

Length (Age + 12)2= depth at the gumline/teeth ◦ Or 3 times the internal diameter

Airway positioning for children <2yrs

External laryngeal manipulation

Two person approach ◦ Assistant’s hand to Anterior neck

Improved POGO scores by 25% ◦ Cricoid Pressure-5% improvement ◦ BURP-4% improvement

Positioning of the Airway- Bimanual Laryngoscopy

Epiglottitis

Inflammation / swelling of epiglottis /surrounding tissues

H. Influenza with bacterial component

Hib vaccines have made this a rare occurrence.

Can cause complete airway obstruction, precipitated by gag reflex stimulation

Avoid examining or suctioning the upper airway

Clinical Presentation: Symptoms occur rapidly,

causing parents to seek medical attention within 24 hrs

Muffled voice Fever Stridor Labor breathing

(supraglotic edema) Drooling Usually anxious Tripod position

Epiglottitis Age Wide range: newborn to adults Average pediatric range 2 to 7 years

Etiology Now no predominant organism

S. aureus S. pneumoniae Beta-hemolytic Strep (group A and C) H. influenza B still possible

6/19 cases in 1 series 5 were fully immunized

(Shah, Laryngoscope 2004)

Epiglottitis – Symptoms Several hours of fever- Toxic child! Abrupt onset (< 12-24 hours)

Progressive sore throat Drooling Dysphagia Viral prodrome is absent Severe stridor usually absent Tripod / “Sniffing” position

Epiglottitis – Diagnosis Usually clinical 70-90% of blood cultures are positive Elevated WBC with bandemia Radiographs – consider only if sub acute

case

Epiglottitis vs. Normal

Treatment

Rapid recognition and treatment of airway obstruction Position of comfort Do not start IV or draw labs Mobilize OR team Intubate with smaller ETT BVM may need higher pressures Steroids not indicated

Retropharyngeal Abscess

Infection of paramedian lymphoid tissue Usually under 4 years old Organisms – usually polymicrobial GAS Anaerobes S. aureus

Fevers, sore throat, neck pain, drooling, stridor

Peri-Tonsillar Abscess Often Grp A Strep Severe Pharyngitis Hot-potato voice Dysphagia Trismus

Treatment Pain control Hydration Drainage-You or ENT

Case

A 3 year old is sent in by his pediatrician at 2 AM after listening to him coughing by phone ◦ URI for 2 days ◦ cough, hoarseness and what sounds like stridor ◦ In ED, Febrile (39), running around the room, without

stridor at rest ◦ RR 30, P 100, PulsOx 99%

CXR / labs ◦ Just say NO----the history and PE favor croup

Quick recheck of immunization status ◦ Epiglottitis still possible

Prior stenosis due to Trisomy 21 or Subglottic

www.andorrapediatrics.com

What can be done diagnostically?

What can be done therapeutically?

Mist therapy ◦ Doesn’t work!

Corticosteroids ◦ Effective in moderate to severe croup---PO/IM superior to

nebulized ◦ Dexamethasone (0.15 - 0.6 mg/kg) PO/IM

Racemic Epinephrine Racemic 0.05 mL/kg (max 0.5 mL) L-epinephrine (1:1,000 solution) 0.5 mL/kg (max 5 mL) Observe for 2hours—rebound unlikely afterward

◦ 2 strikes and you’re OUT! Admit

Don’t upset them!

Cochrane Review 2011

38 studies met the inclusion criteria (4299pts) Glucocorticoid treatment was associated with an

improvement in the croup severity score at 6 hours Fewer returns and ↓ Length of stay

Case

Mother of 2-month-old boy with 3days of a URI now with increasing work of breathing. EMS called

En route patient remained alert and they note a “waterfall of snot” from his nose

◦ P160, RR 60, BP: hahahaha ◦ T 38.4°C, O2 sat 93%, Wt. 5 kg

Affects Children <2yo

Viral, often RSV (may be metapneumovirus)

Differentiate upper vs. Lower in <5second

Other signs and symptoms include: o Upper airway: Stridor, respiratory or

cardiopulmonary arrest o Lower airway: Coughing, wheezing, retractions,

decreased breath sounds, cyanosis

Bronchiolitis

Albuterol?

Works in the 1st 24hrs only

Ribaviran

Costly, ?Efficacy, No AAP support since ‘03

Steroids?

No Help

Bronchiolitis

Hypertonic Saline?

Multiple studies (3%, NS, 5%, Racaemic)

Mixed Bag

Bronchiolitis

Case

A 6 year old presents with a 3 day history of cough, worse with activity

“No one smokes inside the house.” Strong family history of asthma

◦ T 37.2, RR 26, P 90, PulsOx 94%, Wt. 25 kg ◦ PE Mild tachypnea but no Distress

What can be done therapeutically?

Albuterol and Atrovent ◦ Indicated, often X3 ◦ Use spacers

Steroids ◦ give them EARLY, often for 3-5 days, may use

Dexamethasone ◦ Oral as effective as IV

Spacers vs. Nebulizers

No difference in admission rate 95% CI ( OR: 0.4 to 2.1 )

Children’s LOS in the ED shorter mean diff: -0.62 hours 95% CI ( -0.84 to -0.40 )

No difference for LOS in adults Decreased Pulse & tremor in spacer group Each spray = 108 microgram

Cochrane Review, 2009, Cates CJ

Spacers vs. Nebulizers

Conclude ◦MDI + holding chambers produced outcomes that

were at least equivalent to nebulizer delivery ◦ Holding chambers may have some advantages

compared with nebulizers for children with acute asthma

FYI ◦MDI comes out at 60MPH ◦ Spacer decreased med deposition to pharynx by 50%

IV and nebulized MgSO4 for treating acute asthma in adults and children: A systematic

review and Meta analysis:

25 Trials (16 IV, 9 Nebulized) 1754 patients IV MgSO4 (in addition to β2-agonist & Steroids) ◦ Improved pulmonary function and ↓ Admission for

Children ◦ Only improved lung function in adults

Shan Z, Rong Y Respir Med. 2013

CONCLUSIONS

Current therapy in children is based on variable levels of evidence ◦ Level 1 evidence to support steroids, Ipratropium

bromide, MgSO4 ◦ Level 2 evidence for HELIOX ◦ Level 3-5 evidence for ketamine, NO,

aminophylline, anesthetic agents

Otitis Media Update

Otitis media should be diagnosed based on TM: ◦ Mod/Severe Bulging or Otorrhea not related to OE ◦ Mild bulging and recent (<48hrs) otalgia in a non-verbal

NO AOM: ◦ Without effusion

Treatment with antibiotics: ◦ >6mos severe signs or T >39 ◦ Non-severe: B/L AOM 6-23mos

113

Otitis Media Update

Unilateral Otitis media 6-23mos w/o severe ◦ Prescribe antibiotics OR ◦ Offer close observation Need follow up if no improvement in 72hrs

Non-severe >24mos ◦ Prescribe antibiotics OR ◦ Offer close observation Need follow up if no improvement in 72hrs

114

Otitis Media Update

ANTIBIOTICS ◦ Amoxicillin if: NO allergy NO use in the past 30days NO concurrent purulent conjunctivitis

◦ Add β-lactamase Use in the past 30days Concurrent purulent conjunctivitis Hx of AOM unresponsive to Amox

115

Airway Foreign Bodies Age: 75% of patients are less than 3 years

Mortality ~200 deaths in children per year

Balloons Balls/marbles

Case Discussion: Foreign Body Aspiration

Often occurs in children younger than 5 years

Common offending agents: foods and home items

Balloons are the most common FB to result in death

Airway Foreign Bodies – Symptoms

Paroxysmal cough, wheezing and decreased breath sounds in 40% of patients

25% may be asymptomatic

39% may have no PE findings

50% diagnosed in first 24 hours, 30% in first week

Airway Foreign Bodies - Treatment Position of comfort with supplemental O2 Complete obstruction- remember BLS! Direct laryngoscopy with McGill forceps

available Bronchoscopy Intubation with mainstem bronchus

dislodgement Needle cricothyroidotomy Do you know where your difficulty airway

equipment is ???

Esophageal FB’s

3 likely regions to lodge ◦ Level of the thoracic inlet ◦ Level of the aortic arch ◦ At the lower esophageal sphincter

Plain radiographs to determine location Most items that pass the stomach are

appropriate for outpatient Observation. Corrosive (battery), sharp, length >4 cm

require removal.

Pneumonia Etiology Viral: all ages

Parainfluenza, RSV, influenza, adenovirus

Atypical: Mycoplasma: > 3 years old Chlamydia

C. trachomatis: infants < 3 months old C. pneumoniae: older children

Pneumonia Etiology Bacterial

Neonate Group B streptococcus E. coli Listeria monocytogenes

1 to 3 months S. pneumoniae Chlamydia trachomatis Bordetella pertussis S. aureus

(McIntosh, N Engl J Med 2002: LLSA 2005)

Pneumonia Etiology Bacterial

4 months to 4 years S. pneumoniae Mycoplasma (older children in this age group) S. aureus H. influenza (typable and non-typable)

5 to 15 years Mycoplasma S. pneumoniae Chlamydia pneumoniae

(McIntosh, N Engl J Med 2002: LLSA 2005)

Pneumonia Outpatient Treatment Suspected bacterial

3 months to 4 years Amoxicillin 80-100 mg/kg/day

5 to 15 years Macrolide

Erythro, Azithro, Clarithro Consider doxycycline if > 8 years old

(McIntosh, N Engl J Med 2002: LLSA 2005)

Chlamydia Pneumonia One of the most common types of

pneumonia in infants < 3-4 months Afebrile patient, with history of neonatal

conjunctivitis Staccato-like cough, wheezing Hyperinflation, increased interstitial markings

on CXR Oral erythromycin or a sulfonamide

Summary

Children are MUCH smarter than we give them credit to be Talk to everyone at the scene Keep everyone calm

Especially child!

Sleep when you can Eat when you can Pee when you can Never touch the pancreas!

Questions? 131

The END---GOOD LUCK! 132

Family Presence

Supported by ACEP and AAP Annals of Emergency Medicine, 2009

Family Presence at Resuscitation

Family present on even days, not on odd days Measured time to CT scan and total resuscitation time No delay in care from family presence

Family Contact and ICP 135

Presence, touch and voice of family / significant others...

Does not significantly increase ICP Has been demonstrated to decrease Measured time to CT and total resuscitation time

NO delay in care from family presence

Note: Visitors require education and preparation before spending time at bedside !

Bruya (1981) Journal of Neuroscience Nursing, 13

Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)

Mitchell (1985) Nursing Administration Quarterly, 9(4)

Treolar (1991) Journal of Neuroscience Nursing, 23(5)

Family Contact and ICP

Bruya (1981) Journal of Neuroscience Nursing, 13

Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)

Mitchell (1985) Nursing Administration Quarterly, 9(4)

Treolar (1991) Journal of Neuroscience Nursing, 23(5)

Presence, touch and voice of family / significant others...

• Does not significantly increase ICP

• Has been demonstrated to decrease ICP

Family Centered Care

Bruya (1981) Journal of Neuroscience Nursing, 13

• Family Presence during Resuscitation: • Helped recognize the seriousness of condition

• They feel presence was beneficial

• They would choose to be present again

• Helps family adjust to grieving process

Family Centered Care

AAP & ACEP. Patient and family centered care and the role of the emergency physician providing care to a child in the emergency department, Pediatrics 2006

The “risk management literature indicates that patients and families are significantly less likely to initiate

lawsuits, even when mistakes are made, if there is open and effective communication and trusting relationships

between the practitioner and the patient and family”

• NO research has shown the family presence is harmful and evidence is growing that it is beneficial

The Nuclear Question: 2008

Adults age 45 or older

Very low risk of excess cancer for one scan

High prevalence of cancer in patients over 45

May not live long enough to express mutation

Usually past reproductive age

But for a 10 year old

Long lifespan in which to manifest mutation

Immature, rapidly developing body systems, more radiosensitive

May pass mutations to progeny

Radiation exposure from CT Scans in Childhood and subsequent risk of Leukemia and Brain Tumours: A

Retrospective Cohort Study. Lancet 2012

178,604 children (ages <22yo) in U.K. (‘98-’05) ◦ No Cancer prior to first CT ◦ 283,919 CT scans (64% Head CT) Leukemia = 74 Brain Tumors = 135

Compared to children with <5mGy RR Leukemia was 3.18 in those received >30mGy

Brain Tumor RR 2.82 in those received >50mGy

Risks of Ionizing Radiation from Diagnostic Imaging Bottom Line

Absolute risk is small (1/10,000 Head CT) Although the risk is small, it is cumulative ◦ Statistically significant increase in cancer risks

above 50mSv The benefits of an indicated CT far outweigh

the risks

Appropriate Utilization

CT should be avoided when an US or MRI is of comparable diagnostic utility ◦ Body MR: Liver, Pancreatic, and Renal imaging ◦ US vs. CT for appendicitis in children Amer. College of Radiology appropriateness criteria

• US 8/9: Relative Radiation Level= none • CT 7/9: Relative Radiation Level= high

Rating Scale 1,2,3 =not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

What Do Families Want to Know?

The exam is needed to best care for their child The risk of the exam is real, but very low The exam is being performed with the lowest

possible risk

Explaining Radiation Risk

Families are more interested in efforts to control the risk than the actual number

After reading a handout on radiation risk: ◦ preference for CT over no imaging decreased ◦ but no families refused CT

Larson, et al. Amer. Jrnl Rad. 2007

Summary

Ionizing radiation from diagnostic imaging may cause a small increase in the risk of cancer

For an indicated CT scan, the likely benefit is far

greater than the estimated risk We should work together to make the population

exposure ALARA