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!