Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine Children’s Hospital of Eastern Ontario
Feb 16, 2016
Pediatrics ReviewEmergency
Gina Neto, MD FRCPCDivision of Emergency MedicineChildren’s Hospital of Eastern Ontario
Case 1
2 mo male
• 2 day hx rhinorrhea, poor feeding • 1 day hx cough• Few hrs resp distress
• RR60 HR120 T37C • Pink well hydrated smiling • Chest - inspiratory crackles, exp wheezes
• Diagnosis?
Bronchiolitis
• RSV - Respiratory Syncytial Virus most commonParainfluenza, Influenza A, Adenovirus, Human
metapneumovirus
• Peak in winter• Infants more serious illness
• Treatment • Nebulized Epinephrine – short term relief• ? Dexamethasone
1 mg/kg on Day 1 0.6 mg/kg for another 5 days
• ? Nebulized Hypertonic Saline
Case 2
2 yr old girl
• Congestion x 2 days• Awoke tonight with respiratory distress• Harsh, “barky” cough • Improved on the way to hospital
• HR100 RR28 T37 • Minimal distress • Stridor, mild indrawing
• Diagnosis? Treatment?
Croup
• Parainfluenza type III• Hoarse voice, barky cough, inspiratory 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
Case 3
• 18 month female
• Fever x 2 days• Difficulty swallowing
• HR130 RR28 T39C• Exam normal except won’t move neck fully
• What diagnostic test should be performed?
Case 3
Retropharyngeal Abscess
• Complication of bacterial pharyngitis
• Grp A hem strep, oral anaerobes and S. aureus
• Treatment• IV Clindamycin and
Cefuroxime• Consult ENT
Retropharyngeal Soft Tissues *
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
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 *
*
*
Case 4
5 yr old male
• Febrile x 6 hrs • Refusing to eat or drink • Voice muffled, drooling• Not immunized
• Very quiet, doesn't move HR140 RR20 T39.5 • Slight noise on inspiration • Chest clear, exam normal
Case 4
Epiglottitis
• Rarely seen • Strep pneumoniae• H. influenzae
uncommon due to vaccine
• Do not disturb patient
• Consult Anesthesia, intubate
• IV Cefuroxime
Case 5
• 17 mo male
• 1 hr history of noisy and abnormal breathing• Was playing on floor before developing difficulty
breathing
• VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
• Alert, no cyanosis, no drooling, no dyspnea• Chest: Mild wheezing with mild inspiratory stridor
Soft TissuesNeck Lateral View
CXR (PA)
What investigation would you do next?
ExpiratoryCXR
Inspiratory Expiratory
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 period• Cough, gag• Stridor, wheeze• Drooling
• Uncommonly…. Cyanosis and resp arrest
Case 6
9 month old female
• Fever x 2 days• Vomiting (no blood, no bile) x 20 today• Diarrhea (no blood) 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 6
• What is the degree of dehydration of this child?• Management?
Dehydration
Gastroenteritis
• 10% Dehydration
• Rule out UTI
• ORT with rehydration solution (Pedialyte, Gastrolyte)• 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
Fluids and Electrolytes
• Maintenance (D5NS)• 4cc/kg/hr for first 10 kg• 2cc/kg/hr for second 10 kg• 1 cc/kg/hr for rest of weight in kg
• Deficit (NS)• If severely dehydrated give FLUID BOLUS, 20 cc/kg
over 15-60 min • Deficit fluid - first half over 8hrs, second half over
16 hrs
• Ongoing Losses• Diarrhea, vomiting, NG losses, polyuria• Insensible losses with fever
Case 7
15 month old male
• Intermittent sudden severe abdo pain x 24 hrs• crampy abd pain every 30 minutes
• Vomiting (no blood, no bile) x 3 • Diarrhea with blood and mucus
• HR130 RR24 T37 • Tender abdomen with fullness in RUQ
• Diagnosis?• Investigations?
Intussusception
• 1-3 years• Boys 2:1
• Classic Triad (10-30%)• Vomiting• Crampy abdominal pain• “Red currant jelly” stools
• Lethargy is common
• 75% are ileo-colic• Lead point - Peyer's Patches - preceding viral
infection• Meckel diverticulum, polyps, hematoma (HSP),
lymphoma
Intussusception
• Plain AXR
• May be normal
• May have signs of bowel obstruction
• Paucity of air in RLQ • No air in Cecum on
Lateral Decubitus
Intussusception
• Target Sign
Intussusception
• Crescent Sign
Intussusception
Intussusception
• Air Contrast Enema
• Success rate >80%• Recurrence 10-15%
Case 8
• 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.
• Born at 39 weeks gestation. Spontaneous vaginal delivery.
• Looks well. Mild dehydration. • Abdomen soft, non tender, BS present.
• DDx?
Case 8
• 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
Pyloric Stenosis
• 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
• Symptoms of gastric outlet obstruction• Nonbilious vomiting• Emesis increases in frequency and eventually
becomes projectile
Pyloric Stenosis
• Classically:• Hypertrophied pylorus
palpable “olive” in epigastric area
• Peristaltic waves progressing from LUQ to the epigastrium
• Laboratory abnormalities:• Hypokalemic• Hypochloremic• Metabolic alkalosis
Case 9
• 1 month old with bilious vomiting
• Multiple episodes of yellow green vomiting since this morning.
• Progressive lethargy and irritability. Poor feeding.
• Looks unwell, irritable cry.• Abdomen distended.• Weak pulses, cap refill>5 sec.
• DDx? Management?
Volvulus
• Twisting of a loop of bowel around its mesenteric attachment.
• Sudden onset of bilious vomiting in a neonate.
• Acute abdomen with shockmay have a gradual course with
episodic vomiting
• 80% present by the first month40% present in the first week Rarely can be seen in older
children.
Volvulus• 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
Case 10
1 month old girl
• 12 hr history of fever, 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?
Low Risk Criteria (Rochester) for Febrile Infants• Well appearing infants 1-3 months are low risk for
serious bacterial infection if the following criteria are met:
• Previously healthyBorn at term (> 37 weeks)No hyperbilirubinemiaNo hospitalizations No chronic or underlying diseases
• No evidence of focal bacterial infection• Laboratory parameters:
WBC count 5-15/mm3
Urinalysis WBC count < 5/hpfStool WBC count < 5/hpf (if infant has diarrhea)
Case 11
2 year old boy
• Sudden onset 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?
Febrile Seizure
• ABC's, IV access
• Seizure treatment• IV/PR lorazepam or diazepam• phenytoin, phenobarbitol
• Simple Febrile Seizure• T>38.5• <20min, generalized seizure• 6mo-6yr• neurologically normal before and after
• Observe in the ED until child returns to normal neuro status
Case 12
• 2 yr old boy with persistent fever for 6 days
• Red eyes but no discharge.
• Generalized rash, with erythema of the palms of his hands and soles of his feet
• Red, swollen lips and enlarged cervical lymph nodes
Kawasaki Disease
• Usually < 4 yrs old, peak between 1-2 yrs• Unknown etiology, ? infectious
• 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 solesConvalescent stage: desquamation of fingertips and toes
• Changes of lips and oral cavity• Cervical lymphadenopathy ( >1.5 cm)
Kawasaki Disease
• Subacute phase - Days 11-21• Resolving acute symptoms• Desquamation of extremities• Arthritis
• Convalescent phase - > Day 21• 25% develop coronary artery aneurysms • Myocardial infarction
• Other manifestations:• Uveitis• Pericarditis• Hepatitis, Gallbladder hydrops• Sterile pyuria, Aseptic meningitis
Kawasaki Disease
• Investigations:• CBC – thrombocytosis• ESR – elevated• CXR, ECG• Echocardiogram
• 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
Case 13
• 3 yr old girl with rash starting today
Recent URTI
Swollen ankles and knees. Painful walking.
Diagnosis?
Henoch-Schonlein Purpura
• Systemic vasculitis – IGA mediated• 75% of cases between 2-11 years of age
• Clinical Features 100% - rash (non thrombocytopenic purpura) 68% - arthritis 53% - abdominal pain 38% - nephritis (ESRD in ~1%)
• Intussusception (2-3%)
1 yr old boy with mouth lesions for two days...
• What are the two most likely causes for this condition?
Herpes Simplex
Coxsackie
5 yr old girl itchy rash for two days...
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
12 yr old girl baseball hit finger...
Type II
Salter-Harris Classification
10 yr old boy fall onto hand...
Type I
16 yr old hockey player collided with another player and fell...
Type IV
14 yr old boy running and twisted ankle...
Type III
11 yr old fell off garage...
Type V
• 6 yo boy fall from play structure onto outstretched hand
• Pain and swelling at elbow
• Diagnosis?
Radiocapitellar Line
Line down middle of radius bisects capitellum in all views
Anterior Humeral Line
Transects through posterior 2/3 of capitellum
Elbow Alignment
Elbow Ossification Centers
C
CR R
ET
O
O
I
I
C: Capitellum - 1yR: Radial Head - 3yI: Int(Medial)Epicondyle - 5yT: Trochlea - 7yO: Olecranon - 9yE: Ext(Lateral)Epicondyle - 11y
• Slipped Capital Femoral Epiphysis• Male, 10-16 yrs, overweight• Acute or subacute pain, decreased internal
rotation• Klein line
12 yr old with hip pain
• Legg-Calve-Perthe Disease• Avascular necrosis of femoral head• 5-9 yrs, boys > girls• Bilateral in 15%
6 yr old with hip pain
Questions ?