Common PEM Problems for the Emergency Medicine Resident
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Brad Sobolewski, MD, MEd Cincinnati Children's Hospital Medical Center Emergency Department Rotation Director
Febrile Infant
The Bottom Line
28 days old and under = full septic workup
29-60 days we can opt to exclude LP if baby is low risk
Fever defined as temperature 38oC / 100.4oF (rectal)
Viral URI Sx do NOT count as a fever source
H&P are not reliable to rule-out serious bacterial infection (SBI)
12-28% of febrile neonates have SBI UTIs (12-20%)
Bacteremia (3%)
Meningitis (
Other causes Bacterial gastroenteritis
Gonococcal
keratoconjunctivitis
Omphalitis
Osteomyelitis
Peritonitis
Pneumonia
Septic joint
IV access
CBC, blood culture
Cath UA, urine culture
LP + CSF studies
28 days
Glucose if needed
Chest XRay if clinically warranted
Consider need for HSV testing
Enterovirus CSF PCR in the summer
Stool Culture if mucous or gross blood in the stool
Respiratory PCR and influenza
LP success rate increases with early stylet removal and use of lidocaine
Family presence does not alter success rate
Residents get 2 attempts
Take a supervisor with you
Lumbar puncture
CSF Blood
Early stylet removal
CSF Analysis Tube 1 Culture and Gram stain
Tube 2 Glucose, protein
Tube 3 Cell count and dierential
Tube 4 Viral Studies or to be saved for further studies
Lumbar puncture
Labs
WBC 5,000 or 15,000
Bands >1,500
Band:Neutrophil
Low Risk for Bacterial Meningitis 29-60 days old
Full-term (37 weeks gestation)
No prolonged NICU stay
No chronic medical problems
No systemic antibiotics within 72 hours
Well-appearing and easily consolable
No infections on exam
Blood and urine studies reassuring
LP
Empiric Acyclovir Strongly consider for ALL infants 21 days and for infants 22 to 40 days with 1 of the following:
Ill Appearing
Abnormal neurologic status, seizures
Vesicular rash
Hepatitis
Mom known to have primary HSV infection
at delivery
Labs HSV PCR in CSF and blood
HSV PCR of SEM lesions
Liver profile, BMP
HSV?
Antimicrobials 0-21d Ampicillin/Cefotaxime +/- Acyclovir
22-28d Ampicillin/Cefotaxime
29-56d Cefotaxime or Ceftriaxone (>6 weeks and no jaundice)
Additional Considerations Add Vancomycin if
Ill Appearing
CSF
WBC elevated w/abnormal glucose or protein
Gram positive organism on Gram stain
What about? Procalcitonin and CRP do not improve confidence to completely rule out SBI at this time
All babies under 28 days are admitted on empiric antibiotics for 36 hours
Babies 29-60 days with normal CBC and urine can be discharged home o antibiotics
You can get blood, urine and CSF on a baby 29-60 days and D/C home if normal - but NO antibiotics!
Disposition
Babies discharged home must have PMD follow up within 24 hours
Also, trustworthy caregivers with reliable transportation
Always call the PMD
If you cant reach them - baby from out of town consider admission
Disposition
Bronchiolitis
Rare in the first month of life
Peak 2-5 months
90% of kids will have it by age 2
URI Symptoms Rhinitis
LRTI Symptoms Tachypnea Cough Wheezing Crackles Accessory muscle use Nasal flaring Fever in only 30%
RSV #1
If you think it is bronchiolitis you are probably right! Viral testing only if severe disease or concurrent septic workup
Getting a Chest Xray just to be sure increases your likelihood of giving unnecessary antibiotics by 12%
If they have a fever 1/33 risk of UTI
More likely that it is d/t bronchiolitis alone or AOM
Therapies that help Suctioning
Oxygen
Therapies that dont really help Albuterol
Racemic epi
Hypertonic saline
Corticosteroids
CPT
Antibiotics (duh)
Infants with apnea or severe distress may benefit from HFNC
Discharge Criteria RR generally 90% when awake
Adequate oral intake
Mild to moderate increased work of breathing
Reliable caretaker
Able to secure follow up
Resources AAP Clinical practice guideline
PEMBlog Bronchiolitis 8-part series
Fussy Baby
Your goals
Perform a thorough
H&P
Try to get the baby to stop crying
Head Neuro exam mental status (must know development!)
Full fontanelle space-occupying lesion or infection
Hematoma or Ecchymosis Trauma
head circumference (hydrocephalus)
Eyes Corneal abrasion
Eversion of eyelid for retained FB
Red eye and excessive tearing? Conjunctivitis, congenital glaucoma
Ears AOM
Retained FB
Mouth Stomatitis
Thrush
Dry mucous membranes
Lacerated lingual frenulum (?NAT)
adapted from PedEMMorsels - Sean Fox
Chest Rib fractures
SVT
Congenital heart disease
Abdomen UTI
Mass
Hepatomegaly
Intussusception
Appendicitis
Volvulus (bilious emesis)
Bowel Perforation
Hirschsprung Disease
chronic constipation and no meconium
in first 24 hours of life
GU Testicular/Ovarian torsion
Incarcerated hernia
Anal fissure
adapted from PedEMMorsels - Sean Fox
Extremities Hair tourniquet
Fractures
Sickle cell disease (dactylitis)
Septic joint
Post-vaccination (ex, DTaP especially)
Skin Cellulitis
Eczema
Petechiae, purpura, etc.
Toxidromes
adapted from PedEMMorsels - Sean Fox
10-26% of infants
Excessive crying for:
>3 hrs per day
>3 days per week
>3 weeks in duration
Can begin as early as 2nd week of life
Peaks around 6th week of life
Should resolve by 16th week of life
Diagnosis of exclusion!
Colic
Freedman, 2009 Pediatrics
Retrospective review of 237 afebrile
Bottom line If you and/or caregiver can calm the baby in the ED
and H&P is normal the baby is probably fine
If you do any tests, consider U/A and culture
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