Pediatrics Review

1. Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine Children’s Hospital of Eastern Ontario

2. 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?

3. Bronchiolitis • RSV - Respiratory Syncytial Virus most common • Parainfluenza, 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

4. 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?

5. 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 NebulizedBudesonide

6. Croup Steeple Sign

7. 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?

8. Case 3 Retropharyngeal Abscess • Complication of bacterial pharyngitis • GrpA hem strep, oral anaerobes and S. aureus • Treatment • IV Clindamycin and Cefuroxime • Consult ENT

9. Retropharyngeal Soft Tissues* * Retrotracheal Soft Tissues * *

10. 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

11. Epiglottitis Rarely seen Strep pneumoniae H. influenzae uncommon due to vaccine Do not disturb patient Consult Anesthesia, intubate IV Cefuroxime Case 4

12. 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 inspiratorystridor

13. Soft Tissues Neck Lateral View

14. CXR (PA) What investigation would you do next?

15. Expiratory CXR

16. Inspiratory Expiratory

17. 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

18. 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

19. Case 6 • What is the degree of dehydration of this child? • Management?

20. Dehydration

21. 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

22. 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

23. 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?

24. 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'sPatches - preceding viral infection • Meckeldiverticulum, polyps, hematoma (HSP), lymphoma

25. Plain AXR May be normal May have signs of bowel obstruction Paucity of air in RLQ No air in Cecum on Lateral Decubitus Intussusception

26. Intussusception • Target Sign

27. Intussusception • Crescent Sign

28. Intussusception

29. Intussusception • Air Contrast Enema • Success rate >80% • Recurrence 10-15%

30. 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?

31. 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

32. 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

33. Classically: Hypertrophied pylorus palpable “olive” in epigastric area Peristaltic waves progressing from LUQ to the epigastrium Laboratory abnormalities: Hypokalemic Hypochloremic Metabolic alkalosis Pyloric Stenosis

34. 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?

35. Twisting of a loop of bowel around its mesenteric attachment. Sudden onset of bilious vomiting in a neonate. Acute abdomen with shock may have a gradual course with episodic vomiting 80% present by the first month 40% present in the first week Rarely can be seen in older children. Volvulus

36. Volvulus • Evidence of small bowel obstruction • dilated loops, air fluid levels, paucity of distal air

37. Volvulus • Upper GI series • “corkscrew” appearance of the duodenum and jejunum

38. 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?

39. 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 healthy • Born at term (> 37 weeks) • No hyperbilirubinemia • No hospitalizations • No chronic or underlying diseases • No evidence of focal bacterial infection • Laboratory parameters: • WBC count 5-15/mm3 • Urinalysis WBC count < 5/hpf • Stool WBC count < 5/hpf (if infant has diarrhea)

40. 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?

41. 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

42. 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

43. 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 soles • Convalescent stage: desquamation of fingertips and toes • Changes of lips and oral cavity • Cervical lymphadenopathy ( >1.5 cm)

44. 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

45. 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

46. Case 13 • 3 yr old girl with rash starting todayRecent URTISwollen ankles and knees. Painful walking.Diagnosis?

47. 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%) Henoch-Schonlein Purpura

48. 1 yr old boy with mouth lesions for two days... • What are the two most likely causes for this condition?

49. Herpes Simplex

50. Coxsackie