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Pediatrics Review Emergency

Pediatrics Review Emergency. Gina Neto, MD FRCPC Division of Emergency Medicine. Objectives. Review pediatric resuscitation guidelines Recognize pediatric conditions that present to the emergency Describe management of pediatric emergency cases. Pediatric Resuscitation. Pediatric Airway

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Pediatrics Review Emergency

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  1. Pediatrics ReviewEmergency Gina Neto, MD FRCPC Division of Emergency Medicine

  2. Objectives • Review pediatric resuscitation guidelines • Recognize pediatric conditions that present to the emergency • Describe management of pediatric emergency cases

  3. Pediatric Resuscitation • Pediatric Airway • Larger head • Bigger tongue • Narrowest part is subglottic area • Epiglottis is more floppy • Larynx is more anterior and cephalad • Chest wall more compliant

  4. Pediatric Resuscitation • Airway Management • Position, suctioning • Nasal/Oral airway • Endotracheal intubation • Cuffed tube size: age/4 + 3 (+/- 0.5mm) • Medications • Atropine (consider if< 6 yrs) • Paralytic - Succinylcholine, Rocuronium • Ketamine, Midazolam/Fentanyl, Propofol

  5. Pediatric Resuscitation • Bradycardia • Non-Cardiac causes (6 H’s, 5 T’s) • Hypoxia (Most Common) • Hypovolemia, Hypo/Hyperkalemia, Hypoglycemia, Hypothermia • Toxins, Tamponade, Thrombosis, Trauma (ICP) • Cardiac causes - AV block, sick sinus • Epinephrine 0.01 mg/kg (repeat every 5 min) • Consider Atropine 0.02 mg/kg

  6. Pediatric Resuscitation • Tachycardia • Narrow • Wide • Stable or Unstable • Know what is normal for age

  7. Pediatric Resuscitation • Sinus Tachycardia • Rateusually < 220/min • Variable rate • Look for causes • Pain, fever, dehydration, resp distress, poor perfusion • SVT • Rate usually > 220/min infants, > 160 teens • Rate is fixed

  8. Pediatric Resuscitation • SVT • Vagal maneuvers • Ice to face, Valsalva • Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg • If Unstable: • Synchronized Cardioversion 0.5-1 J/kg • If not effective increase to 2 J/kg

  9. Pediatric Resuscitation • Tachycardia with Wide QRS • Stable • Consider Adenosine • Amiodarone 5 mg/kg • Consult Cardiology • Unstable with pulse • Cardioversion 0.5 - 1 J/kg 1st dose, then 2 J/kg

  10. Pediatric Resuscitation • Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation • CPR • Start at 16:2 compressions/breath • Defibrillation 2 J/kg • Then 4 J/kg • Increase subsequent shocks to max of 10 J/kg • Epinephrine 0.01 mg/kg every 3-5 min • Amiodarone 5 mg/kg

  11. Case • 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days. • T 36.5, RR 40, HR 130, O2 Sat 89%. • Suprasternal and scalene retractions, decreased air entry, expiratory wheeze. • Describe your management.

  12. Asthma • Mild Asthma: • Salbutamol MDI x 3 doses prn • Moderate Asthma: • Salbutamol MDI x 3 doses then prn • Steroids • Dexamethasone 0.15-0.3 mg/kg PO (max 12) • Prednisone 1-2 mg/kg PO (max 60 mg)

  13. Asthma • Severe Asthma: • Salbutamol via nebulization with • Ipratropium 250 mcg x 3 doses q20 min • Steroids • Dexamethasone 0.15-0.3 mg/kg PO (max 12) • Prednisone 1-2 mg/kg PO (max 60 mg)

  14. Asthma • If not improving within 60 min or signs of impending respiratory failure: • Magnesium Sulfate50 mg/kg/dose IV (max 2g) • Give over 20-30 min • May cause severe hypotension • IV NS 20 bolus ml/kg • Methylprednisolone 1-2 mg/kg IV

  15. Case • 2 mo male with 2 day hx rhinorrhea, poor feeding and cough.Few hrs resp distress. • RR 60 HR 120 T 37C. Pink, well hydrated. • Chest - inspiratory crackles, exp wheezes. • Diagnosis? • Treatment?

  16. Bronchiolitis • RSV - Respiratory Syncytial Virus most common • Parainfluenza, Influenza A, Adenovirus, Human metapneumovirus • Peak in winter • More serious illness • < 2 months • Hx of prematurity < 35 weeks • Congenital heart disease

  17. Bronchiolitis • Treatment • Nebulized Epinephrine – short term relief • ? Dexamethasone • 1 mg/kg on Day 1 • 0.6 mg/kg for another 5 days • ? Nebulized Hypertonic Saline

  18. Case • 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough. • HR 100 RR 28 T 37 • Mild distress. Stridor at rest. • Diagnosis? • Treatment?

  19. Croup • Parainfluenza most common • Hoarse voice, barky cough, stridor • Peak fall and spring • Infants and toddlers • Treatment • Dexamethasone (0.6 mg/kg) • Nebulized Epinephrine if in respiratory distress • Consider Nebulized Budesonide

  20. Steeple Sign

  21. Case • 18 month female with fever x 2 days. Difficulty swallowing. • HR130 RR28 T39C • Exam normal except won’t move neck fully. • What diagnostic test should be performed?

  22. Retropharyngeal Abscess • < 6yrs • Complication of bacterial pharyngitis • Infection of posterior pharyngeal nodes – regress by school age • Grp A strep, oral anaerobes and S. aureus • Treatment • IV Clindamycin and Cefuroxime • Consult ENT

  23. Retropharyngeal Soft Tissues* * Retrotracheal Soft Tissues * *

  24. Case • 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling. • Not immunized. • HR 140 RR 20 T 39.5 • Very quiet, doesn't move. • Slight noise on inspiration. • Chest clear, exam normal.

  25. Epiglottitis • Rarely seen • Strep pneumoniae • H. influenzae uncommon due to vaccine • Do not disturb patient • Consult Anesthesia, intubate • IV Ceftriaxone and Clindamycin

  26. Case • 17 mo male with sudden onset noisy and abnormal breathing • Was playing on floor before developing difficulty breathing • VS T36.8, P200 (crying), R28 (crying), O2 sat 99% • Mild wheezing with mild inspiratory stridor

  27. What investigation would you do next?

  28. Expiratory CXR

  29. Inspiratory Expiratory

  30. 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

  31. Case • 1 month old girl fever today. Cough and runny nose. Slightly 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?

  32. Fever < 1 month • Etiology is organisms from birth canal • Group B Streptococcus , Escherichia coli (Gram neg), Listeria monocytogenes • Highest rate of bacterial infection of any age group • <2 weeks - 25% • 0-4 weeks - 13% • Septic Work Up • Admission, IV antibiotics

  33. Fever 1-3 months • May still see birth canal organisms, but also: • Streptococcus pneumoniae , Neisseria meningitidis, Haemophilus influenzae type b (uncommon) • Overall rate of bacterial infection is ~8% • Bacteremia 2% • Meningitis 0.8% • UTI 5% • “Low Risk Infant” rate of bacterial infection is 1% • Bacteremia 0.5%

  34. Low Risk Criteria “Rochester” for Febrile Infants • Well appearing infants 1-3 mos are low risk for serious bacterial infection if: • 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)

  35. Fever 3-36 months • Viral infections cause of fever in >90% • 6% of children seen in the ED have a specific, recognizable viral syndrome • e.g. croup, bronchiolitis, roseola, varicella, coxsackie • UTI in ~5% • Bacteremia very low rates now (< 0.2%) • 5% in 1980’s, HIB vaccine 1987 • 2% in 1990’s, Pneumococcal vaccine 2000

  36. Case • 2 year old boy with 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?

  37. 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%

  38. Febrile Seizure • Risk of epilepsy is 1% • ~ same as general population • Higher risk (2.4%) if: • Multiple febrile seizures • < 12 mos at the time of first febrile seizure • Family history of epilepsy

  39. Seizure Management • ABC's • IV access • Seizure treatment • 1st Line - Benzodiazepines • Lorazepam or Diazepam (Rectal or IV) • Midazolam (Intranasal or Buccal) • 2nd Line • Phenytoin, Fosphenytoin • Phenobarbitol

  40. Seizure Management • Seizure treatment • 3rd Line • Midazolam infusion • Thiopental • Propofol • Paraldehyde • Observe in the ED until child returns to normal • After simple febrile seizure no neurological investigations indicated (eg CT, EEG)

  41. Case • 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea 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.

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

  43. Gastroenteritis • ORT with rehydration solution (eg Pedialyte) • 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 • Rule out UTI

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