Pediatrics Review Emergency

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

2. Case 1 • 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.

3. 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)

4. 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)

5. 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

6. Case 2 • 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?

7. 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

8. 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

9. Case 3 • 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?

10. 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

11. Steeple Sign

12. Case 4 • 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?

14. Retropharyngeal Abscess • Complication of bacterial pharyngitis • Grp A strep, oral anaerobes and S. aureus • Treatment • IV Clindamycin and Cefuroxime • Consult ENT

15. Retropharyngeal Soft Tissues* * Retrotracheal Soft Tissues * *

16. Case 5 • 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.

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

19. Case 6 • 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.

21. What investigation would you do next?

22. Expiratory CXR

23. Inspiratory Expiratory

24. 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

25. Case 7 • 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.

26. Case 7 • What is the degree of dehydration of this child? • Management?

27. Dehydration

28. 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

29. Fluids and Electrolytes • Maintenance (D5NS) • 4ml/kg/hr for first 10 kg • 2ml/kg/hr for second 10 kg • 1 ml/kg/hr for rest of weight in kg • Deficit (NS) • If severely dehydrated give NS bolus • 20 ml/kg over 15-60 min • Replace over 24 hours • First half over 8hrs, second half over 16 hrs • Ongoing Losses • Diarrhea, Vomiting, Insensible losses with fever

30. Case 8 • 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus. • HR130 RR24 T37 • Tender abdomen with fullness in RUQ • Diagnosis? • Investigations?

31. Intussusception • 1-3 years • Boys 2:1 • Classic Triad (10-30%) • Vomiting • Crampy abdominal pain • “Red currant jelly” stools • Lethargy is common

32. Intussusception • 75% are ileo-colic • Lead point • Peyer's Patches • preceding viral infection • Meckel diverticulum • Polyps • Hematoma (Henoch Schonlein Purpura) • Lymphoma

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

34. Target Sign

35. Crescent Sign

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

38. Case 9 • 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. • Looks well. Mild dehydration. • Abdomen soft, non tender, BS present. • DDx?

39. Case 9 • 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

40. 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

41. Pyloric Stenosis • Nonbilious vomiting • Emesis increases in frequency and eventually becomes projectile • Classic findings: • Hypertrophied pylorus palpable “olive” in epigastric area • Peristaltic waves progressing from LUQ to the epigastrium

42. Pyloric Stenosis • Laboratory abnormalities: • Hypokalemia • Hypochloremia • Metabolic alkalosis • Ultrasound • Thickened pylorus

43. Case 10 • 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability. • Looks unwell, irritable cry. • Abdomen distended. • Weak pulses, cap refill>5 sec. • DDx? Management?

44. Volvulus • Twisting of a loop of bowel around its mesenteric attachment. • 80% present by the first month • 40% present in the first week • Rarely can be seen in older children.

45. Volvulus • Sudden onset of bilious vomiting in a neonate. • Acute abdomen with shock • May have more gradual course with episodic vomiting

46. Volvulus • Evidence of small bowel obstruction • Dilated loops • Air fluid levels • Paucity of distal air

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

48. Case 11 • 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?

49. 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)

50. Case 12 • 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?