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 ?