pedi̇atri̇k vakalar(fazlası için )
TRANSCRIPT
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Pediyatrik Vakalar
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My stomach hurts
5 year old with vomiting and diarrhea– Arrives because of persistent fever– In general pain actually improved a couple of days ago– Looks very good. Watching TV (the advantage of
having a new ED). In no distress– Abdominal diffusely and nonfocally tender– Ultrasound done to exclude appendicitis because
pediatrician wanted one.– WBC normal
Ultrasound negative– Patient discharged with diagnosis of gastroenteritis
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Pediatric Appendicitis
• Lifetime risk 7%• Misdiagnosis is common
in young children– 100% around age 2– 70% ages 3-5– 40% ages 6-10
• Post-op complication from perforation increase from 8% to 39%
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Why is appendicitis missed
Most common misdiagnosis is
GASTROENTERITIS
Up to 33% of kids under age 3 have “diarrhea”
• 40% of missed appy is called gastroenteritis
• Pay CLOSE attention to exam. Gastro tenderness is diffuse, not localized.
• BEWARE: Kids under 5 are less likely to wall off their appendix and more likely to present with diffuse peritonitis
• CAREFUL physicians should not miss these
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Diagnosis
• Clinical judgment• Labs• Plain Xray• Ultrasound• CT scan
Even in the best of hands the rate of normal appendix on operation in “classic” cases is over 10%. It is higher in more equivocal cases
Up to 20% in pregnancy
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Diagnosis
• Clinical judgment• Labs• Plain Xray• Ultrasound• CT scan
The peripheral WBC is of extremely limited use– Children with VERY
common viral gastroenteritis or bacterial gastro often have high WBC counts
– Children with early appendicitis are OFTEN normal
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Diagnosis
• Clinical judgment• Labs• Plain X-ray• Ultrasound• CT scan
• Plain abdominal Xrays are useless– Obtained because often
other diagnostic tests are unavailable
– This does not make them any better
• Not sensitive or specific
• Do not discriminate• Fecalith is unreliable
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Diagnosis
Ultrasound
• Limited radiation• Relatively sensitive
– VERY dependent on the skills of radiologist
– Up to 80% helpful with good reader
• Does NOT exclude appendicitis
CT Scan
• More radiation• Expensive• Often unavailable• Extremely sensitive
– Less operator dependent
– Up to 95% sensitive• Excludes appendicitis if
normal appendix seen– Avoids operation
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What about our girlCame back 3 days later with perforated
appendicitis
• She was likely perforated on initial evaluation
• She felt better when appendix ruptured a couple days earlier
• Illustrates several pitfalls
• Often misdiagnosed as gastroenteritis
• Often has diarrhea• Often has normal WBC• Often has nonfocal exam• Ultrasound limited in
EXCLUDING appendicitis
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Pediatric hip pain• Septic arthritis• Toxic synovitis• Legg-Calve-Perthes• Aseptic necrosis• SCFE (Slipped
Subcapital Femoral Epiphysis)
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Septic hip vs toxic synovitisThis is the REAL question
Septic Arthritis
• Average age 3-5 years• Time to presentation
– 4+ days• May be afebrile
– But most have low grade temperature
• May not look clinically ill if early
Toxic Synovitis
• Average age 3-4 years• Time to presentation
– 5+ days• May be very febrile
– But most do not have a temperature
• May be extremely uncomfortable and refuse any range of motion
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Septic hip vs toxic synovitisGoal to identify EARLY before extensive
damage
Temperature and ESR are helpful in excluding septic hip– Most kids (66%) with septic
arthritis with temperature over 37.5 °C
– Most kids (80%) with septic arthritis with ESR over 20
– Combination picks up over 90% of sepsis
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Septic hip vs toxic synovitis
Problem with using temp and ESR– Up to 50% of kids with
toxic synovitis have temperature OR a high ESR
Step two: Imaging– Plain films– Ultrasound
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Septic hip vs toxic synovitisLooking for fluid
Plain films• Insensitive & will only
show advanced cases with a lot of fluid
Ultrasound• Sensitive and will find
show small amounts of fluid seen in synovitis
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Septic hip vs toxic synovitisTapping the hip
Up to now the evaluation has been working towards EXCLUDING cases of toxic synovitis.
If there is a temperature or high ESR and fluid in the hip, you must do a diagnostic arthrocentesis– In the US this is an orthopedic procedure– There is some time urgency here– Diagnosis of septic hip should be washing out in the
operating room– Antibiotics for staph and strep should be considered
if ANY delays in operation or arthrocentesis are possible
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Toxic synovitisAfter discharge
Toxic synovitis is a viral reactive arthritis and is managed with ibuprofen or aspirin
BUT…all cases require MANDATORY 12-24 hour follow to make SURE you are not missing septic arthritis
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Other causes hip painLegg-Calve-Perthes
Idiopathic avascular necrosis of the femoral head– Other cases related to
chronic steroid use or sickle cell disease
School age children
Early cases with normal Xray– Need MRI or bone scan
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Slipped Capital Femoral Epiphysis
Slipped growth plate at end of femoral head
Adolescents
Generally (not always) obese
Early cases with normal Xray– Need MRI or bone scan
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Slipped Capital Femoral Epiphysis
Slipped growth plate at end of femoral head
Adolescents
Generally (not always) obese
Early cases with nothing on Xray– Need MRI or bone scan
Klein’s line ?
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Slipped Capital Femoral Epiphysis
Price of a missed case– Complete slip– Disrupted growth plate– Lost growth potential– Avascular necrosis of
femoral hip– Chronic arthritis and DJD or
hip
Early pickups allow placement of a pin and potential recovery
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The toxic neonateThat kid looks BAD!
Some illnesses present in the first two weeks of life with an abrupt deterioration
A good clinician will understand that this is NOT always sepsis
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The toxic neonateThat kid looks BAD!
Important possibilities
• Sepsis• Congenital Cardiac
– Ductal dependent
• Inborn error of metabolism
• Congential adrenal hyperplasia– Boys
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The toxic neonateCritical issues
• Stabilization– Rapid IV access– Adequate fluid
resuscitation– ETT and pressors?
• Ampicillin/Gentamicin– Listeria– E coli– Group B strep
Important possibilities
• Sepsis• Congenital Cardiac
– Ductal dependent
• Inborn error of metabolism
• Congential adrenal hyperplasia– Boys
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The toxic neonateCritical issues
• Recognition• Stabilization
– Rapid IV access– Adequate fluid resuscitation
• Prostaglandin E1– Antibiotics?– Pressors
• Intubation? Yes but BEWARE
Important possibilities
• Sepsis
• Congenital Cardiac– Ductal dependent
• Inborn error of metabolism• Congential adrenal
hyperplasia– Boys
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The toxic neonateCritical issues
• Consideration - get a– Bicarb– Ammonia– Glucose
• Stabilization– Rapid IV access– Adequate fluid– Glucose– Sodium Bicarb
• Possible intubation
Important possibilities
• Sepsis• Congenital Cardiac
– Ductal dependent• Inborn error of metabolism• Congential adrenal
hyperplasia– Boys
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The toxic neonateCritical issues
• Recognition– Low sodium– High Potassium
• Stabilization– Rapid IV access– Adequate fluids
• Hydrocortisone– Pressor-resistant shock
Important possibilities
• Sepsis• Congenital Cardiac
– Ductal dependent• Inborn error of metabolism• Congenital adrenal
hyperplasia– Boys
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Neonatal Vomiting
• Gastroesophageal Reflux
• Pyloric Stenosis• Volvulus
Typical features– Gradual onset– Usually with each feed– Quantity can be large– Consists only of milk
Do we really care?– Only if this is your
misdiagnosis
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Neonatal Vomiting
• Gastroesophogeal Reflux
• Pyloric Stenosis• Volvulus
• Onset in first 2-6 weeks– Boys !
• Early -- looks like reflux• Can have abrupt onset
over 1-2 days• Late -- Vomits everything
each feed
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Neonatal Vomiting
• Gastroesophogeal Reflux
• Pyloric Stenosis• Volvulus
• Diagnosis– Ultrasound– The proverbial Olive– Classically projectile– Typical HUNGRY !
• Stabilization– Adequate fluids– Electrolyte correction
• Over 1-2 DAYS
• Then surgery
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Neonatal Vomiting
• Gastroesophogeal Reflux
• Pyloric Stenosis• Volvulus
– The AAA of pediatrics– You miss this, they die– A true emergency
• Onset usually acute• Onset at birth -- or anytime
in first couple of weeks• Bilious emesis
– Yellow or green
• Exam– Toxic appearing infant– Shocky– Distended, tight abdomen
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Neonatal Vomiting
• Gastroesophogeal Reflux
• Pyloric Stenosis• Volvulus
– The AAA of pediatrics– You miss this, they die– A true emergency
• TIME IS BOWEL• Diagnosis
– Immediate upper GI
• TIME IS BOWEL• Stabilitization
– Rapid IV access– Aggressive fluids
• TIME IS BOWEL• IMMEDIATE surgery
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One more time A missed volvulus is a
death sentence
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Pearl of Neonatal Wisdom
• 6 week old infant• Fussy and not feeding quite as
well– Decent urinary output
• Well appearing on exam– Nonfocal, normal exam– Well hydrated– Normal vital signs
• Discharged
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Pearl of Neonatal Wisdom
A Bad Physician
Does not “hear” or listen to the parents
Paternalistic
Believes the parents are young, ignorant, uneducated
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Pearl of Wisdom
A Good Physician
Listens carefullySOMETHING is
different or they wouldn’t be there
Be very careful ASSUMING nothing is wrong with an infant
Parents know BEST !
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Pearl of Neonatal Wisdom
Just before discharge, the next shift physician asked -- what about the feeding?
Listening carefully, child really was changing.
Subtle decreased sodium and increased potassium suggested CAH so admitted.
Two days later, ruptured kidney unrecognized urethral obstruction
Take home message:
Always LISTEN to the parents
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Pediatric FeverWell appearing 0-36 months of age
The game we play -- Where is it hiding
– Blood– Urine– CNS– Chest
Risk is affected by– Age– Temperature– Appearance– Sex– Circumcision status– Immunization Status
•This discussion is more germane to an urban population not at risk for zoonotic, typhoid, malaria, etc.
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AppearanceWhat should you do?
Ill appearingNormal exam
• CBC/Blood Culture• UA/Urine Culture• Lumbar puncture?• Chest Radiograph?
Well appearing
Normal exam
It depends
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The neonate0-30 days
Incidence of Serious Bacterial illness is high– Limited ability to localize or resist bacterial infection– Limited ability to express this illness
• Cry more, eat less, less active• Fever tends to be LOW (38.0°C)• Delay in recognition
– Rapid deterioration possible– This is true EVEN in the well appearing febrile infant– Don’t be cavalier with neonates
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The neonate 0-30 days
Judgment is limited: evaluation is empiric– Bacteremia: CBC/Blood culture
• Prognostic value of CBC for bacteremia very limited
– Urinary Tract Infection: Urinalysis and culture• 20% of bacterial UTI with normal urinalysis
– Lumbar puncture: Meningitis• Social repertoire of young infants is so limited that clinical
judgment useless• All children need a spinal tap
– CXR: Pneumonia• Good thought but yield low without symptoms
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The neonate0-30 days
Judgment is limited: evaluation is empiric– All children get antibiotics after cultures are drawn– Cover for typical organisms: from mother’s vaginal
tract• Group B streptococcus• E coli• Listeria (extremely uncommon in US)
– Empiric treatment with• Ampicillin• Gentamicin
– Admit (if possible)
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The young infant0-30 days
While judgment is extremely limited:
– Children in first two weeks of life may be at greatest risk
– Children with changes in behavior such as lethargy and poor feeding are very worrisome
– Children with abnormal peripheral WBC (over 15,000 or under 5,000)
– Positive urinalysis– Abnormal CXR
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The young infant30-90 days
Judgment remains limited– This is a transitional age between newborns and
older infants– They remain at risk for vaginal organisms from the
mother but also to typical encapsulated organisms of older children
– Social repertoire remains limited and difficult to assess
– These children can also deteriorate quickly
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The young infant30-90 days
Judgment remains limited: evaluation is empiric– Bacteremia: CBC/Blood culture– Urinary Tract Infection: Urinalysis and culture
• 20% of bacterial UTI with normal urinalysis
– Lumbar puncture: Meningitis• Social repertoire of young infants remains limited• A low threshold for empiric lumbar puncture
– Many people empirically LP up to 6-8 weeks
• Missing meningitis is the most devastating infection possible– CXR: Pneumonia
• Again, yield low in absence of respiratory symptoms
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The young infant30-90 days
Management
Children at higher risk:
– Children with changes in behavior such as lethargy and poor feeding are very worrisome
– Children with abnormal peripheral WBC (over 15,000 or under 5,000)
– Positive urinalysis (5-10 WBC)– Abnormal CXR
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The young infant30-90 days
Children at higher risk should received empiric therapy until cultures back– The majority of pathogenic cultures will be positive within 24
hours
• Typical organisms– Group B strep, E coli (neonatal organisms)– Pneumococcus, Haemophilus type B, meningococcus
• Typical therapy– Third generation cephalosporin (ceftriaxone)– Lumbar puncture in the younger ages (6-8weeks)
• Admission– If ill-appearing or if unreliable followup
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Older Infants3 months to 36 months
Risk is affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
Children at highest risk of occult bacteremia are 12-24 months of age– 3-6 months are at less
risk– But they deteriorate
faster
• This risk is due to a development immunodeficiency
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Older infants3 months to 36 months
Risk is affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
Risk and Temperature thresholds vary by age– 38°C represents real risk under
3 months– Very young children rarely
have high temperatures– 39°C represents real risk over
3 months of age– Risk increases 2-3 fold as
temperatures increase to 39.5°C and 40°C
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Older infants3 months to 36 months
Risk is affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
Boys are WEAK !
The main difference is found in risk of UTI
Highest risk of UTI is in uncircumcised boys under 6 months of age
Lowest risk is in circumcised boys over 12 months of age
Girls are intermediate
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Older infants3 months to 36 months
Risk is affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
The risk of occult bacteremia in well appearing infants in the U.S. in a fully immunized population (against pneumococcus and Haemophilus) is probably less than
0.5%
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3 months to 36 months
Risk are affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
The risk of occult bacteremia in well appearing infants in the U.S. BEFORE universal immunization was on the order of
2-3%And this risk is modified by higher
temperatures, ill appearance, etc.
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The real question to is: what is the risk of progression of occult bacteremia to
to meningitis?
A recent meta-analysis showed that– 25/257 (9.7%) of untreated patients with
pneumococcal bacteremia had persistent bacteremia or focal invasive infections at followup
– The same study showed a 2.7% risk of progression to meningitis
Pediatrics 1997;99:438Pediatrics 2000;106:505
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Older infants3 months to 36 months
Risk are affected by– Age– Temperature– Sex– Circumcision status– Immunization Status
The risk of UTI in this age group is unaffected by immunization status and is on the order of
5%
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Loose recommendations for 3-24 (or 36) months
Well-appearing fever without a source
• UA/ Urine culture– All girls– Circumcised boys less
than 6-12 months– Uncircumcised boys less
than 12-24 months• Lumbar Puncture
– If ill appearing
• CBC/Blood culture– Consider strongly in
the unimmunized– Address WBC count
over 15-20,000 or less than 5,000 with empiric therapy
– May defer in the fully immunized
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Note on treatment
Never administer parenteral (or oral) antibiotics without a reason– “Ear” infections are overdiagnosed. Do NOT use as
an excuse to administer antibiotics– Always obtain cultures (blood or urine) prior to
administering antibiotics (if possible)– NEVER administer antibiotics to a febrile infant
(without an identified source of fever) less than 6-8 weeks without first performing an LP
• Partially treated, unrecognized meningitis is a disaster
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“Early” Pediatric meningitis
Classic signs of meningitis– Kernig’s sign– Brudzinski’s sign– Stiff neck– Irritability– Lethargy
These may NOT be present in early meningitis
Of course one can simply wait until the diagnosis becomes obvious…
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Pediatric meningitisSymptoms can be subtle
Neonates– Well appearing with low grade
fever– Poor feeding– “Not acting right”
Infants 1-3 months– Fever and “a little fussy– Not feeding quite as well– Vomiting without diarrhea and
looking more ill than typical gastroenteritis
Older children– Consider meningitis in
ALL children with a fever who complain of a bad headache
– May be present in children with a bad headache, neck discomfort, or vomiting and NO fever
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Febrile Seizures
• Frequency 1:20-50 children• SIMPLE febrile seizures need NO special evaluation or
treatment– Meaning no empiric spinal tap– Except for evaluating fever
• “Simple” means:– Nonfocal - generalized– Short - less than 15 minutes– Single - only 1 in 24 hours– Return to NORMAL mental status
• Beware the child already on antibiotics for partially treated meningitis
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Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings
• Fever for 5 days– Irritability
• Skin changes– Rash– Peeling digits/perineum
• Mucosal changes– Conjunctivitis– Red lips, tongue
• Lymphadenopathy• Greater than 1.5 cm nodes
• Edema of hands and feet
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Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings
• Fever for more than 5 days• Skin changes
– Rash– Peeling digits/perineum
• Mucosal changes– Conjunctivitis– Red lips, tongue
• Lymphadenopathy• Greater than 1.5 cm nodes
• Edema of hands and feet
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Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings
• Fever for more than 5 days• Skin changes
– Rash– Peeling digits/perineum
• Mucosal changes– Conjunctivitis– Red lips, tongue
• Lymphadenopathy• Greater than 1.5 cm nodes
• Edema of hands and feet
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Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings
• Fever for more than 5 days• Skin changes
– Rash– Peeling digits/perineum
• Mucosal changes– Conjunctivitis– Red lips, tongue
• Lymphadenopathy• Greater than 1.5 cm nodes
• Edema of hands and feet
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Kawasaki DiseaseWhy this diagnosis is important
Nobody every died of Kawasaki disease. Or did they?– Kawasaki’s is a vasculitis and
myocarditis is present– Untreated, 13-40% develop
coronary aneurysms– These giant aneurysms (8mm)
thrombose, resulting in acute MI and death
– This risk is greatest in the first year after the illness
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Kawasaki DiseaseWhy this diagnosis is important
KD and prevention of coronary aneurysms are very responsive to treatment– But the correct diagnosis
must be made– Treatment consists of
• Aspirin• IVIG (Immunoglobulin)• Possibly corticosteroids
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Vomiting and lethargyWhat do these 2 cases have in common?
A 9 month old presents with 6 episodes of emesis for one day– No diarrhea– No fever– Last one bilious– No abdominal pain
On exam, awake in no distress– Glassy-eyed and lethargic– Very soft abdomen
You perform the LP but the results are negative
A 5 year old presents with intermittent, severe abdominal pain – No fever– Emesis once– No diarrhea– History of a vasculitic rash
for one week
On exam, comfortable and well appearing– Abdominal exam benign– Petechiae, purpura on
legs and buttocks
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Intussusception
Classic, text book presentation– Colicky severe abdominal
pain– Acting normal between
episodes– Vomiting– Current jelly stools
• In reality, this presentation may be the exception
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IntussusceptionA tale of two presentations
Classic, text book presentation– Colicky severe
abdominal pain– Acting normal between
episodes– Vomiting– Current jelly stools
• LATE finding!• Represents bowel
ischemia
Altered mental status– Lethargic, appears
almost sedated with drugs
– Meningitis often the primary misdiagnosis
– Vomiting invariable– Abdomen general
soft but may feel the mass
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Diagnosis & Treatment
• Barium or air contrast enema diagnoses AND reduces the intussusceptum
• Refractory cases need surgery
• Do not do enema until surgeon called– Risk of perforation by less
experienced radiologist– Historically (1890s) up to
50% of children perforated and died
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Diagnosis & Treatment
If a barium enema seems invasive, consider CT or ultrasound for diagnosis and then enema if intussusception present
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Diagnosis & TreatmentIn context of Henoch-Schonlein Purpura
With HSP the intussusception – is NOT the typical ilio-colic
intussusception– It is ILIO-ILIAL– Diagnosis will NOT be made
with barium enema– Diagnosis is made on CT
scan– Usual treatment is medical
observation
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Intussusception and HSPHenoch-Schonlein Pupura
IgA mediated vasculitis similar to TTP in adults
Diagnosis is clinical– Typical purpuric rash in
dependent areas• Lower ext in children• Buttocks in infants
– Arthralgias– Renal disease
• May result in renal failure
– Intussusception in some
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Vomiting and tachypneaWhat do these two cases have in common?
8 year old with two days of vomiting– No fever– No diarrhea– Now bilious– Generalized abdominal
pain– Recent history of weight
loss
On exam– Thin and ill appearing– Nonfocal abd tenderness– Candidal perineal rash
2 year old with two days of fast breathing– No cough– No fever– No feeding well– Spits up feeds
On exam– Ill appearing– Dehydrated– Tachypneic– Clear lungs– Tachycardic
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Diabetic ketoacidosisDiagnosed on a routine chemistry
• Diagnosis DKA easy with history of diabetes• Classic presentation polydipsia, polyuria,
weight loss -- but only if you ask• Atypical features
– Altered mental status– Respiratory “distress”– Thrush / Perineal ‘diaper’ rash– Abdominal pain and vomiting
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DKAThree problems in order of importance
• Dehydration• Electrolyte
disturbances• Insulin deficiency
– While this is the underlying cause, it is NOT the immediate problem
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DKADehydration
They are dry, why not give them lots of fluids?– Give only a SINGLE bolus of 10-
20cc/kg UNLESS hemodynamically unstable
– Theoretical risk of inducing cerebral edema– Correct dehydration over 12-24 hours– NEVER bolus with anything except
NORMAL SALINE
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DKAElectrolytes
Potassium is the critical problem– They are profoundly depleted – Hypokalemia from both urinary loss and acid
base shifts in the serum– Never give potassium until you prove there is
no renal failure (urinate once)– If the starting serum potassium is low --
BEWARE -- it will drop quickly with fluids and insulin
• Be prepared to aggressively replace (and monitor -- every 2 hours) potassium once therapy starts
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DKASerum glucose and insulin
No one NEEDS insulin in first hours– Address fluid deficit and potassium– Glucose will drop significantly with simple fluid
administration
Principles of insulin administration– Do NOT bolus insulin
• It does not act faster and simply results in overshoot hypoglycemia
– Start with 0.1 unit/kg/hour– When serum glucose below 250mg/dl do NOT
reduce insulin --- increase dextrose in IVFs
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DKACerebral edema
This is what kills kids with DKA
• Occurs only in kids• Onset can be SUDDEN
– Blown pupil– Apnea– Profound mental status
change
• Be prepared to administer Mannitol IMMEDIATELY– Intubate if necessary
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Stiff neck and StridorWhat do these two cases have in common?
23 month old leaving for Germany tomorrow with a stiff neck and fever– Fever 38.9°C– Holds neck stiffly– Decreased oral intake– Not particularly sick
appearing
19 month old transferred for asthma attack– No wheezing but has
stridor– Low grade fever– Poor response to
racemic epinephrine– Progressive respiratory
distress – Episodic apnea– Diagnosis made
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Retropharyngeal abscess
• Occurs in younger children– Adenoids involute with age
• Multiple potential spaces in the neck
• Clinical presentation resembles meningitis with stiff neck
• Clues are there– Without altered mental status– Subtle swelling of face– Dysphagia/drooling
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Retropharyngeal abscessDiagnosis and treatment
• Textbook diagnosis is a lateral neck film– Not particularly sensitive and
may miss early cases– Not particularly specific if
poor technique
• Money is on the CT scan for diagnosis– Delineates extent of disease– Helps decide whether
therapy is medical or surgical
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Look-a-likes
A 9 month old presents with 6 episodes of emesis for one day– No diarrhea– No fever– Last one bilious– No abdominal pain
On exam, awake in no distress– Glassy-eyed and
lethargic– Very soft abdomen
You perform the LP but the results are negative
A 7 month old presents with 4 episodes of emesis for one day– No diarrhea– No fever– No abdominal pain– Lethargic all day
On exam– Lethargic– Ill-appearing– Non-focal exam
You perform the LP but the results are bloody
6 month old with one day lethargy
– Tactile fever– Sleeping– Little oral intake– Decreased urination– Vomited twice
On exam– Tachypneic– Lethargic– Dry– Low grade
temperature
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Look-a-likes
Intussusception ?Meningitis
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Child abuseShaken baby syndrome
Presents as altered mental status– In younger infants as
lethargy and poor feeding
– Vague story– Nonfocal exam
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Same fractureTwo stories
My 1 year old was playing with a toy my 4 year old wanted
The older one tackled the younger one
His leg got twisted under his leg
He screamed and won’t walk on his leg and we rush him down here as fast as we could
My 1 year old was fine yesterday
Now he won’t walk
He fell off the couch yesterday. That might be it.
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Child abuse
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Child abuse
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Child abuse
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Conscious sedation in kids
Agents
– Midazolam– Midazolam/Opioid– Pentobarbital– Propofol– Etomidate– Ketamine
Problems
– Paradoxical reaction– Respiratory – Respiratory/hypotension– Hypotension – Respiratory– Laryngospasms (rare)
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Ketamine
• Useful in all ages– Concern about use in older kids
misplaced
• Inexpensive• Reliable
– Does not provide analgesia per se– DISSOCIATIVE agent and therefore
unaware of pain– Also amnestic to procedure
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Ketamine
• Useful in all ages• Inexpensive• Reliable• Risks are low
– Protects airway– No respiratory depression– No hypotension– Rare cases of laryngospasm
• Adverse effects– Vomiting (up to 20%)– Emergence reaction (uncommon)
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KetamineAdministration practicalities
• Dosing– 2mg/kg IV– 4mg/kg IM
• Side effects NOT dose related
• Duration IS dose related– 0.5 - 1.0 mg/kg for short
procedures– May repeat multiple doses
if procedure prolonged
• Pretreat with ATROPINE
– Reduces secretions and laryngeal irritation
• No need to pretreat with midazolam– Does not prevent
emergence reaction– Can treat afterwards if
needed
• Laryngospasm– Almost all kids can be
bagged through the event