EM Pediatrics

Consent for Treating Minors

• Life/limb-threatening emergency
• State-protected right to treatment:
  • Child abuse
  • Pregnancy
  • STD
  • Substance abuse
  • Outpatient mental health
• Emancipated Minor:
  • Married
  • Member of armed forces
  • Self-supporting and living on own

Rapid Assessment

• Rapid assessment of a pediatric patient:
• • Remember the PAT ABCs!
  • 1. Appearance (TICLS)
    • – Tone: Is the infant/child limp, listless, or flaccid?
    • – Interactiveness: Is the infant/child uninterested in playing or interacting with the caregiver or HCP?
    • – Consolability: Is the infant/child’s crying or agitation unrelieved by gentle reassurance?
    • – Look (Gaze): Is there a “nobody home,” glassy-eyed stare?
    • – Speech (Cry): is the cry weak or high-pitched?
    • Is the content confused or garbled?
  • 2. Breathing
    • – Abnormal Lung Sounds
    • – Abnormal Positioning
    • – Retractions
    • – Nose Flaring
  • 3. Circulation
    • – Cyanosis
    • – Mottling
    • – Pallor
    • – Cap Refill

HEENT

Fever

• Workup for a newborn:
  • 1. CBC c Diff
    
  • 2. CXR (if respiratory)
    
  • 3. UA c Cx
  • 4. Blood Cx
    
  • 5. LP

Conjunctivitis

• MCC of conjunctivitis during 2-5 days of life:
  • Gonococcal
• MCC of conjunctivitis during 5-14 days of life:
  • Chlamydial
• Treatment for neonatal conjunctivitis:
  • SYSTEMIC* abx to eradicate carrier state and prevent PNA

Acute otitis media

• Demographic is most at risk:
  • 1. Males
    
  • 2. Children in daycares
    
  • 3. Down Syndrome pts
    
  • 4. Cystic Fibrosis pts
• Causative agents for acute otitis media in children > 1-year-old:
  • 1. Streptococcus pneumoniae
    
  • 2. Haemophilus influenzae
    
  • 3. Moraxella catarrhalis
• Causative agents for acute otitis media in INFANTS < 1-year-old:
  • Staphylococcus aureus or E.coli
• Physical Exam:
  • General: Fever, ear pain, pulling on the ears, irritability
    Otoscopy: Injection of TM, purulent discharge, effusion behind the eardrum
• Treatment:
  • Amoxicillin for 7-10 days
    
  • Allergic to PCN: Bactrim

Acute sinusitis

• Sinuses develop:
  • – Maxillary & Ethmoid: Present at birth
    
  • – Sphenoid: Appear around 5 years of age
    
  • – Frontal: May develop unilaterally or may not develop at all
• Causative agents for acute bacterial sinusitis:
  • 1. Streptococcus pneumonia
    
  • 2. Haemophilus influenzae
    
  • 3. Moraxella catarrhalis
• Physical exam:
  • 1. Unresolving URI sx (>10-14 days)
    
  • 2. Periorbital pain and swelling
    
  • 3. Purulent nasal discharge
    
  • 4. Malaise
    
  • 5. Fever
• Nasal discharge:
  • Viral: Thick, opaque discolored nasal discharge
    
  • Bacterial: Purulent nasal discharge
• Treatment:
  • 1. Viral: Self-limiting; decongestants and saline nasal irrigation for symptomatic relief
    
  • 2. Bacterial: 14-day course abx (Augmentin; Cefaclor)

Crying

Congenital heart defects

• Most serious cases of congenital heart defects dx:
  • First-year of life
• MC left-sided congenital heart defects:
  • 1. Coarctation of the Aorta
  • 2. AS (Aortic Stenosis)
    
  • 3. TAPVR (Total Anomalous Pulmonary Venous Return)
    
  • 4. Hypoplastic Left Heart Syndrome
• MC right-sided congenital heart defects:
  • 1. Transposition of the Great Vessels
    
  • 2. Tetralogy of Fallot
    
  • 3. Tricuspid Atresia
    
  • 4. Truncus Arteriosum
    
  • 5. Pulmonary Atresia
    
  • 6. PS (Pulmonary Stenosis)
• Work-up:
  • 1. CXR
    
  • 2. CBC with Diff
    
  • 3. EKG
    
  • 4. ABGs
    
  • 5. Echo (if available)

Left-sided Congenital heart defects

Coarctation of the Aorta

• Etiology:
  • MC occur at the ductus arteriosus
• Physical Exam:
  • 1. Decreased femoral pulses
    
  • 2. Rib notching 2ry to INTERCOSTAL VESSEL HYPERTROPHY*
• Diagnosis:
  • Echocardiography

AS (Aortic Stenosis)

• Physical Exam:
  • 1. Harsh systolic murmur
    
  • 2. Poor perfusion
• Common EKG finding:
  • Left Ventricular Hypertrophy

TAPVR (Total Anomalous Pulmonary Venous Return)

• Path:
  • The pulmonary veins do not connect to the LEFT atrium
• NONobstructive physiology:
  • Left to Right shunt similar to ASD
    
    • – pt usually present with TACHYPNEA
• Obstructive physiology:
  • Decreased filling of the left side of the heart
    
    • – pt usually present with CYANOSIS

Hypoplastic Left Heart Syndrome

• Presentation:
  • Cyanosis
    
  • Circulatory collapse
    
  • Poor perfusion develops as the PDA closes*
• Treatment:
  • PROSTAGLANDIN infusion until surgical intervention is performed
  • Surgical intervention:
    • NORWOOD Procedure or cardiac transplant

R-sided Congenital heart defects

Transposition of the Great Vessels

• Path:
  • When the PULMONARY ARTERY originates from LEFT VENTRICLE and the AORTA originates from the RIGHT VENTRICLE
• Presentation:
  • Cyanosis
    
  • Circulatory collapse
    
  • Poor perfusion develops as the PDA closes*
• Complications:
  • Apnea
    
  • HYPOtension
    
  • HYPERthermia
    
  • Irritability
• Treatment:
  • PROSTAGLANDIN infusion and BALLOON ATRIAL SEPTOSTOMY until surgical intervention is performed

Tetralogy of Fallot

• 4 Components:
  • 1. Pulmonary Stenosis (PS)
    
  • 2. Overriding Aorta (OA)
    
  • 3. Ventricular Septal Defect (VSD)
    
  • 4. Hypertrophy of the Left Ventricle (LVH)
• Tet spell:
  • Cyanosis that worsens when the child cries or exercises
• Physiology of a tet spell:
  • Sudden increase in PULMONARY OUTFLOW RESISTANCE that increases RIGHT-to-LEFT shunt via the VSD
• Treatment of tet spell:
  • Placing the child in a knee-to-chest position or by increasing systemic pressure

Rashes

Chickenpox

• Path:
  • Varicella-zoster virus (VZV)

Hand Foot and Mouth Dz

• Path:
  • Coxsackie A Virus
    • 2 types:
      • 1. Hand Foot and Mouth Dz
        
      • 2. Herpangina
• Presentation:
  • pre-school child with vesicular eruptions in the oral cavity and on the hands and feet

Kawasaki

• Path:
  • predisposition – Previous Staphylococcal or Streptococcal infection
• Presentation:
  • MC seen in < 5 years old (esp. less than 2 years old)
  • Seasons: Winter and Spring
• Physical Exam:
  • 1. Conjunctivitis
    
  • 2. Rash on palms and soles
    
  • 3. Adenopathy (unilateral cervical)
    
  • 4. Strawberry tongue (with dry, cracked lips)
    
  • 5. Hand swelling (due to limb edema)
    
  • 6. High-grade fever present for > 5 days
• DDx:
  • 1. SSSS (Staph Scalded Skin Syndrome; aka Ritter Dz)
    
  • 2. Toxic Shock Syndrome
    
  • 3. SJS Syndrome
    
  • 4. TENS
    
  • 5. RMSF
    
  • 6. EBV Infxn
• Work-up:
  • 1. CBC with Diff (shows ANEMIA & THROMBOCYTOSIS)
    
  • 2. ESR
    
  • 3. UA with Cx (shows STERILE PYURIA)
• Treatment:
  • Large doses of ASA (80-100mg/kg)
  • IVIG (2mg/kg) – shown to decrease the risk of cardiac complications

Exanthems

• In order:
  • 1. Measles (RubEOLA)
    
  • 2. Scarlet Fever
    
  • 3. German Measles (rubELLA)
    
  • 4. Duke’s Dz (4th Dz)
    
  • 5. Erythema Infectiosum (5th Dz)
    
  • 6. Roseola Infantum

Measles (RubEOLA)

• Path:
  • RubEOLA virus
• 3 Cs:
  • Cough, Coryza, and Conjunctivitis
• Koplik spots:
  • White lesions and elevations on the buccal mucosa
  • Appear 2-3 days PRIOR to the exanthem
• Rash:
  • First appears on the scalp and hairline
• Exanthem appears post-vaccination:
  • 5-15 days post vax

Scarlet Fever

• Path:
  • Group A beta-hemolytic streptococci
• Physical Exam:
  • Fine punctate rash that feels like sandpaper
• Complications:
  • 1. Acute Glomerulonephritis
    
  • 2. Rheumatic Fever

German Measles (rubELLA)

• Path:
  • RubELLA virus
• Physical Exam:
  • Light reddish-pink discrete maculopapules which usually start at the hairline
• Forchheimer Spots:
  • petechiae found in the soft palate

Erythema Infectiosum (5th Dz)

• Path:
  • Parvovirus B19
• 3 phases:
  • 1. “Slapped Cheeks” appearance
    
  • 2. Erythematous maculopapular rash on the arms, trunk, and legs
    
  • 3. Reticulated, lacy rash
• Complications:
  • 1. Reactive Arthritis
    
  • 2. Arthralgia
    
  • 3. Hemolytic Anemia
• Pregnancy complications:
  • Fetal Hydrops (during the first half of pregnancy)

Roseola Infantum

• Rash:
  • Often at the end of a fever
• Physical Exam:
  • Rash that STARTS ON TRUNK
    
  • (Rose colored macules, 2-3mm in size that BLANCH with pressure)

Metabolic Abnormalities

Electrolyte deficit

• Calculate electrolyte deficit:
  • (Ideal electrolyte level – Actual electrolyte level) X (Fractional distribution of electrolyte) X (Weight in Kg)

Fluid deficit

• Physical exam findings:
  • Increased urine CONCENTRATION
    
  • Decreased urine OUTPUT
    
  • Decreased tear production
    
  • Tachycardia
    
  • Dry mucous membranes*
    
  • Decreased skin turgor
    
  • Sunken fontanelles
    
  • Metabolic acidosis
    
  • Low BP (very late finding)

HYPERtonic fluid

• Indication for HYPERtonic fluid replacement in patient with HYPOnatremic dehydration:
  • 1. Asx patients
    
  • 2. Sodium < 125 mEq/L

HYPOtonic solution

• A potential complication of rapid resuscitation with a HYPOtonic solution:
  • Cerebral edema
• Typical fluid bolus used in resuscitation of a child:
  • 20cc/kg
• Indications for a fluid bolus LESS than 20cc/kg:
  • 1. Underlying cardiac disorder
    
  • 2. Underlying renal disorder
    
  • 3. Cerebral edema
    
  • 4. Pulmonary edema
• Endpoint for fluid resuscitation:
  • Adequate end-organ perfusion usually measured by URINE OUTPUT
• Causes of ongoing fluid losses:
  • 1. Emesis
    
  • 2. Diarrhea
    
  • 3. Drains (esp. post-op)
    
  • 4. Breaks in the skin (burns)
• Fluid is used for maintenance in pediatrics:
  • 1/4 NS in 5% Dextrose with 20mEq of KCl-

Gastrointestinal

Acute Abdomen

• DDx for acute abdomen in INFANTS and TODDLERS:
  • 1. Malrotation with volvulus
    
  • 2. Appendicitis
    
  • 3. PNA
    
  • 4. Henoch-Schonlein Purpura (HSP)
    
  • 5. DKA*
    
  • 6. UTI
    
  • 7. Intussusception
    
  • 8. Testicular Torsion

GI malrotation

• MC form:
  • Failure of the CECUM to grow and fix to the RLQ resulting in the formation of adhesions

Hyperbilirubinemia

• DDx for UNconjugated hyperbilirubinemia:
  • 1. Infection
    
  • 2. Hypothyroidism
    
  • 3. Physiologic hyperbilirubinemia
    
  • 4. ABO and Rh incompatibility
    
  • 5. Crigler-Najjar Syndrome
    
  • 6. Gilbert’s Syndrome
• Treatment:
  • Phototherapy
• DDx for CONjugated hyperbilirubinemia:
  • 1. Infection
    
  • 2. Metabolic d/o
    
  • 3. Hepatobiliary pathology (biliary atresia)
    
  • 4. Dubin-Johnson Syndrome
    
  • 5. Rotor Syndrome
• Complications cause jaundice:
  • 1. Deafness
    
  • 2. Cerebral Palsy
    
  • 3. Death

Invasive bacterial disease

• MC causes of invasive bacterial disease (sepsis, meningitis, pna, bacteremia) in a newborn:
  • 1. Group B beta-hemolytic streptococci
    
  • 2. Gram-Negative Rods (E.coli, Klebsiella)
    
  • 3. Listeria monocytogenes

Necrotizing Enteritis

• Path:
  • Ischemia/death of the intestinal lining with desquamation
• Presentation:
  • 3-10 days of life
  • MC GI emergency in neonates (2000-4000 cases/yr)
  • Feeding intolerance
  • Bile Stained
  • Vomitus
  • Abdominal distention
  • Bloody Stools
  • Explosive diarrhea
  • Respiratory distress
  • Respiratory acidosis
  • Septic shock
• Risk:
  • Prematurity (50-80%)
  • Congenital heart disease
  • Perinatal asphyxia
• Diagnosis:
  • Late X-ray
    
    • – intramural gas
    • – general bowel dilation
    • – loss of normal gas pattern
    • – pneumatosis intestinalis
    • – portal air
    • – free air
    • – loss of colon haustrations
• Management:
  • Consult surgeon
  • Give broad spectrum Abx

Respiratory

Rapid Breathing in Neonate

Strep pharyngitis

• Centor criteria:
  • 1. Fever
    
  • 2. Pharyngeal Exudates
    
  • 3. ABSENCE of Cough
    
  • 4. TENDER ANTERIOR cervical LAD

• Modified:
  
  • ADD 1 point if < 15 y/o
    
  • SUBTRACT 1 point if > 44 y/o
• Result:
  • 2-3 points: Test (throat culture)
    
  • +4 points: Give abx

Septic

• MCC for septic appearing neonates or infants:
  • Herpes Simplex Virus
• Organ system is MC affected:
  • Respiratory (look for respiratory sx!)

Shock in Pediatrics

• DDx for shock in a newborn:
  • 1. Sepsis
    
  • 2. Meningitis
    
  • 3. PNA
    
  • 4. Heart Dz
    
  • 5. Metabolic d/o
    
  • 6. CAH
    
  • 7. Dehydration
    
  • 8. Posterior Urethral Valves (look into this later)

Vomiting in Infants