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Pediatrics in Review Craig T. Carter, D.O. Associate Professor Department of Emergency Medicine and Pediatrics University of Kentucky 2/2013.

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Presentation on theme: "Pediatrics in Review Craig T. Carter, D.O. Associate Professor Department of Emergency Medicine and Pediatrics University of Kentucky 2/2013."— Presentation transcript:

1 Pediatrics in Review Craig T. Carter, D.O. Associate Professor Department of Emergency Medicine and Pediatrics University of Kentucky 2/2013

2 Some Pictures Do Not Require Captions ….

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8 Ringworm Ringworm Ringworm often causes itchy, red, scaly, slightly raised, expanding rings on the skin of the trunk of the body, face, groin or thigh fold. The ring grows outward as the infection spreads, and the center area becomes less actively infected. Ringworm often causes itchy, red, scaly, slightly raised, expanding rings on the skin of the trunk of the body, face, groin or thigh fold. The ring grows outward as the infection spreads, and the center area becomes less actively infected.

9 Tinea… Athlete's foot (tinea pedis). This form affects the moist areas between your toes and sometimes on your foot itself. Athlete's foot (tinea pedis). This form affects the moist areas between your toes and sometimes on your foot itself. Jock itch (tinea cruris). This form affects your genitals, inner upper thighs and buttocks. Jock itch (tinea cruris). This form affects your genitals, inner upper thighs and buttocks. Ringworm of the scalp (tinea capitis). This form is most common in children and involves red, itchy patches on the scalp, leaving bald patches. Ringworm of the scalp (tinea capitis). This form is most common in children and involves red, itchy patches on the scalp, leaving bald patches.

10 Q: How are kids airways different?

11 Anatomical airway issues in kids big tongue, soft tissue obstruction big tongue, soft tissue obstruction soft trachea no cuff soft trachea no cuff soft VC no stylet soft VC no stylet anterior larynx anterior larynx short trachea narrowest at subglottis nose breathers < 6 mos big occiput big epiglottis straight blade

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13 Airway positioning for children <2yrs

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15 Chalazion

16 Chalazion Chalazions may be treated with any one of the following methods: 1) Antibiotics and/or steroid drops of injections; 1) Antibiotics and/or steroid drops of injections; 2) Warm compresses; Warm compresses can be applied in a variety of ways, The simplest way is to hold a clean washcloth, soaked in hot water, against the closed lid for five to ten minutes, three to four times a day. Repeatedly soak the washcloth in hot water to maintain adequate heat. 2) Warm compresses; Warm compresses can be applied in a variety of ways, The simplest way is to hold a clean washcloth, soaked in hot water, against the closed lid for five to ten minutes, three to four times a day. Repeatedly soak the washcloth in hot water to maintain adequate heat. 3) Massage of expression of the glandular secretions; 3) Massage of expression of the glandular secretions; 4) Surgical incision or excision. 4) Surgical incision or excision.

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21 Pre-septal and Orbital Cellulitis Bacterial infection usually results from local spread of adjacent URTI Bacterial infection usually results from local spread of adjacent URTI Preseptal usually follows periorbital trauma or dermal infection Preseptal usually follows periorbital trauma or dermal infection Orbital most commonly secondary to ethmoidal sinusitis Orbital most commonly secondary to ethmoidal sinusitis Preseptal Staphylococcus aureus and Staphylococcus epidermidis Streptococcus Orbital Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

22 Answers when you do not know the answers…

23 What is this?

24 Burn Depth Superficial partial thickness burn Superficial partial thickness burn Pink, moist,thin walled blisters Pink, moist,thin walled blisters Intact sensation Intact sensation Heal in 2-3 weeks Heal in 2-3 weeks No scarring No scarring

25 Burn Depth Deep partial thickness burn Deep partial thickness burn Red or Blanched Red or Blanched Thick walled blisters Thick walled blisters Decreased two point discrimination Decreased two point discrimination Mild or exquisitely painful Mild or exquisitely painful May heal by epithelialization 3-6 weeks May heal by epithelialization 3-6 weeks High scar and contracture potential High scar and contracture potential

26 Burn Depth

27 Full thickness burn Full thickness burn White, charred leathery White, charred leathery Capillary and nerve beds destroyed Capillary and nerve beds destroyed Less painful/ insensate Less painful/ insensate Only 1-2cm lesions can heal by contraction Only 1-2cm lesions can heal by contraction Grafting required Grafting required High complication rates and prolonged recovery High complication rates and prolonged recovery

28 Burn Depth

29 Extent of Burn What is the Rule of Nines? What is the Rule of Nines?

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31 Itchy, stayed at friends house overnight, woke with pet in bed

32 Flea Bites

33 Rash

34 Rash w/ fever and abd pain

35 So what is it? Get your clickers… 1. Meningococcemia 1. Meningococcemia 2. ITP/TTP 2. ITP/TTP 3. HUS 3. HUS 4. HSP 4. HSP 5. Petichial hemorrhages 5. Petichial hemorrhages 6. RMSF 6. RMSF

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38 Henoch-Schonlein Purpura Clinical Presentation Clinical Presentation Effects predominantly young children, but adults are also affected Effects predominantly young children, but adults are also affected Peak incidence is 4-5 years of age Peak incidence is 4-5 years of age There is a slight male predominance There is a slight male predominance The condition is more prevalent in the winter and early spring The condition is more prevalent in the winter and early spring The onset of illness is usually sudden and is preceded by a URI in at least 1/3 of cases The onset of illness is usually sudden and is preceded by a URI in at least 1/3 of cases

39 HSP - Clinical Presentation Classic Triad of symptoms is the most common presentation Classic Triad of symptoms is the most common presentation Purpura Purpura Colicky abdominal pain Colicky abdominal pain arthritis arthritis 50% of children may present with symptoms other than purpura 50% of children may present with symptoms other than purpura Risk of Intuss Risk of Intuss

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41 Q: How much of their blood volume can a kid lose, and still have a NORMAL bp?

42 40%

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44 Lymphadenitis

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46 Spontaneous subconjunctival haemorrhage Painless red eye without discharge Painless red eye without discharge VA not affected VA not affected Clear borders Clear borders Masks conjunctival vessels Masks conjunctival vessels Check BP and body for other hemorrhages Check BP and body for other hemorrhages No treatment (lubricants) No treatment (lubricants) days to resolve days to resolve If recurrent: clotting, FBC If recurrent: clotting, FBC Always consider abuse… Always consider abuse…

47 Liver Laceration from ATV

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50 What is it? 1. ECM 1. ECM 2. EM 2. EM 3. Fifths disease 3. Fifths disease 4. No clue 4. No clue 5. Erythema Nodosum 5. Erythema Nodosum

51 What is it? 1. ECM 1. ECM 2. EM 2. EM 3. Fifths disease 3. Fifths disease 4. No clue 4. No clue 5. Erythema Nodosum 5. Erythema Nodosum

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53 Erythema Multiforme Symmetrically distributed, erythematous, expanding macules or papules evolve into classic iris or target lesions, with bright red borders and central petechiae, vesicles, or purpura. Symmetrically distributed, erythematous, expanding macules or papules evolve into classic iris or target lesions, with bright red borders and central petechiae, vesicles, or purpura. Lesions may coalesce and become generalized. Lesions may coalesce and become generalized. Vesiculobullous lesions develop within preexisting macules, papules, or wheals. Vesiculobullous lesions develop within preexisting macules, papules, or wheals. Rash favors palms and soles, dorsum of the hands, and extensor surfaces of extremities and face. Rash favors palms and soles, dorsum of the hands, and extensor surfaces of extremities and face. Postinflammatory hyperpigmentation or hypopigmentation may occur. Postinflammatory hyperpigmentation or hypopigmentation may occur. Eye involvement occurs in 10% of EM cases, mostly bilateral purulent conjunctivitis with increased lacrimation. Eye involvement occurs in 10% of EM cases, mostly bilateral purulent conjunctivitis with increased lacrimation. Mucous membrane blistering occurs in about 25% of cases of EM, is usually mild, and typically involves the oral cavity. Mucous membrane blistering occurs in about 25% of cases of EM, is usually mild, and typically involves the oral cavity.

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56 Varicella

57 Varicella Agent: varicella zoster virus Agent: varicella zoster virus Transmission: respiratory Transmission: respiratory Period of communicability: 1 day before eruption of vesicles. Period of communicability: 1 day before eruption of vesicles. Prodromal phase: slight fever, malaise, pruritic rash; macular to papular to vesicular. Prodromal phase: slight fever, malaise, pruritic rash; macular to papular to vesicular.

58 Management of Varicella Isolation Isolation Skin care: tepid bath, calamine lotion, clip finger nails. Skin care: tepid bath, calamine lotion, clip finger nails. Keep from scratching Keep from scratching Antihistamines for itching - Benadryl Antihistamines for itching - Benadryl No ASA – acetaminophen only. No ASA – acetaminophen only. Varicella vaccine now available. Varicella vaccine now available. 97% immunity in 2m-12 y 97% immunity in 2m-12 y 78% immunity in 13y-adult 78% immunity in 13y-adult 2% can have attenuated disease 2% can have attenuated disease

59 Parent of the year…NOT!

60 What is it and what is next best test?

61 Seat Belt sign

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64 What is it? 1. Mumps 1. Mumps 2. Measeles 2. Measeles 3. Ruebella 3. Ruebella 4. Small pox 4. Small pox 5. No clue 5. No clue

65 Measles: Diagnosis / Clinical Clusters of children with fever, cough, conjunctivitis, coryza, morbilliform rash Clusters of children with fever, cough, conjunctivitis, coryza, morbilliform rash

66 Measles: Signs and Symptoms Peak of Illness Peak of Illness 2-4 days after onset of rash 2-4 days after onset of rash Other signs and symptoms Other signs and symptoms Anorexia, malaise, HSM Anorexia, malaise, HSM Resolution Resolution Rapid improvement at end of febrile period (1 week) Rapid improvement at end of febrile period (1 week) Complete recovery in days Complete recovery in days Pearl: darker-skinned children Pearl: darker-skinned children Sandpaper feel to rash may be helpful Sandpaper feel to rash may be helpful

67 Measles or Rubeola Agent: Virus Agent: Virus Transmission: respiratory, blood and urine Transmission: respiratory, blood and urine Incubation period: 10 to 20 days Incubation period: 10 to 20 days Period of Communicability: 4 days before and 5 days after rash appears. Period of Communicability: 4 days before and 5 days after rash appears. Prodromal stage: fever, cough, conjunctivitis, Koplik spots. Prodromal stage: fever, cough, conjunctivitis, Koplik spots. Can get same rash/illness up to 10 d after MMR Can get same rash/illness up to 10 d after MMR

68 Measles: Signs and Symptoms Erythematous papular eruption Erythematous papular eruption Travels inferior over 2-3 days Travels inferior over 2-3 days Coalesces into macular splotches Coalesces into macular splotches Often desquamates at end of illness Often desquamates at end of illness Hairline Behind Ears Face Trunk Limbs Rash

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73 Parent of the year…NOT

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78 Down Syndrome Described by John Landon Down in 1866 Described by John Landon Down in 1866 Etiology: nondisjuction mutation resulting in Trisomy 21 Etiology: nondisjuction mutation resulting in Trisomy 21 Prevalence 1:700 Prevalence 1:700 Most common chromosomal anomaly Most common chromosomal anomaly Associated with Maternal age > 35 Associated with Maternal age > 35

79 Down Syndrome Characteristics Macroglossia Macroglossia Micrognathia Micrognathia Midface hypoplasia Midface hypoplasia Flat occiput Flat occiput Flat nasal bridge Flat nasal bridge Epicanthal folds Epicanthal folds Up-slanting palpebral fissures Up-slanting palpebral fissures Progressive enlargement of lips Progressive enlargement of lips Hands: Simian crease (continuous line in the palm of the hand), short broad hands, underdevelopment of middle portion of the 5th finger resulting in the finger bending towards the outside of the hand. Hands: Simian crease (continuous line in the palm of the hand), short broad hands, underdevelopment of middle portion of the 5th finger resulting in the finger bending towards the outside of the hand.

80 Name 4 medical issues to consider in Down Syndrome patients…especially in ED! Atlantal-axial dislocation – be wary in traumas or downs patient with neck pain or inability to ambulate Atlantal-axial dislocation – be wary in traumas or downs patient with neck pain or inability to ambulate Cardiovascular anomalies (40%) Cardiovascular anomalies (40%) ASD, VSD, Tetralogy of Fallot, PDA ASD, VSD, Tetralogy of Fallot, PDA GI anomalies (10-18%) GI anomalies (10-18%) Pyloric stenosis, duodenal atresia, TE fistula Pyloric stenosis, duodenal atresia, TE fistula Malignancy Malignancy 20 fold higher incidence of ALL 20 fold higher incidence of ALL Gonadal tumors Gonadal tumors

81 Q: What s the formula for minimal systolic bp for age?

82 70 + (Age x 2) Eg for 5 yo: 70+5x2 = 80

83 MCAD ? Group effort - Tell me everything you know (I am certain this will be a very short conversation!)

84 Medium chain acyl-CoA dehydrogenase deficiency (MCAD) Fatty acid oxidation defect Fatty acid oxidation defect Disorder of ammonia detoxification Disorder of ammonia detoxification Most common mitochondrial β oxidation disorder 1/10,000 Most common mitochondrial β oxidation disorder 1/10,000 5% of 313 cases SIDS 5% of 313 cases SIDS Screen all infants of mothers with HELLP syndrome Screen all infants of mothers with HELLP syndrome Results in acute toxic encephalopathy with episodes of nonketotic hypoglycemia in the 1 st 2 years of life provoked by fasting Results in acute toxic encephalopathy with episodes of nonketotic hypoglycemia in the 1 st 2 years of life provoked by fasting v/lethargy after fasting, usually with URI/AGE v/lethargy after fasting, usually with URI/AGE In ED: coma, hypoglycemic hypoketotic, hyperammonemia, LFTs In ED: coma, hypoglycemic hypoketotic, hyperammonemia, LFTs TX: D10 TX: D10 Avoid fasting Avoid fasting Carnitine 100mg/k/d Carnitine 100mg/k/d

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88 Mulluscum Contagiosum

89 Dictation goofs and gaffs.. Unsure the etiology of this left upper shimmy pain. He had reported that he slipped and fell landing primarily with his hip on the patient's right knee. The child did not lose consciousness and did not appear to strike any other body parts. They report a car immediately afterwards History of present illness: Six-year-old nontender by mother mother reports intermitten…

90 Febrile Seizures CRITERIA FOR THE DIAGNOSIS OF SIMPLE FEBRILE SEIZURE Between 6 months and 5 years of age Between 6 months and 5 years of age Seizure lasting less than 15 minutes Seizure lasting less than 15 minutes Fever present prior to the onset of the seizure Fever present prior to the onset of the seizure No other neurologic diagnoses No other neurologic diagnoses Non-focal, generalized seizure, involving all limbs Non-focal, generalized seizure, involving all limbs No severe metabolic disturbance No severe metabolic disturbance No more than a single seizure per 24-hour period No more than a single seizure per 24-hour period No evidence of intracranial infection No evidence of intracranial infection

91 Febrile SZ work-up Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever. Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever. In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging. In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging. PEDIATRICS Vol. 127 No. 2 February 2011, pp PEDIATRICS Vol. 127 No. 2 February 2011, pp

92 Febrile Seizures – Parental Education The risk of febrile seizure in the general population is between ? The risk of febrile seizure in the general population is between ? 2% and 5% 2% and 5% There is no evidence that treating simple febrile seizures with anti- epileptics decreases the incidence of epilepsy later in life or results in improved cognitive outcomes. There is no evidence that treating simple febrile seizures with anti- epileptics decreases the incidence of epilepsy later in life or results in improved cognitive outcomes.

93 Febrile Seizures – Parental Education If a patient is less than 12 months of age at the time of the first simple febrile seizure, the risk of second simple febrile seizure is 50%. If a patient is less than 12 months of age at the time of the first simple febrile seizure, the risk of second simple febrile seizure is 50%. If a patient is over 12 months of age at the time of the first simple febrile seizure, the risk of a second simple febrile seizure is 30%. If a patient is over 12 months of age at the time of the first simple febrile seizure, the risk of a second simple febrile seizure is 30%. Following a second simple febrile seizure, the risk of future simple febrile seizures is 50%, regardless of the age of the initial simple febrile seizure. Following a second simple febrile seizure, the risk of future simple febrile seizures is 50%, regardless of the age of the initial simple febrile seizure. The risk of epilepsy is minimally increased from 1% to 2.4% in patients who have a simple febrile seizure The risk of epilepsy is minimally increased from 1% to 2.4% in patients who have a simple febrile seizure

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96 Mumps Clinical Features Incubation period days Incubation period days Nonspecific prodrome of low-grade fever, headache, malaise, myalgia Nonspecific prodrome of low-grade fever, headache, malaise, myalgia Parotitis in 30%-40% Parotitis in 30%-40% Up to 20% of infections asymptomatic Up to 20% of infections asymptomatic May present as lower respiratory illness, particularly in preschool-aged children May present as lower respiratory illness, particularly in preschool-aged children

97 Mumps Pathogenesis Respiratory transmission of virus Respiratory transmission of virus Replication in nasopharynx and regional lymph nodes Replication in nasopharynx and regional lymph nodes Viremia days after exposure with spread to tissues Viremia days after exposure with spread to tissues Multiple tissues infected during viremia Multiple tissues infected during viremia

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99 Human Bites-ABUSE

100 Q: Name 4 things that can result in an agitated pediatric trauma patient.

101 Causes of agitation… Head Injury Head Injury Decreased Oxygenation Decreased Oxygenation Shock Shock Altered LOC due to Alcohol, drug etc Altered LOC due to Alcohol, drug etc

102 What is this rash? What is this rash? Drug Reaction/Eruption Drug Reaction/Eruption

103 Treatment ?

104 Differential Dx ? List 3…

105 Hand edema – What is it? How about now? How about now? Coronary artery aneurysms - Coronary artery aneurysms -

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107 Kawasaki Disease - Clinical Manifestations High fever High fever Conjunctivitis Conjunctivitis Strawberry tongue Strawberry tongue Edema of hands and feed Edema of hands and feed Reddening of palms and soles Reddening of palms and soles Lymph node swelling Lymph node swelling

108 Kawasaki Disease - Clinical Tests LFTs/TBili LFTs/TBili Albumin Albumin ESR ESR CRP CRP Urine Urine CBC CBC Thrombocytosis Thrombocytosis Leukocytosis Leukocytosis Anemia (normocytic) Anemia (normocytic)

109 A 4yo boy presents with painful rectal bleeding. Mom describes the blood as bright red, my son is going to bleed to death! The most common etiology of painful rectal bleeding in this age group is? a. Juvenile polyposis b. Anal fissure c. Crohn s Disease d. Meckel s diverticulum

110 A 4yo boy presents with painless rectal bleeding. Mom describes the blood as bright red, my son is going to bleed to death! The most common etiology of painless rectal bleeding in this age group is? A 4yo boy presents with painless rectal bleeding. Mom describes the blood as bright red, my son is going to bleed to death! The most common etiology of painless rectal bleeding in this age group is? a. Juvenile polyposis b. Anal fissure c. Crohn s Disease d. Meckel s diverticulum

111 Dictation goofs and gaffs… What??? I discussed this with the family and felt as though he most likely had some dry skin no switching off in this area She is taken to court Riche already performed chest x-ray Patient presents with bruising the posterior thighs which appears consistent with Niceville trauma

112 Salter 1 Salter 1 Salter 2 Salter 2 Salter 3 Salter 3 Salter 4 Salter 4 Salter 5 Salter 5

113 Salter 1 Salter 1 Salter 2 Salter 2 Salter 3 Salter 3 Salter 4 Salter 4 Salter 5 Salter 5

114 Salter 1 Salter 1 Salter 2 Salter 2 Salter 3 Salter 3 Salter 4 Salter 4 Salter 5 Salter 5

115 Salter Fracture I and II

116 Salter Fracture III, IV and V

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118 Abnormal bruising patterns- ABUSE

119 Tripod position Bowden & Greenberg

120 Epiglottitis Symptoms Epiglottitis Symptoms Acute inflammation of supra-glottic structures. Acute inflammation of supra-glottic structures. Medical Emergency Medical Emergency Sudden onset Sudden onset High fever High fever Dysphasia and drooling Dysphasia and drooling Epiglottis is cherry red and swollenDiagnosis made on presenting symptoms Epiglottis is cherry red and swollenDiagnosis made on presenting symptoms No tongue blade in mouth No tongue blade in mouth Emergency tracheostomy set Emergency tracheostomy set No procedures until in the operating room No procedures until in the operating room Keep quiet Keep quiet

121 Purple Rash Characteristic purpuric lesions. Bowden & Greenberg

122 Meningococcemia Necrosis of skin

123 Bacterial Meningitis Pathogens Under 2 months :E-coli, Group B streptococcus, Listeria, Haemophilus influenza type B, and Streptococcus pneumonia Under 2 months :E-coli, Group B streptococcus, Listeria, Haemophilus influenza type B, and Streptococcus pneumonia Beyond neonate: Strep, Haemophilus, Neisseria. Beyond neonate: Strep, Haemophilus, Neisseria.

124 Clinical Manifestation Severe abdominal pain Currant jelly-like stool is a classic sign. Bowden & Greenberg

125 Intussusception Bowden Text Telescoping of part of intestine into an adjacent distal portion.

126 Barium Enema Ball & Bindler

127 Gas filled loops of bowel

128 Necrotizing Enterocolitis Necrotizing = damage and death of cells Entero = refers to intestines Colitis = inflammation of the colon60 to 80% are premature infants Feeding of concentrated formulas Feeding of concentrated formulas Infants who have received blood transfusion Infants who have received blood transfusion Infants with GI infections Infants with GI infections Infants with polycythemia: congenital heart disease Infants with polycythemia: congenital heart disease

129 Q: List 3 trauma considerations that we often forget about, especially in children?

130 Q: List 3 trauma considerations that we often forget about? 1. Hypothermia 2. Child Abuse 3. Hazardous Environments

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133 Myelomeningocele A protruding saclike structure A protruding saclike structure containing meninges, spinal fluid and neural tissue.

134 Bulging anterior fontanelle Eyes deviated downward Setting Sun sign Bates: Physical Assessment

135 Severe Hydrocephalus

136 Hydrocephalus Greek meaning water on the brain Greek meaning water on the brain Dilation of the ventricles Dilation of the ventricles Two primary causes: Two primary causes: Congenital.5 to 1% Congenital.5 to 1% Acquired: Acquired: Lesion, tumors, infection, intracranial bleed, myelomeningocele Lesion, tumors, infection, intracranial bleed, myelomeningocele

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138 Retinal Hemorrhages Normal retinal Retinal hemorrhage

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140 What is it? MRSA MRSA Burn Burn Grp A strep Grp A strep Yeast Yeast No clue No clue

141 Erysipelas Streptococcal Skin Infections Group A Streptococci (Strep. pyogenes), which cause erysipelas, an infection affecting the superficial layers of the skin, and which classically has sharply defined borders. Group A Streptococci (Strep. pyogenes), which cause erysipelas, an infection affecting the superficial layers of the skin, and which classically has sharply defined borders.

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143 Clostridium tetani Anaerobic gram-positive, spore-forming bacteria Anaerobic gram-positive, spore-forming bacteria Spores found in soil, dust, animal feces; may persist for months to years Spores found in soil, dust, animal feces; may persist for months to years Multiple toxins produced with growth of bacteria Multiple toxins produced with growth of bacteria Tetanospasmin estimated human lethal dose = 2.5 ng/kg Tetanospasmin estimated human lethal dose = 2.5 ng/kg

144 Tetanus Clinical Features Incubation period; 8 days (range, 3-21 days) Incubation period; 8 days (range, 3-21 days) Three clinical forms: Local (not common), cephalic (rare), generalized (most common) Three clinical forms: Local (not common), cephalic (rare), generalized (most common) Generalized tetanus: descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms Generalized tetanus: descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms Spasms continue for 3-4 weeks; complete recovery may take months Spasms continue for 3-4 weeks; complete recovery may take months

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147 Pathogenesis of Lyme Borreliosis Lyme disease characterized by three stages: i.Initially a unique skin lesion (erythema chronicum migrans (ECM)) with general malaise ECM not seen in all infected hosts ECM often described as bullseye rash Lesions periodically reoccur ii.Subsequent stage seen in 5-15% of patients with neurological or cardiac involvement iii.Third stage involves migrating episodes of non- destructive, but painful arthritis Acute illness treated with phenoxymethylpenicillin or tetracycline

148 Diagnosis of Lyme Borreliosis

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151 Rickettsia rickettsii - Rocky mountain spotted fever

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155 Q: What are the risk factors for child abuse?

156 Child Abuse History story injuries story injuries history changing history changing injury development injury development delay seeking help delay seeking help inappropriate level of concern inappropriate level of concern Physical Exam multiple old and new bruises posterior rib #, sternum #, spiral # < 3 yo immersion burns, cigarette

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158 Impetigo Impetigo contagiosa The most common form of impetigo is impetigo contagiosa, which usually starts as a red sore on your child's face, most often around the nose and mouth. The sore ruptures quickly, oozing either fluid or pus that forms a honey-colored crust. Eventually the crust disappears, leaving a red mark that heals without scarring. The sores may be itchy Impetigo contagiosa The most common form of impetigo is impetigo contagiosa, which usually starts as a red sore on your child's face, most often around the nose and mouth. The sore ruptures quickly, oozing either fluid or pus that forms a honey-colored crust. Eventually the crust disappears, leaving a red mark that heals without scarring. The sores may be itchy

159 Staphylococcus aureus Topical antibiotics. Your doctor may prescribe an antibiotic that you apply to your child's skin (topical antibiotic), such as mupirocin ointment (Bactroban). Topical antibiotics avoid side effects such as diarrhea that can result from some oral medications, but as with oral antibiotics, bacteria can become resistant to them over time. Topical antibiotics. Your doctor may prescribe an antibiotic that you apply to your child's skin (topical antibiotic), such as mupirocin ointment (Bactroban). Topical antibiotics avoid side effects such as diarrhea that can result from some oral medications, but as with oral antibiotics, bacteria can become resistant to them over time. Oral antibiotics. Your doctor is likely to prescribe an oral antibiotic for ecthyma and severe cases of impetigo contagiosa. The specific antibiotic will depend on the severity of the infection and any allergies or conditions your child might have. Be sure to finish the entire course of medication even if your child seems better. This helps prevent the infection from recurring and makes antibiotic resistance less likely. Oral antibiotics. Your doctor is likely to prescribe an oral antibiotic for ecthyma and severe cases of impetigo contagiosa. The specific antibiotic will depend on the severity of the infection and any allergies or conditions your child might have. Be sure to finish the entire course of medication even if your child seems better. This helps prevent the infection from recurring and makes antibiotic resistance less likely.

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161 Pityriasis Rosea It most often develops in the spring and the fall, and seems to favor adolescents and young adults. It most often develops in the spring and the fall, and seems to favor adolescents and young adults. The skin rash follows a very distinctive pattern. In 3/4 of the cases, a single, isolated oval scaly patch (the "herald patch") appears on the body, particularly on the trunk, upper arms, neck, or thighs. The skin rash follows a very distinctive pattern. In 3/4 of the cases, a single, isolated oval scaly patch (the "herald patch") appears on the body, particularly on the trunk, upper arms, neck, or thighs. These patches often form a pattern over the back resembling the outline of an evergreen tree with dropping branches. Patches may also appear on the neck and, rarely, on the face. These spots usually are smaller than the "herald" patch. The rash begins to heal after 2-4 weeks and is usually gone by These patches often form a pattern over the back resembling the outline of an evergreen tree with dropping branches. Patches may also appear on the neck and, rarely, on the face. These spots usually are smaller than the "herald" patch. The rash begins to heal after 2-4 weeks and is usually gone by Aveeno oatmeal baths, anti-itch medicated lotions and steroid creams may be prescribed to combat the rash. Lukewarm, rather than hot, baths, ERYC, Famvir Aveeno oatmeal baths, anti-itch medicated lotions and steroid creams may be prescribed to combat the rash. Lukewarm, rather than hot, baths, ERYC, Famvir

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163 Fractures of Abuse FIGURE 6. Multiple healing posterior rib fractures (arrows) from a compression injury of the chest. FIGURE 6. Multiple healing posterior rib fractures (arrows) from a compression injury of the chest. FIGURE 7. Metaphyseal or "bucket- handle" fracture (arrow) of the tibia. FIGURE 7. Metaphyseal or "bucket- handle" fracture (arrow) of the tibia.

164 1. Parvovirus B19 2. Chilblans (cold) 3. Fifths Disease 4. Sixth disease 5. SLE butterfly rash 6. Erythema Infectiosum 7. No clue

165 Erythema Infectiosum (Fifth Disease) History: Erythema infectiosum typically has an incubation period of 4-14 days and is spread primarily via aerosolized respiratory droplets. Erythema infectiosum typically has an incubation period of 4-14 days and is spread primarily via aerosolized respiratory droplets. Transmission also occurs through blood products and from mother to fetus. Transmission also occurs through blood products and from mother to fetus. The prodromal phase often is mild enough to be noticed only rarely but may include headache, coryza, low-grade fever, pharyngitis, and malaise. The prodromal phase often is mild enough to be noticed only rarely but may include headache, coryza, low-grade fever, pharyngitis, and malaise. Infrequently, nausea, diarrhea, arthralgias, and abdominal pain may occur. Infrequently, nausea, diarrhea, arthralgias, and abdominal pain may occur. In hosts who are immunocompetent, the patient is viremic and capable of spreading the infection only during the incubation period. In hosts who are immunocompetent, the patient is viremic and capable of spreading the infection only during the incubation period. Classic cutaneous findings follow within 3-7 days for some patients, while other patients may manifest no findings. Classic cutaneous findings follow within 3-7 days for some patients, while other patients may manifest no findings.

166 Erythema Infectiosum (Fifth Disease) Physical: Physical: Pertinent physical findings predominantly are limited to the skin and joints. Pertinent physical findings predominantly are limited to the skin and joints. Skin (first stage): The exanthem begins with the classic slapped-cheek appearance. The bright red erythema appears abruptly over the cheeks and is marked by nasal, perioral, and periorbital sparing. The exanthem may appear like a sunburn, occasionally is edematous, and typically fades over 2-4 days. Skin (first stage): The exanthem begins with the classic slapped-cheek appearance. The bright red erythema appears abruptly over the cheeks and is marked by nasal, perioral, and periorbital sparing. The exanthem may appear like a sunburn, occasionally is edematous, and typically fades over 2-4 days. Skin (second stage): Within 1-4 days of the malar rash, an erythematous macular- to-morbilliform eruption occurs primarily on the extremities. While the eruption tends to favor the extensor surfaces, it can involve the palms and soles. Pruritus is rare. Skin (second stage): Within 1-4 days of the malar rash, an erythematous macular- to-morbilliform eruption occurs primarily on the extremities. While the eruption tends to favor the extensor surfaces, it can involve the palms and soles. Pruritus is rare. Skin (third stage): After several days, most of the second stage eruption fades into a lacy pattern, with particular emphasis on the proximal extremities. Despite its synonym, slapped-cheek disease, the reticulate pattern is distinctly characteristic for erythema infectiosum and may be the only manifestation of the illness. The third stage lasts from 3 days to 3 weeks. After starting to fade, the exanthem may recur over several weeks following physical stimuli, such as exercise, sun exposure, friction, bathing in hot water, or stress. Skin (third stage): After several days, most of the second stage eruption fades into a lacy pattern, with particular emphasis on the proximal extremities. Despite its synonym, slapped-cheek disease, the reticulate pattern is distinctly characteristic for erythema infectiosum and may be the only manifestation of the illness. The third stage lasts from 3 days to 3 weeks. After starting to fade, the exanthem may recur over several weeks following physical stimuli, such as exercise, sun exposure, friction, bathing in hot water, or stress.

167 Erythema Infectiosum (Fifth Disease) Complications of PV-B19 infection include the following: Complications of PV-B19 infection include the following: Aplastic crisis: The parvovirus infects erythroid cells, causing a reticulocytopenia that lasts 7-10 days. A healthy host experiences no consequences, since the normal lifespan of a red blood cell is 120 days. In patients with a background of shortened red blood cell survival, such as hemolytic anemia, an acute aplastic crisis ensues. Aplastic crisis: The parvovirus infects erythroid cells, causing a reticulocytopenia that lasts 7-10 days. A healthy host experiences no consequences, since the normal lifespan of a red blood cell is 120 days. In patients with a background of shortened red blood cell survival, such as hemolytic anemia, an acute aplastic crisis ensues. Congenital infection: PV-B19 can cross the placenta during pregnancy and have a direct cytotoxic effect on fetal red blood cells. Infection Congenital infection: PV-B19 can cross the placenta during pregnancy and have a direct cytotoxic effect on fetal red blood cells. Infection

168 For a 24-kg child, the daily maintenance fluid requirement is approximately which of the following? a.1440cc/24hrs b.1536cc /24hrs c.2400cc/24hrs d.1223cc/24hrs rule rule 0-10 kg 4cc/hr x wt kg 2cc/hr x wt >20 kg 1cc/hr x wt Easy method Anyone >20kg =wt + 40

169 Proper fluid bolus for a 9kg infant who presents as a severe trauma with unstable vitals is? a. 180 cc LR x 2, then 90cc/kg pRBCs b. 180cc NSS, then 90 cc NSS c. 180 cc LR, then 180cc pRBCs d. 180cc LR x 2, then 90cc 5% albumin, then 90cc pRBCs

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172 Scarlet fever / scarlatiniform rash Background: Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, and scarlatiniform rash. It is caused by an infection with a pyogenic exotoxin-producing group A beta-hemolytic streptococci Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, and scarlatiniform rash. It is caused by an infection with a pyogenic exotoxin-producing group A beta-hemolytic streptococci Infections occur year-round, but the incidence of pharyngeal disease is highest in school-aged children (5- 15 y) during winter and spring and in a setting of crowding and close contact. Person-to-person spread by means of respiratory droplets is the most common mode of transmission. Infections occur year-round, but the incidence of pharyngeal disease is highest in school-aged children (5- 15 y) during winter and spring and in a setting of crowding and close contact. Person-to-person spread by means of respiratory droplets is the most common mode of transmission. The incubation period for scarlet fever ranges from 12 hours to 7 days. Patients are contagious during the acute illness and during the subclinical phase. The incubation period for scarlet fever ranges from 12 hours to 7 days. Patients are contagious during the acute illness and during the subclinical phase.

173 Scarlet fever / scarlatiniform rash The rash appears 1-2 days after onset of illness, first on the neck and then extending to the trunk and extremities. The rash appears 1-2 days after onset of illness, first on the neck and then extending to the trunk and extremities. Scarlatiniform rash Scarlatiniform rash Exanthem texture is usually of coarse sandpaper, and the erythema blanches with pressure. Exanthem texture is usually of coarse sandpaper, and the erythema blanches with pressure. The skin can be pruritic but usually is not painful. The skin can be pruritic but usually is not painful. A few days following generalization of the rash, it becomes more intense along skin folds and produces lines of confluent petechiae known as the Pastia sign. These lines are caused by increased capillary fragility. A few days following generalization of the rash, it becomes more intense along skin folds and produces lines of confluent petechiae known as the Pastia sign. These lines are caused by increased capillary fragility. The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and can last up to a month. The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and can last up to a month. TX TX Treat patients with a standard 10-day course of penicillin or erythromycin. This regimen prevents acute renal failure if antibiotics are initiated within 1 week of the onset of acute pharyngitis Treat patients with a standard 10-day course of penicillin or erythromycin. This regimen prevents acute renal failure if antibiotics are initiated within 1 week of the onset of acute pharyngitis

174 Centor Criteria 1. Exudative pharyngitis 1. Exudative pharyngitis 2. Fever 2. Fever 3. Anterior Cervical Lymphadenopathy 3. Anterior Cervical Lymphadenopathy 4. No cold symptoms (ie no cough or runny nose) 4. No cold symptoms (ie no cough or runny nose)

175 ? (Hint – Not E.T.s Finger)

176 Clubbing of Finger/Cystic fibrosis Background: Cystic fibrosis (CF) is the most common lethal inherited disease in white persons. CF is an autosomal recessive disorder, and most carriers of the gene are asymptomatic. CF is a disease of exocrine gland function, involving multiple organ systems and chiefly resulting in chronic respiratory infections, pancreatic enzyme insufficiency, and associated complications in untreated patients. Pulmonary involvement occurs in 90% of patients surviving the neonatal period. End-stage lung disease is the principal cause of death. Background: Cystic fibrosis (CF) is the most common lethal inherited disease in white persons. CF is an autosomal recessive disorder, and most carriers of the gene are asymptomatic. CF is a disease of exocrine gland function, involving multiple organ systems and chiefly resulting in chronic respiratory infections, pancreatic enzyme insufficiency, and associated complications in untreated patients. Pulmonary involvement occurs in 90% of patients surviving the neonatal period. End-stage lung disease is the principal cause of death. Gastrointestinal tract manifestations (intestinal) Gastrointestinal tract manifestations (intestinal) Neonates: Infants may present with intestinal obstruction at birth and a variety of surgical findings, for example, meconium ileus (7-10% of patients with CF), volvulus, intestinal atresia, perforation, and meconium peritonitis. Less commonly, passage of meconium may be delayed (>24-48 h after birth) or cholestatic jaundice may be prolonged. Neonates: Infants may present with intestinal obstruction at birth and a variety of surgical findings, for example, meconium ileus (7-10% of patients with CF), volvulus, intestinal atresia, perforation, and meconium peritonitis. Less commonly, passage of meconium may be delayed (>24-48 h after birth) or cholestatic jaundice may be prolonged. Infants and children: Patients present with increased frequency of stools, which suggests malabsorption (ie, fat in stools, oil drops in stools), failure to thrive, intussusception (ileocecal), or rectal prolapse. Infants and children: Patients present with increased frequency of stools, which suggests malabsorption (ie, fat in stools, oil drops in stools), failure to thrive, intussusception (ileocecal), or rectal prolapse.

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178 Stevens-Johnson syndrome (SJS) Pathophysiology: SJS is an immune-complex– mediated hypersensitivity disorder that may be caused by many drugs, viral infections, and malignancies. Cocaine recently has been added to the list of drugs capable of producing the syndrome. In up to half of cases, no specific etiology has been identified Pathophysiology: SJS is an immune-complex– mediated hypersensitivity disorder that may be caused by many drugs, viral infections, and malignancies. Cocaine recently has been added to the list of drugs capable of producing the syndrome. In up to half of cases, no specific etiology has been identified In 3-15% of cases, patients with severe SJS die In 3-15% of cases, patients with severe SJS die

179 Stevens-Johnson syndrome (SJS) The 4 etiologic categories are (1) infectious, (2) drug-induced, (3) malignancy-related, and (4) idiopathic. The 4 etiologic categories are (1) infectious, (2) drug-induced, (3) malignancy-related, and (4) idiopathic. Viral diseases that have been reported include herpes simplex virus (HSV), AIDS, Coxsackie viral infections, influenza, hepatitis, mumps, mycoplasmal infection, lymphogranuloma venereum (LGV), rickettsial infections, and variola. Viral diseases that have been reported include herpes simplex virus (HSV), AIDS, Coxsackie viral infections, influenza, hepatitis, mumps, mycoplasmal infection, lymphogranuloma venereum (LGV), rickettsial infections, and variola. Bacterial etiologies include group A beta streptococci, diphtheria, Brucellosis, mycobacteria, Mycoplasma pneumoniae, tularemia, and typhoid. Bacterial etiologies include group A beta streptococci, diphtheria, Brucellosis, mycobacteria, Mycoplasma pneumoniae, tularemia, and typhoid. Coccidioidomycosis, dermatophytosis, and histoplasmosis are the fungal possibilities. Coccidioidomycosis, dermatophytosis, and histoplasmosis are the fungal possibilities. Malaria and trichomoniasis have been reported as protozoal causes. Malaria and trichomoniasis have been reported as protozoal causes. In children, Epstein-Barr virus and enteroviruses have been identified. In children, Epstein-Barr virus and enteroviruses have been identified. Drug etiologies include penicillins and sulfa antibiotics. Anticonvulsants including phenytoin, carbamazepine, valproic acid, lamotrigine, and barbiturates have been implicated. Mockenhapupt et al stressed that most anticonvulsant-induced SJS occurs in the first 60 days of use. In late 2002, the US Food and Drug Administration (FDA) and the manufacturer Pharmacia noted that SJS had been reported in patients taking the cyclooxygenase-2 (COX-2) inhibitor valdecoxib. Drug etiologies include penicillins and sulfa antibiotics. Anticonvulsants including phenytoin, carbamazepine, valproic acid, lamotrigine, and barbiturates have been implicated. Mockenhapupt et al stressed that most anticonvulsant-induced SJS occurs in the first 60 days of use. In late 2002, the US Food and Drug Administration (FDA) and the manufacturer Pharmacia noted that SJS had been reported in patients taking the cyclooxygenase-2 (COX-2) inhibitor valdecoxib. Various carcinomas and lymphomas have been associated. Various carcinomas and lymphomas have been associated. SJS is idiopathic in 25-50% of cases SJS is idiopathic in 25-50% of cases

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181 ?

182 TOF Pulmonary stenosis (a narrowing of the blood vessel to the lungs) Pulmonary stenosis (a narrowing of the blood vessel to the lungs) Overriding aorta (the main blood vessel from the heart to the entire body is somewhat displaced) Overriding aorta (the main blood vessel from the heart to the entire body is somewhat displaced) A ventricular septal defect (hole in the wall between the lower two chambers of the heart) A ventricular septal defect (hole in the wall between the lower two chambers of the heart) Right ventricular hypertrophy (a thick muscle in the right pumping chamber) Right ventricular hypertrophy (a thick muscle in the right pumping chamber)

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184 TOF First presentation may include poor feeding, fussiness, tachypnea, and agitation. First presentation may include poor feeding, fussiness, tachypnea, and agitation. Emergency Department Care: Emergency Department Care: The ED physician should be able to recognize and treat a hypercyanotic episode as one of the very few pediatric cardiology emergencies that may present to the ED. The ED physician should be able to recognize and treat a hypercyanotic episode as one of the very few pediatric cardiology emergencies that may present to the ED. Hypoxic tet spell: Hypercyanotic episodes are characterized by paroxysms of hyperpnea, prolonged crying, intense cyanosis, and decreased intensity of the murmur of pulmonic stenosis. Hypoxic tet spell: Hypercyanotic episodes are characterized by paroxysms of hyperpnea, prolonged crying, intense cyanosis, and decreased intensity of the murmur of pulmonic stenosis. Mechanism - Secondary to infundibular spasm and/or decreased SVR with increased right-to-left shunting at the VSD, resulting in diminished pulmonary blood flow Mechanism - Secondary to infundibular spasm and/or decreased SVR with increased right-to-left shunting at the VSD, resulting in diminished pulmonary blood flow If left untreated, may result in syncope, seizure, stroke, or death If left untreated, may result in syncope, seizure, stroke, or death

185 Treatment for the acute setting of hypercyanosis includes the following: Treatment for the acute setting of hypercyanosis includes the following: Knee-chest position: Place the baby on the mother's shoulder with the knees tucked up underneath. This provides a calming effect, reduces systemic venous return, and increases SVR. Knee-chest position: Place the baby on the mother's shoulder with the knees tucked up underneath. This provides a calming effect, reduces systemic venous return, and increases SVR. Oxygen is of limited value since the primary abnormality is reduced pulmonary blood flow. Oxygen is of limited value since the primary abnormality is reduced pulmonary blood flow. Morphine sulfate, mg/kg IM/SC, may reduce the ventilatory drive and decrease systemic venous return. Morphine sulfate, mg/kg IM/SC, may reduce the ventilatory drive and decrease systemic venous return. Phenylephrine, 0.02 mg/kg IV, is used to increase SVR. Phenylephrine, 0.02 mg/kg IV, is used to increase SVR. Treat acidosis with sodium bicarbonate, which may reduce the respiratory center stimulating effect of acidosis. Treat acidosis with sodium bicarbonate, which may reduce the respiratory center stimulating effect of acidosis. General anesthesia is a last resort. General anesthesia is a last resort.

186 ? 1. Candida 2. EBV 3. CMV 4. Diptheria 5. No clue

187 Infectious mononucleosis History: History: IM may have a varied clinical presentation, but the symptoms usually consist of fever, pharyngitis, and lymphadenopathy. IM may have a varied clinical presentation, but the symptoms usually consist of fever, pharyngitis, and lymphadenopathy. The incubation period of IM is 4-6 weeks. Patients usually do not recall a history of possible exposure. The incubation period of IM is 4-6 weeks. Patients usually do not recall a history of possible exposure. Prodromal symptoms consisting of 1-2 weeks of fatigue, malaise, and myalgia are common Prodromal symptoms consisting of 1-2 weeks of fatigue, malaise, and myalgia are common In more than 90% of cases, IM is secondary to EBV infection In more than 90% of cases, IM is secondary to EBV infection

188 Infectious mononucleosis - Labs Liver function tests (LFTs) are abnormal in more than 90% of patients with IM. Liver function tests (LFTs) are abnormal in more than 90% of patients with IM. Serum transaminase and alkaline phosphatase levels usually are modestly elevated. Serum transaminase and alkaline phosphatase levels usually are modestly elevated. The serum bilirubin may be increased in approximately 40% of patients, but jaundice only occurs in approximately 5% of IM cases. The serum bilirubin may be increased in approximately 40% of patients, but jaundice only occurs in approximately 5% of IM cases. CBC : differential that demonstrates greater than 50% lymphocytes, an absolute lymphocyte count greater than 4500, or an elevated lymphocyte count with greater than 10% atypical lymphocytes CBC : differential that demonstrates greater than 50% lymphocytes, an absolute lymphocyte count greater than 4500, or an elevated lymphocyte count with greater than 10% atypical lymphocytes Also can have thrombocytosis Also can have thrombocytosis Splenic rupture is a serious complication of IM, but it occurs in fewer than 0.5% of cases. More than 90% of splenic rupture cases occur in male patients. Splenic rupture is a serious complication of IM, but it occurs in fewer than 0.5% of cases. More than 90% of splenic rupture cases occur in male patients.

189 ?

190 Slipped Capital Femoral Epiphysis The Limping Child What is the red line called?

191 Slipped Capital Femoral Epiphysis Slipped Capital Femoral Epiphysis Kleins line Superior femoral neck- lateral portion femoral head Mild widening, lucency, irregularity of physis Blurring of junction- metaphysis/physis (early)

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196 Radiograph

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198 Legg-Calvé-Perthes Disease Avascular necrosis leading to collapse, fragmentation, and then reossification Avascular necrosis leading to collapse, fragmentation, and then reossification Most frequent between 4 and9 years Most frequent between 4 and9 years Boys more often than girls Boys more often than girls Bilateral in 10% of cases Bilateral in 10% of cases

199 Management - LCP Disease is self-limited – limp can last 2 to 4 years Disease is self-limited – limp can last 2 to 4 years Nonsteroidal anti-inflammatory agents Nonsteroidal anti-inflammatory agents Limit activities Limit activities Crutches/braces occasionally needed Crutches/braces occasionally needed May help maintain spherical femoral head May help maintain spherical femoral head Better outcomes in younger children Better outcomes in younger children

200 ?

201 Clinical Features: Your First Clue Irritability Irritability Fever Fever Erythema Erythema Limp/refusal to walk Limp/refusal to walk Decreased range of motion of limb Decreased range of motion of limb

202 Septic Arthritis of ankle

203 Management Once the diagnosis of septic joint is made, surgical intervention should proceed ASAP. Once the diagnosis of septic joint is made, surgical intervention should proceed ASAP. Needle aspiration or open surgical drainage required Needle aspiration or open surgical drainage required

204 Synovial Fluid Findings

205 Septic Arthritis Treatment by Age

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207 Kerion This is a vigorous inflammatory reaction to dermatophyte infection, occasionally associated with secondary bacterial infection, that occurs on the scalp, resulting in a boggy inflammatory swelling This is a vigorous inflammatory reaction to dermatophyte infection, occasionally associated with secondary bacterial infection, that occurs on the scalp, resulting in a boggy inflammatory swelling Untreated tinea capitis Untreated tinea capitis

208 Dictation Gaffs and Goofs… Patient is a 3-year-old male who presents after a fall from a trampoline heart about an hour and half ago Patient presents to emergency department on orders from right ear CBS worker 7-year-old male female presents to emergency department with complaints of pain or right ankle. Mom prospective about 57 concrete steps last night

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210 Oral thrush Signs and symptoms Signs and symptoms Oral thrush usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese Oral thrush usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese

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213 Rubella/German Measles Background: The name rubella is derived from a Latin term meaning "little red." Rubella is generally a benign communicable exanthematous disease. Background: The name rubella is derived from a Latin term meaning "little red." Rubella is generally a benign communicable exanthematous disease. The major complication of rubella is its teratogenic effects when pregnant women contract the disease, especially in the early weeks of gestation. The virus can be transmitted to the fetus through the placenta and is capable of causing serious congenital defects, abortions, and stillbirths The major complication of rubella is its teratogenic effects when pregnant women contract the disease, especially in the early weeks of gestation. The virus can be transmitted to the fetus through the placenta and is capable of causing serious congenital defects, abortions, and stillbirths

214 Rubella Incubation period: The incubation is usually days after exposure to a person with rubella. Incubation period: The incubation is usually days after exposure to a person with rubella. Prodromal phase: Prodromal symptoms are unusual in young children but are common in adolescents and adults. Prodromal phase: Prodromal symptoms are unusual in young children but are common in adolescents and adults.

215 Rubella The following signs and symptoms usually appear 1-5 days before the onset of rash: The following signs and symptoms usually appear 1-5 days before the onset of rash: Eye pain on lateral and upward eye movement (a particularly troublesome complaint) Eye pain on lateral and upward eye movement (a particularly troublesome complaint) Conjunctivitis Conjunctivitis Sore throat Sore throat Headache Headache General body aches General body aches Low-grade fever Low-grade fever Chills Chills Anorexia Anorexia Nausea Nausea Tender lymphadenopathy Tender lymphadenopathy

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217 Sturge-Weber Syndrome Sturge-Weber syndrome is a neurological disorder indicated at birth by seizures accompanied by a large port-wine stain birthmark on the forehead and upper eyelid of one side of the face. Sturge-Weber syndrome is a neurological disorder indicated at birth by seizures accompanied by a large port-wine stain birthmark on the forehead and upper eyelid of one side of the face. Some children will have developmental delays and mental retardation; most will have glaucoma (increased pressure within the eye) at birth or developing later. Some children will have developmental delays and mental retardation; most will have glaucoma (increased pressure within the eye) at birth or developing later. Port wine stain Port wine stain

218 Peds GCS/EMV - ? 1 year old, MVC, cries during exam, opens eyes spontaneously when saying Dr says name, localizes pain but not following commands 1 year old, MVC, cries during exam, opens eyes spontaneously when saying Dr says name, localizes pain but not following commands No clue

219 1 year old, MVC, cries during exam = 3 or 4 1. opens eyes spontaneously = 4 localizes pain but not following commands = 5 Total = 12 or 13

220 Eye Opening Eye Opening 4 Spontaneously 4 Spontaneously 3 To voice 3 To voice 2 To pain 2 To pain 1 No response 1 No response Verbal Response Verbal Response 5 Appropriate words, spontaneous cooing 5 Appropriate words, spontaneous cooing 4 Inappropriate words 4 Inappropriate words 3 Cries 3 Cries 2 Incomprehensible sounds, grunts 2 Incomprehensible sounds, grunts 1 No response 1 No response Motor Response Motor Response 6 Obeys 6 Obeys 5 Localizes pain 5 Localizes pain 4 Flexion withdrawal 4 Flexion withdrawal 3 Flexion abnormal (decorticate posturing) 3 Flexion abnormal (decorticate posturing) 2 Extension (decerebrate posturing) 2 Extension (decerebrate posturing) 1 No response 1 No response

221 Peds ICI/BHT Found significant ICI is unlikely in a child who does not exhibit at least 1 of the high-risk criteria Found significant ICI is unlikely in a child who does not exhibit at least 1 of the high-risk criteria Evidence of significant skull fx Evidence of significant skull fx Altered level of alertness Altered level of alertness Neuro deficit Neuro deficit Persistent vomiting Persistent vomiting Scalp hematoma Scalp hematoma Abnl behavior Abnl behavior coagulopathy coagulopathy

222 Headache Headache Dizziness Dizziness Depression Depression Confusion Confusion Nausea/vomiting Nausea/vomiting Sensitivity to light or noise Sensitivity to light or noise Anxiety Anxiety Poor memory Poor memory Lethargy Lethargy Slow response to questions Slow response to questions Decreased energy Decreased energy Irritability Irritability Blurred or double vision Blurred or double vision Poor concentration Poor concentration Poor balance Poor balance Insomnia Insomnia

223 SeveritySymptomsManagement Grade 1 (Mild) No LOC, ringing, headache, dizziness, or memory loss Observation May not return to competition until symptom-free upon exertion Grade 2 (Moderate) LOC 30 min Observation May not return to competition for 1 wk after symptom-free upon exertion Grade 3 (Severe) LOC >5 min or PTA >24 h Admit Refer for neurocognitive testing prior to resumption of contact sports LOC=loss of consciousness; PTA=posttraumatic amnesia

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226 Eczema / Atopic Dermatitis

227 The most common surgical cause of vomiting in infancy is a. Intestinal atresias b. Malrotation c. Pyloric stenosis d. Meconium ileus

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230 Pyloric Stenosis Pathophysiology: Marked hypertrophy and hyperplasia of the 2 (circular and longitudinal) muscular layers of the pylorus occurs, leading to narrowing of the gastric antrum. Pathophysiology: Marked hypertrophy and hyperplasia of the 2 (circular and longitudinal) muscular layers of the pylorus occurs, leading to narrowing of the gastric antrum. Frequency: In the US: The incidence of IHPS is 2-4 per 1000 live births Frequency: In the US: The incidence of IHPS is 2-4 per 1000 live births Sex: IHPS has a male-to-female predominance of 4:1, with 30% of patients with IHPS being first-born males Sex: IHPS has a male-to-female predominance of 4:1, with 30% of patients with IHPS being first-born males Age: The usual age of presentation is approximately 3 weeks of life (1-18 wk). Age: The usual age of presentation is approximately 3 weeks of life (1-18 wk). History: History: Classically, the infant will have nonbilious vomiting or regurgitation, which may become projectile (up to 70%), after which the infant is still hungry. Classically, the infant will have nonbilious vomiting or regurgitation, which may become projectile (up to 70%), after which the infant is still hungry. Emesis may be intermittent or occur after each feeding Emesis may be intermittent or occur after each feeding

231 Branchial cleft remnants present most commonly as a(n)? a.pain b.airway obstruction c.intraoral mass d.infection

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233 Pediatric Cardiopulmonary Arrests 10% 80%

234 Age distribution of arrests <7 mos mos Age (years) # Arrests

235 Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335: Arrive in ER in cardiac arrest (N = 80) Admit PICU (N=43) 54 % Died in ER (N=37) 46% Mod Deficit (N=3) PVS at 12 mos (N=2) Dead at 12 mos (N=1) Died in ICU (N=37) 46%

236 List at least 10 signs List at least 10 signs of pediatric Respiratory distress

237 Signs of Respiratory Distress Tachypnea Tachypnea Tachycardia Tachycardia Grunting Grunting Stridor Stridor Head bobbing Head bobbing Flaring Flaring Inability to lie down Inability to lie down Agitation Agitation Retractions Retractions Access muscles Access muscles Wheezing Wheezing Sweating Sweating Prolonged expiration Prolonged expiration Pulsus paradoxus Pulsus paradoxus Apnea Apnea Cyanosis Cyanosis

238 List signs of impending respiratory failure

239 Impending Respiratory Failure Reduced air entry Reduced air entry Severe work Severe work Cyanosis despite O 2 Cyanosis despite O 2 Irregular breathing / apnea Irregular breathing / apnea Altered Consciousness Altered Consciousness Diaphoresis Diaphoresis

240 1.Bruising from abuse 2.Petechial rash 3.Mongolian spots 4.HSP 5.No clue

241 Specificity of Fractures for Abuse High specificity High specificity Metaphyseal Metaphyseal Posterior rib Posterior rib Scapula Scapula Spinous process Spinous process Sternal Sternal Moderate specificity Multiple fractures Fractures of diff. age Epiphyseal Vertebral body Digital Complex skull Low specificity Clavicle Long bone shaft Linear skull

242 Radiographic Dating of Injuries Soft tissue findings Early2-5dPeak4-10dLate10-21d Periosteal new bone 4-10d10-14d14-21d Loss of Fx line; soft callus 10-14d14-21d Hard callus 14-21d21-42d42-90d Remodeling 3 mos 1 yr 2 yr Peds Clin NA 1996

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253 Candidiasis -Signs and symptoms Oral thrush Oral thrush usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese Nyastatin - works by contact! Nyastatin - works by contact! Perineal/diaper rash candidiasis Perineal/diaper rash candidiasis antifungal cream antifungal cream Keep dry and open to air Keep dry and open to air

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255 Speed Round Rashes Go Interns!! Name the rash and everything you know about it Name the rash and everything you know about it Cause Cause Treatment Treatment Prevention Prevention

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263 Question #1 A 1-week-old infant presents for his first newborn evaluation. He had been discharged apparently well and thriving at 48 hours of age. He now exhibits grouped vesicles on an erythematous base that were not present at birth. Wright stain of scrapings from the floor of the vesicles reveals multinucleated giant cells and balloon cells. A 1-week-old infant presents for his first newborn evaluation. He had been discharged apparently well and thriving at 48 hours of age. He now exhibits grouped vesicles on an erythematous base that were not present at birth. Wright stain of scrapings from the floor of the vesicles reveals multinucleated giant cells and balloon cells. Of the following, the MOST likely diagnosis is: A) bullous impetigo A) bullous impetigo B) congenital varicella B) congenital varicella C) herpes simplex virus infection C) herpes simplex virus infection D) incontinentia pigmenti D) incontinentia pigmenti E) recessive dystrophic epidermolysis bullosa E) recessive dystrophic epidermolysis bullosa

264 Skin Lesions (photos: University of California, Australian Herpes Management Forum, and eMedicine)

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