8 “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.
9 Tinea…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.Ringworm of the scalp (tinea capitis). This form is most common in children and involves red, itchy patches on the scalp, leaving bald patches.
16 ChalazionChalazions may be treated with any one of the following methods: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.3) Massage of expression of the glandular secretions;4) Surgical incision or excision.
21 Pre-septal and Orbital Cellulitis Bacterial infection usually results from local spread of adjacent URTIPreseptal usually follows periorbital trauma or dermal infectionOrbital most commonly secondary to ethmoidal sinusitisPreseptalStaphylococcus aureus and Staphylococcus epidermidis StreptococcusOrbitalStrep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes
25 Burn Depth Deep partial thickness burn Red or Blanched Thick walled blistersDecreased two point discriminationMild or exquisitely painfulMay heal by epithelialization 3-6 weeksHigh scar and contracture potential
38 Henoch-Schonlein Purpura Clinical PresentationEffects predominantly young children, but adults are also affectedPeak incidence is 4-5 years of ageThere is a slight male predominanceThe condition is more prevalent in the winter and early springThe 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 presentationPurpuraColicky abdominal painarthritis50% of children may present with symptoms other than purpuraRisk of Intuss
46 Spontaneous subconjunctival haemorrhage Painless red eye without dischargeVA not affectedClear bordersMasks conjunctival vesselsCheck BP and body for other hemorrhagesNo treatment (lubricants)10-14 days to resolveIf recurrent: clotting, FBCAlways consider abuse…
53 Erythema MultiformeSymmetrically 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.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.Postinflammatory hyperpigmentation or hypopigmentation may occur.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.
57 Varicella Agent: varicella zoster virus Transmission: respiratory Period of communicability: 1 day before eruption of vesicles.Prodromal phase: slight fever, malaise, pruritic rash; macular to papular to vesicular.57
58 Management of Varicella IsolationSkin care: tepid bath, calamine lotion, clip finger nails.Keep from scratchingAntihistamines for itching - BenadrylNo ASA – acetaminophen only.Varicella vaccine now available.97% immunity in 2m-12 y78% immunity in 13y-adult2% can have attenuated disease58
64 What is it? 1. Mumps 2. Measeles 3. Ruebella 4. Small pox 5. No clue Occurs more commonly in naïve populationsHarder when physician has never seen a case and non-susceptible population at large = few cases
65 Measles: Diagnosis / Clinical Clusters of children with fever, cough, conjunctivitis, coryza, morbilliform rashOccurs more commonly in naïve populationsHarder when physician has never seen a case and non-susceptible population at large = few cases
66 Measles: Signs and Symptoms Peak of Illness2-4 days after onset of rashOther signs and symptomsAnorexia, malaise, HSMResolutionRapid improvement at end of febrile period (1 week)Complete recovery in daysPearl: darker-skinned childrenSandpaper feel to rash may be helpful
67 Measles or Rubeola Agent: Virus Transmission: respiratory, blood and urineIncubation period: 10 to 20 daysPeriod of Communicability: 4 days before and 5 days after rash appears.Prodromal stage: fever, cough, conjunctivitis, Koplik spots.Can get same rash/illness up to 10 d after MMR
68 Measles: Signs and Symptoms RashHairlineBehind EarsErythematous papular eruptionTravels inferior over 2-3 daysCoalesces into macular “splotches”Often desquamates at end of illnessFaceTrunkLimbs
78 Down Syndrome Described by John Landon Down in 1866 Etiology: nondisjuction mutation resulting in Trisomy 21Prevalence 1:700Most common chromosomal anomalyAssociated with Maternal age > 35
79 Down Syndrome Characteristics Macroglossia Micrognathia Midface hypoplasiaFlat occiputFlat nasal bridgeEpicanthal foldsUp-slanting palpebral fissuresProgressive enlargement of lipsHands: 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 ambulateCardiovascular anomalies (40%)ASD, VSD, Tetralogy of Fallot, PDAGI anomalies (10-18%)Pyloric stenosis, duodenal atresia, TE fistulaMalignancy20 fold higher incidence of ALLGonadal tumors
81 Q: What’s the formula for minimal systolic bp for age?
82 Q: What’s the formula for minimal systolic bp for age? 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 defectDisorder of ammonia detoxificationMost common mitochondrial β oxidation disorder 1/10,0005% of 313 cases SIDSScreen all infants of mothers with HELLP syndromeResults in acute toxic encephalopathy with episodes of nonketotic hypoglycemia in the 1st 2 years of life provoked by fastingv/lethargy after fasting , usually with URI/AGEIn ED: coma, hypoglycemic hypoketotic, hyperammonemia, LFTsTX: D10Avoid fastingCarnitine 100mg/k/d
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 ageSeizure lasting less than 15 minutesFever present prior to the onset of the seizureNo other neurologic diagnosesNon-focal, generalized seizure, involving all limbsNo severe metabolic disturbanceNo more than a single seizure per 24-hour periodNo evidence of intracranial infection
91 Febrile SZ work-upClinicians 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.PEDIATRICS Vol. 127 No. 2 February 2011, pp
92 Febrile Seizures – Parental Education The risk of febrile seizure in the general population is between ?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.
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 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.The risk of epilepsy is minimally increased from 1% to 2.4% in patients who have a simple febrile seizure
96 Mumps Clinical Features Incubation period daysNonspecific prodrome of low-grade fever, headache, malaise, myalgiaParotitis in 30%-40%Up to 20% of infections asymptomaticMay present as lower respiratory illness, particularly in preschool-aged children
97 Mumps Pathogenesis Respiratory transmission of virus Replication in nasopharynx and regional lymph nodesViremia days after exposure with spread to tissuesMultiple tissues infected during viremia
109 A 4yo boy presents with painful rectal bleeding 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?Juvenile polyposisAnal fissureCrohn’s DiseaseMeckel’s diverticulum
110 A 4yo boy presents with painless rectal bleeding 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?Juvenile polyposisAnal fissureCrohn’s DiseaseMeckel’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”
120 Epiglottitis Symptoms Acute inflammation of supra-glottic structures.Medical EmergencySudden onsetHigh feverDysphasia and droolingEpiglottis is cherry red and swollenDiagnosis made on presenting symptomsNo tongue blade in mouthEmergency tracheostomy setNo procedures until in the operating roomKeep quiet
128 Necrotizing Enterocolitis Necrotizing = damage and death of cellsEntero = refers to intestinesColitis = inflammation of the colon60 to 80% are premature infantsFeeding of concentrated formulasInfants who have received blood transfusionInfants with GI infectionsInfants 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? HypothermiaChild AbuseHazardous Environments
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.
143 Clostridium tetani Anaerobic gram-positive, spore-forming bacteria Spores found in soil, dust, animal feces; may persist for months to yearsMultiple toxins produced with growth of bacteriaTetanospasmin estimated human lethal dose = 2.5 ng/kg
144 Tetanus Clinical Features Incubation period; 8 days (range, 3-21 days)Three clinical forms: Local (not common), cephalic (rare), generalized (most common)Generalized tetanus: descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasmsSpasms continue for 3-4 weeks; complete recovery may take months
147 Pathogenesis of Lyme Borreliosis Lyme disease characterized by three stages:Initially a unique skin lesion (erythema chronicum migrans (ECM)) with general malaiseECM not seen in all infected hostsECM often described as bullseye rashLesions periodically reoccurSubsequent stage seen in 5-15% of patients with neurological or cardiac involvementThird stage involves migrating episodes of non-destructive, but painful arthritisAcute illness treated with phenoxymethylpenicillin or tetracycline
156 Child Abuse History story injuries history changing injury developmentdelay seeking helpinappropriate level of concernPhysical Exammultiple old and new bruisesposterior rib #, sternum #, spiral # < 3 yoimmersion burns, cigarette
158 ImpetigoImpetigo 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.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.
161 Pityriasis RoseaIt 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.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 6-14.Aveeno oatmeal baths, anti-itch medicated lotions and steroid creams may be prescribed to combat the rash. Lukewarm, rather than hot, baths , ERYC, Famvir
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.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.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.Classic cutaneous findings follow within 3-7 days for some patients, while other patients may manifest no findings.
166 Erythema Infectiosum (Fifth Disease) Physical: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 (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.
167 Erythema Infectiosum (Fifth Disease) 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.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 cc/24hrsb cc /24hrsc cc/24hrsd cc/24hrs“4-2-1 rule”0-10 kg 4cc/hr x wt11-20 kg 2cc/hr x wt>20 kg 1cc/hr x wtEasy methodAnyone >20kg =wt + 40
169 Proper fluid bolus for a 9kg infant who presents as a severe trauma with unstable vitals is? a cc LR x 2, then 90cc/kg pRBCsb cc NSS, then 90 cc NSSc cc LR, then 180cc pRBCsd cc LR x 2, then 90cc 5% albumin, then 90cc pRBCs
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 streptococciInfections 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.
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.Scarlatiniform rashExanthem texture is usually of coarse sandpaper, and the erythema blanches with pressure.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.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.TXTreat 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 2. Fever 3. Anterior Cervical Lymphadenopathy4. No “cold” symptoms (ie no cough or runny nose)
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.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.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.
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 identifiedIn 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.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.Coccidioidomycosis, dermatophytosis, and histoplasmosis are the fungal possibilities.Malaria and trichomoniasis have been reported as protozoal causes.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.Various carcinomas and lymphomas have been associated.SJS is idiopathic in 25-50% of cases
182 TOF 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)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)
184 TOFFirst presentation may include poor feeding, fussiness, tachypnea, and agitation.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.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 flowIf left untreated, may result in syncope, seizure, stroke, or death
185 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.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.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.General anesthesia is a last resort.
187 Infectious mononucleosis History: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.Prodromal symptoms consisting of 1-2 weeks of fatigue, malaise, and myalgia are commonIn 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.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.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 lymphocytesAlso can have thrombocytosisSplenic 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.
196 Radiograph This is the radiograph taken of the patient. Do you know the diagnosis?
197 Note in the AP pelvis on the left that the joint appears widened – this is a finding seen in septic arthritis (unlikely given the long time course of the pain) and Legg-Calvé-Perthes (LCP) disease.In LCP, the joint space widening represents increased soft tissue in the joint space.In the closeup of the same hip, note the crescent sign. The crescent sign results from the fact that the cortical rim or periosteum is nourished by the synovial fluid but the underlying cortical bone begins to collapse because of lack of blood supply to the area. The result is subcortical collapse, which forms a lucent crescent.These are the earliest findings of LCP disease.
198 Legg-Calvé-Perthes Disease Avascular necrosis leading to collapse, fragmentation, and then reossificationMost frequent between 4 and9 yearsBoys more often than girlsBilateral in 10% of casesLCP disease is an avascular necrosis of the femoral head, leading to collapse, fragmentation, and then finally a reossification process.It occurs most frequently in younger children (ages 4 to 9) but has been reported as early as 2 and as late as 13 years.Boys tend to get it more frequently than girls, and bilateral involvement, although not common, does occur.
199 Management - LCP Disease is self-limited – limp can last 2 to 4 years Nonsteroidal anti-inflammatory agentsLimit activitiesCrutches/braces occasionally neededMay help maintain spherical femoral headBetter outcomes in younger childrenThis disease is generally a self-limited one but can last for several years, and thus supportive care is all that is generally required.The disease is a prolonged one, however, and the patient will need to be quite vigilant over the 2- to 4-year disease period.Generally pain control and limiting of activities are the recommended treatment course.Occasionally braces or crutches are recommended.The primary goal of treatment is to maintain the spherical shape to the femoral head until the reossification period takes place.The younger the child, the better the prognosis.Long-term studies reveal a higher incidence of osteoarthritis and total hip replacement much later in life.
201 Clinical Features: Your First Clue IrritabilityFeverErythemaLimp/refusal to walkDecreased range of motion of limbTo review, the clues to this diagnosis, particularly in the younger child, include irritability, fever (present in 50% of cases), redness overlying the joint, limp or refusal to walk, and decreased range of motion of the limb.
203 ManagementOnce the diagnosis of septic joint is made, surgical intervention should proceed ASAP.Needle aspiration or open surgical drainage requiredOnce the diagnosis is made, surgical intervention should proceed as soon as possible. Needle aspiration or open surgical drainage should be arranged, and antibiotics should be given immediately.
204 Synovial Fluid Findings The synovial fluid of septic arthritis is often turbid or grossly purulent with a WBC greater than 40-50,000/mm3.Glucose in synovial fluid is often low, and protein and lactate are elevated.
205 Septic Arthritis Treatment by Age The correct initial coverage should be for Staphylococcus aureus in the normal host, with broader coverage given to special patient populations such as the sickle cell population (Salmonella), the IV drug abuser (Methicillin-resistant S aureus), and the neonate (Group B strep and Gram-negative organisms).
207 KerionThis is a vigorous inflammatory reaction to dermatophyte infection, occasionally associated with secondary bacterial infection, that occurs on the scalp, resulting in a boggy inflammatory swellingUntreated 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”
210 Oral thrush 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
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.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 RubellaIncubation 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.
215 RubellaThe 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)ConjunctivitisSore throatHeadacheGeneral body achesLow-grade feverChillsAnorexiaNauseaTender lymphadenopathy
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.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”
218 Peds GCS/EMV - ?1 year old, MVC, cries during exam, opens eyes spontaneously when saying Dr says name, localizes pain but not following commands151413121110No clue
219 1 year old, MVC,cries during exam = 3 or 41. opens eyes spontaneously = 4localizes pain but not following commands = 5Total = 12 or 13
220 Modified Pediatric Glasgow Coma Scale Eye Opening4 Spontaneously3 To voice2 To pain1 No responseVerbal Response5 Appropriate words, spontaneous cooing4 Inappropriate words3 Cries2 Incomprehensible sounds, gruntsMotor Response6 Obeys5 Localizes pain4 Flexion withdrawal3 Flexion abnormal (decorticate posturing)2 Extension (decerebrate posturing)1 No response220
221 Peds ICI/BHTFound significant ICI is unlikely in a child who does not exhibit at least 1 of the high-risk criteriaEvidence of significant skull fxAltered level of alertnessNeuro deficitPersistent vomitingScalp hematomaAbnl behaviorcoagulopathy
222 Symptoms and Signs of Concussion HeadacheDizzinessDepressionConfusionNausea/vomitingSensitivity to light or noiseAnxietyPoor memoryLethargySlow response to questionsDecreased energyIrritabilityBlurred or double visionPoor concentrationPoor balanceInsomnia
223 Table 2. Recommendations for Return to Sports after Head Injury Based on Grade of Concussion SeveritySymptomsManagementGrade 1 (Mild)No LOC, ringing, headache, dizziness, or memory lossObservation May not return to competition until symptom-free upon exertionGrade 2 (Moderate)LOC <5 min or PTA >30 minObservation May not return to competition for 1 wk after symptom-free upon exertionGrade 3 (Severe)LOC >5 min or PTA >24 hAdmit Refer for neurocognitive testing prior to resumption of contact sportsLOC=loss of consciousness; PTA=posttraumatic amnesia
230 Pyloric StenosisPathophysiology: 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 birthsSex: IHPS has a male-to-female predominance of 4:1, with 30% of patients with IHPS being first-born malesAge: The usual age of presentation is approximately 3 weeks of life (1-18 wk).History: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
231 Branchial cleft remnants present most commonly as a(n)? a. painairway obstructionintraoral massd. infection
234 Age distribution of arrests 123456789101112131415<7 mos7-12 mosAge (years)
235 Arrive in ER in cardiac arrest (N = 80) Admit PICU (N=43) 54 % Died in ER(N=37) 46%Mod Deficit(N=3)PVS at12 mos(N=2)Dead at12 mos(N=1)Died in ICU(N=37) 46%Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:4
236 List at least 10 signsof pediatricRespiratory distress
237 Signs of Respiratory Distress TachypneaTachycardiaGruntingStridorHead bobbingFlaringInability to lie downAgitationRetractionsAccess musclesWheezingSweatingProlonged expirationPulsus paradoxusApneaCyanosis15
240 Bruising from abuse Petechial rash Mongolian spots HSP No clue The photo on the left is a child with many mongolian spots. The right is a child after sustaining “coining” in an attempt to alleviate his illness.
241 Specificity of Fractures for Abuse High specificityMetaphysealPosterior ribScapulaSpinous processSternalModerate specificityMultiple fracturesFractures of diff. ageEpiphysealVertebral bodyDigitalComplex skullLow specificityClavicleLong bone shaftLinear skull
242 Radiographic Dating of Injuries Soft tissue findingsEarly2-5dPeak4-10dLate10-21dPeriosteal new bone10-14d14-21dLoss of Fx line; soft callusHard callus21-42d42-90dRemodeling3 mos1 yr2 yrPeds Clin NA 1996
253 Candidiasis -Signs and symptoms Oral thrushusually 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 cheeseNyastatin - works by contact!Perineal/diaper rash candidiasisantifungal creamKeep dry and open to air
263 Question #1A 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 impetigoB) congenital varicellaC) herpes simplex virus infectionD) incontinentia pigmentiE) recessive dystrophic epidermolysis bullosa
264 Skin Lesions (photos: University of California, Australian Herpes Management Forum, and eMedicine)