1. Common Paediatric Emergency Referrals Mark Anderson Consultant Paediatrician Great North Children’s Hospital

2. Case 1

3.  Unwell for 2 days with runny nose and cough  Felt hot  Difficulty breathing & wheezy today Archie, 18 months

4.  Examination  Coryzal  Mild subcostal recession  Quiet wheeze throughout chest Archie, 18 months

5. Differential diagnosis?

6.  Viral induced wheeze (VIW) – episodic wheeze  1 st presentation “asthma” – multi-trigger wheeze  (Bronchiolitis) Differential diagnosis

7. How to differentiate VIW from “asthma”?

8.  Can be difficult!  Asthma more likely if  Multiple triggers for wheeze  Interval symptoms  Personal or family history of atopy  Absence of virus (!) How to differentiate VIW from “asthma”?

9. Specific Therapy?

10.  Inhaled bronchodilator  Salbutamol  Ipratropium bromide  ?Steroids Specific therapy

11.  Little evidence for efficacy  120 children aged 1-5y given prednisolone or placebo  No effect on parental reported respiratory symptom score at 7 days  700 preschool children given prednisolone or placebo  No effect on duration of hospitalisation  No effect on respiratory symptom score in first 24 hours Steroids in preschool VIW

12.  Short burst therapy probably should be reserved for clinical features suggestive of atopic asthma  History of multi-trigger wheeze  Severe eczema  Family history of atopy Steroids in preschool VIW

13. What determines need for admission?

14.  Oxygen requirement (SpO2 <93%)  Respiratory effort  Hydration concerns  Social complications What determines need for admission?

15.  Preschool wheeze appears to have multiple phenotypes  Short burst oral steroids no longer the cornerstone of management for all preschool wheeze  Questions? Take home points

16. Case 2

17.  Unwell for 2 days with runny nose and cough  Feels hot  Mum noticed lump in neck Micah, 2 years

18. What do you want to know?

19.  Well/unwell  Location  Size  Heat  Other lymphadenopathy  Spleen/liver What do you want to know?

20.  4-5cm diameter firm swelling in upper cervical chain  Non-fluctuant  A few other small lymph nodes  No swallowing issues  Well otherwise Micah, 2 years

21. Plan of action?

22.  Do nothing?  Investigations?  Oral antibiotics?  Intravenous antibiotics? Plan of action?

23.  “Reactive”  Infection  Bacterial  Atypical mycobacterium  TB  Other Causes of acute cervical lymphadenopathy

24.  Fluctuant node  Incision & drainage/excision  Well  Oral antibiotics for 7-10 days – review in 48-72h  Unwell  IV antibiotics  Investigations probably only indicated for persistent adenitis (>2 weeks) Plan(s) of action

25.  Acute adenitis  If collection suspected, needs I&D  Oral antibiotics & review appropriate for the majority of well children  Questions? Take home points

26. Case 3

27.  Awoke complaining of left hip and thigh pain  Previously fit and well apart from an upper respiratory tract infection 7 days previously Bethany, 6 years

28. What else do you want to know?

29.  Characteristics of the pain  Systemic features  Recent travel or systemic illness  Medication history  (Trauma)

30. Bethany, 6 years  Refused to weight bear  Became very distressed at attempted examination  Temperature 38.7  Flushed & tachycardic

31. Differential diagnosis of the limping child?

32. Differential diagnosis of the limping child  Transient synovitis/ ”reactive” arthritis  Septic arthritis/osteomyelitis  Perthes’ disease  Slipped Upper Femoral Epiphysis  JIA  Malignancy  Abdominal/testicular pathology  Discitis, Lyme disease, NAI

33. Red flags  Severe & unremitting pain  Complete non-weight bearing  Pseudoparalysis  Night pain  Fever  Back pain  Features of malignancy

34. Bethany, 6 years  Differential diagnosis  Septic arthritis  Reactive arthritis

35. Investigations?

36. Investigations  White cell count 11.5 x 10 9 /L  CRP 30mg/L  ESR 15 mm/h  Plain X-ray normal  Urgent ultrasound – hip effusion

37. Kocher’s clinical prediction rule  Factors  Fever >38  Unable to weight bear  ESR>40mm/hr in the first hour  Serum WCC >12x106/L  Probability of septic arthritis  No factors present <0.2%  2 factors present 40%  3 factors present93%  4 factors present>99%

38. Bethany, 6 years  Presumptive diagnosis septic arthritis  Joint aspiration & wash out  Gran stain negative  >50,000 white cells/mm 3 on microscopy  IV antibiotics for 2 weeks, oral for 4 weeks

39. Take home points  Limping is a common presentation  Limping is not a diagnosis  Not all children need excessive investigation  All children need clear follow up plans

40. Thank you!