Major criteria to identify the child at risk suffering from diarrhea/vomiting Dehydration Juanita; Uni Münster general condition vigilance skin turgor fontanelle eyes: tears, dark eye circles (Halo) buccal mucosa: dry Heart rate/blood pressure urine production 10%-dehydration
Useful laboratory examination in children with dehydration for further acute management Electrolytes Blood gas analysis BUN/Creatinin Blood glucose
Top 10 drugs frequently prescribed by family doctors in gastrointestinal infections
Drug therapy in gastrointestinal infections Evidence-based I carbon: obsolet Probiotics: - Antibiotics-associated diarrhea (JAMA 2012): 13 patients must be treated to observe benefit in one subject.(Metaanalysis) - Infect-associated diarrhea (Cochrane Database of Systematic Reviews 2010): Shortening of duration of diarrhea from 3 days to 2.6 days, reduction of stool frequency on day 2 by factor 0.8 and so on
Drug therapy in gastrointestinal infections Evidence-based II Electrolyte-solutions: no effect on duration or severity of diesease, „gruesome“ flavour. Antibiotics: only in septicemia, salmonella infection of the newborn, severe campylobacter infection, immunodeficiency, amebae.
Treatment of diarrhea < 5%: dietary measures (treatment at home): NO COCA COLA!!!! 5-10%: Compliance, assure that fluid intake is guaranteed, vigilance/GC > 10%: acute life-threating, immediate parenteral substitution (e.g. 0,9% NaCl 20ml/kg BW)
Symptomatic treatment of fever Thermical (cool wraps, vinegar wraps (heat of evapuration) drugs: Paracetamol Mefenaminacid Ibuprofen Acetylsalicylic acid
Fever-associated symptoms leading to diagnosis: PAIN Head – many causes Ear - Otitis media, Parotitis epidemica, Tonsillitis sore throat – Tonsillitis, Pharyngitis, Laryngitis thoracal - bronchitis, pneumonia, Pleuritis abdominal – infection of GIT, urinary tract infection, pneumonia, infection of the upper repiratory tract, appendicitis, meningitis Micturition – urinary tract infection
Possible other symptoms associated with fever: likely diagnosis rhinitis- infection of the upper respiratory tract cough - acute bronchitis, pneumonia, pertussis, infection of the upper respiratory tract dyspnea - pneumonia, bronchiolitis, wheezy bronchitis vomiting – Meningitis/encephalitis, infection of the GIT, urinary tract infection, upper respiratory tract infection diarrhea – infection of the GIT, urinary tract infection, upper respiratory tract infection cerebral seizures – Meningitis/encephalitis, febrile convulsion (roseola infantum) journey abroad – Malaria, Dengue-Fever
Fever without focus: patients at risk Newborns: Infection, diabetes insipidus infants: bacterial infections only in 10-15% in the first year of life, younger than 3 months of age only in 5% CAVE: OCCULT SEPTICEMIA Increased risk for septicemia in the age up to 6 months if temperature is >40°C, leucocytes are 15000/µl, CRP is increased. Hyperpyrexia: Meningitis, septicemia,pneumonia; (T > 41°C) DD heatstroke fever with petechiae: septicemia
Primary care determines prognosis The first 24 hours determine the outcome Mortality in Austria 5-10%
DIAGNOSTICS in suspected meningococcal infection Obtain blood for blood culture There is no need for lumbar puncture – avoid waste of time
ANTIBIOTIC TREATMENT Penicilline G i.v. oder i.m. oder Cephalosporine Ceftriaxone 100mg/kgKG i.v. oder i.m.
Treatment guidelines stable child Time to hospital ‹ 45 min Antibiotics i.v. or i.m. Time to hospital › 45min Volume + antibiotics i.v.
Treatment guidelines unstable child VOLUME 20ml/kgKG in 10 min -300ml/kgKG/24h antibiotics intubation catecholamine
Drug groups used for the symptomatical treatment of cough Mucolytics (N-Acetylcystein, Ambroxol, ivy-extracts): Cochrane Database Syst Rev 2010 and Cochrane Database Syst Rev 2002: No benefit in acute respiratory tract infections in children, side-effects (middle ear effusion) Antitussiva (Codein, Pentoxyferin,Thyme-extract with alcohol (4%): Cochrane Database Syst Rev, 2008: should be avoided in children due to side-effects and blocking of mucociliar clearance
Symptomatic treatment of cough in children Rhinitis + cough: decongesting nose drops Rhinitis + cough + wheeze: decongesting nose drops + inhaled beta2-Agonists Pharyngitis/Tonsillitis + cough: nothing Pharyngitis/Tonsillitis + cough + wheeze: inhaled beta2- Agonists Pneumonia + cough: inhaled beta2-Agonists Subglottic laryngitis: cold air, (topical or systemic steroids)
Does the X-ray help us in identification of the pathogen? Radiologic findings are frequently not associated with the pathogen in acute pneumonia.
Age as possible evidence to the pathogen agebacteriaVirus newbornsB-Streptoc., E.coli, Listerien, Haem. infl. CMV, Rubella, HSV 2.week – 12.weekStrept. pneum., Chlam. trach., Bordatella pert., Haem. infl. -> only 10% of all pneumonia RSV, Parainfluenza 1-3 Influenza, Adenovirus, CMV Older infants/toddlers Streptoc. pneum., Haem. infl., Staph.aur., Mycobacterien, Meningococcus RS Virus, Parainfluenza, Adenovirus., Influenza B, Rhinovirus School-aged children/ adolscents Mycoplasma pneumoniae Haem. Infl., Chlamydia pneum. Adenovirus, EBV, Parainfluenza, Influenza, Rhinovirus, RSV
Differenzierung zwischen bakterieller und viraler/atypischer Pneumonie Symptoms/resultsBacterial PneumoniaVirale/atypical Pneumonia onsetacutecreeping fever+++++(+) Rhinitis/Pharyngitisrarelycommonly dyspnoea++(+)+(+) Myalgia++++ wheeze- (+)+(+) Pleural effusionMore frequentrare auscultation++++ LeucozytosisfrequentlyRare (except Adenovirus) CRPincreasedNormal to slightly increased ESRNormal to enhancedenhanced
Age : Which empiric antibiotics? ageOutpatient (p.o.)hopsitalized(i.v.) newborns -Ampicillin/Cefotaxime Aminoglycoside infants<6 Mo -Cephalosporine (e.g. Cefotaxime), Aminopenicilline/Clav. infants >6 Mo toddlers Amox./Clav. Cephalosporine (Cefuroxim, Cefpodoxim, Cefixim) Cephalosporine (e.g. Cefotaxime), Aminopenicilline/Clav. School aged children Macrolide (Clarithromycine, Josamycine) Cephalosporine (Cefuroxime, Cefpodoxime, Cefixime) Amox./Clav. Cephalosporine (Cefuroxime, Cefotaxime), Amox./Clav. Macrolide