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Jen Avegno, MD LSU – New Orleans Emergency Medicine Resident Conference 2010.

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Presentation on theme: "Jen Avegno, MD LSU – New Orleans Emergency Medicine Resident Conference 2010."— Presentation transcript:

1 Jen Avegno, MD LSU – New Orleans Emergency Medicine Resident Conference 2010

2  2006 National Hospital Ambulatory Medical Care Survey showed:  most common ED diagnosis for  kids <1 = upper respiratory infection  kids 2-12 = otitis media/ear disorders  In all, fever is the most common chief complaint of kids presenting to the ED (about 20-30% all peds visits)

3 this lecture is about NOT

4  Review high-yield, commonly encountered, infections of childhood  Discuss pathophysiology, common organisms, presentations, management and treatment of each  See LOTS of pictures of my children

5  Mom brings in a 3-week-old baby girl with a fever for 4 hours. The child was a normal vaginal delivery with no complications and has been feeding and growing well at home. This morning, she began to “spit up” her bottle and had several loose stools. She has been somewhat sleepy but does respond to her parents. Physical exam reveals a child in no distress with a rectal temperature of and a normal exam for age.

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7  what is the risk of serious bacterial illness (SBI) in kids less than 3 months with fever?  SBI = UTI, bacteremia, meningitis, osteo, pneumonia, gastroenteritis, cellulitis, septic arthritis  risk is about 6-10% in these kids, with those younger than 1 month having the highest chance of SBI  kids under 3 months may present looking like “viral syndrome” but still have SBI … in one study, kids less than 60 days with temp>38:  22% had RSV  7% with RSV also had concomitant SBI

8  immature immune system  exposure to pathogens during delivery (esp. GBS)  cannot mount immune response to prevent localized infection from disseminating

9  fever = “a pyrogen-mediated rise in body temperature above normal range”  what is a NORMAL temp?  the magical 98.6 was set as “normal” by a German guy in the 19 th century using a 22cm long mercury glass thermometer … we now think that his instruments may have been OFF by degrees!!  normal temps can vary by age in kids from 99.5 (neonates) to 98 (older kids)  temps are influenced by age, sex, race, time of day, activity level, ambient temp, site of measurement, type of device

10  NO REAL EVIDENCE to support the hard- and-fast cutoff of (38°C) – evidence suggests that oral temps may be considered febrile depending on situation  BEST SITE to measure temperature …  the hypothalamic artery. (yeah, right)  take-home point: fever is an ARBITRARY number – base your workup on overall clinical impression, not a particular cutoff

11  oh, yeah, the “mom hands” … don’t blow them off!  60% of parents use their hands instead of a thermometer to assess fever  is this method accurate? studies show:  74-90% sensitive  76-86% specific  85-94% NPV  the exact number or method doesn’t matter … BELIEVING the parents is!

12 AGEBACTERIALVIRALOTHER 0-28 daysGroup B Strep Listeria E. Coli C. trachomatis N. gonorrhoeae Herpes simplex Varicella Enterovirus RSV Flu Bundling environment 1-3 monthsH. flu S. pneumo N. meningiditis E. coli Varicella Enterovirus RSV flu Bundling environment

13  length of illness  localized symptoms?  pertinent PMH, birth hx of both mom & baby  sick contacts  vaccination status  any meds/ABx

14  VITAL SIGNS (yes, ALL of them!!)  ABCs – respiratory/airway distress? signs of shock? tachycardia?  for infants less than 1 year, HR should increase 10 beats for every 1°C  TAKE THOSE CLOTHES OFF!!  just remember … in non-immunocompetent kids (neonates) … fever may be the ONLY presenting sign of SBI – do not be reassured by a “normal” exam!!

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16  again, ABCs … consider intubation for respiratory distress, hypoxia, altered MS  fluid resuscitation: 20 ml/kg IV/IO fluids to total of ml/kg (if hypovolemia persists)  cultures prior to Abx, if possible  sterilization of CSF can occur as quickly as 15 min – 2 hrs after receiving Abx, so watch results!  BROAD SPECTRUM TREATMENT:  Ampicillin + (Gentamycin or Cefotaxime) – avoid Rocephin in kids <28 days  Vanc? Acyclovir?

17 PHILADELPHIAROCHESTERBOSTON AGE29-60 d<60 d28-89 d TEMP>38.1>37.9 EXAMwell, no focus LAB VALUES (low- risk) WBC <15 Band<0.2 UA < 10 wbc CSF < 8 wbc neg CXR WBC 5-15 band <1500 UA <10 wbc WBC <20 UA <10 wbc CSF <10 wbc neg CXR HIGH-RISK dispoadmit, IV Abx LOW-RISK dispohome, no Abx home, empiric Abx How good is it?? sens/spec PPV/NPV 98%/42% 14%/99.7% 92%/50% 12%/98.9% NPV 94.6% ** these rules miss very few kids with SBI **

18  cancer  toxic shock  autoimmune and/or congenital disorders (cardiac, pulmonary)

19  Dad comes to the ED with little Maria, age 2, and reports that she has had a fever for the last 2 days (up to at home). The parents have tried Tylenol and Motrin to no avail. Maria has not eaten much but is still drinking water and juice. She had a “runny nose” a few days ago, but is not sneezing, coughing, or vomiting. In the ED, Maria has a temperature of She looks droopy, but interacts well with her parents.

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21  fever is the most common complaint in this age group!!  unlike neonates, of young children who present with viral illness (RSV, croup, bronchiolitis etc) and fever (>39), less than 0.5% will also be bacteremic

22  concern here is for OCCULT BACTEREMIA  before HiB and Prevnar, the rate of occult bacteremia in the non-focal febrile child was 5%  currently … it is less than 1% with other pathogens more prevalent  N. meningiditis  urinary pathogens

23  WHY do we treat a fever?  feel better/decrease anxiety  lower morbidity/mortality  prevent febrile seizures  HOW do we treat a fever?  ambient temp control  light clothing/bedding  fluids  sponge bath  warm feet/potatoes or onions in socks (REALLY!)  antipyretics

24  Acetaminophen 15 mg/kg every 4-6 hours  Ibuprofen 10 mg/kg every 6 hours  alternate??  evidence shows some minor benefits in reducing fever faster and lasting longer BUT …  potential for dosage/scheduling errors; synergistic renal toxicity; difficult to understand and comply  detailed information/handout at appropriate reading level on administration of antipyretics should be given to caregivers!!

25 AGEBACTERIALVIRALOTHER 3-36 monthsS. pneumo N. meningiditis E. coli Varicella Enterovirus RSV Flu Mono Roseola Adenovirus Norwalk Coxsackie Leukemia Lumphoma Neuroblastoma Wilms’ tumor

26  length of illness  localized symptoms?  headache – neck pain – sore throat – ears – cough (describe!!) – wheeze – vomiting – RASH – mental status  use of antipyretics (**defervesence after use does NOT exclude bacteremia!)  sick contacts  po intake/output  vaccination status  any meds/ABx

27  VITAL SIGNS (yes, ALL of them!!)  ABCs – respiratory/airway distress? signs of shock? tachycardia?  capillary refill is an easy and reliable indicator of perfusion  TAKE THOSE CLOTHES OFF!!  thorough search for focal findings

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29  most guidelines argue for getting the WBC first, then CXR if WBC > 20k … but who does this?  study showed that rate of pneumococcal bacteremia increased to 0.5% with WBC 10-15k; 3.5% with WBC 15-20k; 18% with WBC>20k  ANC >10k (include all immature forms) increases risk of bacteremia by 10-fold over those with ANC<10k

30  the post-immunization world has resulted in much lower rates of bacteremia for this age group:  where bacteremia rates in febrile kids >1.5%, the most cost-effective strategy is a WBC, blood CX, and empiric Abx (Rocephin)  when rates <0.5%, clinical judgment alone for treatment & management is most useful to select out high-risk groups  kids 3-6 mo are still relatively non- immunocompetent … recommendations are for all kids in this age group with temp >39 to have WBC & BCx; treat all WBC > 15k with empiric ABx

31  CANCER  autoimmune disease: JRA, Kawasaki’s  brain tumors

32  Mom brings in a 6 year-old boy with “pink eye.” She got a call from school today that the child’s right eye was red and draining yellow gunk, and that she needed to pick him up. The boy is afebrile and non toxic, with no recent illnesses or PMH. Immunizations are up to date. He has mildly injected right conjunctiva with some seropurulent drainage from the eye, as well as mild nasal mucoid rhinorrhea. What now?

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34  conjunctivitis = “inflammation of bulbar & palpebral conjunctiva caused by various viral, bacterial, mechanical, allergic & toxic agents”  most frequent pediatric eye complaint in the ED

35  viral: adeno, coxsackie, entero, rhino, flu **MOST COMMON**  bacterial:  S. pneumo  H. flu  S. aureus  M. catarrhalis  N. gonorrhoeae (yuck)  less common: other Gram negatives (Pseudomonas)

36  viral – generally itchy, red, irritated with watery or purulent discharge, preauricular LAN  associated with other URI sc  may start in one eye & spread to other  may last longer than bacterial  bacterial – “pinkeye,” redness, FB sensation, lid swelling, drainage, “eye boogers”  usually no photophobia or vision impairment  allergic – very itchy, usually bilateral

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40 FINDINGBACTERIALVIRAL Bilateral at onset50-74%35% Conjunctival dischargemucopurulentwatery Preauricular adenopathylateearly Concurrent OM20-73%10%

41  viral – artificial tears, cool compresses, antihistamine drops if necessary  bacterial – warm compresses & topical Abx:  sulfa, floxin (ok in kids!), erythromycin, neomycin  ointment vs. drops??  ointment – soothing, prolonged contact with conjunctiva  drops – do not blur vision, ?easier to get in?  tx for 7 days

42  no established guidelines for ED management/care of conjunctivitis (darn.)  bacterial conjunctivitis – most common standard is return to school 24 hours after beginning Abx treatment  viral conjunctivitis – ??  If you don’t think it’s pinkeye … SAY SO & DOCUMENT for parents!

43  ophthalmia neonatorum – conjunctivitis within 1 st month of life  within 1 st 2 weeks – gram stain & culture of drainage  N. gonorrhoeae – usually from birth canal, within 1 st 1-7 days of life – must carefully evaluate for disseminated GC  tx = Rocephin  Chlamydia – usually sx between 5-19 days old  tx = topical Erythromycin  chemical – from ointment given at birth; dx of exclusion  HSV & VZV can affect the eyes and lead to scarring, dry eye

44  Mom brings in a 15-month old girl who woke up last night screaming and with fever to She has not eaten much today but is drinking liquids with normal urine output. All of her immunizations are up to date and she is otherwise healthy. On exam, you note a mildly ill appearing, non-toxic child who responds well to mom. The left TM is red and bulging with loss of landmarks.

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46  Most commonly diagnosed disease in kids <15  By age 3 – estimated that more than 80% of kids have had one episode; 40% have had >3  Risk factors:  Male  Smoking  Day care  Family history  Anatomic abnormalities  Winter  Bottle feeding

47  ACUTE: s/s of acute infxn WITH effusion  aka “acute suppurative” or “prurulent” OM  OME: effusion WITHOUT s/s of acute infxn  aka “serous,” “mucoid,” “secretory,” “nonsuppurative”  CHRONIC: chronic ear discharge from perforated membrane  RECURRENT: >3 episodes in 6 mo or >4 episodes in 1 year

48  It’s all about the tube – functions of the eustachian tube:  Ventilates middle ear for pressure equilibration  Drains middle ear  Protects ear from NP secretions  Only open when yawning/chewing/swallowing CHILD When the eustachian tube becomes obstructed … Middle ear ventilation Negative middle ear cavity pressure causes fluid to move into middle ear (transudate)and combine with NP secretions & bacteria

49 S. Pneumoniae H. flu –higher % in OME M. catarrhalis S. aureus S. pyogenes gram-negative bacteria VIRUSES:

50  “Pulling at ears”  Cough  Vomiting & diarrhea  Decreased po intake  Fever – may be present in only ¼ of cases, with less than 10% having temp >40  URI sx

51 pars flaccida umbo malleus light reflex pars tensa eustachian tube opening

52  What does the TM look like? normal bulging erythematous hemorrhagic

53 Middle ear effusions other indicators of AOM: lack of TM mobility *** (MOST RELIABLE SIGN) cloudy, retracted, dull TM 1/3 of cases may NOT have symptoms!

54 AAP/AAFP guidelines state that the following should be present to dx AOM: 1. Recent, usually abrupt onset of s/s 2. Presence of middle ear effusion (bulging, limited TM mobility, air-fluid level, otorrhea) 3. S/s of middle ear inflammation (erythema or otalgia)

55  AAP guidelines on management of AOM in kids:  Dx by hx of acute onset + signs of effusion + signs of middle ear inflammation  Assess for pain – if present, treat  Limited role for observation in select patients > 2 years (must have “a ready means of communication with clinician”)  If treat with ABx – start with amox mg/kg/day  If treatment failure by hours – reconsider dx or change ABx

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57  Important points:  “treatment failure” = lack of clinical improvement and/or persistent signs of AOM  Bactrim & macrolides often considered 2 nd line, but resistance rates approach 30-40%  Courses are generally 10 days in patients < 2 yrs, perf TM, and recurrent OM, recommended in patients <6 years  NO INDICATION for antihistamines, decongestants, steroids, or tubes in single episode AOM  Auralgan may be useful for pain relief  Tx of OME (either alone or following episode of OM) is controversial – ABx? Antihistamines?  Tubes for patients with OME for 4-6 months, failed tmt, and hearing loss

58  otitis externa  mastoiditis

59  Parents bring an 8 year old boy to the ED with fever of 102.3, and complaints of headache and abdominal pain. He was otherwise healthy until this morning, and his shots are all up to date. The patient is febrile and tachycardic to 120 with normal blood pressure. He is ill-appearing but non- toxic, speaks normally, and is not drooling. His oropharynx is red with bilateral white exudates and tender, palpable cervical lymphadenopathy.

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61  dx of tonsillitis/acute pharyngitis is made more than 7 million times/year  MCC is viral in kids  MCC bacterial pharyngitis is GABHS (15-30%)  kids 5-15 y/o predominantly  Group C & G Strep are likely much more common than typically thought & may be missed by routine testing  about 1 in 4 kids with acute sore throat has serologically confirmed GABHS  MC in winter when respiratory viruses predominate

62  BACTERIAL:  Strep  Group A  Groups C & G  mixed anaerobic (“Vincent’s angina”)  N. gonorrhoeae  C. diphtheriae  Arcanobacterium haemolyticum; Yersinia; tularemia  atypicals

63  VIRAL: rhino, corona, adeno, paraflu, flu, CMV;  HSV 1 & 2 – oral gingivostomatitis  Coxsackie – aka herpangina – fever & painful, white-gray papulovesicular lesions/ulcers in posterior OP  EBV - **mono**  severe pharyngitis with GENERALIZED LAD (posterior cervical), hepatosplenomegaly, periorbital edema, palatal petechiae  Amoxil rash!!  HIV** may be most common presenting sx!

64 weird looking throats herpangina HSV stomatitis Vincent’s angina diphtheria

65  sick contacts – common in both bacterial & viral causes  how to differentiate viral vs. bacterial sore throat? BACTERIAL (GABHS)VIRAL Sudden onsetMore gradual + fever+/- fever headacheconjunctivitis N/V/abd paindiarrhea Tender anterior LADCough, hoarseness, coryza Patchy discrete exudatesmyalgias Scarlatiniform rash

66  single throat swab & culture is 90-95% sensitive; rapid kits are 90-99%  Modified Centor criteria for dx of GABHS in kids:  tonsillar exudates  tender anterior cervical LAD or lymphadenitis  absence of cough  hx of fever  age < 15 add 1 point SCORERISK OF GABHS MGT %No testing or Abx 15-10% %Culture; Abx for + results % %Tx without test

67  most common viral causes are self-limited and resolve with supportive tx  GABHS is generally self-limited and resolves without tx … but … why do we treat with Abx?  symptom relief; decrease spread; shorten duration of illness (16 hrs)  prevent complications (1 in 1000)  suppurative – bacteremia, endocarditis, mastoiditis, meningitis, OM, PTA, RPA, pneumonia  nonsuppurative – PSGN, RF

68  Abx options:  Pen V K po or Pen G IM  Amox  PCN allergy – Keflex, Azithromycin (resistance rates near 10% thanks to us!)  supportive measures – antipyretics, warm salt water gargles, cool soothing fluids, etc.

69  mono  retropharyngeal abscess  peritonsillar abscess (older adolescents)  epiglottitis (more common in adults now)  scarlet fever – caused by pyrogenic exotoxin- producing form of GABHS in non-immune individuals  outbreaks are cyclical  rash hours after onset of symptoms (may be longer)

70  Two worried parents rush their 1 year old baby to the ER at 2 am because of “breathing problems” and fever. She was a normal healthy infant until she woke up at midnight with a high fever, breathing fast, and wheezing. There is no prior history of asthma and no sick contacts. The baby is febrile to 101.3, breathing 40 times a minute with some retractions and audible wheezes but has a vigorous cry.

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72  worldwide phenomenon, usually winter – spring  transmitted through secretions  may manifest as  bronchiolitis – may result in bronchial obstruction  pneumonia – severe inflammation in alveoli & interstitial tissue – greatest in kids < 1 yr  greatest % of hospitalizations for respiratory reasons in infants (2-5% of those hospitalized will need intubation)  increased risk in preemies, congenital conditions, boys, lower socioeconomics

73  most likely (75%) caused by parainfluenza virus  peak incidence 3 mo – 3 years  MCC infectious airway obstruction in kids (subglottic … at narrowest diameter)

74  3-5 day incubation period, followed by:  cough  WHEEZE  prolonged expiratory phase  apnea (up to 20% infants with RSV)  may have RAPID decompensation (kids have less pulmonary reserve)  CXR may be normal, show lobar pneumonia or peribronchial inflammation

75  1-4 day incubation period  barking, “seal-like” cough with “whistling” (stridor) on inspiration, sneezing, nausea/vomiting, fever, hoarseness  often worse at night … then gets better when the kid is taken outside to drive to ER …  90% of cases are mild! (whew) steeple sign

76  treatment is largely SUPPORTIVE  supplemental oxygen  secretion management  admitted kids – consider ribavirin, NO, heliox  high-risk kids get preventative antibody/immunoglobulin  nebulized B-agonists – short-term improvement in oxygenation, unclear if there is a real benefit (same for racemic epi)  NO significant benefit for steroids

77  Westley croup score SIGN/SX RetractionsNoneMildModerateSevere StridorNoneWith agitation At rest CyanosisNoneWith agitation At rest LOCNormalDisoriented Air entryNormalDecreasedMarkedly decreased ≤2 = mild croup 3-7 = moderate ≥8 = severe croup

78  about 6% kids with croup are hospitalized, only 1% of these are intubated  moderate – severe croup despite tmt usually means admission  mist inhalers, steam showers  nebulized racemic epi?  short-lived benefit; sx may recur within 2 hours  may give q1 hr – but >1 dose often means admission  steroids  IM or po dexamethasone (0.6 mg/kg) may decrease need for hospitalization and/or return visits

79  aspirated FBs  underlying lung pathology (CF)  other causes of pneumonia/bronchitis

80  kids will be kids and get SICK  fortunately, most of the time they are not TOO SICK  (let us all say a prayer of thanks to the guy(s) who invented vaccines)  when you hear hoofbeats … it’s OK to consider a zebra, as long as the herd of horses doesn’t trample you while you’re thinking …

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