Symptoms, why children were examined at the emergency unit at the University Children´s Hospital Vienna (2012)

The „banal“ Infection

Question to parents: Do you know simple actions against….?

Assessement the severity of disease by parents and nurses (accorting to the Manchester Triage Systeme)

Drug therapy

2013: 80 cases; 6 deaths in <3a and 1 in the age of 13a

Which „banal“ decisions must be made Acute/chronic Severe/harmless infection no/further diagnostics Immediate treatment in emergency unit treatment at the ward

GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE GCVIGILANCEGCVIGILANCE

Diarrhea and vomiting

Gastrointestinal Urogenital ZNS Respiratorisch Cardial Infectious diseases causing causing diarrhea/vomiting

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

Pathogens Bacterial (ca. 5%) Salmonella Campylobacter jejunii Shigella Amebae; etc. Viral (ca. 95%) Rotavirus Adenovirus Norovirus Enterovirus …..

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

Conclusion Volume i.v. Immediate antibiotic treatment ofter obtaining blood culture

COUGH IS A PROTECTIVE REFLEX Cough will be induced in the area of nervus vagus.

COUGH Acute – chronic/recurrent Patient at risk: yes – no Accompanying symptoms (Fever, rhinitis, pain, and so on)

COUGH Signs of hazard: Vigilance, GC, shortness of breath, tachypnoea, dyspnoea, cyanosis, accessory muscle use

COUGH – differential diagnosis Infections Bronchial hyperreactivity Aspiration Psychogenic Toxic-Environmental Anomalies Autoimmune - disease Tumor

COUGH- Infections Upper respiratory tract Lower respiratory tract Upper and lower respiratory tract

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