Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine

Objectives Review pediatric resuscitation guidelines Recognize pediatric conditions that present to the emergency Describe management of pediatric emergency cases

Pediatric Resuscitation Pediatric Airway Larger head Bigger tongue Narrowest part is subglottic area Epiglottis is more floppy Larynx is more anterior and cephalad Chest wall more compliant

Pediatric Resuscitation Airway Management Position, suctioning Nasal/Oral airway Endotracheal intubation Cuffed tube size: age/4 + 3 (+/- 0.5mm) Medications Atropine (consider if< 6 yrs) Paralytic - Succinylcholine, Rocuronium Ketamine, Midazolam/Fentanyl, Propofol

Pediatric Resuscitation Bradycardia Non-Cardiac causes (6 H’s, 5 T’s) Hypoxia (Most Common) Hypovolemia, Hypo/Hyperkalemia, Hypoglycemia, Hypothermia Toxins, Tamponade, Thrombosis, Trauma (ICP) Cardiac causes - AV block, sick sinus Epinephrine 0.01 mg/kg (repeat every 5 min) Consider Atropine 0.02 mg/kg

This is the child’s ECG which shows narrow complex tachycardia at a fixed rate of 290 BPM

Pediatric Resuscitation Tachycardia Narrow Wide Stable or Unstable Know what is normal for age

Pediatric Resuscitation Sinus Tachycardia Rate usually < 220/min Variable rate Look for causes Pain, fever, dehydration, resp distress, poor perfusion SVT Rate usually > 220/min infants, > 160 teens Rate is fixed

Pediatric Resuscitation SVT Vagal maneuvers Ice to face, Valsalva Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg If Unstable: Synchronized Cardioversion 0.5-1 J/kg If not effective increase to 2 J/kg

Pediatric Resuscitation Tachycardia with Wide QRS Stable Consider Adenosine Amiodarone 5 mg/kg Consult Cardiology Unstable with pulse Cardioversion 0.5 - 1 J/kg 1st dose, then 2 J/kg

Pediatric Resuscitation Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation CPR Start at 16:2 compressions/breath Defibrillation 2 J/kg Then 4 J/kg Increase subsequent shocks to max of 10 J/kg Epinephrine 0.01 mg/kg every 3-5 min Amiodarone 5 mg/kg

Case 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days. T 36.5, RR 40, HR 130, O2 Sat 89%. Suprasternal and scalene retractions, decreased air entry, expiratory wheeze. Describe your management.

Asthma Mild Asthma: Salbutamol MDI x 3 doses prn Moderate Asthma: Salbutamol MDI x 3 doses then prn Steroids Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma Severe Asthma: Salbutamol via nebulization with Ipratropium 250 mcg x 3 doses q20 min Steroids Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma If not improving within 60 min or signs of impending respiratory failure: Magnesium Sulfate 50 mg/kg/dose IV (max 2g) Give over 20-30 min May cause severe hypotension IV NS 20 bolus ml/kg Methylprednisolone 1-2 mg/kg IV

Case 2 mo male with 2 day hx rhinorrhea, poor feeding and cough. Few hrs resp distress. RR 60 HR 120 T 37C. Pink, well hydrated. Chest - inspiratory crackles, exp wheezes. Diagnosis? Treatment?

Bronchiolitis RSV - Respiratory Syncytial Virus most common Parainfluenza, Influenza A, Adenovirus, Human metapneumovirus Peak in winter More serious illness < 2 months Hx of prematurity < 35 weeks Congenital heart disease

Bronchiolitis Treatment Nebulized Epinephrine – short term relief ? Dexamethasone 1 mg/kg on Day 1 0.6 mg/kg for another 5 days ? Nebulized Hypertonic Saline

Case 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough. HR 100 RR 28 T 37 Mild distress. Stridor at rest. Diagnosis? Treatment?

Croup Parainfluenza most common Hoarse voice, barky cough, stridor Peak fall and spring Infants and toddlers Treatment Dexamethasone (0.6 mg/kg) Nebulized Epinephrine if in respiratory distress Consider Nebulized Budesonide

Steeple Sign

Case 18 month female with fever x 2 days. Difficulty swallowing. HR130 RR28 T39C Exam normal except won’t move neck fully. What diagnostic test should be performed?

Retropharyngeal Abscess < 6yrs Complication of bacterial pharyngitis Infection of posterior pharyngeal nodes – regress by school age Grp A strep, oral anaerobes and S. aureus Treatment IV Clindamycin and Cefuroxime Consult ENT

Retropharyngeal Soft Tissues * Age (yrs) Maximum (mm) 0-1 1.5 x C2 1-3 0.5 x C2 3-6 0.4 x C2 6-14 0.3 x C2 * Retrotracheal Soft Tissues * * Age (yrs) Maximum (mm) 0-1 2.0 x C5 1-2 1.5 x C5 2-3 1.2 x C5 3-6 6-14

Case 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling. Not immunized. HR 140 RR 20 T 39.5 Very quiet, doesn't move. Slight noise on inspiration. Chest clear, exam normal.

Epiglottitis Rarely seen Strep pneumoniae H. influenzae uncommon due to vaccine Do not disturb patient Consult Anesthesia, intubate IV Ceftriaxone and Clindamycin

Case 17 mo male with sudden onset noisy and abnormal breathing Was playing on floor before developing difficulty breathing VS T36.8, P200 (crying), R28 (crying), O2 sat 99% Mild wheezing with mild inspiratory stridor

What investigation would you do next?

Expiratory CXR

Inspiratory Expiratory

Foreign Body Aspiration Highest risk between 1 -3 yrs old Immature dentition, poor food control More common with food than toys peanuts, grapes, hard candies, sliced hot dogs Acute respiratory distress (resolved or ongoing) Witnessed choking Cough, Stridor, Wheeze, Drooling Uncommonly…. Cyanosis and resp arrest

Case 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding. Looks well, alert and interactive T 38.9o HR 176 RR 42 BP 100/50 Font flat, neck supple, exam non remarkable What is your approach to this case?

Fever < 1 month Etiology is organisms from birth canal Group B Streptococcus , Escherichia coli (Gram neg), Listeria monocytogenes Highest rate of bacterial infection of any age group <2 weeks - 25% 0-4 weeks - 13% Septic Work Up Admission, IV antibiotics

Fever 1-3 months May still see birth canal organisms, but also: Streptococcus pneumoniae , Neisseria meningitidis, Haemophilus influenzae type b (uncommon) Overall rate of bacterial infection is ~8% Bacteremia 2% Meningitis 0.8% UTI 5% “Low Risk Infant” rate of bacterial infection is 1% Bacteremia 0.5%

Low Risk Criteria “Rochester” for Febrile Infants Well appearing infants 1-3 mos are low risk for serious bacterial infection if: Previously healthy Born at term (> 37 weeks) No hyperbilirubinemia No hospitalizations No chronic or underlying diseases No evidence of focal bacterial infection Laboratory parameters: WBC count 5-15/mm3 Urinalysis WBC count < 5/hpf Stool WBC count < 5/hpf (if infant has diarrhea)

Fever 3-36 months Viral infections cause of fever in >90% 6% of children seen in the ED have a specific, recognizable viral syndrome e.g. croup, bronchiolitis, roseola, varicella, coxsackie UTI in ~5% Bacteremia very low rates now (< 0.2%) 5% in 1980’s, HIB vaccine 1987 2% in 1990’s, Pneumococcal vaccine 2000

Case 2 year old boy with generalized tonic clonic movements. Duration 5 min. T 39.2o HR 110 RR 24 BP 110/60 Awake now, normal neurological exam. Right TM bulging, neck supple, no rash. Past med history unremarkable. Approach?

Febrile Seizure Simple Febrile Seizure T>38.5 6 mo-5 yr Generalized seizure, < 15 min One seizure within 24 hours Neurologically normal before and after Occur in ~ 5% of children Recurrence in 30%

Febrile Seizure Risk of epilepsy is 1% ~ same as general population Higher risk (2.4%) if: Multiple febrile seizures < 12 mos at the time of first febrile seizure Family history of epilepsy

Seizure Management ABC's IV access Seizure treatment 1st Line - Benzodiazepines Lorazepam or Diazepam (Rectal or IV) Midazolam (Intranasal or Buccal) 2nd Line Phenytoin, Fosphenytoin Phenobarbitol

Seizure Management Seizure treatment 3rd Line Midazolam infusion Thiopental Propofol Paraldehyde Observe in the ED until child returns to normal After simple febrile seizure no neurological investigations indicated (eg CT, EEG)

Case 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea x 10 today. Voiding scant amounts. HR 120 RR 36 BP 100/50 T 38.5 Cap refill 2 sec, pink, decreased skin turgor. Font sunken, eyes sunken. Abdo + GU normal.

Case What is the degree of dehydration of this child? Management?

Gastroenteritis ORT with rehydration solution (eg Pedialyte) 5 ml/kg/hr divided every 5 min, continue until appears hydrated Consider Ondansetron (0.15 mg/kg) Early refeeding (including milk) within 12 hrs Rule out UTI

Fluids and Electrolytes Maintenance (D5NS) 4ml/kg/hr for first 10 kg 2ml/kg/hr for second 10 kg 1 ml/kg/hr for rest of weight in kg Deficit (NS) If severely dehydrated give NS bolus 20 ml/kg over 15-60 min Replace over 24 hours First half over 8hrs, second half over 16 hrs Ongoing Losses Diarrhea, Vomiting, Insensible losses with fever

Case 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus. HR130 RR24 T37 Tender abdomen with fullness in RUQ Diagnosis? Investigations?

Intussusception 1-3 years Boys 2:1 Classic Triad (10-30%) Vomiting Crampy abdominal pain “Red currant jelly” stools Lethargy is common

Intussusception 75% are ileo-colic Lead point Peyer's Patches preceding viral infection Meckel diverticulum Polyps Hematoma (Henoch Schonlein Purpura) Lymphoma

Intussusception Plain AXR May be normal May have signs of bowel obstruction Paucity of air in RLQ No air in Cecum on Lateral Decubitus

Target Sign

Crescent Sign

Intussusception Air Contrast Enema Success rate >80% Recurrence 10-15% Intussusception

Case 4 week old boy with vomiting for past week. Initially one emesis per day now emesis with every feed. Forceful. No bile. No fever. No diarrhea. Looks well. Mild dehydration. Abdomen soft, non tender, BS present. DDx?

Case Na 140 K 3.0 Cl 90 BUN 24 CR 50 WBC 8.5 Hgb 120 Plts 360 Venous gas pH 7.50, PCO2 44, HCO3 30

Pyloric Stenosis Most common surgical condition < 2 mos 4-6 wks of age Ratio male to female is 4:1 Increased in first born males Occurs in 5% of siblings and 25% if mother was affected

Pyloric Stenosis Nonbilious vomiting Emesis increases in frequency and eventually becomes projectile Classic findings: Hypertrophied pylorus palpable “olive” in epigastric area Peristaltic waves progressing from LUQ to the epigastrium

Pyloric Stenosis Laboratory abnormalities: Hypokalemia Hypochloremia Metabolic alkalosis Ultrasound Thickened pylorus

Case 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability. Looks unwell, irritable cry. Abdomen distended. Weak pulses, cap refill>5 sec. DDx? Management?

Volvulus Twisting of a loop of bowel around its mesenteric attachment. 80% present by the first month 40% present in the first week Rarely can be seen in older children.

Volvulus Sudden onset of bilious vomiting in a neonate. Acute abdomen with shock May have more gradual course with episodic vomiting

Volvulus Evidence of small bowel obstruction Dilated loops Air fluid levels Paucity of distal air

Volvulus Upper GI series “corkscrew” appearance of the duodenum and jejunum

Case 2 yr old boy with fever for 6 days. Red eyes but no discharge. Generalized rash. Erythema of the palms of hands and soles of feet. Red, swollen lips. Enlarged cervical lymph nodes.

Kawasaki Disease Usually < 4 yrs old, peak between 1-2 yrs Fever for > 5 days and 4 of the following: Bilateral non-purulent conjunctivitis Polymorphous skin eruption Changes of peripheral extremities Initial stage: reddened palms and soles Convalescent stage: desquamation of fingertips and toes Changes of lips and oral cavity Cervical lymphadenopathy ( >1.5 cm)

Kawasaki Disease Subacute phase - Days 11-21 Desquamation of extremities Arthritis Convalescent phase - > Day 21 25% develop coronary artery aneurysms if untreated Other manifestations: Uveitis, Pericarditis, Hepatitis, Gallbladder hydrops Sterile pyuria, Aseptic meningitis

Kawasaki Disease Treatment IV Immunoglobulin ASA Reduces incidence of coronary aneurysms to 3% if given within 10 days of onset of illness Defervescence with 48 hrs ASA High dose during acute phase then lower dose for 3 mos

Case 3 yr old girl with rash starting today. Recent URTI. Swollen ankles and knees. Painful walking. Diagnosis?

Henoch-Schonlein Purpura Systemic vasculitis – IGA mediated 75% are 2-11 yrs Clinical Features Rash (non thrombocytopenic purpura) 100% Arthritis (ankles, knees) - 68% Abdominal pain - 53% Nephritis - 38% (ESRD in ~1%) Intussusception (2-3%)

Case 1 yr old boy with mouth lesions for two days What are the two most likely causes?

Herpetic Gingivostomatitis Herpes Simplex Severe primary infection HSV1 (80%), HSV2 (20%) Fever, irritability, poor intake Ulcers on mucous membranes Treatment Acyclovir Pain control, IV hydration

Hand, Foot and Mouth Disease Coxsackievirus, usually A16 Summer Ulcers on tonsilar pillars can have generalized stomatitis Vesicles on hands and feet URTI, pharyngitis Vomiting and diarrhea Generalized maculopapular rash

Case 5 yr old girl with itchy rash Varicella Zoster This child comes back to the ED three days later with worsening fever and pain...

Diagnosis? Necrotizing Fasciitis Invasive group A streptococcal infection IV Penicillin and Clindamycin Consult ID, surgery MRI

Case 3 yr old girl fever for 3 days, unwell Rash spreading over entire body with skin peeling

Diagnosis?

Staphylococcal Scalded Skin Syndrome Exotoxin causes separation of epidermis < 2yr Fever, toxic appearance, generalized erythema Exfoliation of skin, accentuated in flexor surfaces skin lifts to touch (Nikolsky’s sign) Perioral crusting, “honey coloured” lesions Fluid resuscitation IV Cloxacillin, Cefazolin or Clindamycin

Case 10 yr old boy with fever Unwell today Rapidly progressing rash since this morning

Meningococcemia Usually < 5 yrs, Adolescents outbreaks Fever, toxic appearance Petechiae, purpura DIC, shock High mortality (25-80%) Resuscitation IV Ceftriaxone Treat household contacts

Septic Shock How are you going to resuscitate this child? First intervention? Next?

Septic Shock Leading cause of death in infants and children 6 million deaths per year worldwide Etiology of sepsis Streptococcus pneumonia Escherichia coli Neisseria meningitidis Other: Group A strep, other Gram neg bacilli, Staph. aureus, Enterococcus IV Antibiotics: Ceftriaxone and Vancomycin

Septic Shock Sepsis if systemic inflammatory response signs (SIRS) and signs of infection Fever,  or  HR,  RR,  or  WBC Severe sepsis if signs of organ dysfunction or tissue hypoperfusion Septic Shock if cardiovascular dysfunction

Septic Shock Hypotension is DECOMPENSATED SHOCK Most children have “cold shock” Decreased cardiac output and increased systemic vascular resistance Poor perfusion, cool extremities, delayed cap refill  Adolescents more likely to have “warm shock” Low systemic vascular resistance Bounding pulses, wide pulse pressure

Case 6 month old with swollen L leg Parents state 3 yr old brother fell onto baby Approach to this case?

Child Abuse Suspect if history vague, inconsistent with injury or child’s development Bruises Can not date bruises by color “If they don’t cruise they don’t bruise” Toddlers don’t bruise buttocks, inner arms/legs, neck or trunk Patterned marks – linear, hand prints Bites – adult if > 3 cm

Child Abuse Fractures Metaphyseal (corner, bucket handle) Shearing force from shaking Usually < 1yr Posterior ribs Femur in non-ambulatory child Multiple fractures, different ages Low risk – clavicle, tibia in toddler

Child Abuse Head trauma Direct contact injuries Scalp hematoma Depressed skull fracture Epidural hematoma Rotational acceleration injuries Subdural hemorrhages Retinal hemorrhages

Child Abuse Admit all children < 2 yrs Skeletal survey for < 2 yrs (consider for 2-5 yrs) CT head if < 1 yr Opthalmologic exam Ideally within 24 hours (must be <72 hrs) Mandatory reporting to child welfare agency

Case 2 yr old at grandmother’s house Took unknown amount of pills that he found in her purse 30 minutes ago No symptoms What is your approach?

Poisoning in Children Young children Adolescents Exploratory ingestion Ingest small amount of a single substance Can grasp single pill at 1 yr Can’t hold handful of pills until > 15 mos Child preparations have small opening – spills out Adolescents Ingest large amounts of one or more substances Suicidal gesture

Poisoning in Children Common ingestions Household products Cough/cold, vitamins, antibiotics Acetaminophen and Ibuprofen Antidepressants Pills that are harmful if single dose taken Oral hypoglycemics, calcium channel blockers, tricyclic antidepressants

Approach to Unknown Ingestion History Attempt to identify possible drug ingested Friends, parents, paramedics, police Physical Exam Look for toxidrome signs Neurologic impairment Skin marks, Breath odour Look for signs of trauma, head injury

Approach to Unknown Ingestion Management ABC’s Check Glucose Cardiac Monitoring Gastric decontamination – Charcoal, WBI Antidotes Benzodiazepines for agitation, seizures NaHCO3 for arrhythmias

Approach to Unknown Ingestion Diagnostic testing CBC, lytes, BUN/Cr, glucose, gas, osmolality Anion gap, Osmolar gap Specific serum drug levels (Acet, ASA, Alcohols) ECG Abd Xray for radio-opaque toxins C - Calcium, Condoms H - Heavy metals I - Iron P - Phenothiazines, Potassium S - Slow-release preparations

Toxidromes Anticholinergic Cholinergic Mad as a hatter - Agitation and hallucinations Blind as a bat - Dilated pupils Hot as hell - Fever, Flushed Dry as a bone - MM, skin; Urine retention; Decreased GI motility Tachycardia. Hypertension Cholinergic Salivation, Lacrimation, Urination, Defecation, GI cramps, Emesis Pulmonary edema Bradycardia Agitation, confusion. seizures

Toxidromes Sympathomimetic Opioid Agitation and hallucinations Dilated pupils Fever, Tachycardia, Hypertension Diaphoretic Increased bowel sounds Opioid Coma Respiratory depression Hypotension Miosis

GI Decontamination Activated Charcoal 1 g/kg Greatest benefit is within 1 hr of ingestion At 30 min 89% decrease At 1 hr 37% decrease Not useful for Alcohols Hydrocarbons Anions or Cations (Iron, Lithium) Acids or Alkali

GI Decontamination Whole Bowel Irrigation PegLyte 0.5-2 L per hour via NG For substances not adsorbed by charcoal and sustained release preparations Iron Lithium EC ASA

Acetaminophen Clinical Effects 0-24 hrs 24-48 hrs 72-96 hrs GI irritation, may be asymptomatic 24-48 hrs Signs of liver involvement begin 72-96 hrs Fulminant hepatic failure Renal failure

Acetaminophen

Acetaminophen > 4 hr Acetaminophen level Plot on nomogram N-Acetylcysteine Precursor for glutathione Increases sulfation metabolism Directly reduces NAPQI to APAP Directly conjugates NAPQI

Salicylates Clinical Effects GI upset - N&V, Gastritis Tinnitus – often the first symptom CNS – Confusion, Lethargy, Cerebral edema Hyperpnea – Early have respiratory alkalosis Hyperthermia Renal and Liver toxicity – rare Impaired platelet function

Salicylates Mechanism of Action Uncoupling of oxidative phosphorylation Hyperthermia Glycogenolysis, Lipolysis Hyperglycemia initially then hypoglycemia from impaired gluconeogenesis Inhibits Kreb’s cycle Anaerobic metabolism Lactic acidosis

Salicylates Urine alkalinization Ion trapping – ASA is weak acid Hemodialysis If signs of multiorgan failure

Tricyclic Antidepressants Triad of clinical effects: Cardiovascular Prolonged QRS, QT, PR, Arrhythmias Hypotension CNS Coma, Seizures Anticholinergic symptoms

Tricyclic Antidepressants Mechanisms of toxicity Blockade of fast Na+ channels Type 1A “quinidine-like effects” Membrane stabilizing effects Inhibition of GABA reuptake Blockade of alpha 1 receptors Anticholinergic effects

Tricyclic Antidepressants NaHCO3 1-2 meq/Kg then infusion D5W + 150 meq NaHCO3/L at 1.5 x maintenance Benzodiazepines Sedation, seizures Lipid therapy May be helpful, case reports

SSRI’s Much safer than TCA’s Clinical Effects: N&V Sedation QT prolongation Seizures Serotonin Syndrome

SSRI’s Serotonin Syndrome Treatment Benzodiazepines, Active cooling Agitation, Hypervigilance Myoclonus, Muscle rigidity Seizures Diaphoresis, shivering Hyperthermia, Autonomic dysfunction – HR, BP Diarrhea Treatment Benzodiazepines, Active cooling

Summary Review of pediatric emergency cases: Resuscitation Respiratory emergencies Fever in infant, 3-36 months Febrile seizures, Status epilepticus GI presentation Rashes associated with serious illness Sepsis Child abuse Poisoning

Questions ?