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

Case 1 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 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 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 min May cause severe hypotension IV NS 20 bolus ml/kg Methylprednisolone 1-2 mg/kg IV

Case 2 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 3 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 4 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 Complication of bacterial pharyngitis Grp A strep, oral anaerobes and S. aureus Treatment IV Clindamycin and Cefuroxime Consult ENT

Retropharyngeal Soft Tissues * Age (yrs)Maximum (mm) x C x C x C x C2 Age (yrs)Maximum (mm) x C x C x C x C x C5 Retrotracheal Soft Tissues * * *

Case 5 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 Cefuroxime and Clindamycin

Case 6 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 7 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 7 What is the degree of dehydration of this child? Management?

Dehydration

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 min Replace over 24 hours  First half over 8hrs, second half over 16 hrs Ongoing Losses Diarrhea, Vomiting, Insensible losses with fever

Case 8 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

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

Target Sign

Crescent Sign

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

Case 9 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 9 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 10 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 11 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding. Looks well, alert and interactive T 38.9 o HR 176 RR 42 BP 100/50 Font flat, neck supple, exam non remarkable What is your approach to this case?

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/mm 3 Urinalysis WBC count < 5/hpf Stool WBC count < 5/hpf (if infant has diarrhea) Low Risk Criteria “Rochester” for Febrile Infants

Case 12 2 year old boy with generalized tonic clonic movements. Duration 5 min. T 39.2 o 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> 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 1 st Line - Benzodiazepines IV/PR Lorazepam or Diazepam Buccal Midazolam 2 nd Line  Phenytoin, Fosphenytoin  Phenobarbitol

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

Case 13 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.

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 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 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 Kawasaki Disease

Case 13 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% of cases between 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%)

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

Herpes Simplex

Coxsackie

5 yr old girl itchy rash for two days... 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

12 yr old girl baseball hit finger... Type II

Salter-Harris Classification

10 yr old boy fall onto hand... Type I

Type IV

Type III

11 yr old fell off garage... Type V

6 yo boy fall from play structure onto outstretched hand Pain and swelling at elbow Diagnosis? Supracondylar Fracture

Radiocapitellar Line Line down middle of radius bisects capitellum in all views Anterior Humeral Line Transects through posterior 2/3 of capitellum Elbow Alignment

Elbow Ossification Centers C C R R E T O O I I C: Capitellum - 1y R: Radial Head - 3y I: Int(Medial)Epicondyle - 5y T: Trochlea - 7y O: Olecranon - 9y E: Ext(Lateral)Epicondyle - 11y

12 yo boy fall from bike Painful, swollen elbow

E R C TO Where is the Internal (Medial) Epicondyle? I ??

Slipped Capital Femoral Epiphysis Male, yrs, overweight Acute or subacute pain, decreased internal rotation Klein line 12 yr old with hip pain

Legg-Calve-Perthe Disease Avascular necrosis of femoral head 5-9 yrs, boys > girls Bilateral in 15% 6 yr old with hip pain

Questions ?