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

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

3. 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

4. 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

6. 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 Pediatric Resuscitation

8. Tachycardia Narrow Wide Stable or Unstable Know what is normal for age

9. 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

10. SVT Vagal maneuvers  Ice to face, Valsalva Adenosine 0.1 mg/kg 1 st 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

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

13. 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 Pediatric Resuscitation

14. 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. Case

15. 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

16. 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

17. 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 Asthma

18. 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? Case

19. 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

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

21. 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? Case

22. 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 Croup

23. Steeple Sign

24. 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? Case

26. < 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 Abscess

27. Age (yrs)Maximum (mm) 0-11.5 x C2 1-30.5 x C2 3-60.4 x C2 6-140.3 x C2 Retropharyngeal Soft Tissues * Age (yrs)Maximum (mm) 0-12.0 x C5 1-21.5 x C5 2-31.2 x C5 3-61.2 x C5 6-141.2 x C5 Retrotracheal Soft Tissues * * *

28. 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. Case

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

31. 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 Case

33. What investigation would you do next?

34. Expiratory CXR

35. Inspiratory Expiratory

36. 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 Foreign Body Aspiration

37. 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? Case

38. 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 month

39. 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% Fever 1-3 months

40. 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

41. 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 Fever 3-36 months

42. 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? Case

43. 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

44. 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 Febrile Seizure

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

46. Seizure treatment 3 rd 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) Seizure Management

47. 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

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

50. 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 Gastroenteritis

51. 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 Fluids and Electrolytes

52. 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? Case

53. 1-3 years Boys 2:1 Classic Triad (10-30%) Vomiting Crampy abdominal pain “Red currant jelly” stools Lethargy is common Intussusception

54. 75% are ileo-colic Lead point Peyer's Patches  preceding viral infection Meckel diverticulum Polyps Hematoma (Henoch Schonlein Purpura) Lymphoma Intussusception

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

56. Target Sign

57. Crescent Sign

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

60. 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

61. 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 Case

62. 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

63. 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

64. Laboratory abnormalities: Hypokalemia Hypochloremia Metabolic alkalosis Ultrasound Thickened pylorus

65. 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? Case

66. 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.

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

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

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

70. 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. Case

71. 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

72. 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

73. 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

74. 3 yr old girl with rash starting today. Recent URTI. Swollen ankles and knees. Painful walking. Diagnosis? Case

75. 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%) Henoch-Schonlein Purpura

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

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

78. 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

79. 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...

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

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

82. Diagnosis?

83. 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 Staphylococcal Scalded Skin Syndrome

84. 10 yr old boy with fever Unwell today Rapidly progressing rash since this morning Case

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

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

87. 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

88. 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

89. 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 Septic Shock

92. Catecholamine Resistant Shock Administer Hydrocortisone 2 mg/kg

93. Normal perfusion o Cap Refill < 2 sec o Normal pulses with no diff between central and peripheral pulses Urine output > 1 ml/kg/hr Normal level of consciousness Normal mean arterial pressure (MAP) Normal lactate Normal central venous pressure (CVP) Central venous O 2 saturation (ScvO2) > 70% Sepsis – Goal Directed Therapy

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

95. 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

96. 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

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

98. 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 Child Abuse

99. 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? Case

100. Young children  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

101. 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 Poisoning in Children

102. 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

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

104. 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 Approach to Unknown Ingestion

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

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

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

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

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

111. > 4 hr Acetaminophen level Plot on nomogram N-Acetylcysteine o Precursor for glutathione o Increases sulfation metabolism o Directly reduces NAPQI to APAP o Directly conjugates NAPQI

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

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

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

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

116. 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

117. 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 Tricyclic Antidepressants

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

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

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

121. Questions ?