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

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

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. 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

6. 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

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

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

9. 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

10. 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 J/kg
If not effective increase to 2 J/kg

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

13. 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

14. 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.

15. 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)

16. 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)

17. 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

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

19. 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

20. 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

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

22. 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

23. Steeple Sign

24. 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?

26. 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

27. 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

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

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

31. 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

33. What investigation would you do next?

34. Expiratory
CXR

35. Inspiratory Expiratory

36. 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

37. 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?

38. 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

39. 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%

40. 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)

41. 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

42. 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?

43. 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%

44. 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

45. 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

46. 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)

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

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

50. 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

51. 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

52. 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?

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

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

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

60. 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?

61. 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

62. 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

63. 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

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

65. 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?

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

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

70. 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.

71. 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)

72. 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

73. 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

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

75. 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%)

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

77. 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

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. 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

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

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

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

87. 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

88. 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

89. 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

94. 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?

95. 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

96. 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

97. 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

98. 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

99. 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

100. Acetaminophen

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

102. 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

103. 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

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

105. Ibuprofen Low incidence of toxicity, most asymptomatic
Reversibly blocks cycloxygenase,  prostaglandins
Clinical Effects
GI upset, bleeding
Renal failure
Bronchospasm
Massive overdoses > 400 mg/kg
metabolic acidosis, seizures, coma, hypotension

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

107. 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

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

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

110. 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

111. Summary Review of pediatric emergency cases: Resuscitation
Asthma, Bronchiolitis, Croup, Upper airway
Fever in infant, 3-36 months
Febrile seizures, Status epilepticus
Gastroenteritis, Pyloric stenosis, Intussusception
Rashes associated with serious illness
Sepsis
Poisoning

112. Questions ?