1. Pediatrics Review
Gina Neto, MD FRCPC
Pediatric Emergency Medicine

2. Objectives Pediatric Emergency in 45 min!
Recognize and manage acute pediatric presentations from newborn to older children
Describe evidence based management of selected pediatric conditions

3. Case 4 day old girl presents to the ED with jaundice.
Today is sleepy and has to be woken for feeds.
Born at term, SVD. No complications. BW 3.5 kg.
T 37.2, HR 140, RR 36, BP 90/50. Wt 3.1 kg
No distress. Sleeping but arouses easily.
Skin jaundiced, sclera icteric.

4. Case
Further history
Baby is breastfeeding every 3 hrs but falling asleep, stays on breast for 30 min.
No urine output since last evening.
GBS neg, SROM 1 hr before delivery.
Asian ethnicity. Mom is O pos.

5. Case Assessment? Initial management? Jaundice is a medical emergency!
Start phototherapy immediately
> 10% wt loss– dehydration vs poor weight gain
IV fluids
Sleepy vs Lethargic
? Needs septic work up

6. Neonatal Jaundice Most common medical presentation in 1st week of life
Unconjugated vs Conjugated
Physiologic jaundice
3rd day of life
 RBC mass, Immature liver conjugation, Increased enterohepatic circulation
Poor feeding and dehydration
“Not Enough Breastfeeding Jaundice”
Increased enterohepatic circulation, Decreased bilirubin clearance

7. Neonatal Jaundice Breast milk jaundice Blood destruction Sepsis
Starts Day 5-7, Well baby
May last for several weeks
? Component in milk that inhibits conjugation
Blood destruction
Immune (Hemolysis)
ABO incompatibility, Rh Disease
Non-Immune
Blood Disorders (G6PD, Spherocytosis)
Hematoma, Polycythemia
Sepsis
Other (Gilbert, Crigler-Najjar, Hypothyroidism)

8. Neonatal Jaundice Conjugated hyperbilirubinemia is always pathologic
Liver Disease
Biliary obstruction (atresia, choledochal cyst)
Hepatitis
Sepsis
STORCH infection
Syphilis, Toxoplasmosis, Rubella, CMV, HSV, Hep B
Metabolic disorders
Galactosemia, Tyrosinemia

9. Neonatal Jaundice Bilirubin Induced Encephalopathy Early Late
Basal ganglia involvement
Early
High-pitched cry, lethargy, hypotonia
Late
Hypertonia, extensor rigidity, seizures, coma, death
Long term
Athetoid cerebral palsy, deafness

10. Neonatal Jaundice Labs Start phototherapy immediately
Bilirubin – total and conjugated  STAT !
CBC, Blood group, Direct antibody test (Coombs)    
Consider Septic Workup, Lytes, BUN, Cr, Glu, VBG
Start phototherapy immediately
Converts unconjugated bilirubin into water soluble isomers
If treatment needed:
Consider IV hydration, Keep baby warm
Catheter Urine (~8% will have a UTI)

11. Neonatal Jaundice
Remember to also plot on Exchange Transfusion Graph if in treatment range

12. Case 5 day old boy presents with vomiting and lethargy
Over the past 24 hrs the baby has become increasingly sleepy and difficult to feed.
Vomited several times.
No wet diapers since last night.
Born at term. SVD. No complications. BW 3.5 kg

13. Case
T 35.2oC, HR 200, RR 60, BP 90/50.
O2 sat 96%
Lethargic, mottled infant
Chest - clear, mild intercostal indrawing
CV - normal HS, cap refill 5 sec
Abd - slightly distended

14. Case What is the physiologic status of the infant? Shock
Compensated or decompensated?
Initial management?
ABC’s O2
IV fluids
Check glucose
Warm the baby!!

15. Septic Appearing Newborn
“THE MISFITS” (Causes of Shock in the Newborn)
Trauma
Non-accidental
Heart
Duct dependent lesions
Coarctation of aorta, Hypoplastic left heart, Aortic stenosis
Arrythmias – SVT
Endocrine
Congenital Adrenal Hyperplasia
Thyrotoxicosis

16. Septic Appearing Newborn
“THE MISFITS” (Causes of Shock in the Newborn)
Metabolic - Hypoglycemia, Hyponatremia
Inborn errors of metabolism
Sepsis
Formula errors
Intestinal catastrophes - Volvulus, Necrotizing Enterocolitis
Toxins
Seizures

17. Sepsis Risk factors Pathogens Prematurity PROM >18 hrs
Fever in mother or infant at delivery
Multiple births
Previous sibling with GBS infection
Pathogens
Group B Strep 30%, E. coli 30-40%, Other Gram neg 15-20%
Gram pos (including Listeria monocytogenes) 10%
Viral (HSV, HZV, RSV, Coxsackie), Chlamydia

18. Sepsis ABC’s, Fluid Resuscitation, Glucose “Septic work up” Treatment
CBC, Blood C&S
Cath urine R&M, C&S
LP - if stable
CXR - if resp sx's
Viral serology
Treatment
Ampicillin &
Gentamycin or Cefotaxime
If suspect herpes – Add Acyclovir

19. Congenital Adrenal Hyperplasia
Most common is 21 hydroxylase deficiency (95%)
Aldosterone and cortisol deficiency
Excess production of testosterone
Girls - Ambiguous genitalia
Boys - Adrenal crisis/shock at ~1 week
Management:
Correct fluid and electrolyte imbalances
Low Glu, Low Na, High K
Hydrocortisone
Fludrocortisone

20. Cardiogenic Shock Acyanotic duct dependent lesions
Critical left heart obstruction
Poor systemic blood flow
Acidosis and shock
Hypoplastic left heart syndrome
Coarctation of the aorta
Aortic stenosis
Total anomalous pulmonary venous return

21. PDA Closure
Increased O2 sat with first breath  contraction of ductus arteriosus
physiologic closure at ~12 hrs
anatomic closure at 2-3 wks
Duct dependent lesions
No pulmonary blood flow  cyanosis
No systemic blood flow  shock

22. Cardiogenic Shock Acyanotic duct dependent lesions ABC’s
Fluid resuscitation
Consider Intubation
Maintain relative hypoxia and hypercarbia
Start Prostaglandin E1
Infusion at g/kg/min
Complications:
Apnea in ~15%, Hypotension, Fever, Seizures
Improvement within min

23. Case
3 day old girl brought to the ED with a history of progressive cyanosis and irritablity
T 36.3oC, HR 160, RR 48, BP 94/40. O2 sat 74%
Irritable, cyanotic infant
Chest clear. S1 S2, soft systolic murmur, normal pulses, cap refill 3 sec
What is your approach to this infant?
Differential diagnosis?

24. Cyanotic Newborn Cyanotic heart lesions Decreased pulmonary blood flow
Tetralogy of Fallot (TOF)
Pulmonary atresia or stenosis
Desaturated blood shunted to systemic circulation
Transposition of great vessels (TGA)
Truncus arteriosus
Tricuspid atresia
Total anomalous pulmonary venous return (TAPVR)

25. Cyanotic Newborn Non Cardiac Causes Upper airway obstruction
Choanal atresia
Pulmonary disease
Pneumonia
Diaphragmatic hernia
Persistent pulmonary hypertension
Neurologic
Hemorrhage, hydrocephalus, infection
Neuromuscular disorders
Polycythemia
Methemoglobinemia

26. Cyanotic Newborn Management ABC’s, Glucose 100% oxygen test
Poor response to oxygen suggests cyanotic cardiac lesion
Use only diagnostically  O2 promotes closure of PDA
Maintain relative hypercarbia and hypoxia
pCO , O2 sat <90%
Start Prostaglandin E1
Infusion at g/kg/min

27. Case
1 month old boy with 2 day history of irritability and poor feeding. Difficulty breathing today.
No fever or URTI sx’s. Born at term, healthy.
T 37.5oC, HR 160, RR 80, BP 85/50. O2 sat 92%
Mild respiratory distress, indrawing, bilateral crackles
S1 S2, III/VI systolic murmur, normal pulses
Liver at 5 cm below CM

28. Case
What is the most likely diagnosis?

29. Congestive Heart Failure
Left to Right shunts
Presentation at 1 month
Decreasing pulmonary vascular resistance 1st month of life
Increased blood flow into lungs
Symptoms
Irritability, Diaphoresis
Poor feeding (early fatigue), Failure to thrive
Signs
Tachypnea, Tachycardia, Respiratory distress
Enlarged liver

30. Congestive Heart Failure
VSD most common
Other: ASD, PDA
Diagnosis
Pansystolic Murmur, Hyperactive precordium
ECG – LVH
CXR – cardiomegaly, vascular redistribution
ED Management
ABC’s, Glucose
Furosemide
CPAP

31. Congenital Heart Disease - Age of presentation

32. Case 3 week old boy vomiting every feed for 24 hours.
Vomit is yellow. No diarrhea. Dry diaper since this morning.
HR 180, RR 40, T 37.2 R. Irritable and restless.
Eyes sunken. Mouth dry. Cap refill 5 sec.
Abd distended and diffusely tender.
What is your approach to this infant?
Differential diagnosis?

33. Volvulus 40% present in first week, 80% present by 1 month Malrotation
Short small bowel mesentery, ligament of Treitz poorly fixed
Twisting of the bowel around the superior mesenteric artery
Sudden onset of bilious vomiting
Acute abdomen with shock
Bowel ischemia and necrosis, GI bleeding
ABC’s, Fluid resuscitation, Glucose
Upper GI series
Emergent surgery

34. Pyloric Stenosis 4-6 weeks of age Male to female 4:1, first born males
5% of siblings and 25% if mother was affected
Symptoms of gastric outlet obstruction
Non-bilious vomiting
Emesis increases in frequency and eventually becomes projectile
Peristaltic wave, palpable mass in epigastrium “olive”
Labs – low K, low Cl, metabolic alkalosis
Ultrasound

35. Case 1 yr boy with vomiting and diarrhea since last night.
This morning he had three loose stools with blood.
He cries intermittently in cycles of 10 to 20 minutes.
T36.5, HR 118, RR 40, BP 100/50.
Pale and lethargic.
Abd soft, mild tenderness. Mass palpable in RLQ.
Investigations?
Diff Dx?

36. Intussusception Usually invagination of ileum into cecum (75%)
6 months to 3 yrs
Males to female 3:2
90% are idiopathic
Post viral illness – hypertrophy of Peyer patches
Pathologic causes - Meckel diverticulum, polyps, hematoma (Henoch-Schonlein Purpura), lymphoma/leukemia, cystic fibrosis

37. Intussusception Classic triad present in 10-30% Lethargy in 25%
Intermittent, crampy abdominal pain
Vomiting
“Currant jelly" stools
Late sign, indicates intestinal edema and mucosal bleeding
Lethargy in 25%
Ultrasound (Sens %, Spec %)
AXR (Sens 45%, Spec 21%)
Lack of air in RLQ, obstruction
Target sign, Crescent sign

38. Intussusception
Target sign

39. Intussusception
Crescent Sign

40. Intussusception Air Contrast Enema Recurrence rate 10-15%
Success rate 95%
Bowel perforation in 1-3%
Recurrence rate 10-15%
50% within first 24 hrs
Other 50% within 10 mos

41. Case 4 yr old with bruising to both legs today
Pain with walking, swollen ankles.
Abdominal pain with blood in stool.
Diagnosis?
Complications?

42. Henoch-Schonlein Purpura
IGA mediated vasculitis
2-11 yrs
Rash 100%
Palpable petechiae/purpura, can be urticarial
Arthritis 70%
Ankles > knees >wrists > elbows
Abdominal pain 50%
Intussusception 2%
Nephritis 40% (ESRD in ~1%)

43. Henoch-Schonlein Purpura
Investigations
CBC, PT PTT, Lytes, BUN, CR; Urinalysis
Prot, Alb, Immunoglobulins
Strep testing – Throat swab, ASOT
Weekly U/A and BP until sxs resolve then monthly for 6 mos
Treatment
NSAID’s for pain relief
Consider steroids for abdominal, testicular, CNS involvement
Controversial for renal complications
Nephrology consult if hypertension, nephrotic sx’s

44. 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.
Diagnosis?
Complications?

45. Kawasaki Disease Usually < 4 yrs old
peak 1-2 yrs
Fever for > 5 days and 4 of:
Bilateral non-purulent conjunctivitis
Rash
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)

46. Kawasaki Disease Subacute phase - Days 11-21
Desquamation of extremities
Arthritis
Convalescent phase - > Day 21
If untreated ~ 25% coronary artery aneurysms
Other manifestations:
Uveitis, Pericarditis, Myocarditis
Hepatitis, Gallbladder hydrops
Aseptic meningitis

47. Kawasaki Disease Incomplete (Atypical) Fever >5 d with 2-3 criteria
AAP Kawasaki statement Newburger et al. Pediatrics, 2004

48. Kawasaki Disease Supplemental Lab Criteria ESR >40 CRP >3
WBC > /mm
Anemia
Platelets after 7 days > 450
Elevation of ALT
Albumin < 3
Urine >10 WBC/hpf

49. Kawasaki Disease Treatment IV Immunoglobulin (2 g/kg)
Reduces coronary aneurysms to 3% if given within 10 days of onset of illness
Defervescence with 48 hrs
ASA
During acute phase high dose ( mg/kg/day) then low dose (3-5 mg/kg/day) for 6-8 weeks
Stop if normal ECHO

50. Case 4 month old with difficulty breathing x 2 days.
Cough and congestion. Poor Feeding.
Moderate distress. T 37. RR 80. HR Sat 94%
Crackles and wheezes bilaterally. Indrawing.
Management?

51. Bronchiolitis Respiratory Syncytial Virus most common Peak in winter
Parainfluenza, Influenza, Adenovirus, Human metapneumovirus
Peak in winter
More serious illness
< 2 months
Hx of prematurity < 35 weeks
Congenital heart disease
Bronchiolitis with fever < 3 mos
Bacteremia rare, UTI in 5%

52. Bronchiolitis Nebulized Epinephrine - short term relief Dexamethasone
Synergistic effect with Epi – time dependent effect
1 mg/kg on Day 1 then 0.6 mg/kg for 3-5 days
Nebulized Hypertonic Saline
Benefit in inpatient studies, May be helpful in ED
Causes bronchoconstriction – Give with Epi
No benefit of Salbutamol, CXR not helpful

53. Case 2 yr old boy wakes up at 3 AM with difficulty breathing
URTI sxs for 3 days. Hoarse voice and barky cough.
T 39, RR 48, HR 140, O2 sat 95%
Moderate distress. Stridor at rest. Indrawing.
Management?
Differential diagnosis?

54. Croup Parainfluenza most common Hoarse voice, barky cough, stridor
RSV, influenza, adenovirus
Hoarse voice, barky cough, stridor
Young children, Peak fall and spring
Neck soft tissue xray if atypical, severe, not improving
Dexamethasone (0.6 mg/kg) for all, effect by 6 hrs
Nebulized Epinephrine effect by 30 min
Consider Nebulized Budesonide if severe
Difficult airway!!!

55. Croup Mild 0-3, Moderate 4-7, Severe >8
Respiratory failure if >12        

56. Retropharyngeal Abscess
Complication of Pharyngitis, Head & Neck infections, Penetrating trauma
Grp A strep, oral anaerobes and S. aureus
< 6 yrs
Retropharnygeal lymph nodes regress
Stridor, sore throat, muffled voice
Neck pain and stiffness
Fever, unwell appearance

57. 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

58. Retropharyngeal Abscess
Complications
Airway compromise
Erosion into carotid artery
Aspiration pneumonia
Mediastinitis
Lateral pharyngeal space rupture
Extension into spine
IV Ceftriaxone and Clindamycin
Consult ENT
Consider CT

59. Epiglottitis Involves all supraglottic tissues GAS, Strep pneumoniae
H.influenza rare
Rapid onset of severe sore throat, stridor, drooling, tripod position
Do not disturb patient
Consult Anesthesia, ENT- Intubate in OR
IV Ceftriaxone and Clindamycin

60. Bacterial Tracheitis Toxic, unwell appearing
Severe Croup sxs – non responsive to treatment
Mortality 4%
Streptococcus, Staphylococcus aureus
Also H.influenza, M.catarrhalis, C.diphtheriae
ICU admission
Consult anesthesia if need intubation
IV Ceftriaxone and Clindamycin (or Clox, or Vanco)

61. 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

62. Inspiratory Expiratory

63. Case 4 yr old with 2 week history of polyuria and polydipsia
Very sleepy today. Complaining of headache.
Normal vital signs. Tired but arousable. Dry MM. Eyes sunken. Normal cap refill.
Blood sugar at triage “HIGH”
Initial Management?

64. Diabetic Ketoacidosis
pH<7.30 and/or HCO3<15 mmol/L
Ketonuria
Symptoms
Polyuria/Polydipsia, Wt loss
Abdominal pain, Fatigue
Signs
Kussmaul respirations
Ketotic breath
“Look dry”; usually mild-mod dehydration
CNS changes – headache, confusion, irritability, lethargy

65. Diabetic Ketoacidosis
Cerebral edema in %
Patient risk factors
Age < 5 years
New onset DM, Longer duration of Sx
High initial urea, Low initial pC02, pH < 7.1
Treatment risk factors
Rapid administration of hypotonic fluids
IV bolus of insulin
Early insulin infusion
Failure of serum Na to rise during treatment
Use of NaHCO3

66. Diabetic Ketoacidosis
Diabetic ketoacidosis in children and adolescents with diabetes. Wolfsdorf J et al. Pediatric Diabetes 2009

67. Diabetic Ketoacidosis
Fluid bolus only if hypotensive
10 ml/kg over min
Calculate fluids based on 10% dehydration replaced over 48 hrs
NS + 40 meq KCl/L (if voiding and K<5)

68. Diabetic Ketoacidosis
Start Insulin infusion 1-2 hrs after IV fluids
Insulin 0.1 units/kg/hr
No Insulin bolus
No Bicarbonate
Monitor hourly VS, neurovitals, glucose
Gas, lytes, osm, urine ketones q2-4h

69. Diabetic Ketoacidosis
Cerebral Edema
For headache alone
Raise head of the bed to 30o
Decrease fluids to maintenance
If altered LOC (GCS<10)
3% Saline 5 cc/kg over 20 min OR
Mannitol 0.5 gm/kg iv over 20 min
Prepare for intubation
STAT CT scan

70. Case 2 yr old with generalized tonic clonic seizure.
Noted to be seizing at home. Ambulance called, ongoing seizure on arrival.
T 40, HR 120, RR 36, Sat 98%
Management?
Definition of febrile seizure?

71. 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%

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

73. Seizure Management ABC’s, Check Glucose Extended lytes
Anticonvulsant levels
Phenytoin, Phenobarbitol, Valproic acid, Carbamazepine
Septic work up? Imaging?
Consider ingestion
Anion gap, Osm gap, ASA, Acet, Toxic alcohols
1st line - Benzodiazepines
2nd line - Phenytoin, Phenobarb
3rd line - Midazolam infusion
Other – Thiopental, Pentobarbitol, Paraldehyde, Propofol, Valproic acid, Topiramate, Levetiracetam

74. Status Epilepticus
CPS Guidelines
Paediatr Child Health 2011;16(2):91-7

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

76. Child Abuse
Suspect if history vague, changing, inconsistent with degree of injury or child’s development
Bruises
Can not date bruises by color
“If they don’t cruise they don’t bruise”
Uncommon for toddlers to bruise buttocks, genitalia, inner arms or legs, neck or trunk
Patterned marks – linear, hand prints
Bites – adult if > 3 cm

77. Child Abuse Fractures Metaphyseal (corner, bucket handle)
shearing force from shaking
usually < 1yr
Posterior ribs
Femoral in non-ambulatory child
Scapular, sternal, spinous process
Multiple fractures, different ages
Low risk – clavicle, tibia in toddler

78. Child Abuse Head trauma Direct contact injuries
scalp hematoma, subgaleal hematoma
depressed skull fracture
epidural hematoma
Rotational acceleration injuries
subdural hemorrhages
cerebral edema
retinal hemorrhages

79. Child Abuse Retinal hemorrhages
Multiple layers with peripheral extension
most specific for abuse
Bilateral, flame shaped
uncommon in accidental trauma (<1.5%)
Other causes
40% of normal newborns
Glutaric aciduria II (retinal and subdural hemorrhages)
CPR – prolonged duration, coagulopathy
Infectious – CMV, malaria, endocarditis

80. 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)
Arrange clinical photography of marks/bruises
Mandatory reporting to child welfare agency

81. Case 4 yr old boy fall from play structure Vomited twice
Headache initially, now resolved
Normal exam in ED
Does he need a CT?

82. Minor Head Injury
CATCH - Canadian Assessment of Tomography for Childhood Head Injury
Inclusion criteria
Witnessed loss of consciousness or disorientation
Definite amnesia
Persistent vomiting (two or more distinct episodes of vomiting 15 minutes apart)
Persistent irritability in the ED if < 2 yrs
GCS > 13 in the ED
Injury within the past 24 hours.
Osmond et al, CMAJ 2010

83. Minor Head Injury

84. Minor Head Injury
Identification of children at very low risk of clinically-important brain injuries
Inclusion criteria
Any child with injury < 24 hours
Looks at who does not need a CT rather than who needs a CT
Kupperman et al, Lancet 2009

85. Minor Head Injury
< 2 yrs

86. Minor Head Injury
> 2 yrs

87. Summary Quick tour through key PEM cases Neonatal presentations
Pediatric cardiac emergencies
Abdominal emergencies
Bronchiolitis, Upper airway infections
DKA
Febrile Seizure
Child Abuse
Minor head injury

88. Questions ?