1. Pediatrics Review Emergency Gina Neto, MD FRCPC Division of Emergency Medicine Children’s Hospital of Eastern Ontario

2. Case 1 2 month old male 2 day hx rhinorrhea, poor feeding 1 day hx cough Few hrs resp distress RR60 HR120 T37C Pink well hydrated smiling Chest - inspiratory crackles, exp wheezes Diagnosis?

3. Bronchiolitis RSV - Respiratory syncytial virus most commonRSV - Respiratory syncytial virus most common  parainfluenza, influenza A, adenovirus Peak in winterPeak in winter Infants more serious illnessInfants more serious illness TreatmentTreatment Nebulized Epinephrine – short term relief ? Dexamethasone  1 mg/kg on Day 1  0.6 mg/kg for another 5 days

4. Case 2 2 yr old girl Congestion x 2 days Awoke tonight with respiratory distress Loud noise on breathing in, harsh “barky” cough Improved on the way to hospital HR100 RR28 T37 Minimal distress Stridor, mild indrawing Diagnosis?

5. Croup Parainfluenza type IIIParainfluenza type III Hoarse voice, barky cough, inspiratory stridorHoarse voice, barky cough, inspiratory stridor Peak fall and springPeak fall and spring Infants and toddlersInfants and toddlers TreatmentTreatment Dexamethasone (0.6 mg/kg) Nebulized Epinephrine if in respiratory distress Consider Nebulized Budesonide

6. Croup Steeple Sign

7. Case 3 18 month female18 month female Fever x 2 days Difficulty swallowing HR130 RR28 T39C Exam normal except won’t move neck fully What diagnostic test should be performed?

8. Case 3 Retropharyngeal Abscess Complication of bacterial pharyngitis Group A hemolytic strep, oral anaerobes and S. aureus Treatment IV Clindamycin and Cefuroxime Consult ENT

9. Retropharyngeal Soft Tissues * Age (yrs)Maximum (mm) 0-11.5 x C5 1-30.5 x C5 3-60.4 x C5 6-140.3 x C5 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 * * *

10. Case 4 5 yr old male Febrile x 6 hrs Refusing to eat or drink Voice muffled, drooling Not immunized Very quiet, doesn't move HR140 RR20 T39.5 Slight noise on inspiration Chest clear, exam normal

11. Case 4 Epiglottitis Rarely seenRarely seen Strep pneumoniae H. influenzae uncommon due to vaccine Do not disturb patientDo not disturb patient Consult anesthesia, intubateConsult anesthesia, intubate IV cefuroximeIV cefuroxime

12. 17 month old male with a one-hour history of noisy and abnormal breathing Improved now, but at the time, parents thought he was quite distressed. Coughing and having trouble breathing at home. VS T36.8, P200 (crying), R28 (crying), O2 sat 99%VS T36.8, P200 (crying), R28 (crying), O2 sat 99% Alert, no cyanosis, no drooling, no dyspneaAlert, no cyanosis, no drooling, no dyspnea Chest: Mild wheezing with mild inspiratory stridorChest: Mild wheezing with mild inspiratory stridor Case

13. Soft Tissues Neck Lateral View

14. CXR (PA) What investigation would you do next?

15. Expiratory CXR

16. Inspiratory Expiratory

17. Foreign Body Aspiration Highest risk between 1 -3 years old Immature dentition – no molars, poor food control) More common with food than toys peanuts, grapes, hard candies, sliced hot dogs Acute respiratory distress (now resolved or ongoing) witnessed choking period cough, gag stridor, wheeze drooling muffled voice Uncommonly …Cyanosis and resp arrest

18. Case 5 9 month old female Fever x 2 days Vomiting (no blood, no bile) x 20 today Diarrhea (no blood) 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

19. Case 5 What is the degree of dehydration of this child?What is the degree of dehydration of this child? Management?Management?

20. Dehydration

21. Gastroenteritis 10% Dehydration10% Dehydration Rule out UTIRule out UTI ORT with rehydration solution (Pedialyte, Gastrolyte)ORT with rehydration solution (Pedialyte, Gastrolyte) 5 ml every 2 min continue until appears hydrated Consider Ondansetron (0.15 mg/kg)Consider Ondansetron (0.15 mg/kg) Early refeeding ( including milk) within 12 hrsEarly refeeding ( including milk) within 12 hrs

22. Fluids and Electrolytes Maintenance 4cc/kg/hr for first 10 kg 2cc/kg/hr for second 10 kg 1 cc/kg/hr for rest of weight in kg  D5WNS Deficit If severely dehydrated give FLUID BOLUS, 20 cc/kg over 15-60 min  NS Deficit fluid - first half over 8hrs, second half over 16 hrs Ongoing Losses Diarrhea, vomiting, polyuria, NG losses Insensible losses with fever ADD MAINTENANCE + DEFICIT + ONGOING LOSSES

23. Case 6 15 month old male Intermittent sudden severe abdo pain x 24 hrsIntermittent sudden severe abdo pain x 24 hrs crampy abd pain every 30 minutes Vomiting (no blood, no bile) x 3Vomiting (no blood, no bile) x 3 Diarrhea with blood and mucusDiarrhea with blood and mucus HR130 RR24 T37HR130 RR24 T37 Tender abdomen with fullness in RUQTender abdomen with fullness in RUQ Diagnosis?Diagnosis? Investigations?Investigations?

24. Intussusception 1-3 years1-3 years Boys 2:1 Classic Triad (10-30%)Classic Triad (10-30%) Vomiting Crampy abdominal pain “Red currant jelly” stools Lethargy is commonLethargy is common 75% are ileo-colic75% are ileo-colic Lead point  ? Peyer's Patches - preceding viral infection  Other: Meckel diverticulum, polyps, hematoma (HSP), lymphoma

25. Intussusception Plain AXRPlain AXR May be normal May have sxs bowel obstruction Paucity of air in RLQ  No air in Cecum on Lateral Decub

26. Intussusception Target SignTarget Sign

27. Intussusception Crescent SignCrescent Sign

28. Intussusception

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

30. Case 7 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. Born at 39 weeks gestation. Spontaneous vaginal delivery. Looks well. Mild dehydration. Abdomen soft, non tender, BS present. DDx?

31. Case 7 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

32. Pyloric Stenosis Most common surgical condition in first two months of life. Usually 4-6 weeks 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 Symptoms of gastric outlet obstruction Nonbilious vomiting Emesis increases in frequency and eventually becomes projectile

33. Pyloric Stenosis Classically:Classically: hypertrophied pylorus is palpable as an “olive” in the epigastric area peristaltic waves may be seen progressing from LUQ to the epigastrium Laboratory abnormalities:Laboratory abnormalities: hypokalemic, hypochloremic, metabolic alkalosis

34. Case 8 1 month old with bilious vomiting1 month old with bilious vomiting Multiple episodes of yellow green vomiting since this morning.Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability. Poor feeding.Progressive lethargy and irritability. Poor feeding. Looks unwell, irritable cry.Looks unwell, irritable cry. Abdomen distended.Abdomen distended. Weak pulses, cap refill>5 sec.Weak pulses, cap refill>5 sec. DDx? Management?DDx? Management?

35. Volvulus Twisting of a loop of bowel around its mesenteric attachment.Twisting of a loop of bowel around its mesenteric attachment. Sudden onset of bilious vomiting in a neonate.Sudden onset of bilious vomiting in a neonate. Acute abdomen with shockAcute abdomen with shock  may have a gradual course with episodic vomiting 80% present by the first month80% present by the first month  40% present in the first week  Rarely can be seen in older children.

36. Volvulus Evidence of small bowel obstructionEvidence of small bowel obstruction  dilated loops, air fluid levels, paucity of distal air

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

38. Case 9 1 month old girl 12 hr history of fever, 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?

39. Low Risk Criteria (Rochester) for Febrile Infants Well appearing infants 1-3 months are low risk for serious bacterial infection if the following criteria are met: 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)

40. Case 10 2 year old boy Sudden onset 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?

41. Febrile Seizure ABC's, IV accessABC's, IV access Seizure treatmentSeizure treatment IV/PR lorazepam or diazepam phenytoin, phenobarbitol Simple Febrile SeizureSimple Febrile Seizure T>38.5 <20min, generalized seizure 6mo-6yr neurologically normal before and after Observe in the ED until child returns to normal neuro statusObserve in the ED until child returns to normal neuro status

42. Case 11 2 yr old boy with persistent fever for 6 days2 yr old boy with persistent fever for 6 days Red eyes but no discharge.Red eyes but no discharge. Generalized rash, with erythema of the palms of his hands and soles of his feetGeneralized rash, with erythema of the palms of his hands and soles of his feet Red, swollen lips and enlarged cervical lymph nodesRed, swollen lips and enlarged cervical lymph nodes

43. Kawasaki Disease Usually < 4 yrs old, peak between 1-2 yrsUsually < 4 yrs old, peak between 1-2 yrs Unknown etiology, ? infectiousUnknown etiology, ? infectious Fever for > 5 days and 4 of the following: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)

44. Kawasaki Disease Subacute phase - Days 11-21Subacute phase - Days 11-21 Resolving acute symptoms Desquamation of extremities Arthritis Convalescent phase - > Day 21Convalescent phase - > Day 21 25% develop coronary artery aneurysms Myocardial infarction Other manifestations:Other manifestations: Uveitis Pericarditis Hepatitis, Gallbladder hydrops Sterile pyuria, Aseptic meningitis

45. Kawasaki Disease Investigations:Investigations: CBC – thrombocytosis ESR – elevated CXR, ECG Echocardiogram TreatmentTreatment 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

46. Case 12 3 year old boy Found eating acetaminophen from open container on kitchen counter Bottle contained 60 x 160mg tabs and only 10 found on the floor No distress HR90 RR24 T37 BP 110/BO Exam normal Management?

47. Poisoning in Children Present at 2 ages: Present at 2 ages: Young children  exploratory ingestion  ingest small amount of a single substance Adolescents  ingest large amounts of one or more substances  suicidal gesture

48. Acute Ingestion ABC’sABC’s Gastric Decontamination:Gastric Decontamination: Charcoal  Not to be used routinely for all ingestions  Greatest benefit is within 1 hr of ingestion 89% decrease if within 30 min 37% decrease at 1 hr  Substances not adsorbed by charcoal – alcohols, iron, lithium Whole Bowel Irrigation  For substances not adsorbed by charcoal and sustained release preparations  GoLytely – by NG at a rate of 500 ml -2 L/hr

49. Acute Ingestion Acetaminophen PoisoningAcetaminophen Poisoning Most Common ingestion Toxic dose 150 mg/kg or >7.5 g Clinical findings:  <24 hrs - vomiting, may be asymptomatic  24-72 hrs - liver enzyme abnormalities  72-96 hrs - liver failure, multi-system organ failure  4 days - recovery or death Do acetaminophen level at 4 hours, plot on nomogramDo acetaminophen level at 4 hours, plot on nomogram

50. Rumack-Matthew Nomogram

51. Acetaminophen - Metabolism

52. N-Acetylcysteine Mechanisms of action:Mechanisms of action: Precursor for glutathione Increases sulfation metabolism Directly reduces NAPQI to APAP Directly conjugates NAPQI Late effect - proposed mechanisms:Late effect - proposed mechanisms: Modulates inflammatory response  antioxidant, free radical scavenger  effect on leukocyte function Improves oxygen delivery Reservoir for glutathione

53. 12 yr old girl baseball hit finger... Type II

54. Salter-Harris Classification

55. 10 yr old boy fall onto hand... Type I

56. 16 yr old hockey player collided with another player and fell... Type IV

57. 14 yr old boy running and twisted ankle... Type III

58. 11 yr old fell off garage... Type V

59. 3 yr old girl with rash starting today 3 yr old girl with rash starting today Recent URTI Swollen ankles and knees. Painful walking. Diagnosis?

60. Henoch-Schonlein Purpura Systemic vasculitis – IGA mediatedSystemic vasculitis – IGA mediated 75% of cases between 2-11 years of age75% of cases between 2-11 years of age Clinical FeaturesClinical Features  100% - rash (non thrombocytopenic purpura)  68% - arthritis  53% - abdominal pain  38% - nephritis (ESRD in ~1%) Intussusception (2-3%)Intussusception (2-3%)

61. 1 yr old boy with mouth lesions for two days... What are the two most likely causes for this condition?What are the two most likely causes for this condition?

62. Herpes Simplex

63. Coxsackie

64. 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...This child comes back to the ED three days later with worsening fever and pain...

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

66. Questions ?