1. Pediatric Emergencies the 411 for ED Residents Amy Buoncristiani, MD Contra Costa Regional Medical Center Department of Emergency Medicine

2. Topics Covered Upper Airway Emergencies Fever without Source Asthma

3. Pediatric Upper Airway Emergencies DDx of stridor and fever: Croup Tracheitis Retropharyngeal abscess Epiglottitis

4. Croup aka viral laryngotracheobronchitis Sx: Rhinorrhea, fever, barking cough, stridor, tachypnea, retractions, hypoxia Dx: Clinical plus/minus lateral soft tissue neck to exclude epiglottitis in severe stridor Path: parainfluenza mostly ; others adeno, influenza, rsv, mycoplasma Peak: fall and winter Age: 6 mos – 4 years

5. Evidence Based Croup Management Dexamethasone 0.6 mg/kg po (iv form) or IM x 1 – Give to any severity of Croup – Reduces symptoms in 6 hrs – Fewer visits/hospitalizations – Decreased ED time and decreased use of Epi Racemic Epinephrine – For stridor at rest or severe Upper Airway obstxn – Dose 0.5 mL (0.05-0.1 ml/kg) – Observe 3-4 hrs and can d/c if no stridor at rest, good MS *Cool Mist not considered helpful, but used for comfort

6. Tracheitis - watch for it! Due to Hib immunization and steroid treatment, tracheitis now exceeds epiglottitis and croup as the most common life- threatening infection of the upper respiratory tract in children Mortality high Staph aureus most common

7. Tracheitis Sx: – Has features of epiglottitis and viral croup – Starts with viral upper respiratory symptoms, low grade F, cough – Then rapid onset of high fever, respiratory distress, variable stridor, and appears toxic. – Unlike patients with epiglottitis, these children typically have a cough, are comfortable lying flat, and do not drool

8. Tracheitis Management Airway support Contact ENT for endoscopic diagnosis and intubation Bug Juice: Vancomycin, Ampicillin-Sulbactam Contact CHO ICU for transfer/transport

9. Retropharyngeal Infections: Abscess and Cellulitis RP Space is potential space between pharynx and prevertebral fascia Etiology: spread of infection from pharyngitis, tonsillitis, sinusitis, or cervical lymphadenitis Age: < 6 years, peak age 3

10. RP Infections Sx: fever neck and throat pain neck swelling decreased movement of neck (extension) drooling decreased po intake Stridor and resp distress less common

11. RPI Management Dx : CT of the neck soft tissues the standard if your attending insists, you may wind up ordering first a: lateral neck film that may (or may not) show expansion of the prevertebral space = > 1 vertebral body width >7 mm at C2, and > 14 mm at C7 Tx : Broad Spectrum antibiotics transfer to CHO

12. Retropharyngeal Abscess Image and Clinical

13. Epiglottitis Epidemiology:  Rapid decline since 1990  Rise in Adults since that time  Most likely caused by Staph and Strep now  H. Influenza epiglottitis still rarely occurs in vaccinated children

14. Epiglottitis Dx & Management Suspect in child with rapid progression of fever, stridor, drooling, throat pain, but young children may have more subtle course Lateral Neck film may show ‘thumbprint’ Contact ENT to take child to OR for direct laryngoscopy and intubation Broad Spectrum Antibiotics, no good evidence for other Rx. Some try steroids, racemic Epi while considering DDx

15. Lateral Soft Tissue Neck Imaging Epiglottis NormalAbby Normal

16. Pediatric Fever Management in ED Initial and Basic Care: Children under 36 months require a rectal temperature Triage nurse usually gives child given tylenol (15 mg/kg) or motrin (10mg/kg) Ask nurse to start Oral Rehydration Therapy (ORT) which is pedialyte administered by caregiver 5 ml every 5 min by syringe and recording this on sheet for Staff to review

17. Febrile Child Triage Infants < 3 months with – either a history of T> 100.4 by caregiver or – nurse identified T>100.4 or 38 – are made a Triage Level 1 to facilitate physician exam and ordering work up in under 30 minutes Any febrile child who is toxic – Triage Level 1 and needs to be seen by physician within 10 minutes of triage

18. Fever Without a Source (FWS) Source not found in 20% febrile kids But, several percent have a Serious Bacterial Infection (SBI) or UTI Guidelines are AGE based due to differences in pathogens and immune function

19. Sources of Fever Any obvious site of infection: – Pneumonia – bacterial diarrhea – cellulitis – overt otitis media (>1 month old) – abscess – clinical croup – Varicella

20. Sources of Fever Viral sources – A positive rapid RSV, Influenza, Parainfluenza, adenovirus test places child at much lower risk of SBI/UTI – Still Strongly consider check for UTI in F < 24 mo and UCB < 6 mos Despite positive test, or ‘source’: **ALL NEONATES < 1 MONTH GET FULL SEPSIS WORKUP**

21. Pneumococcal Vaccine and Our Approach to Fever Heptavalent PNC Vaccine = Prevnar or PCV-7 added to immunization schedule in August 2000 Infants receive at 2, 4, 6 and 12 – 15 mo Efficacy against IPD from vaccine serotypes is 97.3 % and from all types 89.1%

22. Pneumococcal Vaccine and Our New Approach to Fever Since IPD is responsible for majority of non UTI Serious Bacterial Infections in infants > 3 mo, the risk of SBI in vaccinated children is <1 % regardless of WBC count – (translation: non toxic child over 3 months, don’t absolutely need CBC anymore!) IPD SBI’s still exist, so CLOSE FOLLOW UP ***Vaccine doesn’t change management of diagnosing UTI***

23. Facts about Fever in Neonates < 1 month old Incidence SBI/UTI = 4-12 % UTI associated with up to 20 % bacteremia Clinical exam unreliable Even if viral test positive, UTI, or other infection found, need to still do full sepsis work up because of high rate and risk of bacteremia and meningitis from source of infection, and high rate of concomitant SBI in virally infected neonates

24. FWS Management < 1 month All get: Cath UA and Culture CBC, Blood Culture x 1 Lumbar Puncture for – Cell count, Gram Stain, Culture, HSV PCR if pleiocytosis or infant ill appearing IV Amp and Gent Transfer to John Muir WC (CCHP-MediCal) or CHO (straight MediCal) and depending on home town

25. FWS Epidemiology in 1 – 3 month old T> 38C, 100.4F UTI Prevalence High: UCBoys>girls>Cboys CBC helps place infant at low or high risk Rate of SBI (not UTI) in – Low risk infants = WBC between 5 and 15K= 1-3% – High risk infants WBC>15, <5 =20 %!

26. FWS Management in 1 – 3 month old T> 38 Cath UA and Culture CBC Blood Culture IM or IV Ceftriaxone if WBC >15, strongly consider if <5 LP if irritable, lethargic, and strongly consider if antibiotics are to be given. Follow up in 24 hours, admit if unreliable

27. Risk Stratifying for FWS 3 – 36 months Unvaccinated = < 2 doses Prevnar Rate of Bacteremia 2.6 – 6 % in unvaccinated child regardless of WBC But, 2 large RCT’s tell us that WBC can be used to stratify into high and low risk groups when T>39.5 – WBC > 15K Rate Bacteremia = 10% – WBC < 15 Rate Bacteremia = 1%

28. Pneumococcal Vaccinated 3-36 mo with fever > 39.5 A child is considered vaccinated if has at least 2 doses of pneumococcal vaccine, second dose more than 2 weeks before presentation Risk of SBI drops to < 1% in this group, thus CBC or Blood Culture unlikely to change management in well appearing child Pneumococcal Vaccine doesn’t protect against UTI

29. Prevalence of UTI and Risk Stratification 3-36 mo group: Girls 6-8% in < 12 months Girls 5-10 % < 24 months  High Risk Girls = < 24 months Boys< 6 mos: 2.7 % (mostly Uncirc) Circ Boys > 3 mo rate UTI very low <<1%  High risk boys are Uncirc = < 6 months old

30. Management for UTI of Febrile T > 39 and 3-36 months High Risk Infants = F<24 mo, UCB<6 mo:  All get Cath UA and Culture Consider Screening Low Risk, especially if F> 48 hr (F > 24 mo, UCB to 12 mo, CB to 6 mo) Options: 1. Cath UA and send Culture or 2. Bag UA (don’t culture), but if LE/Nitrite +, send Cath UA and culture

31. Management for SBI T > 39.5 (103.1), child 3-36 months If child is NOT pneumococcal vaccinated  CBC and Blood Culture,  Treat IM/IV Ceftriaxone if WBC > 15 DO LP on any child with fever of any degree who is lethargic, irritable, ill appearing

32. Treatment of Febrile 3-36 mo child UTI: – Oral as good as IV for UTI – First dose in ED – IM/IV Ceftriaxone – Oral Keflex, Cefixime Unvaccinated with T > 39.5 (103.1) and WBC>15: – IM/IV Ceftriaxone Any toxic appearing child: – IV amp + gent + vanco (if pneumococcal suspected)

33. Questions to ask about Febrile Children 3-36 mo Is the child toxic? Is there a fever source? Is the boy circumcised? How many and when was most recent Prevnar? What is the likelihood of good follow up?

34. Final Notes Use your clinical judgment with children, and treat them not as a child, but as a little patient. If it is the right thing to do, then do it, even if it is invasive, or takes monitoring or more time, i.e., LP’s, IV pain meds when indicated Arrange closer follow up for children than others: 24 hr return is common in ED with febrile children FWS

35. Overview of ED Pediatric Asthma Management Inhaled Beta Agonists Supplemental Oxygen prn, Moniter prn Corticosteroids Systemic Medications for Status Asthmaticus Step Up Home therapy in Persistent Asthmatics Education Disposition decision

36. Albuterol Evidence: – Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses – Nebulized albuterol for severe disease, infants or when there is strong parent preference

37. Albuterol Dosing in ED MDI+ Spacer: 1-8 puffs every 20 minutes x 3 Spacers: Face Mask style for 1 – 10 years old Albuterol MDI 8 puffs = 2.5 mg UD nebulized

38. Albuterol Dosing in ED Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h >5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h Nebulized Continuous: 5-10 mg/hr calculate and caution <1 yr old 0.3-0.5mg/kg/hr

39. Overview of ED Pediatric Asthma Management Inhaled Beta Agonists Supplemental Oxygen prn, Moniter prn Corticosteroids Systemic Medications for Status Asthmaticus Step Up Home therapy in Persistent Asthmatics Education Disposition decision

40. Albuterol Evidence: – Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses – Nebulized albuterol for severe disease, infants or when there is strong parent preference

41. Albuterol Dosing in ED MDI+ Spacer: 1-8 puffs every 20 minutes x 3 Spacers: Face Mask style for 1 – 10 years old Albuterol MDI 8 puffs = 2.5 mg UD nebulized

42. Albuterol Dosing in ED Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h >5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h Nebulized Continuous: 5-10 mg/hr calculate and caution <1 yr old 0.3-0.5mg/kg/hr

43. Atrovent Anticholinergic Nebulizer solution (0.25 mg/mL) < 20 kg : 0.25 mg = ½ UD < 20 kg : 0.5 mg = 1 UD every 20 minutes for 3 doses, then as needed q6h

44. Corticosteroids in ED Short bursts of steroids beneficial in acute asthma and reduce hospitalizations, duration Strongly consider corticosteroids for every asthma exacerbation or viral reactive airways. Down side is negligible and Benefits are evidence based.

45. The New FavoriteCorticosteroid Oral Dexamethasone (T ½ 36-72 hr) – May give tasteless IV form orally!! – 0.6 mg/kg/day for 2 doses. – Give 2 nd dose 24-36 hrs after the first. – May send home family with syringe of the correct second dose of the IV form – Or Rx oral tablet form and crush in pudding or jam

46. Adjunct Meds in Status Asthmaticus Evidence: Magnesium is first line systemic bronchodilator RCTs and Metas have established safety and efficacy in kids, reduces hospitalization Single dose: 25-75 mg/kg (max 2 g) IV over 20 minutes Adverse: flushing and nausea

47. Injectable Beta 2 Agonists: Terbutaline and Epinephrine No proven benefit, but used when faced with impending respiratory failure and possible intubation

48. Terbutaline 0.01 mg/kg SC every 20 minutes for 3 doses then every 2–6 hours as needed Max dose 0.25 mg, or adult dose

49. Epinephrine 1:1000 =1 mg/mL Dose Child and Adult: 0.01 mg/kg SC Max dose 0.5 mg every 20 minutes x 3 doses

50. Step up Home Therapy Send home patients with inhaled corticosteroids, who have persistent or not well controlled asthma* *Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations Journal of Allergy and Clinical Immunology - Volume 124, Issue 2 Suppl (August 2009)

51. What is Uncontrolled Asthma? Rule of 2’s More than 2 daytime/exercise symptoms/week or >2 episodes of albuterol use/week, or >2 nighttime awakenings per MONTH or > 2 steroid courses or hospitalizations in last YEAR