Topnotch Pediatrics For Moonlighters

ì

GETTING READY FOR PEDIATRICS

Ruby L. Punongbayan, MD, MA, FPPS Associate Professor in Pediatrics

Intended Learning Outcomes: ì To recognize the salient features of the clinical condition

encountered by the general practitioner in the pediatric outpatient and emergency setting

ì To come up with an initial diagnosis based on thorough history

taking and a comprehensive and focused physical examination

ì To formulate an appropriate diagnostic plan of management for

the pediatric patient seen by a general physician and correctly interpret its results

ì To create a therapeutic plan of management for the patient

that is appropriate and justifiable for the given clinical scenario




ì Consider the age group in establishing rapport and doing

PE.

ì Make entries in the history and PE that are age-

appropriate.

ì Perform the invasive procedures last. ì Use acceptable ways of immobilization. ì Know the natural course of the illness.

Age-specific blood cell indices Age

Hb (g/dL)

Hct (%)

WBC (x10 to 2/uL)

1-3 days old

18.5 (14.5)

56 (45)

18.9 (9.4-34)

2 weeks old

16.6 (13.4)

53 (41)

11.4 (5-20)

1 month old

13.9 (10.7)

44 (33)

10.8 (4-19.5)

2 months old

11.2 (9.4)

35 (28)

-----

6 months old

12.6 (11.1)

36 (31)

11.9 (6.-17.5)

6 mo-2 years old

12.0 (10.5)

36 (33)

10.6 (6-17)

2-6 years old

12.5 (11.5)

37 (34)

8.5 (5-15.5)

Age-specific blood cell indices Age

Hb (g/dL)

Hct (%)

WBC (x10 to 2/uL)

6- 12 years old

13.5 (11.5)

40 (35)

8.1 (4.5-13.5)

12- 18 years old Male Female

14.5 (13.5) 14.0 (12)

43 (36) 41 (37)

7.8 (4.5-13.5) 7.8 (4.5-13.5)

Vital signs at various ages AGE

Heart rate (Beats/ min)

Blood Pressure

RR (breaths/ min)

Prema-ture 120-170

55-75/ 35-45

40-70

0-3 months 100-150

65-85/ 45-55

35-55

3-6 months 90-120

70-90/ 50-65

30-45

6-12 months

80-100 55-65

25-40

80-120

Vital signs at various ages AGE

Heart rate (Beats/ min)

Blood Pressure

RR (breaths/ min)

1-3 yrs

70-110

90-105/ 55-70

20-30

3-6 yrs

65-110

95-110/ 60-75

20-25

6-12 yrs

60-95

100-120/ 60-75

14-22

>12 yrs

55-85

110-135 65-85

12-18

Important Points re: taking the BP ì Use the RIGHT SIZE BP CUFF!

Blood chemistries Reference values

Conventional units

SI units

Serum ALT (SGPT) infant adult male adult female

13-45 U/L 10-40 U/L 7-35 U/L

13-45 U/L 10-40 U/L 7-35 U/L

Amylase newborn adult

5-65 U/L 27-131 U/L

5-65 U/L 27-131 U/L

Serum AST (SGOT) infant 1-3 yrs old 4-6 yrs old 7-9 yrs old 10-11 yrs old 12-19 yrs old

15-60 U/L 20-60 U/L 15-50 U/L 15-40 U/L 10-60 U/L 15-45 U/L

15-60 U/L 20-60 U/L 15-50 U/L 15-40 U/L 10-60 U/L 15-45 U/L

Blood chemistries Reference values BILIRUBIN (TOTAL) 1-2 days preterm term 3-5 days preterm term Older infant preterm term BILIRUBIN (CONJUGATED) Neonate Infants / Child

Conventional units

SI units

<12 mg/dL <11.5 mg/dL

<205 umol/L <197 umol/L

<16 mg/dL <12 mg/dL

<274 umol/L <205 umol/L

<2 mg/dL <1.2 mg/dL

<34 umol/L <21 umol/L

<0.6 mg/dL <0.2 mg/dL

<10 umol/L <3.4 umol/L

Blood chemistries Reference values

Conventional units

C-REACTIVE PROTEIN

0.0.5 mg/dL

CREATININE Infant Child Adolescent

0.2-0.4 mg/dL 0.3-0.7 mg/dL 0.5-1.0 mg/dL

ESR Child

4-20 mm/hr

LIPASE 3-12 months old 1-11 yrs old > 11 yrs old

9-128 U/L 10-150 U/L 10-220 U/L

SI units

18-35 umol/L 27-62 umol/L 44-88 umol/L

9-128 U/L 10-150 U/L 10-220 U/L

Blood chemistries Reference values

Conventional units

SI units

GLUCOSE (serum) Preterm Newborn, > 1 day Child > 16 years old

20-60 mg/dL 50-80 mg/dL 60-100 mg/dL 74-106 mg/dL

1.1-3.3 mmol/L 2.8-4.5 mmol/L 3.3-5.5 mmol/L 4.1-5.9 mmol/L

Blood chemistries LIPIDS

CHOLESTEROL (mg/dL)

Child / Adolescent Desirable 170

Borderline 170-199

High >200

110-129

>130

-----

------

LDL (mg/dL) Child/ Adolescent

<110 HDL (mg/dL)

Child / Adolescent

45

Common reasons for 
 pediatric consultations: ì Difficulty of breathing / respiratory distress ì Diarrhea and/or vomiting ì Fever with or without rashes ì Abdominal pain ì Seizures ì Chest pain ì Headache ì Trauma ì Allergies ì Parasitism

respiratory distress / dyspnea ì

Respiratory problem by severity: Respiratory distress

Respiratory failure

Clinical state characterized by abnormal respiratory rate and effort

Clinical state of inadequate oxygenation, ventilation, or both End stage of respiratory distress

Respiratory effort: > Increased: nasal flaring, retractions, use of accessory muscles > Inadequate: e.g. hypoventilation, bradypnea

Change in airway sounds Associated changes in skin color and mental status

➢ Tachypnea (early), bradypnea (late) ➢ increased, decreased, or no respiratory effort ➢ poor to absent distal air movement ➢ Tachycardia (early), bradycardia ➢ Cyanosis ➢ Stupor, coma (late)

Question: ì A 4 year-old girl presents with fever for 3 days,

rhinorrhea, and a barking cough. On PE, she was heard to be hoarse with a musical adventitious breath sound heard on inspiration. What is the expected neck X ray finding in this patient?

a. Diffuse infiltrates on both lung fields b. Right upper lung consolidation c. Subglottic narrowing (steeple sign) d. Thumbprint sign

ì A 15 year-old girl ate out with her family in a seafood

restaurant. Two hours later, she developed wheezing, hives, and tongue swelling. She was brought to the ER 20 minutes later. A delay in the administration of which of the following medications has been strongly associated with mortality from this condition?

a. IV crystalloid



c. IV Methylprednisolone

b. Epinephrine IM



d. inhaled salbutamol

IDENTIFICATION OF RESPIRATORY PROBLEMS BY TYPE: ì

Upper Airway Obstruction

(croup, anaphylaxis, foreign body aspiration) ❖

SIGNS:

❖

Tachypnea

❖

Increased inspiratory respiratory effort (inspiratory retractions, nasal flaring)

❖

Changes in voice (e.g. hoarseness), cry, or presence of barking cough

❖

Stridor (usually inspiratory but may be biphasic)

❖

Poor chest rise

❖

Poor air entry on auscultation

Laryngotracheobronchitis ì also called viral croup ì acute inflammatory disease of the larynx (within the

subglottic space)

ì most common etiology is parainfluenza virus ì SSx: rhinorrhea, pharyngitis, and low-grade fever 1-3

days before signs of UAO, inspiratory stridor, hoarse voice, barking cough

ì neck x-ray: subglottic narrowing - “steeple sign” (X ray

findings do not correlate well with disease severity)

Westley croup score: Clinical sign

Degree

Score

Stridor

None At rest on auscultation At rest without auscultation

0 1 2

Chest wall retractions

None Mild Moderate Severe

0 1 2 3

Air entry

Normal Decreased Severely decreased

0 1 2

Cyanosis

None With agitation At rest

0 4 5

Consciousness level

Normal Altered

0 5

LTB ➢ Westley croup score: 0-17 ➢ Mild: 0-4 ➢ Moderate: 4-6 ➢ Severe: >6 ì Tx: ì It is strongly recommended that a single dose of

glucocorticoids be administered to children presenting to the ED with mild, moderate, or severe croup. (2011, Level 1A)

Management of croup: SEVERITY OF CROUP

INTERVENTION

MILD

Consider dexamethasone (0.6 mg/kg/dose po/IV/IM)

MODERATE TO SEVERE

Administer humidified 02 Give nothing by mouth Administer nebulized epinephrine (<4 yrs: 0.05 ml/kg/dose diluted to 3 ml NS with max of 0.5 ml/dose; > 4 yrs: 0.5 ml/ dose diluted to 3 ml NS) Observe for at least 2 hours Administer dexamethasone

IMPENDING RESPIRATORY Administer a high concentration of 02 FAILURE Use non rebreathing mask if available: Assist ventilation (bag mask ventilation) Administer dexamethasone IV/IM Perform endotracheal intubation Use smaller ET tube size

Management of LTB: ì Airway management and treatment of hypoxia ì mild (at home): oral fluids ì moderate to severe stridor at rest, hypoxia, need for intubation: nebulized racemic epinephrine (<4 yrs old: 0.05 ml/kg/dose diluted to 3 ml NSS with max of 0.5 ml/dose; >4 yrs old: 0.5 ml/dose diluted to 3 ml NSS) ì Single dose of oral dexamethasone 0.6 mg/kg (as

effective as IM) to decrease laryngeal edema

Adverse reactions to food ì Any untoward reaction following ingestion of food and divided into: ➢ Food intolerance – adverse physiologic responses based on

functional properties of food

➢ Food allergy – adverse immunologic response and allergies due to IgE-mediated and/or cell-mediated mechanisms

ì EPINEPHRINE- drug of choice for anaphylaxis ➢ Prevents or reverses airway obstruction and cardiovascular collapse ➢ Dose: 0.01 ml/kg with 0.5 ml max IM

ANAPHYLAXIS ì Diagnostic criteria: ➢ Criterion 1: 1. Acute onset of illness involving skin, mucosal tissue,

or both 2. Respiratory compromise 3. Reduced blood pressure

ANAPHYLAXIS ì

Diagnostic criteria:

➢

Criterion 2:

1.

2 or more of the following that occur rapidly after exposure to a “likely allergen” for that patient:

a.

Involvement of the skin-mucosal tissue

b.

Respiratory compromise

c.

Reduced BP or associated symptoms

d.

Persistent gastrointestinal symptoms

Signs and symptoms: ì SKIN ➢ Flushing

ì RESPIRATORY

➢ Itching

➢ Nose: itching, congestion, rhinorrhea, sneezing

➢ Urticaria

➢ Lungs: shortness of breath,

➢ Angioedema ➢ Hair standing on end ì ORAL

> Itching or tingling of lips, tongue, or palate

dyspnea, chest tightness, wheezing, cough

➢ Laryngeal: pruritus &

tightness in throat, dysphagia, hoarseness

Signs and symptoms: ì CARDIOVASCULAR ➢ Feeling of faintness or

dizziness

➢ Syncope ➢ Chest pain ➢ Palpitations ➢ Hypotension (tunnel

vision, difficulty hearing)

ì GASTROINTESTINAL ➢ Nausea ➢ Abdominal pain ➢ Vomiting ➢ Diarrhea

NEUROLOGIC ➢ Anxiety ➢ Apprehension ➢ Sense of impending doom ➢ Confusion ➢ Headache ➢ seizures

Signs and symptoms ì OCULAR

ì OTHERS

➢ Periorbital itching

➢ Lower back pain due to

➢ Erythema ➢ Edema ➢ Tearing ➢ Conjunctival erythema

uterine cramping in females

➢ Vaginal bleeding

Management ì Airway, breathing, circulation (02, fluids) ì EPINEPHRINE- drug of choice ➢ Prevents or reverses airway obstruction and cardiovascular collapse ➢ Dose: 0.01 ml/kg with 0.5 ml max IM

ì ANTIHISTAMINE: ➢ H1: relieve itching & hives: Diphenhydramine (1 mg/kg IM max 50 mg), Cetirizine, Hydroxyzine ➢ H2: minimal evidence to support use

Management •

BETA-ADRENERGIC AGONISTS

➢ Nebulize with Albuterol or Salbutamol if with wheezing

•

GLUCOCORTICOIDS

➢ May help prevent biphasic or protracted course ➢ Do not provide rapid relief or upper/lower airway obstruction,

shock, or other symptoms

➢ Hydrocortisone 5 mg/kg or Methylprednisolone 2 mg/kg IV

Management of foreign body aspiration: 1. For a conscious infant or child, use manual techniques appropriate for age. < 1 year - give 5 slaps followed by 5 chest thrust > 1 year – give abdominal thrust 2. If become unresponsive, start CPR beginning with chest compression Before you deliver a breath, look into the mouth, if you see a foreign body that can easily be removed.

* Do not do blind finger sweep in an effort to dislodge foreign body. This may push the foreign body further into the airway. It may also cause bleeding and trauma.

Question: ì A 2 year-old male presents with 3 days cough, colds, and fever.

On PE, his RR 55 breaths/min, with subcostal retractions, had wheezes on all lung fields, and a prolonged expiratory phase. What is the most likely etiologic organism of this patient’s condition?

a.

Respiratory syncitial virus

b.

Parainfluenza virus

c.

Streptococcus pneumoniae

d.

Mycoplasma pneumoniae

Bronchiolitis ì acute inflammation of the small airways in children less than 2

yrs old

ì most commonly caused by RSV (respiratory syncitial virus) ì S/sy: low-grade fever, rhinorrhea, cough, wheezing,

hyperresonance to percussion, prolonged expiratory phase

2014 AAP guidelines on management of bronchiolitis: ì Routine radiographic and laboratory tests are unnecessary and

clinicians should diagnose it and assess its severity based on history and PE.

ì The AAP no longer recommends a trial dose of a

bronchodilator because evidence to date shows that it is ineffective in changing the course of bronchiolitis. (evidence quality B, strong recommendation)

ì NO chest physiotherapy nor use of epinephrine ì 1st yr of life: (+) heart disease or CLD of prematurity:

Palivizumab (max.of 5 monthly doses, 15 mg/kg/dose during the RSV season)

Question: ì A 5 year-old girl presented with cough for 5 days and

undocumented low-grade fever for the past 2 days. His sleep is interrupted by his coughing. 4 hrs PTC, he was seen to have increased difficulty of breathing and was only able to speak in phrases.

ì PE: irritable, hunched forward, CR= 130/min, RR=65/

min, T=36.8°C, 02 sat 90%, no TPC, (+) subcostal retractions, (+) wheezing on lower lung fields, no murmurs.

ì Which of the following is incorrect in the

management of this patient’s acute condition?

a. Inhaled beta 2 agonist b. Oral Prednisolone c. Cetirizine tablet d. Methylprednisolone IV

Management: ì Management of acute attacks: ì short-acting inhaled beta2-agonist ì oral or IV steroids (Prednisolone/

Methylprednisolone) ì anticholinergics (ipratropium bromide) – never used alone ì methylxanthines (theophylline, aminophylline) - NOT first line

ì Management in between attacks: ì inhaled corticosteroids ì long-acting inhaled beta2-agonist ì leukotriene modifiers (Montelukast)

IDENTIFICATION OF RESPIRATORY PROBLEMS BY TYPE: ì Lower Airway Obstruction

(bronchiolitis, acute asthma) SIGNS: ì Tachypnea ì Wheezing (most commonly expiratory but may be inspiratory or

biphasic)

ì Increased respiratory effort (retractions, nasal flaring, and prolonged

expiration)

ì Prolonged expiratory phase associated with increased expiratory effort

(i.e. expiration is an active rather than passive process)

ì Cough

Management of asthma exacerbations 
 in acute care setting 
 (children 6 years & older):

ì

Initial assessment (Airway, Breathing, Circulation)

ì

No

Further TRIAGE BY CLINICAL STATUS according to worst feature

Are any of the ff present? drowsiness, confusion, silent chest

Yes Consult ICU, start SABA and O2 and prepare patient for intubation

Management of asthma exacerbations 
 in acute care setting (children 6 years & older): Mild or moderate Talks in phrases Prefers sitting to lying Not agitated Increased RR Accessory muscles not used PR 100-120 bpm 02 sat on air 90-95% PEF > 50% predicted or best

Severe Talks in words Sits hunched forward Agitated RR >30/min Accessory muscles being used PR >120 bpm 02 sat on air < 90% PEF less than or equal to 50%

SABA Consider ipratropium bromide Controlled 02 to maintain 02 sat at 93-95% (children 94-98%) Oral glucocorticosteroids

SABA Consider ipratropium bromide Controlled 02 to maintain 02 sat at 93-95% (children 94-98%) Oral glucocorticosteroids Consider IV magnesium Consider high dose ICS

If continuing deterioration, treat as severe & re-assess for ICU

Management of asthma exacerbations 
 in acute care setting (children 6 years & older): Assess clinical progress frequently Measure lung function in all patients 1 hour after initial tx

FEV1 or PEF 60-80% of predicted or personal best and symptoms improved MODERATE Consider for discharge planning

FEV1 or PEF < 60% of predicted or personal best or lack of clinical response SEVERE Consider Tx as above and re-assess frequently

Treatment of exacerbations in acute care setting such as the ED: ■ Oxygen by nasal cannula or mask ➢ 94-98% children 6-11 yrs old; 93-95% for adolescents ➢ Severe exacerbation: low flow 02 therapy associated

with better physiological outcome than with high flow 100% 02 therapy

Treatment of exacerbations in acute care setting such as the ED: ì Inhaled SABA ➢ Most cost effective and efficient delivery is

by MDI with a spacer

➢ Conflicting results for intermittent vs

continuous nebulized SABA

➢ Reasonable approach: initial continuous

therapy followed by intermittent on-demand therapy for in-patients

Treatment of exacerbations in acute care setting such as the ED: ■ Systemic corticosteroids ➢ Speed resolution of exacerbations and

prevent relapse & should be utilized in all but the mild attacks in adults, adolescents, and children 6-11 years old

➢ Should be given to patients within 1 hour of

presentation

➢ Route ???

Treatment of exacerbations in acute care setting such as the ED: ■ Systemic corticosteroids ➢ OCS 50 mg Prednisolone daily as a single

morning dose ➢ Children: Prednisolone 1-2 mg/kg up to a

max. of 40 mg ➢ Duration: 5-7 days for adults; 3-5 days for

children (NO tapering needed)

Treatment of exacerbations in acute care setting such as the ED: ■ Inhaled corticosteroids ➢ Within the ED: high dose given within the 1st

hr after presentation reduces the need for hospitalization in patients not receiving systemic steroids ➢ Conflicting evidence when given in addition

to systemic steroids

Treatment of exacerbations in acute care setting such as the ED: ■ Inhaled corticosteroids ➢ Upon discharge: prescribe regular ongoing

ICS tx because: 1. The occurrence of a severe exacerbation is a risk factor for future exacerbations 2. ICS-containing meds significantly reduce the risk of asthma-related death or hospitalization

Other treatments: ■ Ipratropium bromide ➢ For adults and children with moderate-severe

exacerbations, treatment in the ED with both SABA and ipratropium was associated with fewer hospitalizations and greater improvement in FEV1 and PEF compared with SABA alone.

Other treatments: ■ Aminophylline and theophylline ➢ NOT used in the management of

exacerbations due to poor efficacy and safety profile

➢ Use of IV aminophylline is associated with

severe and potentially fatal side effects esp. in patients already treated with sustainedrelease theophylline

Other treatments: ì Magnesium ➢ IV Mg sulfate not for routine use however when

administered as a single 2 g infusion over 20 mins, it reduces hospital admissions in some patients like those who have persistent hypoxemia and in children whose FEV1 falls to 60% predicted after 1 hr of care ➢ Overall efficacy is still unclear

Other treatments: ■ LTRA ➢ Limited evidence to support a role for oral or IV

LTRA in acute asthma ■ Antibiotics (NOT recommended) ➢ Evidence does not support antibiotics in

exacerbations unless there is strong evidence of lung infection ➢ NO sedatives !!!

Initial assessment of 
 acute asthma in children: SYMPTOMS

MILD

SEVERE

Altered consciousness 02 sat

No > 95%

Agitated, confused, drowsy < 92%

Talks in…

sentences

words

Pulse rate

< 100 bpm

>200 bpm (0-3 yrs); >180 bpm (3-5 yrs)

Central cyanosis

absent

Likely to be present

Wheeze intensity

variable

May be quiet

How to use PEFR: ì (Ht

in cms - 100) x 5 + 175 in males

ì (Ht in cms - 100) x 5 + 170 in females ì The answer to this represents the EXPECTED PEFR. ì Let the patient use the peak flow meter 3x and get the

highest value which represents the ACTUAL PEFR. ì actual / expected x 100%

Example: Ht is 160 cms. male ì Given: actual PEFR 300 ì Answer 63% ì Based on the table: ➢ mild: >80 ➢ Moderate: 60-80 ➢ Severe: <60

*** an increase in 15- 20% from the baseline after 3 nebulizations --> response to bronchodilators

Case: ì A 2 year-old girl presents with cough and colds for

the past 3 days with undocumented fever. No consultation at that time. On the day of consultation, she was noted to have decreased appetite and irritability. Vital signs: CR = 160/min, RR was 65/ min, T=38.8°, 02 sat 90%, no TPC, no murmurs, (+) intercostal retractions, (+) crackles on both lung fields.

ì What is your impression?

Identification of respiratory 
 problems by type:

ì DISORDERED CONTROL OF BREATHING

(neuromuscular disease)

ì LUNG TISSUE DISEASE (pneumonia, cardiogenic

pulmonary edema, ARDS, pulmonary contusion)

LUNG TISSUE DISEASE SIGNS: ì Tachypnea (often marked) ì Increased respiratory effort ì Grunting ì Crackles (rales) ì Diminished breath sounds ì Tachycardia ì Hypoxemia (may be refractory to administration of

supplemental 02)

Cardiogenic pulmonary edema: ì High pressure in the pulmonary vessels causes fluid

to leak into the lungs interstitium and alveoli

ì e.g., congenital heart disease, myocarditis,

inflammatory processes, hypoxia, and cardiac depressant drugs


 MANAGEMENT:


ì A. PNEUMONIA

1. Perform diagnostic test 2. Administer antibiotic therapy 3. Consider using CPAP or non invasive ventilation 4. In severe cases, endotracheal intubation and mechanical ventilation maybe required. 5. Reduce metabolic demand by normalizing temperature and reducing the work of breathing


 MANAGEMENT


B. CHEMICAL PNEUMONITIS
 1.Treat wheezing with nebulized bronchodilator 2. Consider using CPAP or non invasive ventilation 3. With rapidly progressive symptoms, obtain early consultation 4. Refer to a specialized center C. ASPIRATION PNEUMONITIS 1.

Consider using CPAP or non invasive ventilation

2.

Intubation and mechanical ventilation

3.

Consider antibiotics if with fever and infiltrates

DISORDERED CONTROL OF BREATHING: SIGNS: ì Variable or irregular respiratory rate (tachypnea

alternating with bradypnea) ì Variable respiratory effort ì Shallow breathing (frequently resulting in hypoxemia) ì Central apnea (apnea without respiratory effort)

Case: ì A 6 year-old boy had colds for the past 10

days. Fever was noted on the 7th day of the illness along with signs of irritability and tugging of his ear on the day of consultation.

ì What is your initial diagnosis?

Acute Otitis Media ì Cough and colds, fever, irritability, decreased

appetite, vomiting

ì Hyperemic TM, bulging TM, effusion, absent

cone of light

ì Strep. pneumoniae, H.influenzae b, Moraxella

catarrhalis

ì 1st line drug: Amoxicillin (40 mg/kg/day for

7-10 days)

Sample computation: ì Wt 20 kgs ì 20 kgs x 40 mgkgday x 5/250 = 5 ml every 8 hrs ì Amoxicillin has 100 mg/ml; 125 mg/5 ml; 250 mg/5ml ì Co-Amoxiclav has 312.5mg/5 ml; 457 mg/5 ml; 600

mg/42.9 ml

AOM management: 2013 guidelines: ì Clinicians should prescribe an antibiotic with

additional β-lactamase coverage for AOM when: 1.

a decision to treat with antibiotics has been made

2.

and the child has received amoxicillin in the last 30 days

3.

has concurrent purulent conjunctivitis

4.

has a history of recurrent AOM unresponsive to amoxicillin

Case: ì A 17 year-old male

presents with mucopurulent discharge on both eyes. He has colds 3 days prior to the eye discharge. Impression?

Conjunctivitis ì Inflammation of the loose connective tissue that

covers the surface of the eyeball (bulbar) and the inner layer of the eyelid (palpebral) ì Staph.epidermidis, Strep.pyogenes, Strep.

pneumoniae, Moraxella, H.influenzae ì Viral / bacterial / allergic

AAO Conjunctivitis guidelines 2013: ì The choice of antibiotic is usually empiric. Because

a 5-7 day course of a broad spectrum topical antibiotic is usually effective, the most convenient or least expensive option can be selected; there is no clinical evidence suggesting the superiority of any particular antibiotic. (Level III evidence)

ì Mild bacterial conjunctivitis is usually self-limited

and typically resolves spontaneously without specific treatment in immune competent adults. (Level I evidence)

ORBITAL & PERIORBITAL CELLULITIS ì Infection preceded by a break in the skin caused by S.

aureus, grp A strep, Moraxella catarrhalis, pneumococcus, HiB ì Both present with warm, tender, erythematous lid

swelling, mucoid discharge, conjunctival swelling ì Orbital: proptosis, limited EOM, change in VA, ocular

pain, chemosis ì Cephalexin or Cefadroxil; Nafcillin or Cefuroxime

Common Colds/ Rhinitis ì organisms: rhinovirus*, parainfluenza virus,

RSV, coronavirus (children are reservoirs)

ì incubation of 2-5 days, resolved by 5-7 days ì SSx: sore throat, sneezing, rhinorrhea, nasal

congestion, pharyngitis ì Tx: supportive ì complications are otitis media, sinusitis,

pneumonia

Sinusitis ì organisms: S. pneumoniae, H. influenzae type b, M.

catarrhalis (acute), anaerobes (chronic)

ì

anything that impairs mucociliary transport or

causes nasal obstruction predisposes to sinusitis ì

SSx: cold symptoms >7-10 days, purulent nasal discharge, headache, tenderness over the sinuses

ì

x-ray: air-fluid levels, opacification of the sinuses

ì

Tx: antibiotics x 14 days (Amoxicillin)

ì

complications are abscess, meningitis

Acute Pharyngitis Viral gradual onset ➢moderate throat pain ➢symptoms of viral URTI ➢contacts with cold Sx ➢vesicles & ulcers (HSV) ➢conjunctivitis (adenovirus) ➢

GABHS headache, vomiting, abdominal pain ➢NO URTI symptoms ➢palatal petechiae & diffuse erythema of tonsils and pillars ➢sandpaper rash in inguinal & antecubital areas ➢

Acute Pharyngitis ì Dx for GABHS: rapid strep Ag test, throat culture ì Tx for viral: symptomatic ì Tx for GABHS: Penicillin or Amoxicillin x 10 days ì complications of GABHS: ì rheumatic fever ì post-streptococcal glomerulonephritis ì peritonsillar / retropharyngeal abscess

Case: ì A 17 year-old boy was having fever and sore

throat for the past 7 days without any consultation with a doctor. He was given Paracetamol 500 mg prn by his mother for the fever. On the day of consultation, he was still febrile and has dysphagia. When asked to open his mouth, you saw this:

Peritonsillar Abscess ì Bacterial invasion through the capsule of the tonsils ì Adolescents ì Group A streptococcus and anaerobes ì Fever, sore throat, dysphagia, trismus ì PE: tonsils may be markedly red with swelling and uvula is

displaced

ì CT scan - ideally ì Surgical drainage and antibiotics

Retropharyngeal abscess ì 3-4 years old ì Retropharyngeal space located between the

pharynx & the cervical vertebrae & extending down into the superior mediastinum ì Can result from penetrating trauma to the

oropharynx, dental infection, and vertebral osteomyelitis

What are the manifestations? ì Group A streptococcus, anaerobes,

Staphylococcus aureus ì Fever, progressive dysphagia ì PE: drooling, neck held in hyperextension, bulge

seen behind the posterior pharyngeal wall, neck pain, muffled voice, respiratory distress

Approach to RASHES

ì

Case: A 7 year-old male presents at the ER with 1 day history of pruritic rash on the trunk and extremities. PE: wheals on trunk, arms, and thighs, clear breath sounds, non tender abdomen with T=37.6 C

Hypersensitivity reaction ■

Spectrum: urticaria --> erythema multiforme --> anaphylaxis

■

Papules or wheals are evanescent, raised, erythematous lesions that are pruritic

■

Bull’s eye lesions in EM

■

2 or more systems involved (gastrointestinal, circulatory, skin, etc.): consider anaphylaxis

Hypersensitivity Reaction ■ Identify and avoid/discontinue the offending agent. ■ Nuts, fish, seafood, preservatives, eggs, chocolates,

change in weather, plants, hormonal changes, dust mites, insect bites

■ Diphenhydramine 1 mg/kg/dose IM (max. 50 mg) ■ Prednisolone 1-2 mg/kg/day for 3-5 days ■ Epinephrine 0.01 ml/kg/dose IM, anterolateral part of

the thigh (max. 0.5 ml)

■ H2 receptor antagonist ■ Fluids (crystalloid) at 20 cc/kg fast drip if in shock

Case: ì 15 year-old male with

pruritic papules for 1 week most prominent on the waist, inguinal area, abdomen, interdigital areas ì Other younger siblings

have the same lesions

Scabies ■ Secondary impetigo is common ■ Treat the infection first with Cloxacillin (50-100

mg/kg/day q 6h 7 days) OR Cefalexin (50-100 mg/ kg/day q 6h 7 days)

■ Permethrin 5% applied in the body for 12 hours for

5 days (cure rate 98%)

■ Lindane lotion 1 6-hr application on the body for 5

days

■ Antihistamine for pruritus (Cetirizine, Loratadine)

Candidiasis ■ Neonates & infants: white plaques on a red base

(thrush) in the buccal mucosa; intertriginous areas (beefy erythema with elevated margins and satellite red plaques) like inframammary, axillary, neck & inguinal body folds

■ Adolescent females: whitish plaques on red mucous

membrane of vulvovaginal areas with cheesy vaginal discharge

■ Oral thrush: oral Nystatin 4x/day for 5 days ■ Skin: Ketoconazole, Miconazole, Clotrimazole

Oral thrush

Case: ì A 14 month-old male

presents with fever and irritability for 3 days. PE: tender bullae on the trunk and thighs with moist, shiny surface that tend to separate ì Impression?

Staphylococcal Scalded Skin Syndrome ■ Spectrum: from bullous impetigo to generalized

involvement

■ Skin rapidly becomes tender with crusting around the

mouth, eyes & neck

■ Mild rubbing of the skin results in epidermal separation

leaving a shiny, moist, red surface---(+)Nikolsky sign

■ Oxacillin 100-200 mg/kg/day q 6 hrs IV; fluid and

electrolyte correction

Case: ì A 4 year-old girl

presents with honeycrusted lesions on the face with low-grade fever. ì No other systemic

manifestations

Impetigo ■ Erosions covered by moist, honey-colored crusts in face,

nares, extremities, trunk

■ Bullous – lesions with central moist crust and an outer

zone of translucent blister

■ Staph.aureus, group A streptococcus

■ Cefalexin 50-100 mg/kg/day q 6 hrs 7 days OR

Cloxacillin 50-100 mg/kg/day q 6 hrs 7 days

Case: ì A 9 year-old girl with

fever, erythematous legs with ill-defined border, warm & tender to touch. It started as an insect bite and after vigorous scratching, it developed into a swollen, tender plaque; patient walks with a limp ì Impression?

Cellulitis ì Strep, Staph, H.influenzae b ì Penicillin 600,000 – 1.2 M units/kg/day q 6 hours IV

for streptococci

ì Oxacillin 100-200 mg/kg/day q 6 hours IV ì Ampicillin (100-200 mg/kg/day) + Chloramphenicol

(50-100 mg/kg/day) for H.influenzae

ì Cefuroxime (20-30 mg/kg/day BID po q 12 hrs),

Ceftriaxone, Cefotaxime

What type of rash is this?

Measles ì prodrome of high-grade fever with conjunctivitis,

catarrh (3-5 days)

ì Height of fever: maculopapular rash appears on the

hairline or face and spreads cephalocaudally

ì Branny desquamation ì Supportive ì Vitamin A ➢ Less than 6 months old: 50,000 units po ➢ 6-12 months old: 100,000 units po ➢ More than 12 months old: 200,000 units po

Vitamin A

Management ■ Postexposure prophylaxis: measles Ig for prevention

& attenuation of measles within 6 days of exposure (0.25 mL/kg max.of 15 mL) intramuscularly

■ Measles vaccine can be given for susceptible

children > 1 yr old within 72 hours

■ Pregnant & immunocompromised persons should

receive Ig but not active vaccine

Identify!

Rubella ■ Most characteristic sign: retroauricular, posterior

cervical & postoccipital lymphadenopathy (begins 24 hrs before the rash and remains for 1 week)

■ Maculopapular rash beginning on the face, trunk and

extremities

■ Active vaccine can theoretically prevent illness if

given within 72 hours of exposure

■ Use of immune globulin for post exposure

prophylaxis is not routine but may be considered if termination of pregnancy is not an option (0.55 mL/ kg IM)

Temporal relation of rash to fever

Roseola (HHV-6) ■ more than 95% occur in < 3 yrs old with peak at

6-15 months old ■ HHV-6 can suppress all cellular lineages within the

bone marrow

■ High grade fever for 3-5 days but most behave

normally despite this

■ Rash appears within 12-24 hours of fever resolution:

discrete, small pink lesions on the trunk then spreads to the neck, face & extremities that fades in 1-3 days

Identify the lesions!

Varicella • Rash start from the trunk then spread to other parts of the body • Rapid progression; all stages are present simultaneously; pruritic • Macule/papule à

vesicle à

crust

■ Increased risk of severity: Acyclovir 30 mg/kg/day

IV q8 hrs or 80 mg/kg/day PO QID for 5 days (max.dose 3200 mg/day)

■ Active vaccine within 72 hours of exposure ■ VZIG 1 dose up to 96 hours after exposure

Herpes Zoster ì same rash as varicella

with severe pain & tenderness along the posterior nerve roots ì Acyclovir ì antihistamine

Case: ì A 2 year-old female

presents with tender vesicles on the palms, soles, and oral mucosa, low-grade fever, and poor appetite for the past 48 hours. ì Impression?

Hand, foot, and mouth disease ì Coxsackievirus A16 ì Ulcerative intraoral lesions seen esp. in the

tongue & buccal mucosa, hands, and feet ì Clear by absorption of fluid in about 1 wk

Case ì A 3 year-old male

presents with fever, anorexia, irritability & vomiting.

ì PE: Small vesicles &

ulcers with a red ring found mainly on the anterior tonsillar pillars; may be seen on the soft palate, uvula & pharyngeal wall

ì Impression?

Where is the rash most obvious?

Erythema Infectiosum ì Prodrome: low grade fever, headache, URTI ì Hallmark: rashà

erythematous facial flushing (“slapped-cheek”) and spreads rapidly to the trunk & proximal extremities as a diffuse macular erythema

ì Palms and soles are spared ì Rash resolves without desquamation

Check the predilection of ulcers

Herpetic gingivostomatitis ì Initially with irritability, sore throat, anorexia

ì Thin walled vesicles on a red base usually at the

mucocutaneous junction & gum line that heal without scars within 7-10 days

ì Oral acyclovir 15 mg/kg 5x/day for 7 days started within

72 hours of onset of lesions has benefits in children with HGS

Case: ì An 18 month-old girl

had 2 days high-grade fever, chills, irritability, and vomiting. Red rashes were noted all over the body that spread quickly on the 2nd day. PE: lethargic, tachycardic, tachypneic, diffuse rales on both lung fields, purpuric & ecchymotic lesions all over the body

ì Impression?

Meningococcemia ì Neisseria meningitidis with 13 recognized serotypes:

A,B,C, W135, Y

ì Mode pf transmission: person to person through infected

droplets

ì Period of communicability: until 24 hours after initiating

effective treatment

ì Abrupt onset of fever, chills, headache, vomiting ì Rapid worsening of symptoms within hours ì Initially morbilliform rash --> petechial then purpuric

within hours

Diagnosis and Management: ■

Culture of blood, CSF, petechial scrapings, sputum

■

Penicillin G 200,000-300,000 U/kg/day IV in 4 - 6 divided doses for at least 7 days and until patient is afebrile for 72 hours

■

Chloramphenicol (if allergic to Pen) 50-100 mg/kg/day IV q6h; Ceftriaxone 50 mg/kg IV q12h or Cefotaxime 50 mg/kg IV q6h

Post-exposure prophylaxis: ì Household, school. or day care contacts should

receive antibiotic prophylaxis within 24 hours of dx

ì Prophylaxis NOT routinely recommended for

medical personnel except those with intimate exposure

ì Rifampicin <1 mo: 5 mg/kg PO q12h for 2 days; >1

mo: 10 mg/kg PO q12h for 3 days

ì Ciprofloxacin (adults only): 500 mg PO single dose ì Ceftriaxone: <15 yrs: 125 mg IM single dose; >15

yrs: 250 mg IM single dose

DIARRHEA

ì

Fluid management for diarrhea ì

ICF – 2/3

ì

ECF – 1/3 > ¼ - plasma volume > ¾ - interstitial fluid

➢ Infant has a relatively larger interstitial volume ì A larger surface area in relation to the height and the

weight compared with adults.

Clinical assessment of changes
 in fluid compartments: ì

Plasma compartment – fixed compartment with continuous circulation composed of forward or afterload (pulse & BP) & backward or preload circulation (venous pressure)

ì

Interstitial compartment – edema, skin elasticity, dryness of mucous membranes, anterior fontanel

ì

Intracellular compartment – indirect assessment; headache, confusion, seizures

Maintenance Fluids: ì

Body weight method for calculating maintenance fluid volume (Holliday-Segar method)

ì

weight (kg) daily requirement 3- 10

100 ml/kg

10-20

1000 ml + 50 ml/kg for each kg >10

>20

1500 ml + 20 ml/kg for each kg >20

Maintenance electrolytes: 1.

Sodium: 2-3 mEq/kg/24 hrs

2.

Potassium: 1-2 mEq/kg/24 hrs

ì

Average composition of diarrhea: Sodium – 55 mEq/L Potassium – 25 mEq/L Bicarbonate – 15 mEq/L

Composition of IV fluids: Fluid

Na

K

Cl

HC03

Dextrose

0.9 NSS

154

----

154

---

---

D5 LRS

130

4

109

28

5

D5 0.3 NaCl

51

---

51

---

5

0.45 NaCl

77

---

77

---

---

D5 IMB

25

20

22

23

5

D5 NM

40

13

40

16

5

D5 NR

140

5

98

27

5

Example: Calculate the total fluid volume required by a 10 kg child: First 10 kg = 100 ml/ kg = 1,000 ml over 24 hours = 40 cc/ hr

Caloric Requirements: ì Recall that D5 means 5 grams in 100 ml ì Therefore 50 grams in 1000 ml ì How much glucose does D10 contain?

10 grams in 100 ml 100 grams in 1,000 ml

Case: Calculate the fluid and electrolytes and glucose requirements of a 1year old boy who weighs 10 kg.

Answer: ì Water required 1,000 ml ì Na required 3 x 10 = 30 mEq ì K required 2 x 10 = 20 mEq ì glucose required 1 g/kg = 10 g

What fluid contains approximately the above electrolytes?

Composition of IV fluids: Fluid

Na

K

Cl

HC03

Dextrose

0.9 NSS

154

----

154

---

---

D5 LRS

130

4

109

28

5

D5 0.3 NaCl

51

---

51

---

5

0.45 NaCl

77

---

77

---

---

D5 IMB

25

20

22

23

5

D5 NM

40

13

40

16

5

D5 NR

140

5

98

27

5

WHO ASSESSMENT CHART Clinical Parameter

A No

Gen. Condition well, alert

B Some restless, irritable

C Severe Dehydration lethargic, unconscious

Eyes

normal

sunken

sunken

Thirst*

none

drinks eagerly

drinks poorly

Skin retraction* quick

slow (< 2 sec)

very slow (> 2 sec)

Wt loss (%)

<5%

Fluid deficit (ml/kg) < 50

* Major sign of dehydration

5-10% 50-100

11% or more > 100

Only 2 parameters needed in category

Recommendations: Unified Fluid & Electrolyte Management, 2000 Clinical Parameter

Mild Dehydration

Moderate Dehydration

Mental status Thirst Anterior fontanel Eyes Tears Mucous membranes Respiration Skin retraction Radial pulse, HR Extremities Urine flow Capillary refill Estimated fluid deficit

normal slightly increased normal normal present slightly dry normal immediate normal warm slightly reduced normal 3-5%

irritable moderately increased sunken sunken reduced to absent dry deep/rapid slowly; < 2 sec rapid, weak slightly cool reduced; <1ml/kg/hr < 2 sec 6-9%

Recommendations: Unified Fluid & Electrolyte Management, 2000


Severe Dehydration

ì normal to lethargic to comatose ì very thirsty or too weak to drink ì very sunken eyes, anterior fontanel; tears absent; ì ì ì ì ì

parched mucous membranes skin retraction > 2 sec cool, mottled, acrocyanotic; capillary refill > 2 sec Inc. or dec.HR, (N) or dec. BP, rapid, feeble to imperceptible pulses, deep/rapid respiration severe oliguria to anuria (< 1 ml/kg/hr) estimated fluid deficit: > 10% (> 100 ml/kg)

Joint WHO/UNICEF Statement
 (August 2004)

■ Efficacy of glucose-based ORS for

treatment of children w/ acute non-cholera diarrhea is improved by reducing sodium to 50-75 mEq/L, glucose to 75-90 mmol/L and total osmolarity to 210- 268 mOsm/L

Composition of Standard ORS: Standard WHO-ORS (mEq or mmol/L)

Reduced Osm ORS (mEq or mmol/L)

Glucose

111

75

Sodium

90

75

Chloride

80

65

Potassium

20

20

Citrate

10

10

Osmolarity

311

245

Composition of Various ORS: Solution

Osm (mOsm/L)

Na (mmol/L)

K (mmol/L)

Cl (mmol/L)

Oresol (Old)

311

90

20

80

10 (citrate)

Cholyte

247

50

20

40

10 (citrate)

Glucolyte 60

255

60

20

50

10 (citrate)

Glucolyte Plus

245

75

20

65

10(citrate)

Hydrite

245

75

20

65

30 (HCO3)

Pedialyte 45

250

45

20

35

30 (citrate)

Pedialyte 90

346

90

20

80

30 (citrate)

Reduced Osm

245

75

20

65

10(citrate)

Base (mmol/L)

Composition of Commonly Used Fluids: Fluid Commercial soups Apple juice Orange juice Grape juice Pepsi/Coke Seven-up Coconut Gatorade Powerade Pocari Sweat WHO recommendation

Na (mmol/L)

K (mmol/L)

Osmolality (mOsm/ kg H2O)

114 - 251 0.1 - 3.5 0.6 - 2.5 1.3 - 2.8 1.3 - 1.7 5.0 - 5.5 0 - 5.4 14.6 8

2.2 - 17 24 - 30 41 - 65 28 – 32 0.1 1.0 - 2.0 32.6 - 53.5 3.5 4

290 - 507 654 - 734 290 - 507 1167 - 1190 591 - 601 523 - 548 255 - 333 58g (S + G/Fr) 80g (S + maltdex)

21 50-75

5 20

641 210-268

Case: Calculate the fluids, electrolytes, and glucose requirements of a 20 kg child.

Answer: ì Total fluid = 1, 500 ml ì Na = 60 meq ì K = 40 meq ì Glucose = 100 grams ì D5 NM fits the requirements of a 20 kg child ì But it contains only 13 meq of potassium ì You can add at most 40 meq of potassium to a 1,000 ml

bag if child is totally NPO and has a peripheral line

11 kg child with severe dehydration ì Hypotensive shock 1. FLUID RESUSCITATION: Correct shock: plain NSS or

plain LRS 20 ml/kg as bolus

( repeat as needed ) 2. After fluid resuscitation, compute DEFICIT: ì Severe dehydration (15%)

Recommendations: Unified Fluid & 
 Electrolyte Management, 2000


Severe Dehydration

ì normal to lethargic to comatose ì very thirsty or too weak to drink ì very sunken eyes, anterior fontanel; tears absent; ì ì ì ì ì

parched mucous membranes skin retraction >2 sec cool, mottled, acrocyanotic; capillary refill > 2 sec Inc. or dec.HR, (N) or dec. BP, rapid, feeble to imperceptible pulses, deep/rapid respiration severe oliguria to anuria (< 1 ml/kg/hr) estimated fluid deficit: > 10% (> 100 ml/kg)

Dehydration ì Percent of dehydration is equivalent to the % body

weight loss ì In the example: 15% dehydration

MAINTENANCE PLUS 
 DEFICIT IN 24 HOURS: ì Maintenance is 1,050 ml; Deficit is 1,650 ml (post-bolus) ì 1st 8 hrs: give 1/3 of M+ 1/2D ì 2nd 16 hrs: give 2/3 of M+ 1/2D ì 1st 8 hrs: 350 + 825 ml = 1,175 / 8 =













147 cc/hr

ì 2nd 16 hrs: 700 + 825 ml = 1,526 / 16 =















95 cc/hr

11 kg child with mild dehydration 1. Compute for maintenance fluids first. ➢ 10 kgs with excess of 1 kg = 1000 ml + 50 ml =

1,050 ml

2. Add deficit: for mild: add 30 ml/kg ➢ 1,050 ml + 330 ml = 1,380 ml in 24 hrs ➢ Rate: 57 cc/hr ➢ this is also true if you opt to compute it as 1,050 x

30% (315) = 1,365 ml to run in 57 cc/hr

WHO ASSESSMENT CHART Clinical Parameter

A No

Gen. Condition well, alert

B Some restless, irritable

C Severe Dehydration lethargic, unconscious

Eyes

normal

sunken

sunken

Thirst*

none

drinks eagerly

drinks poorly

Skin retraction* quick

slow (< 2 sec)

very slow (> 2 sec)

Wt loss (%)

<5

Fluid deficit (ml/kg) < 50

* Major sign of dehydration

5-10

>10

50-100

> 100

Only 2 parameters needed in category

Another example: ì 18 kg child with mild dehydration at 30% ì Compute for maintenance fluids. ì Add deficit. ì What is the rate?

Answers: ì Maintenance rate of 1,400 ml in 24 hrs ì Deficit of 540 ml (at 30 ml/kg) ì M + D = 1,940 ml in 24 hrs ì Rate = 80 ml/hr

** if you opt to do it as 1,400 x 30% (420) = 1,820 ml/24 = 76 cc/hour

Fever

ì

Case: ì An 8 year-old girl was brought to the ER because

of 5 days moderate to high grade intermittent fever with headache and abdominal pain. Worsening of symptoms noted with body malaise and anorexia. PE: weak-looking, CR 106/min, RR 25/min, T 39°C and BP=80/60; with clear breath sounds, flushed skin, fair pulses. ì Impression ?

Dengue Fever • Transient, macular, generalized rash that blanches under pressure seen during the 1st 24-48 hrs of fever • 1-2 days after defervescence, a generalized maculopapular rash appears which spares the palms & soles & disappears in 1-5 days with desquamation (Hermann’s rash)

Dengue fever rash

Helpful laboratory tests: ì Dengue blot IgM : samples should be collected not

earlier than 5 days nor later than 6 wks after onset ì Dengue NS-1 Ag : Day 1 until Day 3 of the illness ì CBC: hematocrit and platelet, PT, PTT

Timing of diagnostic tests of dengue fever ì At the end of the acute phase of infection: ➢ Serology is the method of choice ➢ IgM detected in 80% of patients by day 5 and 99%

by day 10

➢ IgM peaks in 2 wks after onset of symptoms &

decline in 2-3 months

Timing of diagnostic tests in dengue fever ì Primary infection: anti-dengue serum IgG is

detectable in low titers at the end of 1st wk of illness --> increases slowly after --> IgG detectable after several months

ì Secondary infection: IgG detected even in the

acute phase & persists from 10 months to life

Dengue Fever Guidelines 2012: ì

DENGUE WITHOUT WARNING SIGNS:

➢ Fever and 2 of the following criteria: 1.

Nausea, vomiting

2.

Rashes

3.

Aches / pains

4.

Tourniquet test (+)

5.

Leukopenia

Dengue Fever Guidelines 2012: ì

DENGUE WITH WARNING SIGNS:

1.

Abdominal pain with tenderness

2.

Persistent vomiting

3.

Clinical fluid accumulation

4.

Mucosal bleed

5.

Lethargy, restlessness

6.

Liver enlargement >2 cms

7.

Increase in Hct with concurrent rapid decrease in platelet count

Dengue Fever Guidelines 2012: ì

SEVERE DENGUE:

1.

Severe plasma leakage (leading to):

a)

Shock (DSS)

b)

Fluid accumulation with respiratory distress

2.

Severe bleeding

* As evaluated by clinician

Dengue Fever Guidelines 2012: 3. Severe organ involvement a)

Liver: AST or ALT >/=1000

b)

CNS: impaired consciousness

c)

Heart and other organs

Management of dengue 
 without warning signs: ì

Encourage oral fluids.

ì

If not tolerated, start IVF therapy of NSS or LRS with or without dextrose at maintenance rate.

a)

4 mL/kg/h for first 10 kg body weight

b)

+ 2 mL/kg/h for next 10 kg body weight

c)

+ 1 mL/kg/h for subsequent kg body weight

With compensated shock ì Start IVF resuscitation with isotonic crystalloid

solutions at 5-10 ml/kg/hr over 1 hr

ì Re-assess condition: vital signs, CRT, hct, UO ì (+)improvement: reduce IVF to 5-7 ml/kg/hr to 1-2

hrs, then 3-5 ml/kg/hr for 2-4 hrs, and then further depending on hemodynamic status which can be maintained for 24-48 hrs.

With decompensated / hypotensive shock ì Give crystalloid at 20 ml/kg as a bolus over 15 minutes ì If (+) improvement, continue crystalloid at 5-7 ml/kg/

hr at 1-2 hrs, then 3-5 ml/kg/hr at 2-4 hrs, then 2-3 ml/kg/hr or less which can be maintained at 24-48 hrs ì If shock persists, get Hct; if low, cross-match and

transfuse

With decompensated /
 hypotensive shock ì If Hct is high compared to baseline, use colloid

solution at 10-20 ml/kg as a 2nd bolus for 30 mins-1 hr ì After the 2nd bolus, re-assess the pt. ì If (+) improvement, reduce the rate to 7-10 ml/kg/hr

for 1-2 hrs, then change back to crystalloid and reduce the rate of infusion as mentioned above

Interpreting Hematocrit Changes 1.

a rising or persistently high hct with unstable vital signs (esp. narrowing of the pulse pressure) indicates active plasma leakage and the need for a further bolus of fluid replacement

1.

a rising or persistently high hct with stable hemodynamic status and adequate urine output does not require extra IVF; continue to monitor closely and it is likely that the hct will start to fall within the next 24 hours as the plasma leakage stops

Interpreting Hematocrit Changes 3. A decrease in hct with unstable vital signs

(particularly narrowing of the pulse pressure, tachycardia, metabolic acidosis, poor urine output) indicates major hemorrhage and the need for urgent blood transfusion 4. A decrease in hct with stable hemodynamic status

and adequate urine output indicates hemodilution and/or reabsorption of extravasated fluids, IVF must be discontinued immediately to avoid pulmonary edema

Management of dengue fever 
 with warning signs ➢ Obtain a reference hematocrit before fluid therapy. ➢ Give only isotonic solutions such as 0.9% saline,

plain LRS, or Hartmann’s solution. Start with 5-7 ml/ kg/hour for 1-2 hours, then reduce to 3-5 ml/kg/hr for 2-4 hours, and then reduce to 2-3 ml/kg/hr or less according to the clinical response.

Management of DF 
 with warning signs ■ Reassess the clinical status and repeat the hematocrit.

If the hematocrit remains the same or rises only minimally, continue with the same rate (2-3 ml/kg/hr) for another 2-4 hours. ■ If the vital signs are worsening and Hct is rising rapidly,

increase the rate to 5-10 ml/kg/hour for 1-2 hours. ■ Reassess the clinical status, repeat the Hct, and review

fluid infusion rates accordingly.

Management of DF 
 with warning signs ì Give the minimum IVF volume required to

maintain good perfusion & UO of about 0.5 ml/kg/ hr.

ì IVF are usually needed for 24-48 hrs. ì Reduce IVF gradually when the rate of plasma

leakage decreases towards the end of the critical phase indicated by:

a. UO and/or oral fluid intake that is/are adequate

b. Hct decreasing below the baseline value in a stable patient.

Case: ì A 7 year-old female presents with 9 days

intermittent fever, abdominal pain, nausea, malaise, anorexia. PE: BP 100/60, CR=90/ min, RR=20/min, T=38.5 C, non-hyperemic pharyngeal wall, periumbilical tenderness, soft abdomen, with loose stool on consultation.

ì Impression?

Enteric Fever / Typhoid Fever ì High-grade fever, generalized myalgia, abdominal

pain, hepatosplenomegaly, anorexia, diarrhea / constipation

ì If no complications occur, the symptoms & physical

findings gradually resolve wihtin 2-4 wks

ì (+)blood culture in 40-60% early in the disease; (+)

stool & urine culture after the 1st week

ì Mainstay of diagnosis remains clinical. ì Typhidot --- has cross-reactions

Typhoid Fever ì Intestinal hemorrhage (<1%) & perforation (0.5-1%), typhoid ileitis, toxic myocarditis ì Antibiotic tx influenced by the prevalence of antimicrobial

resistance in the area

ì Uncomplicated & fully sensitive: Chloramphenicol 50-75

mg/kg/day Q 6h for 14-21 days

ì Uncomplicated multidrug resistant: Fluoroquinolone 15

mg/kg/day for 5-7 days or Cefixime 15-20 mg/kg/day 7-14 days

Typhoid Fever ■

Uncomplicated quinolone resistant: Azithromycin 8-10 mg/ kg/day for 7 days or Ceftriaxone 60-75 mg/kg/day for 10-14 days

■

For severe typhoid fever:

1.

Sensitive: Ampicillin 100 mg/kg-day for 14 days or Ceftriaxone 60-75 mg/kg/day for 10-14 days

2.

Multidrug resistant: Fluoroquinolone 15 mg/kg/day for 10-14 days

3.

Quinolone resistant: Ceftriaxone 60-75 mg/kg/day for 10-14 days

***Typhoid fever vaccine (oral vs intramuscular)

Case: ì A 20-day old male presents with his mother to the ED for a

rectal temperature of 38°C. Maternal and birth history were unremarkable. He is feeding 3 ozs every 4 hours and has adequate UO. PE revealed flat anterior fontanel and a well hydrated baby. When you explain to the mother that he will need to undergo the full sepsis workup, including lumbar puncture, she asks if all the testing is necessary.

ì What is the probability, since her baby looks well, that he has a

SBI?

ì Can other infections besides bacterial ones cause a fever and

does the baby need testing for these?

ì Will the baby need to be admitted to the hospital?

Clinical Pathway for Evaluation of Febrile Young Infants (<29 days old): ì ì

ì ì ì ì ì ì

Age < 29 days old

Ill appeari ng

> ABCs, glucose >Admit; full sepsis workup if stable > IV Ampicillin, Cefotaxime > Consider Vancomycin in patients with CSF pleocytosis > IV Acyclovir >Consider prostaglandin if cardiac disease suspected

ì ì ì ì ì ì ì

Well appearing

> Full sepsis workup (Class I) > Consider HSV testing if <21 days (Class II) > Admit (Class II) > IV Ampicillin, Cefotaxime (add Vancomycin if CSF pleocytosis or if with gm+ on CSF Gram stain) > Consult infectious disease specialist if gm-negative organisms on CSF Gram stain > IV Acyclovir if HSV testing performed (Class II)

Risk management pitfalls: ■ “The neonate had a fever but he was so well-

appearing, I couldn’t justify doing the full sepsis workup.”

➢ The febrile neonate is at high risk for an SBI; nearly 1

in 5 febrile neonates will have an SBI.

➢ The rate of infection is too high to defer testing in this

age group.

Risk management pitfalls: ì “The mother denied any history of HSV so her baby

most probably does not have neonatal HSV.”

➢ Consider testing for HSV in <21 days old even in the

absence of vesicles or maternal history of HSV infection (Long SS, Pool TE et al 2011 case series, Kimberlin DW, Lin CY et al 2001, prospective)

➢ Highest risk for transmission of neonatal HSV is to

babies born to mother who have a primary infection at the time of delivery (Brown et al 2003) – rate of 30.8%

On neonatal HSV infection: ì Incidence of neonatal HSV is 9.6 per 100,000 births or about

1,500 cases per year

ì Aside from vesicles (63% of patients), other symptoms are

lethargy, fever, seizure, and coagulopathy

ì Most cost-effective strategy for febrile neonates with CSF

pleocytosis: test with CSF HSV PCR and empirical treatment with IV Acyclovir à delay in acyclovir therapy is associated with worse outcomes (Shah SS, Aronson PL, Mohamad Z et al 2011 – retrospective 1086 patients)

Risk management pitfalls: ì “The urinalysis, CBC, and CSF cell count were all normal so

he met the low-risk criteria. I felt comfortable sending him home and just follow up the culture results with his doctor.”

➢ The low-risk criteria do not perform well as in neonates as

shown by retrospective studies that showed a lower NPV of the criteria. (Schwartz, S., Raveh, D. et al 2009; Baker MD, Bell LM 1999)

➢ Potential to falsely classify 1 in 10 febrile neonates as low

risk

➢ Therefore, neonates should be admitted on empiric

antibiotics pending culture results.

Most common low-risk criteria for management of febrile young infants: Criterion

Rochester criteria (0-60 days old)

Philadelphia criteria Boston criteria (28-89 (29-56 days old) days old)

History and PE

➢ Full-term ➢ Normal prenatal and postnatal histories ➢ No postnatal antibiotics ➢ Well appearing ➢ No focal infection

➢ Well appearing ➢ No focal infection

➢ No antibiotics within preceding 48 hours ➢ No immuniza- tions within preceding 48 hrs ➢ Well appearing ➢ No focal infection

Most common low-risk criteria for 
 management of febrile young infants: Criterion

Rochester criteria (0-60 days old)

Philadelphia criteria Boston criteria (28-89 (29-56 days old) days old)

Laboratory parameters (defines low risk)

➢ WBC 5000-15,000/ mm3 ➢ Absolute band count <1500/mm3 ➢ UA equal or less than 10 WBC/hpf ➢ Stool equal or less than 5 WBC/hpf

➢ WBC <15,000/ mm3 ➢ Band:total neutrophil ratio <0.2 ➢ UA equal or <10 WBC/hpf ➢ CSF: <8 WBC/mm3 ➢ CSF: Gram stain negative ➢ Normal chest X ray ➢ Normal stool

➢ WBC <20,000/ mm3 ➢ UA <10 WBC/hpf ➢ CSF <10 WBC/mm3 ➢ Chest X ray: no infiltrates

Most common low-risk criteria for management of febrile young infants: Criterion

Rochester criteria (0-60 Philadelphia criteria days old) (29-56 days old)

Boston criteria (28-89 days old)

Treatment for high-risk Hospitalize + empiric patients antibiotics

Hospitalize + empiric antibiotics

Hospitalize + empiric antibiotics

Treatment for low-risk ➢ Home patients ➢ 24-hr follow-up required ➢ No empiric antibiotics

➢ Home, if patients lives within 30 minutes of the hospital ➢ 24-hr follow-up required ➢ No empiric antibiotics

➢ Home, if caregiver available by telephone ➢ Empiric IM Ceftriaxone 50 mg/ kg ➢ Return for 24-hr follow-up for 2nd dose of drug

Performance of lowrisk criteria

NPV: 100%

NPV: 94.6%

NPV: 98.9%

Case: ■ You are looking at a 40 day-old febrile baby who

was very irritable on examination. The laboratory tests were normal so he met the low-risk criteria and you sent him home.

■ All the low-risk criteria require the baby to be well

appearing on PE. Even with normal lab studies, if the infant is ill appearing or has a focal infection, the baby should be admitted on empiric antibiotics.

Clinical pathway for evaluation of 
 febrile young infants (29-56 days old): Age 29-56 days old Ill appearing

➢ Admit; full sepsis work-up if stable ➢ IV Cefotaxime ➢ Consider Vancomycin in patients with CSF pleocytosis ➢ Consider Acyclovir

Well appearing

No bronchiolitis

Bronchiolitis

Clinical pathway for evaluation of 
 febrile young infants (29-56 days old):

Full sepsis workup (Class I)

High risk per criteria: >Admit (Class I) >IV Cefotaxime (+Vancomycin if CSF pleocytosis or gm+ on CSF Gram stain) >Consult ID specialist if Gm(-) on CSF Gm stain

Low risk per criteria: ➢ Discharge home if 24 hr follow-up arranged ➢ No empiric antibiotics (Class I)

➢ UA and urine culture (Class I) ➢ Strongly consider CBC and blood culture (Class II) ➢ Strongly consider CSF if high WBC count (Class III)

Admit if high risk per criteria or in respiratory distress (Class III)

Workup up for alternative
 sources of infection in <56 days old: ■

Does the febrile infant aged less than 56 days with bronchiolitis require the full sepsis workup?

■

Can the fever be attributed to a viral source?

■

Levine et al (2004) prospective study of 1,248 febrile patients: 269 were (+) for RSV

■

Results: RSV (-) patients had an SBI rate of 12.5%; RSV (+) patients had an SBI rate of 7% (lower rate of SBI in febrile young infants with RSV was significant and all infections were UTI)

Workup up for alternative
 sources of infection in <56 days old:

ì Febrile young infants with RSV or

bronchiolitis are still at risk for serious bacterial infection, especially UTI, and they should be thoroughly evaluated for sources of infection.

Case: ■

“A 70-day old baby is highly febrile but is well appearing and no other symptoms were elicited. He is beyond the upper age limit of both the Philadelphia and Rochester criteria. I did not have to do any testing.”

➢ The Boston criteria extend the upper age limit for doing the

full sepsis workup through 89 days old.

➢ Infants of this age group does not become low risk for SBI. ➢ Incidence of UTI is still high (Hsiao AL, Chen I, Baker MD

2006 prospective study)

Workup of febrile infants 
 57-89 days old: ■ Urinalysis and urine culture should be performed

(at minimum)

■ Consider CBC and blood culture

■ If infant is ill-appearing or has a high serum WBC,

CSF studies should be ordered.

Clinical pathway for evaluation of 
 febrile young infants (57-89 days old):


Age 57-89 days old Ill appearing

➢ Admit; full sepsis work-up if stable ➢ IV Cefotaxime ➢ Consider Vancomycin in patients with CSF pleocytosis

Well appearing

No bronchiolitis

Bronchiolitis

Clinical pathway for evaluation of 
 febrile young infants (57-89 days old):

➢ UA and urine culture (Class I) ➢ Consider CBC and blood culture (Class II) ➢ Consider CSF if high WBC count (Class III) High risk per criteria: ➢ Admit (Class II) ➢ IV Cefotaxime ➢ Add Vancomycin if CSF pleocytosis or gm+ on CSF Gram stain ➢ Consult ID specialist if gm(-) on CSF Gram stain

UA and urine culture (Class II)

Low risk per criteria: ➢ Discharge home ➢ No empiric antibiotics

Antibiotic therapy for neonates and 
 high-risk febrile infants 29-60 days old: ■

Susceptible to GBS, E.coli, S. pneumoniae, S. aureus, L. monocytogenes

■

Well-appearing febrile neonate: IV Ampicillin 200 mg/kg/day every 6 hours and IV Cefotaxime 150 mg/kg/day every 8 hours

■

Well-appearing febrile infant >28 days: Cefotaxime or Ceftriaxone monotherapy is sufficient

Antibiotic therapy for neonates and 
 high-risk febrile infants 29-60 days old: ■ Ill-appearing febrile infant or infants with CSF

pleocytosis or (+) Gram stain: addition of Vancomycin to the aforementioned antibiotics (15 mg/kg/dose for 0-89 day-old infants)

■ If (+) CSF Gram stain of gram-negative rods:

consult ID specialist and cover with broadspectrum antibiotics (Imipenem or Amikacin)

Do we adjust the CSF WBC
 count for CSF RBC? ■

2010 cross-sectional study by Kestenbaum et al provided the best evidence for CSF norms in the febrile young infant

➢ Low-risk criteria used <8 WBC/mm3 to define normal CSF ➢ For neonates: cutoff of <19 WBC/mm3 is reasonable

■

Retrospective study by Greenberg RG, Smith PB, Cotton CM et al (2008) : adjustment of CSF WBCs for CSF RBCs only improved specificity slightly while decreasing sensitivity

*** Adjustment for RBCs should not be performed in the high-risk febrile young infant

Urinalysis in 57-89 days old? ■ The well-appearing febrile infant should undergo

testing with urinalysis and urine culture. *** Hsiao Al, Chen L, Baker MD (2006 prospective study)

Risk management pitfall: ■ ”I checked a bag urine sample in my 70 day-old patient. The urinalysis was negative so I did not do a catheterization for urine culture.”

➢ In infants <90 days, the urinalysis is not as sensitive as in

older infants and children (McGillivray et al, 2005 cross sectional study; Schroeder AR et al 2005 prospective study) à 77% sensitivity from bagged specimens

➢ AAP 2011 UTI CPG recommends that catheterized or

suprapubic aspiration be used to obtain both urinalysis and culture in febrile children age 2-24 months.

How about imaging studies? ■

Routine chest X ray in the febrile young infant is NOT recommended unless signs and symptoms of pneumonia are present.

➢ None of the 361 febrile patients <90 days old without

respiratory signs or symptoms had an abnormal chest X ray (Bramson et al 1993 prospective study)

➢ Only 2 of 148 asymptomatic infants had an abnormal chest

X ray (Crain et al 1991 prospective study)

Fever without a source
 in 3-36 months old: ■

Fever 39°C or higher is the threshold above which evaluation for a source of occult infection (like UTI) may be warranted (Baraff et al 1993)

■

Immunization to prevent Hib and pneumococcal disease has dramatically lowered the incidence of occult bacteremia from 5 to <1% (Bressan et al 2012, BenitoFernandez et al 2010, Craig et al 2010, Waddle et al 2009, Wilkinson et al 2009, Carstairs et al 2007, Herz et al 2006, Sard et al 2006, Stoll et al 2004)

Sources of infection: ■

Serious bacterial infections that occur in children 3-36 months old include meningitis, pneumonia, and focal skin infections.

■

Subtle sources of infection (like pneumonia or osteomyelitis) can sometimes be identified with a careful history and PE.

■

Relatively common occult sources of infection include pneumonia and UTI with occasional cases of bacteremia.

Approach to ill-appearing child: ■

Full evaluation for serious infection with cultures of blood, urine, and CSF if meningitis is suspected

■

Chest X ray in patients with tachypnea or respiratory distress and is also warranted for those with WBC equal or >20,000 even in the absence of PE findings of pneumonia

■

Admit and start IV antibiotics targeting the likely pathogens (S. pneumoniae, S. aureus, N. meningitidis, Hib)

Approach to well-appearing child: ì Workup of INCOMPLETELY IMMUNIZED: ì Risk of occult bacteremia is as high as 5% ➢ CBC ➢ Blood culture (for those with WBC of equal or >15,000) ➢ Urinalysis and urine culture by bladder catheterization or

suprapubic aspiration

➢ Chest X ray if WBC is equal or >20,000 even in the absence of

respiratory distress and 02 sat of equal or <95%

Approach to well-appearing child: ■ Preliminary evidence suggests that rise in levels of

inflammatory mediators (like CRP and procalcitonin) may be better markers of SBI than WBC and ANC in children at significant risk for bacterial infection (Gilsdorf, JR. Journal of Pediatrics, 2011) ■

CRP concentrations do not generally increase until 12 hours after the onset of fever and can rise in both viral and bacterial infections (Peltola et al, 1998)

■

CRP has wide range of sensitivity and specificity that vary by cutoff levels in identifying SBI in young children (Lacour et al 2008, Fernandez-Lopez et al 2003, Isaacman et al 2002, Pulliam et al 2001)

Approach to well-appearing child: ■ Procalcitonin levels rise in response to bacterial

infections more rapidly than those of CRP. ➢ Limited preliminary data suggest that PCT levels

may be more sensitive and specific markers for severe invasive bacterial infection than WBC, ANC, and CRP. (Dubos et al 2008, Andreola et al 2007, Hsiao et al 2005, van Rossum et al 2004)

Approach to well-appearing child: ■ Meta-analysis of 5 studies (1,379 children) found

that the diagnostic accuracy of CRP and procalcitonin were comparable for serious infection. (Van den Bruel et al, British Medical Journal, 2011)

➢ High risk: >80 mg/L for CRP and >2 ng/mL for PCT

(sensitivity 40-50%, specificity 90%)

➢ Low risk: <20 mg/L for CRP and <0.5 ng/mL for PCT (80%

sensitivity and 70% specificity for both)

Recommended treatment for well-appearing incompletely immunized child: ■

Selective treatment of high-risk children with FWLS and WBC of equal or >15,000 pending culture results (AAP and ACEP practice guidelines) – Grade 1B ***Lee GM, Fleisher GR et al 2001

➢ Give IM Ceftriaxone 50 mg/kg ➢ IV Clindamycin 10 mg/kg followed by oral form 8 hours later

for patients allergic to cephalosporins

■

Outpatient follow-up within 24 hrs; admit if uncertain to follow-up

Approach to well-appearing child: ■ COMPLETELY IMMUNIZED: ■ Risk of bacteremia is <1% ■ Risk of UTI as an occult source of infection remains

substantial depending on age, gender, and circumcision status (Jhaveri et al, 2011)

Recommended treatment for 
 well-appearing completely immunized child: ■

For >6 months old with FWLS: urinalysis and urine culture for girls <24 months old and uncircumcised boys <12 months by catheterization or suprapubic aspiration (Hoberman et al 1993, Shaikh et al 2007)

■

For girls >24 months old, uncircumcised boys >12 months old and circumcised boys >6 months old with FWLS: no routine laboratory evaluation and should not receive presumptive treatment with antibiotics – Grade 1B

Recommended treatment for well-appearing
 completely immunized child: ■

Do urinalysis and urine culture in those with signs or symptoms of UTI, with a prior history of UTI, urogenital abnormalities or >48 hours fever

■

Patients with a (+) urine culture require treatment tailored to the identified organism and their clinical status

■

Children with fever that persists for >48 hrs or with a deterioration in clinical condition undergo repeat medical evaluation

Recommended treatment for well-appearing 
 completely immunized child: ■

(+) blood culture require re-evaluation and management based on their appearance, persistence of fever, and specific isolate

■

WBC of equal or >15,000 had a sensitivity of 86% and a specificity of 77% for occult bacteremia with frequency of bacteremia of 1.5% (Lee et al, 1998 prospective single center observational study)

■

WBC of <15,000 had a NPV of 99.5% with a frequency of bacteremia of 1.6% (Herz et al 2006 multicenter retrospective observational study)

What of probable culture contaminant? ■ With the decline in the prevalence of occult

bacteremia, it is now more likely that a blood culture will be (+) for a contaminant than for a pathogen. (Herz et al 2006, Sard et al, 2006, Stoll et al 2004, Alpern et al, 2000)

■ Microbiologic features like Gram stain, (+) rods, (+)

cocci that are coagulase (-), and slow growth suggest a contaminant.

Urinary tract infection 
 2011 AAP guidelines: 1. Diagnosis – Abnormal urinalysis as well as positive culture – Positive culture = ≥50,000 colony-forming units (cfu)/mL – Assessment of likelihood of UTI 2. Treatment: oral as effective as parenteral 3. Imaging: Voiding cystourethrography (VCUG) not

recommended routinely after first febrile UTI

4. Follow-up: Emphasis on urine testing with subsequent febrile

illnesses

Urinary tract infection 
 2011 AAP guidelines: ì Infants and young children, 2–24 months of age,

with unexplained fever ì Rate of UTI: ~5% ì Rate of scarring: Higher than in older children

Action statement 1: If a clinician decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy because of ill appearance or another pressing reason, a urine specimen should be obtained by catheterization for both culture and urinalysis before an antimicrobial is given. ✓ ✓

Evidence quality: A Strong recommendation

Methods of collecting specimen: ì Suprapubic aspiration is “gold standard” but: ì Variable success rates: 23–90% (higher with

ultrasound guidance) ì Requires technical expertise and experience ì Often viewed as invasive ì More painful than catheterization ì May be no alternative in boys with severe phimosis or girls with tight labial adhesions

Methods of collecting specimen: ì Bag urine ì Cannot avoid getting “vaginal wash” in girl or contamination in uncircumcised boy ì Not suitable for culture ▪ Negative culture rules out UTI, but ▪ Positive culture likely to be false-positive o 88% false-positive overall o 95% in boys o 99% in circumcised boys ì Positive culture requires confirmation, which is not

possible once antibiotic is started.

Methods of collecting specimen: ì Catheterization ì Compared to suprapubic aspiration: ▪ Sensitivity = 95% ▪ Specificity = 99% ì Requires some skill, particularly in small infant

girls.

Action statement 2: If a febrile infant is assessed as not requiring immediate antimicrobial therapy, then the likelihood of UTI should be assessed. • If likelihood is low (<2%), it is reasonable to follow the child clinically. • If the likelihood is not low, there are two options: – Obtain specimen by catheter for culture and urinary analysis (UA). – Obtain specimen by any means for UA and only culture those with positive UA.

Probability of UTI: Infant GIRLS Individual Factors • • • • •

Race: White Age: <12 months Temperature: ≥39⁰C Fever: ≥2 days Absence of another source of infection

Probability of UTI # of Factors Present ≤1%

No more than 1

≤2%

No more than 2

Probability of UTI: Infant BOYS Individual Factors • • • •

Race: Non-black Temperature: ≥39⁰C Fever: >24 hours Absence of another source of infection

Probability of UTI ≤1%

≤2%

# of Factors Present Circumcised No

Yes

*

No more than 2

None

No more than 3

*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.

Action statement 3: Diagnosis of UTI requires both: • Positive culture – ≥50,000 cfu/mL of uropathogen cultured from catheter specimen, AND • Positive urinalysis ✓Evidence quality: C ✓Recommendation

Urinalysis ì Positive urinalysis required for diagnosis ì Positive culture with “negative” urinalysis ì Contamination ì Asymptomatic bacteriuria ì Urinalysis not sensitive enough ì Positive ì Dipstick: +LE (leukocyte esterase) and/or +nitrite ì Microscopy: White blood cells ± bacteria

Action statement 4: Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations. ✓ Evidence quality: A ✓ Strong recommendation

Choice of drug: Based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen ✓ Evidence quality: A ✓ Strong recommendation

Duration of treatment: 7–14 days ✓ Evidence quality: B ✓ Recommendation

Action statement 5: Febrile infants with UTIs should undergo RBUS. ✓Evidence quality: C ✓Recommendation

Why: • Yield of abnormal findings: 12–16% • Permanent renal damage (1 year later) – Sensitivity: 41% – Specificity: 81% • Actionable findings sufficient to warrant? When: • Decide clinically: Within 48 hours if not responding to treatment as expected, unusually ill, or extenuating circumstances; otherwise, when convenient.

Action statement 6: VCUG is not recommended to be performed routinely after the first febrile UTI if RBUS is normal. ✓

Evidence quality: B

If RBUS is abnormal, VCUG may be part of additional imaging required to evaluate the abnormality. ✓

Evidence quality: B

Further evaluation should be conducted if there is a recurrence of febrile UTI. ✓

Evidence quality: C

Abdominal pain:

ì

Case: ì A 12 month-old male presents with paroxysmal

abdominal pain characterized as episodes of being well and incessant crying for the past 24 hrs. He was noted to have flexed legs with loud crying. PE: tender mass on the RUQ which becomes firm during crying ì Impression?

Intussusception ì Upper portion of

bowel (intussusceptum) invaginates into the lower part (intussuscipiens) ì 60% of infants pass

currant jelly stool

Intussusception ì Plain abdominal X-ray: (+)density ì Barium enema: filling defect or cupping in the head

of barium; coiled-spring sign (thin rim of barium trapped around the invaginating part within the intussuscipiens) ì Ultrasound: tubular mass & a doughnut or target

appearance ì Hydrostatic reduction vs “air” reduction

Acid-related disease / 
 peptic ulcer disease ì Classic symptom of epigastric pain alleviated by

ingestion of food is present only in a minority of children ì Majority with poorly localized pain ì After 6 yrs old, clinical features may be similar to

those in adults; dull or aching pain, GI blood loss, have exacerbations & remissions

Peptic Ulcer Disease ì AlMgOH empiric dose after meals and at bedtime ì Ranitidine 2-4 mg/kg/day q 8h IV or oral for 4-6

weeks

ì Endoscopy ì H.pylori testing (urea breath test, Ag detection in

stool)

ì Amoxicillin (14d) + Clarithromycin (14d) + PPI (1

month) OR Amox + Metronidazole + PPI OR Clarithro + Metro + PPI

ABDOMINAL PAIN in children in the ED: ì

Surgical causes:

1.

Acute appendicitis

2.

Intussusception

3.

Pyloric stenosis

4.

Gastrointestinal obstruction/perforation

5.

Incarcerated hernia

6.

Meckel diverticulum

7.

Trauma including abuse

8.

Torsion of testes

9.

Peritonitis

The Alvarado score for predicting acute appendicitis: 
 A systematic review (BMC Medicine, Ohle, et al, 2011) Feature

Score

Migration of pain 1

ì 1-4: discharge ì 5-6: observation / admission

Anorexia

1

Nausea

1

ì 7-10: surgery

Tenderness in RLQ 2 Rebound pain

1

Elevated temperature

1

Leukocytosis

2

Shift of WBC count to the left

1

TOTAL

10

➢ Predicted number of patients

with appendicitis:

Score 1-4: 30% Score 5-6: 66% Score 7-10: 93%


 Conclusion of systematic review: ì The Alvarado score is a useful diagnostic “rule out”

score at a cut point of 5 for all patient groups. ì The score is well calibrated in men, inconsistent in

children, and over predicts the probability of appendicitis in women across all strata of risk.

ABDOMINAL PAIN in children in the ED:

ì Medical causes: 1.

Gastrointestinal: colic (until 6 wks old), gastroenteritis, constipation, pancreatitis, peptic ulcer disease, hepatitis, acute cholangitis, lactose intolerance

2.

Diabetic ketoacidosis

3.

Urinary tract infection / stones / renal / colic

4.

Lower lobe pneumonia / effusion / aspiration pneumonia / concomitant lung pathology

ABDOMINAL PAIN in children in the ED: ì

Gynecological causes:

1.

Pelvic inflammatory disease

2.

Ectopic pregnancy

3.

Primary amenorrhea

4.

Torsion of fallopian tubes

*** Do RECTAL exam!

History: 1.

Course and character of pain

2.

Diarrhea

3.

Melena/ Hematochezia

4.

Fever

5.

Last oral intake

6.

Menstrual history

7.

Vaginal discharge/bleeding

8.

Urinary symptoms

9.

Respiratory symptoms

10.

Assess past GI history, travel history and diet

Examination: 1.

General state: drowsy, toxic appearing, jaundice, dehydration

2.

Abdomen: Always fully expose and check for hernia, palpate testes if male, site of abdominal pain/tenderness:

➢

Epigastric: peptic ulcer disease/acid related disease, pancreatitis

➢

RUQ: hepatitis

➢

RLQ: appendicitis

➢

LLQ: diverticulitis, constipation, torsion

➢

Suprapubic: UTI, torsion of ovary

Investigation: ì

Clinical judgment is required to order investigations:

1.

CBC

2.

Urinalysis (UTI, DKA)

3.

Pregnancy test (all girls after menarche presenting with abdominal pain)

4.

Electrolytes

5.

ESR

6.

Amylase, lipase

7.

AXR (Intestinal obstruction, perforated viscus, foreign body or calcification)

8.

CXR: perforated viscus (free gas under the diaphragm)

9.

Abdominal UTZ

Indications for admission: 1. Surgical abdomen 2. Abdomen difficult to examine 3. Severe dehydration or inability to retain 4. Significant blood loss 5. Abdominal pain persisting more than 4 hours 6. ALL tender testes

Important Reminders: ì Never discharge a patient if there is still residual

abdominal pain. Prior to discharge, you must document that there is no more abdominal pain and tenderness.

ì Patients with appendicitis may or may not have

pyuria.

ì Patients with prior antibiotic therapy may have

abdominal signs masked due to partial treatment with the antibiotics.

Helminth/Protozoal infections ■

For amebiasis: Metronidazole 35-50 mg/kg/day in 3 doses for 7-10 days; if asymptomatic, Diloxanide Furoate 20 mg/kg/day in 3 doses for 10 days

■

For ascariasis: Mebendazole 100 mg BID po for 3 days or 500 mg PO once for all ages or Pyrantel Pamoate 11 mg/ kg PO once

Helminth/Protozoal infections ■ Ascariasis: Piperazine citrate 150 mg/kg PO initially then 6

doses of 65 mg/kg Q 12 hrs PO (causes neuromuscular paralysis of the parasite and rapid expulsion of the worms is TOC for intestinal or biliary obstruction given as syrup through NGT)

■ Hookworm and Trichuriasis: Mebendazole 100 mg BID for

3 days po

■ Enterobiasis: Mebendazole 100 mg PO for all ages and

the family members repeated in 2 weeks

Febrile Seizure ì 6 months- 6 years old: incidence ì (+) family history ì Normal neurological exam ì Simple vs. complex ì SIMPLE: <15 minutes duration, occurs once in 24

hours, no focal lateralizing signs, normal developmental milestones

Evaluation: History: ì Investigate source of fever from associated

symptoms ì Check oral intake (hypoglycemia or hyponatremia) ì recent immunization (DPT) ì recent medication use (anticholinergic) ì recent head trauma ì previous CNS dysfunction and infection

Evaluation: PE: ì Vital Signs & GCS ì Hydration status ì Look for focus of infection especially fontanel and

neck stiffness

ì Scalp hematoma ì Pupil size and symmetry, eye movements,

asymmetry of movement, muscle tone, reflexes and upgoing toes

ì Complete neurologic examination

ED Management: ì Glucose, CBC ì Diazepam 0.2-0.5 mg/kg/dose IV or per rectum ì Paracetamol suppository 10-15 mg/kg/dose ì Put in the recovery position and give supplemental

oxygen if drowsy

ì Correction of dehydration and hypoglycemia

Criteria for admission: ì All first febrile seizure episode if patient is <18 months old ì After 18 months old: If partially treated meningitis cannot be

excluded (recent antibiotic use)

ì Complex febrile seizure ì Abnormal neurological findings ì Serious infections ì Abnormal glucose ì Anxious parents/unable to cope

Discharge from the ED & 
 follow-up plans: ì

Discharge criteria:

1. No recurrence of seizure at the ED 2. Temperature going down 3. GCS 15 4. Child is well 5. Parents able to cope and confident to monitor at home ì

Discharge medications:

1.

Paracetamol 10-15 mg/kg/dose Q4 hours, or:

2.

Ibuprofen 5-10 mg/kg/dose Q6 hours

STATUS EPILEPTICUS ì

Recurrent seizures without recovery of consciousness between convulsions lasting 30 minutes

ì

Goals of management:

1.

Ensure adequate brain oxygenation and cardiorespiratory function

2.

Control seizure as soon as possible

3.

Identify causative and precipitating factors

4.

Treat metabolic and medical complications

5.

The seizure should be terminated while the child is still in ED.

Management: ì A - establish airway, clear secretions, recovery position ì B - supply 100% 02 with respiratory support, monitor RR and 02 sat ì C - evaluate circulation and establish IV access (NSS

maintenance unless hypovolemic); monitor BP, CR, do CBC, serum Na, K, Mg, Ca, glucose, tox screen * If glucose is <40 mg/dL: give 5 ml/kg 10% dextrose IV (<30 mg/dL in newborns)

Management: ■ If with IV access: Diazepam 0.2-0.3 mg/kg slow IV

over 2 mins (IO); after 5 minutes, re-assess and give another dose if still with seizures

■ If seizure persists, load with Phenobarbital IV 15-20

mg/kg/dose at 1 mg/kg/min (not to exceed 25 mg/ min) – use plain NSS or LRS to avoid crystallization in dextrose fluids

■ Give another dose of Phenobarbital at 5 mg/kg/dose

during the 0-5 minute timeline

Management: ì 30-60 minutes: Add Phenobarbital at 5-10 mg/kg IV : a total

of 30 mg/kg if symptoms persist

ì If symptoms persist, may give additional 5-10 mg/kg/dose of

Phenobarbital IV but do NOT exceed 30 mg/kg as it is cardiotoxic (i.e. conduction block) at a rate of 1 mg/kg/min with max. of 25 mg/min

ì If symptoms are controlled, maintain Phenobarbital IV at 5

mg/kg/DAY in 2 divided doses -à 1st maintenance dose given 12 hours after the loading dose (do NOT use Phenobarbital if with cardiac disease)

Management: ì If symptoms persist, use either Phenytoin or Valproic

acid ì Child >2 years old: in shock or if patient with cardiac

disease: Valproic acid IV loading dose 20-30 mg/kg at a rate of 3 mg/kg/min of infusion ì If seizures are controlled, maintain VPA at 5-6 mg/kg/

dose every 6 hours

Management: ì 60 minutes: REFRACTORY SEIZURES ì Load with Midazolam at 0.2 mg/kg IV bolus followed

by IV infusion à Start at 2 mg/kg/min and increase by 4 ug/kg/min every 5 minutes until seizure stops or maximum of 24 ug/kg/min is reached ì Preparation: Dilute 3 mg/kg in 50 ml D5W where 1

ug/kg/min is equivalent to 1 ugtt/min or cc/hr

Management: ■ Phenobarbital can cause respiratory depression and

hypotension

■ If patient does not have good airway protection

reflexes, prophylactic intubation prior to administration

■ Transfer to PICU and under EEG monitoring

Chest pain / Arrhythmias ì

Case: ì A 15 month-old male presents with high-grade

fever, irritability, and tachypnea at the ER. He was being treated as an outpatient for the past 2 days for an acute viral infection. Few minutes PTC, he was noted to be very irritable and having difficulty of breathing. Vital signs: T=40.4°C, CR=190 beats/ min. ì What is the most likely diagnosis?

Ventricular complexes are normal in contour with fixed RR interval





SVT ì Palpitation, shortness of breath, chest pain,

respiratory distress, dizziness, syncope, irritability, pallor, poor feeding ì Heart rate 150-300 bpm ì Vagal maneuvers; pharmacotherapy (adenosine,

verapamil, digoxin)

Difference between 
 SVT & sinus tachycardia: ì Increased HR for age originating from the sinus node ì Most common causes: anxiety, fever, anemia,

hypovolemia, CHF, exercise, hyperthyroidism, medications

ì Rate between 100-180 bpm ì Negative P waves in leads I and AVF (SVT) ì Treat underlying condition

Ventricular tachycardia ì In the ED, assume that a wide complex tachycardia is

ventricular tachycardia.

ì QRS duration varies with age ì Series of 3 or more consecutive ectopic beats ì Etiologies: primary electrical disease, hyperkalemia,

ingestions

ì Rate is 120-200 bpm

Management of VT: ì

Stable patients: IV Lidocaine (1 mg/kg)

ì

Unstable patients: cardioversion 1 J/kg

Pediatric Tachycardia:

Approach to Chest Pain: ì Common complaint in late childhood and

adolescence ì Note characteristic of pain, subjective quality,

position in which it is greatest, radiation, duration, alleviating or exacerbating factors ì Cardiac pain usually associated with exercise and

improves with rest

Noncardiac etiologies: 1.

Musculoskeletal problems

ì

Most common cause of chest pain

ì

Tietzes’s syndrome (costochondritis)

ì

Precordial catch syndrome (intercostal muscle cramping)

2. Psychogenic causes ì

Hyperventilation or anxiety

ì

Hysterical behavior

Noncardiac etiologies: 3. Pulmonary chest pain ì Pleuritic in nature exacerbated by deep inspiration,

swallowing or coughing

ì Inflammation or irritation of the pleura ì Pneumonia, pleurodynia, pneumothorax

4. Gastroesophageal disease ì GER, esophagitis, gastritis, GI spasm ì Similar segmental innervation of heart and

esophagus---”burning” pain

Cardiac etiologies: 1. Pericarditis ì Pleuritic-type of pain relieved by sitting up and

referred to the neck, shoulders, and abdomen

ì Unable to assume supine position ì Pericardial friction rub on supine ì ECG shows ST-segment elevation and cardiomegaly

or pericardial effusion on chest X-ray

Cardiac etiologies 2. Arrhythmias ì Inadequate coronary blood flow

3. Mitral Valve Prolapse ì Vague anterior chest pain ì Midsystolic click and late systolic murmur confirmed by 2D-

echo

4. Aortic dissection ì Extremely rare in childhood ì Connective tissue disorders

Cardiac etiologies ì Severe pain, sudden in onset, “tearing” in quality ì Radiates to the neck and back

5. Coronary artery disease ì Extremely rare in pediatric age group ì Myocardial ischemia, angina pectoris, myocardial

infarction

Initial Approach to Trauma: A. Historical findings 1. Mechanism of injury to assess severity, likelihood /

location of injuries; assess if consistent with injury and developmentally appropriate

1. Preceding events to assess for precipitating

etiologies: syncope, seizure, cardiac arrhythmias

Initial Approach to Trauma: B. PE findings 1.

Primary survey: ABCDEFG

a.

Airway and cervical spine control; suction secretions, reposition airway, or placement of advanced airway

b.

Breathing and ventilation: supplemental 02, pneumothorax decompression, chin lift, or intubation

c.

Circulation and hemorrhage control: pulses, perfusion, HR, BP

Initial Approach to Trauma: d. Disability, decontamination, dextrose: assess mental status (GCS) and pupillary response to light; remove clothing, Hgt e. Exposure: undress patient and log roll to find injuries, then cover f. Fasting: last time the patient ate/drank g. General health

Indications for endotracheal intubation 
 in children with trauma: 1. Inability to ventilate by bag mask ventilation 2. GCS score of equal or less than 8 3. Concern for impending brain herniation 4. Respiratory failure from hypoxemia or

hypoventilation 5. Decompensated shock to initial fluid resuscitation 6. Loss of laryngeal reflexes

GCS and Modified Infant GCS: Action

GCS

Infant GCS

Score

Eye opening

Spontaneous To voice To pain None

Spontaneous To voice To pain None

4 3 2 1

Verbal response

Oriented Confused Inappropriate Incomprehensible None

Coos/babbles/smiles Irritable / consolable Cries to pain Moans to pain None

5 4 3 2 1

Motor response

Obeys commands Localizes pain Withdraws to pain Flexion (decorticate) Extension (decerebrate) Flaccid

Spontaneous movements Withdraws to touch Withdraws to pain Flexion (decortication) Extension (decerebration) Flaccid

6 5 4 3 2 1

Some primary survey findings and life-threatening conditions: Abnormal findings

Life-threatening conditions

Airway

Hoarseness, stridor, subcutaneous emphysema, airway foreign body or secretions

Obstruction by blood, secretions, laryngeal tear

Breathing

Decreased, asymmetric breaths Tension pneumothorax, sounds, flail chest, tracheal deviation, hemopneumothorax, flail chest, hypoxia pulmonary contusion

Circulation

Tachycardia, abnormal pulses or perfusion

Hemorrhagic shock, pneumothorax, pericardial effusion

Disability

Abnormal GCS score, mental status, pupillary response

Intracranial injury, increased ICP, brain herniation

Initial Approach to Trauma: 2. Secondary survey: head-to-toe examination and focused history a. Inspect entire body b. Head/face: intraoral trauma, rhinorrhea c. Eyes: pupils, eye movements, raccoon eyes d. Ears: hemotympanum, CSF otorrhea, Battle sign e. Neck: deformity, tenderness, tracheal deviation f.

Chest: accessory muscle use: breath and heart sounds

Initial Approach to Trauma: 2. Secondary survey: head-to-toe examination and focused history g. Abdomen/pelvis: tenderness, guarding, compress pelvis for integrity h. Urogenital: urethral and vaginal bleeding i. Rectal: exam if concerned for spinal cord injury; trauma j. Musculoskeletal: assess pulses; examine all joints and limbs k. Neurologic: level of consciousness, cranial nerves, strength, sensation, DTRs

Initial Approach to Trauma: 3. Tertiary survey: identify potentially missed injuries, consider comorbidities C. Laboratory tests/imaging: ➢ Type and screen, CBC, hepatic and pancreatic

enzymes, electrolytes

➢ Urine pregnancy, toxicology screen if needed ➢ Imaging guided by mechanism of injury and PE

findings

Head trauma decision rules for <2 Head trauma decision rules for >2 years old (at very low risk of TBI years old (at very low risk of TBI who do not need head CT) who do not need head CT) Normal mental status

Normal mental status

No hematoma or isolated frontal hematoma

No loss of consciousness

No LOC or loss of consciousness for <5 seconds No vomiting Non-severe injury mechanism Severe defined as any of the ff: ➢ MV crash with patient ejection ➢ Death of another passenger ➢ Rollover ➢ Pedestrian or bicyclist without helmet struck by a motorized vehicle ➢ Falls of >3 feet ➢ Head struck by a high-impact object

Non-severe injury mechanism: Severe defined as any of the ff: ➢ MV crash with patient ejection ➢ Death of another passenger ➢ Rollover ➢ Pedestrian or bicyclist without helmet struck by a motorized vehicle ➢ Falls of >5 feet ➢ Head struck by a high-impact object

No palpable skull fracture

No signs of basilar skull fracture

Acting normally according to caretaker

No severe headache

Concussion ì brain injury not

demonstrable in radiographs but associated with a transient loss of consciousness

Contusion

➢ area of focal

edema with or without hemorrhage on CT scan; with LOC and focal deficit

Epidural hematoma ➢ tear in middle

meningeal artery; temporoparietal skull fracture in 75% ➢ concussion followed

by a lucid interval and LOC with inc. ICP; rare in <2 year old kids

Subdural hematoma ➢ tearing of the

bridging veins between the cerebral cortex & dura asso.with severe brain injury; coma or seizures

➢ common in infants

Basilar skull fracture ì common fracture of the base of the skull including longitudinal

or transverse fractures of the petrous portion of the temporal bone and of the cribriform plate

➢ (+)hemotympanum or Battle’s sign, CSF otorrhea, racoon’s eye

(periorbital ecchymosis), facial palsy, hearing loss = petrous fracture

➢ hemorrhage in nose or nasopharynx, CSF rhinorrhea, anosmia =

cribriform plate fracture

Approach to poisoning: A.

Epidemiology

1.

Children <5 y/o: unintentional

2.

Teens: intentional (suicide attempt, recreational substance abuse)

3.

Any age: forced (child abuse)

B. Historical findings a.

History may not be accurate if unwitnessed or unknown

b.

Drug, concentration and dose, type, time of ingestion

Approach to poisoning: C. PE findings 1.

Toxidrome

2.

VS, mental status, pupils

a.

Sympathomimetics / stimulants: tachycardia, hypertension, hyperthermia, agitation, mydriasis (normal light response)

b.

Anticholinergics: tachycardia, hypertension, hyperthermia, agitation, mydriasis (sluggish light response)

c.

Opioids and barbiturates: lethargy, bradycardia, hypotension, decrease in RR, miosis

Toxidromes: Toxin

Clinical findings

Therapy

Opiates

Miosis, coma, CNS and respiratory depression, low BP, low HR, low T

Naloxone

Organophosphates (irreversible AChE inhibitors)

Nicotinic: muscle fasciculations, weakness, paralysis CNS: coma, seizures, apnea Muscarinic: often improve with atropine challenge ➢ lacrimation, bronchorrhea ➢ Delayed onset, improves in 2 wks ➢ Delayed neurotoxicity: occurs 1-3 weeks post ingestion

Atropine improves muscarinic activity; Pralidoxime treats muscarinic and nicotinic blockade; activated charcoal as indicated; benzodiapines for seizure

Tricyclic antidepressants

Coma, arrhythmia, seizure, widened QRS NaHC03 complexes, dilated unreactive pupils

Methanol

Decreased visual acuity, metabolic acidosis, osmolar and anion gap, hyperventilation

NaHCO3, hemodialysis

Toxidromes: Toxin

Clinical findings

Therapy

Carbon monoxide

Flu-like illness, Hgb desaturation, metabolic acidosis

100% 02

Digitalis

visual disturbances, nausea, vomiting, low BP and CR

Atropine for low CR

Hydrocarbons

Pneumonitis, pulmonary edema and hemorrhage, typical odor

Gastric decontamination for benzenes, heavy camphor, halogenated compounds

Iron

Vomiting, diarrhea, abdominal pain, coma, metabolic acidosis

Deferoxamine

Mothballs (paradichloro- Weakness, pallor or jaundice, dark benzene and naphthalene) urine, oliguria

Activated charcoal

Approach to poisoning: D. Laboratory testing and imaging ➢ Depends on suspected toxins and clinical status: 1. Urine toxicology screen: mostly illicit drugs 2. Serum toxicology screen: acetaminophen, salicylate,

ethanol, other drugs 3. Other tests depending on situation (pregnant?) or

toxidrome (LFTs?)

Ingestions ì Conditions that give a metabolic acidosis with increased

anion gap:

M – methanol U – uremia D – DKA P – paraldehyde I – idiopathic acidosis, iron, INH E – ethylene glycol, ethanol S - salicylates

Ingestions ì Toxins that may be seen on abdominal X-ray:

C – chloral hydrate H – heavy metals (Pb, Fe, Sb) I - iodides P – phenothiazines E – enteric-coated medications S – sodium, calcium, potassium, bismuth

ED Management: 1. Secure a patent airway. 2. Establish adequate ventilation. 3. Maintain hemodynamic status. 4. GI decontamination: activated charcoal or whole bowel

irrigation for Fe and aspirin

5. Skin decontamination for organophosphates or

gasoline/caustics

6. Ocular decontamination >20 mins w/ NSS

Decontamination: 1.

Activated charcoal

a.

Works best if given within 1 hour of ingestion

b.

Does NOT absorb heavy metals, corrosives, alcohols, hydrocarbons, inorganic ions

2. Whole bowel irrigation a.

Large volume balance electrolyte solution usually given by NGT

b.

For sustained-release drugs

Acetaminophen poisoning: ì Peak serum concentration: 4 hours after ingestion ì Minimum single toxic dose: 150 mg/kg ì Chronic toxic ingestion: 150 mg/kg over 2-4 days ì Acetaminophen level drawn 4-24 hours after dose: plot value

on nomogram

ì Include serial LFTs, BUN/creatinine ratio, ABG if severe

ingestion

Acetaminophen poisoning: ì Clinical features: a.

Stage 1 (30 minutes-24 hours after ingestion): nausea, sweating, lethargy, or asymptomatic; normal labs

b.

Stage 2 (24-72 hours): hepatotoxicity, nephrotoxicity

c.

Stage 3 (72-96 hours): peak of LFT levels, hepatic encephalopathy, hyperammonemia, bleeding, hypoglycemia, lactic acidosis, death

d.

Stage 4 (4-14 days): recovery, improved symptoms, LFTs recover

Acetaminophen poisoning: ì Activated charcoal indicated if within 4 hours of ingestion ì Indications for NAC antidote (acts as glutathione precursor): 1.

Level above “possible hepatic toxicity” line on nomogram

2.

Single ingestion of >150 mg/kg when level not obtainable

3.

Unknown ingestion time and acetaminophen level >10 mcg/ mL

4.

Hepatotoxicity and history of ingestion

Salicylate poisoning ì MOA: activates respiratory center of medulla causing

tachypnea, respiratory alkalosis ì Significant coagulopathy through decreased platelet

function and clotting factors ì Mild overdose: inc. RR and HR, tinnitus, vertigo,

nausea, diarrhea ì Later findings: noncardiogenic pulmonary edema,

altered mental status, death

Management of salicylate poisoning: ì Beware of endotracheal intubation: must maintain very high

minute ventilation to avoid acidosis

ì Careful fluid resuscitation with alkalinized fluids ì Correct hypokalemia and hypoglycemia ì GI decontamination ì Urine alkalinization to improve salicylate removal (goal = urine

pH 7.5-7.6)

ì Hemodialysis in severe cases

Calcium channel blocker poisoning

Beta-blocker poisoning

Abnormal AV node conduction or AV block

Changes in mental status (lipophilic BBs)

Glucose level is high

Glucose level is low

➢ IV calcium

➢ Glucagon

ì ECG: prolonged PR interval, bradyarrhythmias, prolonged QRS

in BBs

ì Aggressive fluid resuscitation for hypotension ì Atropine for bradycardia, norepinephrine for low BP ì GI decontamination

Oral hypoglycemic poisoning Sulfonylureas

Metformin

Cause hypoglycemia 8-12 hours after ingestion

➢ Normal glucose ➢ Metabolic acidosis peaks at 4-6 hours after ingestion

Lethargy or seizure from lack of brain glucose

Nausea, abdominal pain, inc. HR and RR, low BP from metabolic acidosis

➢ IV dextrose ➢ Bicarbonate and/or dialysis only if ➢ Octreotide (inhibits insulin release severe acidosis from pancreas) considered if unable ➢ Observe for 6-8 hours after to maintain blood glucose despite ingestion to monitor for symptoms dextrose ➢ Observe for 12-24 hours ➢ Hgt, electrooytes, ABG, consider activated charcoal

➢ Hgt, electrolytes, ABG, consider activated charcoal

Anticholinergic ingestion ì Acetylcholine actions ➢ Muscarinic receptors: sweating, salivation, intestinal and urinary

motility, miosis, dec. HR

➢ Nicotinic receptors: sympathetic ganglia, NMJ ➢ Central receptors: memory, cognition, motor coordination ì Extreme hyperthermia, myoclonus, seizure, coma ì Arrhythmia, inc. QT and QRS intervals ì Activated charcoal if alert, benzodiazepines for agitation,

bicarbonate IV for ECG abnormalities

ì Physostigmine in severe cases

Caustic ingestions ì Cosmetics, cleaning agents, button batteries ì Alkali: usually cause more injury than acids with esophagus

most severely affected (liquefaction necrosis, resultant burn, perforation, delayed injury from stricture formation)

ì Acids: penetrate less deeply, mostly cause gastric or upper

airway injury; coagulation necrosis

ì Button batteries: electrical discharge in esophagus and rapid

corrosive injury to esophagus

Caustic ingestions ì PE: signs of upper airway injury: stridor, hoarseness,

respiratory distress; oral lesions do not predict esophageal lesions; abdominal pain

ì Neck, chest, abdomen X rays ì Stabilize ABCs ì Emergent removal of esophageal button battery ì Immediate upper airway laryngoscopy or upper GI endoscopy

Hydrocarbon poisoning ì Due to low viscosity, often inhaled: pulmonary toxicity à

destruction of surfactant, alveoli collapse, pneumonitis

ì Systemic toxicity with only some compounds; poorly absorbed

from GIT

ì Aspiration: immediate or delayed coughing, wheezing,

respiratory distress

ì Large ingestions: emesis, CNS symptoms, arrhythmias, hepatic/

renal injury with some compounds

ì Chest X ray; supportive treatment

Methemoglobinemia Congenital

Acquired

Dec. reduction of methgb back to hgb reductase

Ingestion: agents that cause metHgb (nitrites, lidocaine, dapsone) Infectious: diarrhea in young children with nitrite-forming bacteria

Usually asymptomatic or “cyanotic”

➢ Low level (<20%): asymptomatic ➢ Moderate level (20-40%): headache, lethargy, fatigue, dyspnea ➢ High level (>40%): altered mental status, shock, seizure, death

Avoid exposure to aniline derivatives and nitrates

➢ If symptomatic: methylene blue

Methemoglobinemia ì PE findings ➢ Cyanosis (“slate gray” in severe cases) in presence of normal

Fi02

➢ Pulse oximeters often inaccurate

ì Laboratory evaluation ➢ Serum testing for metHgb presence and level

Acute iron poisoning ì Highest risk: prenatal vitamins; children’s vitamins less likely to

cause harm

ì Clinical features of toxidrome: 1.

GI phase: 30 minutes to 6 hours

a. Abdominal pain, vomiting, diarrhea, hematemesis, melena,

shock

b. Vomiting most sensitive sign of severe toxicity

2. Latent phase: 6-24 hours: usually asymptomatic
 3. Shock/metabolic acidosis/hepatoxicity: 6-96 hours 4. Bowel obstruction: 2-8 weeks later from scarring

The art of discovering the key findings in the initial history taking and examination of a child is one of the hallmarks of a skilled clinician.