Pediatrics in Review

Craig T. Carter, D.O.

Associate Professor Department of Emergency Medicine and

PediatricsUniversity of Kentucky

2/2013

Some Pictures Do Not Require Captions ….

“Ringworm”

Ringworm often causes itchy, red, scaly, slightly raised, expanding rings on the skin of the trunk of the body, face, groin or thigh fold. The ring grows outward as the infection spreads, and the center area becomes less actively infected.

Tinea…

Athlete's foot (tinea pedis). This form affects the moist areas between your toes and sometimes on your foot itself.

Jock itch (tinea cruris). This form affects your genitals, inner upper thighs and buttocks.

Ringworm of the scalp (tinea capitis). This form is most common in children and involves red, itchy patches on the scalp, leaving bald patches.

Q: How are kids airways

different?

Anatomical airway issues in kids

big tongue, soft tissue obstruction

soft trachea no cuff

soft VC no stylet

anterior larynx

short trachea narrowest at

subglottis nose breathers

< 6 mos

big occiput big epiglottis

straight blade

Airway positioning for children <2yrs

Chalazion

ChalazionChalazions may be treated with any one of

the following methods: 1) Antibiotics and/or steroid drops of

injections;

2) Warm compresses;Warm compresses can be applied in a variety of ways, The simplest way is to hold a clean washcloth, soaked in hot water, against the closed lid for five to ten minutes, three to four times a day. Repeatedly soak the washcloth in hot water to maintain adequate heat.

3) Massage of expression of the glandular secretions;

4) Surgical incision or excision.

Pre-septal and Orbital Cellulitis

Bacterial infection usually results from local spread of adjacent URTI

Preseptal usually follows periorbital trauma or dermal infection

Orbital most commonly secondary to ethmoidal sinusitis

Preseptal

Staphylococcus aureus and Staphylococcus epidermidis Streptococcus

Orbital

Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

Answers when you do not know the answers…

What is this?

Burn Depth

Superficial partial thickness burn Pink, moist,thin

walled blisters Intact sensation Heal in 2-3 weeks No scarring

Burn Depth

Deep partial thickness burn Red or Blanched Thick walled blisters Decreased two point

discrimination Mild or exquisitely painful May heal by

epithelialization 3-6 weeks High scar and contracture

potential

Burn Depth

Burn Depth

Full thickness burn White, charred leathery Capillary and nerve

beds destroyed Less painful/ insensate Only 1-2cm lesions can

heal by contraction Grafting required High complication rates

and prolonged recovery

Burn Depth

Extent of Burn

What is the Rule of Nines?

Itchy, stayed at friends house overnight, woke

with pet in bed

Flea Bites

Rash

Rash w/ fever and abd pain

So what is it? Get your clickers…

1. Meningococcemia 2. ITP/TTP 3. HUS 4. HSP 5. Petichial hemorrhages 6. RMSF

Henoch-Schonlein Purpura

Clinical Presentation

Effects predominantly young children, but adults are also affected

Peak incidence is 4-5 years of age There is a slight male predominance The condition is more prevalent in the

winter and early spring The onset of illness is usually sudden

and is preceded by a URI in at least 1/3 of cases

HSP - Clinical Presentation

Classic Triad of symptoms is the most common presentation Purpura Colicky abdominal pain arthritis

50% of children may present with symptoms other than purpura

Risk of Intuss

Q: How much of their blood volume can a kid lose, and still have a

NORMAL bp?

Q: How much of their blood volume can a kid lose, and still have a

NORMAL bp?40%

Lymphadenitis

Spontaneous subconjunctival haemorrhage

Painless red eye without discharge VA not affected Clear borders Masks conjunctival vessels Check BP and body for other

hemorrhages No treatment (lubricants) 10-14 days to resolve If recurrent: clotting, FBC Always consider abuse…

Liver Laceration from ATV

What is it?

1. ECM 2. EM 3. Fifths disease 4. No clue 5. Erythema Nodosum

What is it?

1. ECM 2. EM 3. Fifths disease 4. No clue 5. Erythema Nodosum

Erythema Multiforme Symmetrically distributed, erythematous,

expanding macules or papules evolve into classic iris or target lesions, with bright red borders and central petechiae, vesicles, or purpura.

Lesions may coalesce and become generalized. Vesiculobullous lesions develop within

preexisting macules, papules, or wheals. Rash favors palms and soles, dorsum of the

hands, and extensor surfaces of extremities and face.

Postinflammatory hyperpigmentation or hypopigmentation may occur.

Eye involvement occurs in 10% of EM cases, mostly bilateral purulent conjunctivitis with increased lacrimation.

Mucous membrane blistering occurs in about 25% of cases of EM, is usually mild, and typically involves the oral cavity.

Varicella

Varicella

Agent: varicella zoster virus Transmission: respiratory Period of communicability: 1 day

before eruption of vesicles. Prodromal phase: slight fever,

malaise, pruritic rash; macular to papular to vesicular.

Management of Varicella Isolation Skin care: tepid bath, calamine

lotion, clip finger nails. Keep from scratching Antihistamines for itching -

Benadryl No ASA – acetaminophen only. Varicella vaccine now available.

97% immunity in 2m-12 y 78% immunity in 13y-adult 2% can have attenuated disease

Parent of the year…NOT!

What is it and what is next best test?

Seat Belt sign

What is it?

1. Mumps 2. Measeles 3. Ruebella 4. Small pox 5. No clue

Measles: Diagnosis / Clinical

Clusters of children with fever, cough, conjunctivitis, coryza, morbilliform rash

Measles: Signs and Symptoms

Peak of Illness 2-4 days after onset of rash

Other signs and symptoms Anorexia, malaise, HSM

Resolution Rapid improvement at end of febrile period

(1 week) Complete recovery in 10-14 days

Pearl: darker-skinned children Sandpaper feel to rash may be helpful

Measles or Rubeola

Agent: Virus Transmission: respiratory, blood and

urine Incubation period: 10 to 20 days Period of Communicability: 4 days

before and 5 days after rash appears.

Prodromal stage: fever, cough, conjunctivitis, Koplik spots.

Can get same rash/illness up to 10 d after MMR

Measles: Signs and Symptoms

Erythematous papular eruption

Travels inferior over 2-3 days

Coalesces into macular “splotches”

Often desquamates at end of illness

Hairline Behind Ears

Face

Trunk

Limbs

Rash

Nothing here

Parent of the year…NOT

Down Syndrome

Described by John Landon Down in 1866

Etiology: nondisjuction mutation resulting in Trisomy 21

Prevalence 1:700 Most common chromosomal anomaly

Associated with Maternal age > 35

Down SyndromeCharacteristics

Macroglossia Micrognathia Midface hypoplasia Flat occiput Flat nasal bridge Epicanthal folds Up-slanting palpebral fissures Progressive enlargement of lips Hands: Simian crease (continuous line in the

palm of the hand), short broad hands, underdevelopment of middle portion of the 5th finger resulting in the finger bending towards the outside of the hand.

Name 4 medical issues to consider in Down Syndrome patients…especially in

ED!

Atlantal-axial dislocation – be wary in traumas or downs patient with neck pain or inability to ambulate

Cardiovascular anomalies (40%) ASD, VSD, Tetralogy of Fallot, PDA

GI anomalies (10-18%) Pyloric stenosis, duodenal atresia, TE fistula

Malignancy 20 fold higher incidence of ALL Gonadal tumors

Q: What’s the formula for

minimal systolic bp for age?

Q: What’s the formula for

minimal systolic bp for age?

70 + (Age x 2)

Eg for 5 yo: 70+5x2 = 80

MCAD ?

Group effort - Tell me everything you know

(I am certain this will be a very short conversation!)

Medium chain acyl-CoA dehydrogenase deficiency (MCAD)

Fatty acid oxidation defect Disorder of ammonia detoxification Most common mitochondrial β oxidation disorder

1/10,000 5% of 313 cases SIDS Screen all infants of mothers with HELLP syndrome

Results in acute toxic encephalopathy with episodes of nonketotic hypoglycemia in the 1st 2 years of life provoked by fasting

v/lethargy after fasting , usually with URI/AGE In ED: coma, hypoglycemic hypoketotic,

hyperammonemia, LFTs TX: D10

Avoid fasting Carnitine 100mg/k/d

Mulluscum Contagiosum

Dictation goofs and gaffs..

“Unsure the etiology of this left upper shimmy pain.”

“He had reported that he slipped and fell landing primarily with his hip on the patient's right knee. The child did not lose consciousness and did not appear to strike any other body parts. They report a car immediately afterwards”

“History of present illness: Six-year-old nontender by mother mother reports intermitten…”

Febrile Seizures CRITERIA FOR THE DIAGNOSIS

OF SIMPLE FEBRILE SEIZURE

Between 6 months and 5 years of age Seizure lasting less than 15 minutes Fever present prior to the onset of the

seizure No other neurologic diagnoses Non-focal, generalized seizure, involving

all limbs No severe metabolic disturbance No more than a single seizure per 24-hour

period No evidence of intracranial infection

Febrile SZ work-up

Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever.

In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging.

PEDIATRICS Vol. 127 No. 2 February 2011, pp. 389-394

Febrile Seizures – Parental Education

The risk of febrile seizure in the general population is between ?

2% and 5%

There is no evidence that treating simple febrile seizures with anti-epileptics decreases the incidence of epilepsy later in life or results in improved cognitive outcomes.

Febrile Seizures – Parental Education

If a patient is less than 12 months of age at the time of the first simple febrile seizure, the risk of second simple febrile seizure is 50%.

If a patient is over 12 months of age at the time of the first simple febrile seizure, the risk of a second simple febrile seizure is 30%.

Following a second simple febrile seizure, the risk of future simple febrile seizures is 50%, regardless of the age of the initial simple febrile seizure.

The risk of epilepsy is minimally increased from 1% to 2.4% in patients who have a simple febrile seizure

Mumps Clinical Features

Incubation period 14-18 days Nonspecific prodrome of low-grade

fever, headache, malaise, myalgia Parotitis in 30%-40% Up to 20% of infections asymptomatic May present as lower respiratory

illness, particularly in preschool-aged children

Mumps Pathogenesis

Respiratory transmission of virus Replication in nasopharynx and

regional lymph nodes Viremia 12-25 days after exposure

with spread to tissues Multiple tissues infected during

viremia

?

Human Bites-ABUSE

Q: Name 4 things that can

result in an agitated pediatric trauma patient.

Causes of agitation…

Head Injury Decreased Oxygenation Shock Altered LOC due to Alcohol, drug etc

What is this rash?

Drug Reaction/Eruption

Treatment ?

Differential Dx ? List 3…

Hand edema – What is it?

How about now?

Coronary artery aneurysms -

Kawasaki Disease - Clinical Manifestations

High fever Conjunctivitis Strawberry tongue Edema of hands and feed Reddening of palms and soles Lymph node swelling

Kawasaki Disease - Clinical Tests

LFTs/TBili Albumin ESR CRP Urine CBC

Thrombocytosis Leukocytosis Anemia (normocytic)

A 4yo boy presents with painful rectal bleeding. Mom describes the blood as “bright red, my son is going to bleed to death!” The most common etiology of

painful rectal bleeding in this age group is?

a. Juvenile polyposis

b. Anal fissure

c. Crohn’s Disease

d. Meckel’s diverticulum

A 4yo boy presents with painless rectal bleeding. Mom describes the blood as “bright red, my son is going to bleed to death!” The most common etiology of

painless rectal bleeding in this age group is?

a. Juvenile polyposis

b. Anal fissure

c. Crohn’s Disease

d. Meckel’s diverticulum

Dictation goofs and gaffs…

What??? “I discussed this with the family and

felt as though he most likely had some dry skin no switching off in this area”

“She is taken to court Riche already performed chest x-ray”

“Patient presents with bruising the posterior thighs which appears consistent with Niceville trauma”

Salter 1 Salter 2 Salter 3 Salter 4 Salter 5

Salter 1 Salter 2 Salter 3 Salter 4 Salter 5

Salter 1 Salter 2 Salter 3 Salter 4 Salter 5

Salter Fracture I and II

Salter Fracture III, IV and V

?

Abnormal bruising patterns-ABUSE

Tripod position

Bowden & Greenberg

Epiglottitis Symptoms Acute inflammation of supra-glottic structures. Medical Emergency Sudden onset High fever Dysphasia and drooling Epiglottis is cherry red and swollenDiagnosis

made on presenting symptoms No tongue blade in mouth Emergency tracheostomy set No procedures until in the operating room Keep quiet

Purple Rash

Characteristic purpuric lesions.

Bowden & Greenberg

Meningococcemia

Necrosis of skin

Bacterial Meningitis Pathogens

Under 2 months :E-coli, Group B streptococcus, Listeria, Haemophilus influenza type B, and Streptococcus pneumonia

Beyond neonate: Strep, Haemophilus, Neisseria.

Clinical Manifestation

Severe abdominal pain

Currant jelly-like stool is a classic sign.

Bowden & Greenberg

Intussusception

Bowden Text

Telescoping of part of

intestine into an adjacent

distal portion.

Barium Enema

Ball & Bindler

Gas filledloops of bowel

Necrotizing Enterocolitis

Necrotizing = damage and death of cells

Entero = refers to intestines

Colitis = inflammation of the colon60 to 80% are premature infants

Feeding of concentrated formulas Infants who have received blood transfusion Infants with GI infections Infants with polycythemia: congenital heart

disease

Q: List 3 trauma considerations that we often forget about, especially in

children?

Q: List 3 trauma considerations that we often forget about?

1. Hypothermia2. Child Abuse3. Hazardous Environments

Myelomeningocele A protruding saclike structure

containing meninges, spinal fluid and

neural tissue.

Bulging anterior fontanelle

Eyes deviated downward

“Setting” Sun sign

Bates: Physical Assessment

Severe Hydrocephalus

Hydrocephalus Greek meaning water on the brain Dilation of the ventricles Two primary causes:

Congenital .5 to 1% Acquired:

Lesion, tumors, infection, intracranial bleed, myelomeningocele

Retinal Hemorrhages

Normal retinal Retinal hemorrhage

What is it?

MRSA Burn Grp A strep Yeast No clue

ErysipelasStreptococcal Skin

Infections

Group A Streptococci (Strep. pyogenes), which cause erysipelas, an infection affecting the superficial layers of the skin, and which classically has sharply defined borders.

Clostridium tetani

Anaerobic gram-positive, spore-forming bacteria

Spores found in soil, dust, animal feces; may persist for months to years

Multiple toxins produced with growth of bacteria

Tetanospasmin estimated human lethal dose = 2.5 ng/kg

Tetanus Clinical Features Incubation period; 8 days

(range, 3-21 days) Three clinical forms: Local (not common),

cephalic (rare), generalized (most common) Generalized tetanus: descending symptoms of

trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms

Spasms continue for 3-4 weeks; complete recovery may take months

Pathogenesis of Lyme Borreliosis Lyme disease characterized by three stages:

i. Initially a unique skin lesion (erythema chronicum migrans (ECM)) with general malaise ECM not seen in all infected hosts ECM often described as bullseye rash Lesions periodically reoccur

ii. Subsequent stage seen in 5-15% of patients with neurological or cardiac involvement

iii. Third stage involves migrating episodes of non-destructive, but painful arthritis

Acute illness treated with phenoxymethylpenicillin or tetracycline

Diagnosis of Lyme Borreliosis

Rickettsia rickettsii - Rocky mountain spotted

fever

Q: What are the risk factors for child abuse?

Child Abuse

History story injuries history changing injury

development delay seeking

help inappropriate

level of concern

Physical Exam multiple old and

new bruises posterior rib #,

sternum #, spiral # < 3 yo

immersion burns, cigarette

Impetigo

Impetigo contagiosaThe most common form of impetigo is impetigo contagiosa, which usually starts as a red sore on your child's face, most often around the nose and mouth. The sore ruptures quickly, oozing either fluid or pus that forms a honey-colored crust. Eventually the crust disappears, leaving a red mark that heals without scarring. The sores may be itchy

Staphylococcus aureus

Topical antibiotics. Your doctor may prescribe an antibiotic that you apply to your child's skin (topical antibiotic), such as mupirocin ointment (Bactroban). Topical antibiotics avoid side effects such as diarrhea that can result from some oral medications, but as with oral antibiotics, bacteria can become resistant to them over time.

Oral antibiotics. Your doctor is likely to prescribe an oral antibiotic for ecthyma and severe cases of impetigo contagiosa. The specific antibiotic will depend on the severity of the infection and any allergies or conditions your child might have. Be sure to finish the entire course of medication even if your child seems better. This helps prevent the infection from recurring and makes antibiotic resistance less likely.

Pityriasis Rosea It most often develops in the spring and the fall,

and seems to favor adolescents and young adults. The skin rash follows a very distinctive pattern.

In 3/4 of the cases, a single, isolated oval scaly patch (the "herald patch") appears on the body, particularly on the trunk, upper arms, neck, or thighs.

These patches often form a pattern over the back resembling the outline of an evergreen tree with dropping branches. Patches may also appear on the neck and, rarely, on the face. These spots usually are smaller than the "herald" patch. The rash begins to heal after 2-4 weeks and is usually gone by 6-14.

Aveeno oatmeal baths, anti-itch medicated lotions and steroid creams may be prescribed to combat the rash. Lukewarm, rather than hot, baths , ERYC, Famvir

Fractures of Abuse FIGURE 6. Multiple healing

posterior rib fractures (arrows) from a compression injury of the chest.

FIGURE 7. Metaphyseal or "bucket-handle" fracture (arrow) of the tibia.

1. Parvovirus B192. Chilblans (cold)3. Fifths Disease4. Sixth disease5. SLE butterfly rash6. Erythema Infectiosum7. No clue

Erythema Infectiosum (Fifth Disease)

History:

Erythema infectiosum typically has an incubation period of 4-14 days and is spread primarily via aerosolized respiratory droplets.

Transmission also occurs through blood products and from mother to fetus.

The prodromal phase often is mild enough to be noticed only rarely but may include headache, coryza, low-grade fever, pharyngitis, and malaise.

Infrequently, nausea, diarrhea, arthralgias, and abdominal pain may occur.

In hosts who are immunocompetent, the patient is viremic and capable of spreading the infection only during the incubation period.

Classic cutaneous findings follow within 3-7 days for some patients, while other patients may manifest no findings.

Erythema Infectiosum (Fifth Disease)

Physical:

Pertinent physical findings predominantly are limited to the skin and joints. Skin (first stage): The exanthem begins with the classic

slapped-cheek appearance. The bright red erythema appears abruptly over the cheeks and is marked by nasal, perioral, and periorbital sparing. The exanthem may appear like a sunburn, occasionally is edematous, and typically fades over 2-4 days.

Skin (second stage): Within 1-4 days of the malar rash, an erythematous macular-to-morbilliform eruption occurs primarily on the extremities. While the eruption tends to favor the extensor surfaces, it can involve the palms and soles. Pruritus is rare.

Skin (third stage): After several days, most of the second stage eruption fades into a lacy pattern, with particular emphasis on the proximal extremities. Despite its synonym, slapped-cheek disease, the reticulate pattern is distinctly characteristic for erythema infectiosum and may be the only manifestation of the illness. The third stage lasts from 3 days to 3 weeks. After starting to fade, the exanthem may recur over several weeks following physical stimuli, such as exercise, sun exposure, friction, bathing in hot water, or stress.

Erythema Infectiosum (Fifth Disease)

Complications of PV-B19 infection include the following: Aplastic crisis: The parvovirus infects

erythroid cells, causing a reticulocytopenia that lasts 7-10 days. A healthy host experiences no consequences, since the normal lifespan of a red blood cell is 120 days. In patients with a background of shortened red blood cell survival, such as hemolytic anemia, an acute aplastic crisis ensues.

Congenital infection: PV-B19 can cross the placenta during pregnancy and have a direct cytotoxic effect on fetal red blood cells. Infection

For a 24-kg child, the daily maintenance fluid requirement is approximately which of the

following?

a. 1440cc/24hrsb. 1536cc /24hrs

c. 2400cc/24hrs

d. 1223cc/24hrs

“4-2-1 rule”0-10 kg 4cc/hr x wt11-20 kg 2cc/hr x wt>20 kg 1cc/hr x wt

Easy methodAnyone >20kg =wt

+ 40

Proper fluid bolus for a 9kg infant

who presents as a severe trauma with

unstable vitals is? a. 180 cc LR x 2, then 90cc/kg pRBCs

b. 180cc NSS, then 90 cc NSS

c. 180 cc LR, then 180cc pRBCs

d. 180cc LR x 2, then 90cc 5% albumin, then 90cc pRBCs

http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1119114779

Scarlet fever / scarlatiniform rash

Background: Scarlet fever is a syndrome characterized

by exudative pharyngitis, fever, and scarlatiniform rash. It is caused by an infection with a pyogenic exotoxin-producing group A beta-hemolytic streptococci

Infections occur year-round, but the incidence of pharyngeal disease is highest in school-aged children (5-15 y) during winter and spring and in a setting of crowding and close contact. Person-to-person spread by means of respiratory droplets is the most common mode of transmission.

The incubation period for scarlet fever ranges from 12 hours to 7 days. Patients are contagious during the acute illness and during the subclinical phase.

Scarlet fever / scarlatiniform rash

The rash appears 1-2 days after onset of illness, first on the neck and then extending to the trunk and extremities.

Scarlatiniform rash Exanthem texture is usually of coarse sandpaper, and the

erythema blanches with pressure. The skin can be pruritic but usually is not painful. A few days following generalization of the rash, it becomes more

intense along skin folds and produces lines of confluent petechiae known as the Pastia sign. These lines are caused by increased capillary fragility.

The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and can last up to a month.

TX Treat patients with a standard 10-day course of penicillin or

erythromycin. This regimen prevents acute renal failure if antibiotics are initiated within 1 week of the onset of acute pharyngitis

Centor Criteria 1. Exudative pharyngitis

2. Fever

3. Anterior Cervical Lymphadenopathy

4. No “cold” symptoms (ie no cough or runny nose)

? (Hint – Not E.T.’s Finger)

Clubbing of Finger/Cystic fibrosis

Background: Cystic fibrosis (CF) is the most common lethal inherited disease in white persons. CF is an autosomal recessive disorder, and most carriers of the gene are asymptomatic. CF is a disease of exocrine gland function, involving multiple organ systems and chiefly resulting in chronic respiratory infections, pancreatic enzyme insufficiency, and associated complications in untreated patients. Pulmonary involvement occurs in 90% of patients surviving the neonatal period. End-stage lung disease is the principal cause of death.

Gastrointestinal tract manifestations (intestinal) Neonates: Infants may present with intestinal obstruction at

birth and a variety of surgical findings, for example, meconium ileus (7-10% of patients with CF), volvulus, intestinal atresia, perforation, and meconium peritonitis. Less commonly, passage of meconium may be delayed (>24-48 h after birth) or cholestatic jaundice may be prolonged.

Infants and children: Patients present with increased frequency of stools, which suggests malabsorption (ie, fat in stools, oil drops in stools), failure to thrive, intussusception (ileocecal), or rectal prolapse.

Stevens-Johnson syndrome (SJS)

Pathophysiology: SJS is an immune-complex–mediated hypersensitivity disorder that may be caused by many drugs, viral infections, and malignancies. Cocaine recently has been added to the list of drugs capable of producing the syndrome. In up to half of cases, no specific etiology has been identified

In 3-15% of cases, patients with severe SJS die

Stevens-Johnson syndrome (SJS) The 4 etiologic categories are (1) infectious, (2)

drug-induced, (3) malignancy-related, and (4) idiopathic. Viral diseases that have been reported include herpes

simplex virus (HSV), AIDS, Coxsackie viral infections, influenza, hepatitis, mumps, mycoplasmal infection, lymphogranuloma venereum (LGV), rickettsial infections, and variola.

Bacterial etiologies include group A beta streptococci, diphtheria, Brucellosis, mycobacteria, Mycoplasma pneumoniae, tularemia, and typhoid.

Coccidioidomycosis, dermatophytosis, and histoplasmosis are the fungal possibilities.

Malaria and trichomoniasis have been reported as protozoal causes.

In children, Epstein-Barr virus and enteroviruses have been identified.

Drug etiologies include penicillins and sulfa antibiotics. Anticonvulsants including phenytoin, carbamazepine, valproic acid, lamotrigine, and barbiturates have been implicated. Mockenhapupt et al stressed that most anticonvulsant-induced SJS occurs in the first 60 days of use. In late 2002, the US Food and Drug Administration (FDA) and the manufacturer Pharmacia noted that SJS had been reported in patients taking the cyclooxygenase-2 (COX-2) inhibitor valdecoxib.

Various carcinomas and lymphomas have been associated.

SJS is idiopathic in 25-50% of cases

?

TOF

Pulmonary stenosis (a narrowing of the blood vessel to the lungs)

Overriding aorta (the main blood vessel from the heart to the entire body is somewhat displaced)

A ventricular septal defect (hole in the wall between the lower two chambers of the heart)

Right ventricular hypertrophy (a thick muscle in the right pumping chamber)

TOF First presentation may include poor

feeding, fussiness, tachypnea, and agitation.

Emergency Department Care:

The ED physician should be able to recognize and treat a hypercyanotic episode as one of the very few pediatric cardiology emergencies that may present to the ED.

Hypoxic tet spell: Hypercyanotic episodes are characterized by paroxysms of hyperpnea, prolonged crying, intense cyanosis, and decreased intensity of the murmur of pulmonic stenosis.

Mechanism - Secondary to infundibular spasm and/or decreased SVR with increased right-to-left shunting at the VSD, resulting in diminished pulmonary blood flow

If left untreated, may result in syncope, seizure, stroke, or death

Treatment for the acute setting of hypercyanosis includes the following: Knee-chest position: Place the baby on the

mother's shoulder with the knees tucked up underneath. This provides a calming effect, reduces systemic venous return, and increases SVR.

Oxygen is of limited value since the primary abnormality is reduced pulmonary blood flow.

Morphine sulfate, 0.1-0.2 mg/kg IM/SC, may reduce the ventilatory drive and decrease systemic venous return.

Phenylephrine, 0.02 mg/kg IV, is used to increase SVR.

Treat acidosis with sodium bicarbonate, which may reduce the respiratory center stimulating effect of acidosis.

General anesthesia is a last resort.

?

1. Candida2. EBV3. CMV4. Diptheria5. No clue

Infectious mononucleosis

History: IM may have a varied clinical

presentation, but the symptoms usually consist of fever, pharyngitis, and lymphadenopathy.

The incubation period of IM is 4-6 weeks. Patients usually do not recall a history of possible exposure.

Prodromal symptoms consisting of 1-2 weeks of fatigue, malaise, and myalgia are common

In more than 90% of cases, IM is secondary to EBV infection

Infectious mononucleosis - Labs

Liver function tests (LFTs) are abnormal in more than 90% of patients with IM. Serum transaminase and alkaline phosphatase

levels usually are modestly elevated. The serum bilirubin may be increased in

approximately 40% of patients, but jaundice only occurs in approximately 5% of IM cases.

CBC : differential that demonstrates greater than 50% lymphocytes, an absolute lymphocyte count greater than 4500, or an elevated lymphocyte count with greater than 10% atypical lymphocytes

Also can have thrombocytosis

Splenic rupture is a serious complication of IM, but it occurs in fewer than 0.5% of cases. More than 90% of splenic rupture cases occur in male patients.

?

Slipped Capital Femoral Epiphysis

The Limping Child

What is the red line called?

Slipped Capital Femoral Epiphysis

Klein’s line Superior femoral neck-

lateral portion femoral head

Mild widening, lucency, irregularity of physis

Blurring of junction-metaphysis/physis (early)

Radiograph

Legg-Calvé-Perthes Disease

Avascular necrosis leading to collapse, fragmentation, and then reossification

Most frequent between 4 and9 years Boys more often than girls Bilateral in 10% of cases

Management - LCP

Disease is self-limited – limp can last 2 to 4 years

Nonsteroidal anti-inflammatory agents

Limit activities Crutches/braces occasionally needed

May help maintain spherical femoral head

Better outcomes in younger children

?

Clinical Features: Your First Clue

Irritability Fever Erythema Limp/refusal to walk Decreased range of motion of limb

Septic Arthritis of ankle

Management

Once the diagnosis of septic joint is made, surgical intervention should proceed ASAP. Needle aspiration or open surgical

drainage required

Synovial Fluid Findings

Septic Arthritis Treatment by Age

Kerion

This is a vigorous inflammatory reaction to dermatophyte infection, occasionally associated with secondary bacterial infection, that occurs on the scalp, resulting in a boggy inflammatory swelling

Untreated tinea capitis

Dictation Gaffs and Goofs…

“Patient is a 3-year-old male who presents after a fall from a trampoline heart about an hour and half ago”

“Patient presents to emergency department on orders from right ear CBS worker”

“7-year-old male female presents to emergency department with complaints of pain or right ankle. Mom prospective about 57 concrete steps last night”

Oral thrush

Signs and symptoms

Oral thrush usually produces creamy white lesions on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese

Rubella/German Measles Background: The name rubella is derived from

a Latin term meaning "little red." Rubella is generally a benign communicable exanthematous disease.

The major complication of rubella is its teratogenic effects when pregnant women contract the disease, especially in the early weeks of gestation. The virus can be transmitted to the fetus through the placenta and is capable of causing serious congenital defects, abortions, and stillbirths

Rubella

Incubation period: The incubation is usually 14-21 days after exposure to a person with rubella.

Prodromal phase: Prodromal symptoms are unusual in young children but are common in adolescents and adults.

Rubella The following signs and symptoms usually appear 1-5

days before the onset of rash: Eye pain on lateral and upward eye movement (a

particularly troublesome complaint) Conjunctivitis Sore throat Headache General body aches Low-grade fever Chills Anorexia Nausea Tender lymphadenopathy

Sturge-Weber Syndrome

Sturge-Weber syndrome is a neurological disorder indicated at birth by seizures accompanied by a large port-wine stain birthmark on the forehead and upper eyelid of one side of the face.

Some children will have developmental delays and mental retardation; most will have glaucoma (increased pressure within the eye) at birth or developing later. 

“Port wine stain”

Peds GCS/EMV - ?

1 year old, MVC, cries during exam, opens eyes spontaneously when saying Dr says name, localizes pain but not following commands

1. 152. 143. 134. 125. 116. 107. No clue

1 year old, MVC,

cries during exam = 3 or 4

1. opens eyes spontaneously = 4

localizes pain but not following commands = 5

Total = 12 or 13

Modified Pediatric Glasgow Coma Scale Eye Opening

4 Spontaneously 3 To voice 2 To pain 1 No response

Verbal Response 5 Appropriate

words, spontaneous cooing

4 Inappropriate words

3 Cries 2 Incomprehensible

sounds, grunts 1 No response

Motor Response 6 Obeys 5 Localizes pain 4 Flexion

withdrawal 3 Flexion abnormal

(decorticate posturing)

2 Extension (decerebrate

posturing) 1 No response

Peds ICI/BHT

Found significant ICI is unlikely in a child who does not exhibit at least 1 of the high-risk criteria Evidence of significant skull fx Altered level of alertness Neuro deficit Persistent vomiting Scalp hematoma Abnl behavior coagulopathy

Symptoms and Signs of Concussion

Headache Dizziness Depression Confusion Nausea/vomiting Sensitivity to light

or noise Anxiety Poor memory

Lethargy Slow response to

questions Decreased energy Irritability Blurred or double

vision Poor concentration Poor balance Insomnia

Table 2. Recommendations for Return to Sports after Head Injury Based on Grade of Concussion

Severity Symptoms Management

Grade 1 (Mild) No LOC, ringing, headache, dizziness, or memory loss

ObservationMay not return to competition until symptom-free upon exertion

Grade 2 (Moderate)

LOC <5 min or PTA >30 min

ObservationMay not return to competition for 1 wk after symptom-free upon exertion

Grade 3 (Severe) LOC >5 min or PTA >24 h

AdmitRefer for neurocognitive testing prior to resumption of contact sports

LOC=loss of consciousness; PTA=posttraumatic amnesia

Eczema / Atopic Dermatitis

The most common surgical cause of vomiting in infancy is

a. Intestinal atresias

b. Malrotation

c. Pyloric stenosis

d. Meconium ileus

Pyloric Stenosis Pathophysiology: Marked hypertrophy and hyperplasia of

the 2 (circular and longitudinal) muscular layers of the pylorus occurs, leading to narrowing of the gastric antrum.

Frequency: In the US: The incidence of IHPS is 2-4 per 1000

live births Sex: IHPS has a male-to-female predominance of 4:1, with

30% of patients with IHPS being first-born males Age: The usual age of presentation is approximately 3

weeks of life (1-18 wk). History: Classically, the infant will have nonbilious vomiting or

regurgitation, which may become projectile (up to 70%), after which the infant is still hungry.

Emesis may be intermittent or occur after each feeding

Branchial cleft remnants present most

commonly as a(n)?

a. painb. airway obstructionc. intraoral massd. infection

Pediatric Cardiopulmonary

Arrests

1° Respiratory

Shock

1° Cardiac

10% 10%

80%

Age distribution of arrests

0

5

10

15

20

25

30

35

40

<7 mos 151413121110987654321

7-12

mos

Age (years)

# A

rres

ts

Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-1479.

Arrive in ER in cardiac arrest

(N = 80)

Admit PICU(N=43) 54 %

Died in ER(N=37) 46%

Mod Deficit(N=3)

PVS at 12 mos(N=2)

Dead at 12 mos(N=1)

Died in ICU(N=37) 46%

List at least 10 signs of pediatricRespiratory distress

Signs of Respiratory Distress

Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie

down Agitation

• Retractions• Access muscles• Wheezing• Sweating• Prolonged

expiration• Pulsus paradoxus• Apnea• Cyanosis

List signs of impending respiratory failure

Impending Respiratory Failure

Reduced air entry Severe work Cyanosis despite O2

Irregular breathing / apnea Altered Consciousness Diaphoresis

1. Bruising from abuse2. Petechial rash3. Mongolian spots4. HSP5. No clue

Specificity of Fractures for Abuse

High specificity Metaphyseal Posterior rib Scapula Spinous process Sternal

Moderate specificity Multiple fractures Fractures of diff. age Epiphyseal Vertebral body Digital Complex skull

Low specificity Clavicle Long bone shaft Linear skull

Radiographic Dating of Injuries

Soft tissue findings

Early2-5d

Peak4-10d

Late10-21d

Periosteal new bone

4-10d 10-14d 14-21d

Loss of Fx line; soft callus

10-14d 14-21d

Hard callus 14-21d 21-42d 42-90d

Remodeling 3 mos 1 yr 2 yr

Peds Clin NA 1996

Candidiasis -Signs and symptoms

Oral thrush usually produces creamy white lesions

on your tongue and inner cheeks and sometimes on the roof of your mouth, gums and tonsils. The lesions, which resemble cottage cheese

Nyastatin - works by contact! Perineal/diaper rash candidiasis

antifungal cream Keep dry and open to air

Speed Round RashesGo Interns!!

Name the rash and everything you know about it Cause Treatment Prevention

Question #1 A 1-week-old infant presents for his first newborn

evaluation. He had been discharged apparently well and thriving at 48 hours of age. He now exhibits grouped vesicles on an erythematous base that were not present at birth. Wright stain of scrapings from the floor of the vesicles reveals multinucleated giant cells and balloon cells.

Of the following, the MOST likely diagnosis is:

A) bullous impetigo B) congenital varicella C) herpes simplex virus infection D) incontinentia pigmenti E) recessive dystrophic epidermolysis bullosa

Skin Lesions (photos: University of California, Australian Herpes Management Forum, and

eMedicine)