Pediatrics ReviewEmergency

Gina Neto, MD FRCPCDivision of Emergency Medicine

• Review pediatric resuscitation guidelines

• Recognize pediatric conditions that present to the emergency

• Describe management of pediatric emergency cases

Objectives

Pediatric Resuscitation

• Pediatric Airway• Larger head• Bigger tongue• Narrowest part is

subglottic area• Epiglottis is more floppy• Larynx is more anterior

and cephalad• Chest wall more

compliant

• Airway Management• Position, suctioning• Nasal/Oral airway• Endotracheal intubation

Cuffed tube size: age/4 + 3 (+/- 0.5mm)

• MedicationsAtropine (consider if< 6 yrs)Paralytic - Succinylcholine, RocuroniumKetamine, Midazolam/Fentanyl, Propofol

Pediatric Resuscitation

• Bradycardia• Non-Cardiac causes (6 H’s, 5 T’s)

Hypoxia (Most Common) Hypovolemia, Hypo/Hyperkalemia,

Hypoglycemia, HypothermiaToxins, Tamponade, Thrombosis, Trauma (ICP)

• Cardiac causes - AV block, sick sinus

• Epinephrine 0.01 mg/kg (repeat every 5 min)• Consider Atropine 0.02 mg/kg

Pediatric Resuscitation

Pediatric Resuscitation

• Tachycardia• Narrow• Wide• Stable or Unstable

• Know what is normal for age

• Sinus Tachycardia• Rate usually < 220/min• Variable rate• Look for causes

Pain, fever, dehydration, resp distress, poor perfusion

• SVT• Rate usually > 220/min infants, > 160

teens• Rate is fixed

Pediatric Resuscitation

• SVT• Vagal maneuvers

Ice to face, Valsalva

• Adenosine 0.1 mg/kg 1st dose then 0.2 mg/kg

• If Unstable:• Synchronized Cardioversion 0.5-1 J/kg

If not effective increase to 2 J/kg

Pediatric Resuscitation

• Tachycardia with Wide QRS• Stable• Consider Adenosine• Amiodarone 5 mg/kg• Consult Cardiology

• Unstable with pulse• Cardioversion 0.5 - 1 J/kg 1st dose, then 2

J/kg

Pediatric Resuscitation

• Tachycardia with Wide QRS and No Pulse or Ventricular Fibrillation• CPR

Start at 16:2 compressions/breath

• Defibrillation 2 J/kg Then 4 J/kg Increase subsequent shocks to max of 10 J/kg

• Epinephrine 0.01 mg/kg every 3-5 min• Amiodarone 5 mg/kg

Pediatric Resuscitation

• 10 yr old boy with asthma, difficulty breathing today. Cough and runny nose for 3 days.

• T 36.5, RR 40, HR 130, O2 Sat 89%.• Suprasternal and scalene retractions,

decreased air entry, expiratory wheeze.

• Describe your management.

Case

• Mild Asthma:• Salbutamol MDI x 3 doses prn

• Moderate Asthma:• Salbutamol MDI x 3 doses then prn• Steroids

Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma

• Severe Asthma:• Salbutamol via nebulization with• Ipratropium 250 mcg x 3 doses q20 min• Steroids

Dexamethasone 0.15-0.3 mg/kg PO (max 12) Prednisone 1-2 mg/kg PO (max 60 mg)

Asthma

• If not improving within 60 min or signs of impending respiratory failure:• Magnesium Sulfate 50 mg/kg/dose IV

(max 2g)• Give over 20-30 min• May cause severe hypotension• IV NS 20 bolus ml/kg

• Methylprednisolone 1-2 mg/kg IV

Asthma

• 2 mo male with 2 day hx rhinorrhea, poor feeding and cough. Few hrs resp distress.

• RR 60 HR 120 T 37C. Pink, well hydrated.• Chest - inspiratory crackles, exp wheezes.

• Diagnosis?• Treatment?

Case

• RSV - Respiratory Syncytial Virus most common• Parainfluenza, Influenza A, Adenovirus,

Human metapneumovirus• Peak in winter• More serious illness• < 2 months• Hx of prematurity < 35 weeks• Congenital heart disease

Bronchiolitis

• Treatment • Nebulized Epinephrine – short term relief

• ? Dexamethasone 1 mg/kg on Day 1 0.6 mg/kg for another 5 days

• ? Nebulized Hypertonic Saline

Bronchiolitis

• 2 yr old girl awoke tonight with respiratory distress. Harsh, “barky” cough.

• HR 100 RR 28 T 37 • Mild distress. Stridor at rest.

• Diagnosis? • Treatment?

Case

• Parainfluenza most common• Hoarse voice, barky cough, stridor • Peak fall and spring• Infants and toddlers • Treatment• Dexamethasone (0.6 mg/kg)• Nebulized Epinephrine if in respiratory

distress• Consider Nebulized Budesonide

Croup

Steeple Sign

• 18 month female with fever x 2 days. Difficulty swallowing.

• HR130 RR28 T39C• Exam normal except won’t move neck fully.

• What diagnostic test should be performed?

Case

• < 6yrs• Complication of bacterial

pharyngitis• Infection of posterior

pharyngeal nodes – regress by school age

• Grp A strep, oral anaerobes and S. aureus

• Treatment• IV Clindamycin and

Cefuroxime• Consult ENT

Retropharyngeal Abscess

Age (yrs) Maximum (mm)

0-1 1.5 x C2

1-3 0.5 x C2

3-6 0.4 x C2

6-14 0.3 x C2

Retropharyngeal Soft

Tissues *

Age (yrs) Maximum (mm)

0-1 2.0 x C5

1-2 1.5 x C5

2-3 1.2 x C5

3-6 1.2 x C5

6-14 1.2 x C5

Retrotracheal Soft Tissues *

*

*

• 5 yr old male fever x 6 hrs. Refusing to eat or drink. Voice muffled, drooling.

• Not immunized.

• HR 140 RR 20 T 39.5 • Very quiet, doesn't move. • Slight noise on inspiration. • Chest clear, exam normal.

Case

• Rarely seen • Strep pneumoniae• H. influenzae uncommon

due to vaccine

• Do not disturb patient• Consult Anesthesia,

intubate • IV Ceftriaxone and

Clindamycin

Epiglottitis

• 17 mo male with sudden onset noisy and abnormal breathing

• Was playing on floor before developing difficulty breathing

• VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

• Mild wheezing with mild inspiratory stridor

Case

What investigation would you do next?

ExpiratoryCXR

Inspiratory Expiratory

• Highest risk between 1 -3 yrs old Immature dentition, poor food control More common with food than toys

• peanuts, grapes, hard candies, sliced hot dogs

• Acute respiratory distress (resolved or ongoing)• Witnessed choking• Cough, Stridor, Wheeze, Drooling• Uncommonly…. Cyanosis and resp arrest

Foreign Body Aspiration

• 1 month old girl fever today. Cough and runny nose. Slightly decreased feeding.

• Looks well, alert and interactive• T 38.9o HR 176 RR 42 BP 100/50 • Font flat, neck supple, exam non remarkable

• What is your approach to this case?

Case

• Etiology is organisms from birth canal Group B Streptococcus , Escherichia coli

(Gram neg), Listeria monocytogenes

• Highest rate of bacterial infection of any age group• <2 weeks - 25%• 0-4 weeks - 13%

• Septic Work Up• Admission, IV antibiotics

Fever < 1 month

• May still see birth canal organisms, but also: Streptococcus pneumoniae , Neisseria

meningitidis, Haemophilus influenzae type b (uncommon)

• Overall rate of bacterial infection is ~8%Bacteremia 2%Meningitis 0.8%UTI 5%

• “Low Risk Infant” rate of bacterial infection is 1%

Bacteremia 0.5%

Fever 1-3 months

• Well appearing infants 1-3 mos are low risk for serious bacterial infection if:

Previously healthy• Born at term (> 37 weeks)• No hyperbilirubinemia• No hospitalizations • No chronic or underlying diseases

No evidence of focal bacterial infection Laboratory parameters:

• WBC count 5-15/mm3

• Urinalysis WBC count < 5/hpf• Stool WBC count < 5/hpf (if infant has diarrhea)

Low Risk Criteria “Rochester” for Febrile Infants

• Viral infections cause of fever in >90%• 6% of children seen in the ED have a

specific, recognizable viral syndrome e.g. croup, bronchiolitis, roseola, varicella,

coxsackie

• UTI in ~5% • Bacteremia very low rates now (< 0.2%)• 5% in 1980’s, HIB vaccine 1987• 2% in 1990’s, Pneumococcal vaccine 2000

Fever 3-36 months

• 2 year old boy with generalized tonic clonic movements. Duration 5 min.

• T 39.2o HR 110 RR 24 BP 110/60 • Awake now, normal neurological exam.• Right TM bulging, neck supple, no rash. • Past med history unremarkable.

• Approach?

Case

• Simple Febrile Seizure• T>38.5• 6 mo-5 yr• Generalized seizure, < 15 min• One seizure within 24 hours• Neurologically normal before and after

• Occur in ~ 5% of children• Recurrence in 30%

Febrile Seizure

• Risk of epilepsy is 1% • ~ same as general population

• Higher risk (2.4%) if:• Multiple febrile seizures• < 12 mos at the time of first febrile seizure• Family history of epilepsy

Febrile Seizure

• ABC's• IV access• Seizure treatment• 1st Line - Benzodiazepines

• Lorazepam or Diazepam (Rectal or IV)• Midazolam (Intranasal or Buccal)

• 2nd Line Phenytoin, Fosphenytoin Phenobarbitol

Seizure Management

• Seizure treatment• 3rd Line

Midazolam infusion Thiopental Propofol Paraldehyde

• Observe in the ED until child returns to normal

• After simple febrile seizure no neurological investigations indicated (eg CT, EEG)

Seizure Management

• 9 month old female with fever x 2 days. Vomiting x 20 today. Diarrhea x 10 today. Voiding scant amounts.

• HR 120 RR 36 BP 100/50 T 38.5• Cap refill 2 sec, pink, decreased skin turgor.• Font sunken, eyes sunken.• Abdo + GU normal.

Case

• What is the degree of dehydration of this child?

• Management?

Case

• ORT with rehydration solution (eg Pedialyte)• 5 ml/kg/hr divided every 5 min, continue

until appears hydrated

• Consider Ondansetron (0.15 mg/kg)

• Early refeeding (including milk) within 12 hrs

• Rule out UTI

Gastroenteritis

• Maintenance (D5NS)4ml/kg/hr for first 10 kg2ml/kg/hr for second 10 kg1 ml/kg/hr for rest of weight in kg

• Deficit (NS)• If severely dehydrated give NS bolus

20 ml/kg over 15-60 min • Replace over 24 hours

First half over 8hrs, second half over 16 hrs• Ongoing Losses• Diarrhea, Vomiting, Insensible losses with fever

Fluids and Electrolytes

• 15 month old male with intermittent sudden severe abdo pain x 24 hrs. Vomiting x 3. Diarrhea with blood and mucus.

• HR130 RR24 T37 • Tender abdomen with fullness in RUQ

• Diagnosis?• Investigations?

Case

• 1-3 years• Boys 2:1

• Classic Triad (10-30%)• Vomiting• Crampy abdominal pain• “Red currant jelly” stools

• Lethargy is common

Intussusception

• 75% are ileo-colic• Lead point• Peyer's Patches

preceding viral infection• Meckel diverticulum• Polyps• Hematoma (Henoch Schonlein Purpura)• Lymphoma

Intussusception

Intussusception

• Plain AXR• May be normal

• May have signs of bowel obstruction

• Paucity of air in RLQ • No air in Cecum on

Lateral Decubitus

• Target Sign

• Crescent Sign

• Air Contrast Enema

• Success rate >80%• Recurrence 10-15%

Intussusception

• 4 week old boy with vomiting for past week. Initially one emesis per day now emesis with every feed. Forceful. No bile.

• No fever. No diarrhea.

• Looks well. Mild dehydration. • Abdomen soft, non tender, BS present.

• DDx?

Case

• Na 140 K 3.0 Cl 90 BUN 24 CR 50

• WBC 8.5 Hgb 120 Plts 360

• Venous gas pH 7.50, PCO2 44, HCO3 30

Case

• Most common surgical condition < 2 mos

• 4-6 wks of age• Ratio male to female is 4:1• Increased in first born males

• Occurs in 5% of siblings and 25% if mother was affected

Pyloric Stenosis

• Nonbilious vomiting• Emesis increases in frequency and

eventually becomes projectile

• Classic findings:• Hypertrophied pylorus palpable “olive” in

epigastric area• Peristaltic waves progressing from LUQ to

the epigastrium

Pyloric Stenosis

Pyloric Stenosis

• Laboratory abnormalities:• Hypokalemia• Hypochloremia• Metabolic alkalosis

• Ultrasound• Thickened pylorus

• 1 month old with bilious vomiting. Multiple episodes of yellow green vomiting since this morning. Progressive lethargy and irritability.

• Looks unwell, irritable cry.• Abdomen distended.• Weak pulses, cap refill>5 sec.

• DDx? Management?

Case

Volvulus

• Twisting of a loop of bowel around its mesenteric attachment.

• 80% present by the first month

40% present in the first week

Rarely can be seen in older children.

Volvulus

• Sudden onset of bilious vomiting in a neonate.

• Acute abdomen with shock

• May have more gradual course with episodic vomiting

• Evidence of small bowel obstruction • Dilated loops• Air fluid levels• Paucity of distal air

Volvulus

• Upper GI series • “corkscrew”

appearance of the duodenum and jejunum

Volvulus

• 2 yr old boy with fever for 6 days.

• Red eyes but no discharge.• Generalized rash.• Erythema of the palms of

hands and soles of feet.• Red, swollen lips.• Enlarged cervical lymph

nodes.

Case

• Usually < 4 yrs old, peak between 1-2 yrs• Fever for > 5 days and 4 of the following:

Bilateral non-purulent conjunctivitis Polymorphous skin eruption Changes of peripheral extremities

• Initial stage: reddened palms and soles• Convalescent stage: desquamation of fingertips and

toes Changes of lips and oral cavity Cervical lymphadenopathy ( >1.5 cm)

Kawasaki Disease

• Subacute phase - Days 11-21• Desquamation of extremities• Arthritis

• Convalescent phase - > Day 21• 25% develop coronary artery aneurysms if

untreated

• Other manifestations:• Uveitis, Pericarditis, Hepatitis, Gallbladder

hydrops• Sterile pyuria, Aseptic meningitis

Kawasaki Disease

• Treatment

• IV Immunoglobulin• Reduces incidence of coronary aneurysms to 3%

if given within 10 days of onset of illness• Defervescence with 48 hrs

• ASA• High dose during acute phase then lower dose for

3 mos

Kawasaki Disease

• 3 yr old girl with rash starting today.

• Recent URTI.

• Swollen ankles and knees. Painful walking.

• Diagnosis?

Case

• Systemic vasculitis – IGA mediated

• 75% are 2-11 yrs • Clinical Features

Rash (non thrombocytopenic purpura) 100%

Arthritis (ankles, knees) - 68% Abdominal pain - 53% Nephritis - 38% (ESRD in ~1%)

• Intussusception (2-3%)

Henoch-Schonlein Purpura

Case

• 1 yr old boy with mouth lesions for two days

• What are the two most likely causes?

• Herpes Simplex• Severe primary

infection• HSV1 (80%), HSV2

(20%)

• Fever, irritability, poor intake

• Ulcers on mucous membranes

• Treatment• Acyclovir• Pain control, IV

hydration

Herpetic Gingivostomatitis

Hand, Foot and Mouth Disease

• Coxsackievirus, usually A16• Summer• Ulcers on tonsilar pillars• can have generalized

stomatitis• Vesicles on hands and feet

• URTI, pharyngitis• Vomiting and diarrhea• Generalized maculopapular rash

Case

• 5 yr old girl with itchy rash

• Varicella Zoster

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

Diagnosis?Necrotizing

Fasciitis

• Invasive group A streptococcal infection

• IV Penicillin and Clindamycin

• Consult ID, surgery• MRI

Case

• 3 yr old girl fever for 3 days, unwell

• Rash spreading over entire body with skin peeling

Diagnosis?

• Exotoxin causes separation of epidermis• < 2yr• Fever, toxic appearance, generalized

erythema• Exfoliation of skin, accentuated in flexor

surfaces• skin lifts to touch (Nikolsky’s sign)

• Perioral crusting, “honey coloured” lesions

• Fluid resuscitation• IV Cloxacillin, Cefazolin or Clindamycin

Staphylococcal Scalded Skin Syndrome

• 10 yr old boy with fever

• Unwell today• Rapidly progressing

rash since this morning

Case

• Usually < 5 yrs, Adolescents outbreaks• Fever, toxic appearance• Petechiae, purpura• DIC, shock• High mortality (25-80%)

• Resuscitation• IV Ceftriaxone• Treat household contacts

Meningococcemia

• How are you going to resuscitate this child?

• First intervention?

• Next?• Next?• Next?

Septic Shock

• Leading cause of death in infants and children

6 million deaths per year worldwide

• Etiology of sepsis• Streptococcus pneumonia• Escherichia coli • Neisseria meningitidis• Other: Group A strep, other Gram neg bacilli,

Staph. aureus, Enterococcus

• IV Antibiotics: Ceftriaxone and Vancomycin

Septic Shock

• Sepsis if systemic inflammatory response signs (SIRS) and signs of infection• Fever, or HR, RR, or WBC

• Severe sepsis if signs of organ dysfunction or tissue hypoperfusion

• Septic Shock if cardiovascular dysfunction

Septic Shock

• Hypotension is DECOMPENSATED SHOCK

• Most children have “cold shock” Decreased cardiac output and increased

systemic vascular resistance Poor perfusion, cool extremities, delayed cap

refill

•  Adolescents more likely to have “warm shock”

Low systemic vascular resistanceBounding pulses, wide pulse pressure

Septic Shock

Case

• 6 month old with swollen L leg

• Parents state 3 yr old brother fell onto baby

• Approach to this case?

• Suspect if history vague, inconsistent with injury or child’s development

Bruises• Can not date bruises by color• “If they don’t cruise they don’t bruise”• Toddlers don’t bruise buttocks, inner arms/legs,

neck or trunk• Patterned marks – linear, hand prints• Bites – adult if > 3 cm

Child Abuse

Fractures• Metaphyseal (corner, bucket handle)

Shearing force from shakingUsually < 1yr

• Posterior ribs• Femur in non-ambulatory child• Multiple fractures, different ages

• Low risk – clavicle, tibia in toddler

Child Abuse

Head trauma• Direct contact injuries

Scalp hematoma Depressed skull fracture Epidural hematoma

• Rotational acceleration injuries Subdural hemorrhages Retinal hemorrhages

Child Abuse

• Admit all children < 2 yrs

• Skeletal survey for < 2 yrs (consider for 2-5 yrs)

• CT head if < 1 yr• Opthalmologic exam

Ideally within 24 hours (must be <72 hrs)

• Mandatory reporting to child welfare agency

Child Abuse

• 2 yr old at grandmother’s house• Took unknown amount of pills that he found

in her purse 30 minutes ago

• No symptoms

• What is your approach?

Case

• Young childrenExploratory ingestionIngest small amount of a single substance

• Can grasp single pill at 1 yr • Can’t hold handful of pills until > 15 mos• Child preparations have small opening – spills out

• AdolescentsIngest large amounts of one or more

substancesSuicidal gesture

Poisoning in Children

• Common ingestions• Household products• Cough/cold, vitamins, antibiotics• Acetaminophen and Ibuprofen• Antidepressants

• Pills that are harmful if single dose taken• Oral hypoglycemics, calcium channel

blockers, tricyclic antidepressants

Poisoning in Children

• History• Attempt to identify possible drug ingested• Friends, parents, paramedics, police

• Physical Exam• Look for toxidrome signs• Neurologic impairment• Skin marks, Breath odour• Look for signs of trauma, head injury

Approach to Unknown Ingestion

• Management• ABC’s• Check Glucose• Cardiac Monitoring• Gastric decontamination – Charcoal, WBI• Antidotes• Benzodiazepines for agitation, seizures• NaHCO3 for arrhythmias

Approach to Unknown Ingestion

• Diagnostic testing• CBC, lytes, BUN/Cr, glucose, gas,

osmolalityAnion gap, Osmolar gap

• Specific serum drug levels (Acet, ASA, Alcohols)

• ECG• Abd Xray for radio-opaque toxins

C - Calcium, Condoms H - Heavy metals I - Iron P - Phenothiazines, Potassium S - Slow-release preparations

Approach to Unknown Ingestion

Toxidromes

• AnticholinergicMad as a hatter - Agitation and hallucinationsBlind as a bat - Dilated pupilsHot as hell - Fever, FlushedDry as a bone - MM, skin; Urine retention; Decreased GI

motilityTachycardia. Hypertension

• CholinergicSalivation, Lacrimation, Urination, Defecation, GI

cramps, EmesisPulmonary edemaBradycardiaAgitation, confusion. seizures

Toxidromes

• SympathomimeticAgitation and hallucinationsDilated pupilsFever, Tachycardia, Hypertension

• Diaphoretic• Increased bowel sounds

• OpioidComaRespiratory depressionHypotensionMiosis

• Activated Charcoal• 1 g/kg• Greatest benefit is within 1 hr of ingestion

At 30 min 89% decreaseAt 1 hr 37% decrease

• Not useful forAlcoholsHydrocarbonsAnions or Cations (Iron, Lithium)Acids or Alkali

GI Decontamination

• Whole Bowel Irrigation• PegLyte

0.5-2 L per hour via NG

• For substances not adsorbed by charcoal and sustained release preparationsIronLithiumEC ASA

GI Decontamination

• Clinical Effects• 0-24 hrs

GI irritation, may be asymptomatic

• 24-48 hrsSigns of liver involvement begin

• 72-96 hrs Fulminant hepatic failureRenal failure

Acetaminophen

Acetaminophen

Acetaminophen

• > 4 hr Acetaminophen level

• Plot on nomogram

• N-AcetylcysteinePrecursor for glutathione Increases sulfation

metabolismDirectly reduces NAPQI to

APAPDirectly conjugates NAPQI

Salicylates

• Clinical Effects• GI upset - N&V, Gastritis • Tinnitus – often the first symptom• CNS – Confusion, Lethargy, Cerebral

edema• Hyperpnea – Early have respiratory

alkalosis• Hyperthermia• Renal and Liver toxicity – rare• Impaired platelet function

Salicylates

• Mechanism of Action• Uncoupling of oxidative phosphorylation

HyperthermiaGlycogenolysis, LipolysisHyperglycemia initially then hypoglycemia

from impaired gluconeogenesis

• Inhibits Kreb’s cycle Anaerobic metabolismLactic acidosis

• Urine alkalinization• Ion trapping – ASA is weak acid

• Hemodialysis• If signs of multiorgan failure

Salicylates

• Triad of clinical effects:• Cardiovascular

Prolonged QRS, QT, PR, ArrhythmiasHypotension

• CNSComa, Seizures

• Anticholinergic symptoms

Tricyclic Antidepressants

Tricyclic Antidepressants• Mechanisms of toxicity

• Blockade of fast Na+ channels

• Type 1A “quinidine-like effects”

• Membrane stabilizing effects

• Inhibition of GABA reuptake

• Blockade of alpha 1 receptors

• Anticholinergic effects

• NaHCO3• 1-2 meq/Kg then infusion

D5W + 150 meq NaHCO3/L at 1.5 x maintenance

• Benzodiazepines• Sedation, seizures

• Lipid therapy• May be helpful, case reports

Tricyclic Antidepressants

• Much safer than TCA’s

• Clinical Effects:• N&V• Sedation• QT prolongation• Seizures

• Serotonin Syndrome

SSRI’s

• Serotonin SyndromeAgitation, HypervigilanceMyoclonus, Muscle rigiditySeizuresDiaphoresis, shiveringHyperthermia, Autonomic dysfunction – HR, BPDiarrhea

• Treatment• Benzodiazepines, Active cooling

SSRI’s

• Review of pediatric emergency cases: Resuscitation Respiratory emergencies Fever in infant, 3-36 months Febrile seizures, Status epilepticus GI presentation Rashes associated with serious illness Sepsis Child abuse Poisoning

Summary

Questions ?