Common PEM Problems for the Emergency Medicine Resident

3

Brad Sobolewski, MD, MEd Cincinnati Children's Hospital Medical Center Emergency Department Rotation Director

Febrile Infant

The Bottom Line

28 days old and under = full septic workup

29-60 days we can opt to exclude LP if baby is low risk

Fever defined as temperature 38oC / 100.4oF (rectal)

Viral URI Sx do NOT count as a fever source

H&P are not reliable to rule-out serious bacterial infection (SBI)

12-28% of febrile neonates have SBI UTIs (12-20%)

Bacteremia (3%)

Meningitis (

Other causes Bacterial gastroenteritis

Gonococcal

keratoconjunctivitis

Omphalitis

Osteomyelitis

Peritonitis

Pneumonia

Septic joint

IV access

CBC, blood culture

Cath UA, urine culture

LP + CSF studies

28 days

Glucose if needed

Chest XRay if clinically warranted

Consider need for HSV testing

Enterovirus CSF PCR in the summer

Stool Culture if mucous or gross blood in the stool

Respiratory PCR and influenza

LP success rate increases with early stylet removal and use of lidocaine

Family presence does not alter success rate

Residents get 2 attempts

Take a supervisor with you

Lumbar puncture

CSF Blood

Early stylet removal

CSF Analysis Tube 1 Culture and Gram stain

Tube 2 Glucose, protein

Tube 3 Cell count and dierential

Tube 4 Viral Studies or to be saved for further studies

Lumbar puncture

Labs

WBC 5,000 or 15,000

Bands >1,500

Band:Neutrophil

Low Risk for Bacterial Meningitis 29-60 days old

Full-term (37 weeks gestation)

No prolonged NICU stay

No chronic medical problems

No systemic antibiotics within 72 hours

Well-appearing and easily consolable

No infections on exam

Blood and urine studies reassuring

LP

Empiric Acyclovir Strongly consider for ALL infants 21 days and for infants 22 to 40 days with 1 of the following:

Ill Appearing

Abnormal neurologic status, seizures

Vesicular rash

Hepatitis

Mom known to have primary HSV infection

at delivery

Labs HSV PCR in CSF and blood

HSV PCR of SEM lesions

Liver profile, BMP

HSV?

Antimicrobials 0-21d Ampicillin/Cefotaxime +/- Acyclovir

22-28d Ampicillin/Cefotaxime

29-56d Cefotaxime or Ceftriaxone (>6 weeks and no jaundice)

Additional Considerations Add Vancomycin if

Ill Appearing

CSF

WBC elevated w/abnormal glucose or protein

Gram positive organism on Gram stain

What about? Procalcitonin and CRP do not improve confidence to completely rule out SBI at this time

All babies under 28 days are admitted on empiric antibiotics for 36 hours

Babies 29-60 days with normal CBC and urine can be discharged home o antibiotics

You can get blood, urine and CSF on a baby 29-60 days and D/C home if normal - but NO antibiotics!

Disposition

Babies discharged home must have PMD follow up within 24 hours

Also, trustworthy caregivers with reliable transportation

Always call the PMD

If you cant reach them - baby from out of town consider admission

Disposition

Bronchiolitis

Rare in the first month of life

Peak 2-5 months

90% of kids will have it by age 2

URI Symptoms Rhinitis

LRTI Symptoms Tachypnea Cough Wheezing Crackles Accessory muscle use Nasal flaring Fever in only 30%

RSV #1

If you think it is bronchiolitis you are probably right! Viral testing only if severe disease or concurrent septic workup

Getting a Chest Xray just to be sure increases your likelihood of giving unnecessary antibiotics by 12%

If they have a fever 1/33 risk of UTI

More likely that it is d/t bronchiolitis alone or AOM

Therapies that help Suctioning

Oxygen

Therapies that dont really help Albuterol

Racemic epi

Hypertonic saline

Corticosteroids

CPT

Antibiotics (duh)

Infants at risk for rapid progression Adjusted gestational age

Infants with apnea or severe distress may benefit from HFNC

Discharge Criteria RR generally 90% when awake

Adequate oral intake

Mild to moderate increased work of breathing

Reliable caretaker

Able to secure follow up

Resources AAP Clinical practice guideline

PEMBlog Bronchiolitis 8-part series

Fussy Baby

Your goals

Perform a thorough

H&P

Try to get the baby to stop crying

Head Neuro exam mental status (must know development!)

Full fontanelle space-occupying lesion or infection

Hematoma or Ecchymosis Trauma

head circumference (hydrocephalus)

Eyes Corneal abrasion

Eversion of eyelid for retained FB

Red eye and excessive tearing? Conjunctivitis, congenital glaucoma

Ears AOM

Retained FB

Mouth Stomatitis

Thrush

Dry mucous membranes

Lacerated lingual frenulum (?NAT)

adapted from PedEMMorsels - Sean Fox

Chest Rib fractures

SVT

Congenital heart disease

Abdomen UTI

Mass

Hepatomegaly

Intussusception

Appendicitis

Volvulus (bilious emesis)

Bowel Perforation

Hirschsprung Disease

chronic constipation and no meconium

in first 24 hours of life

GU Testicular/Ovarian torsion

Incarcerated hernia

Anal fissure

adapted from PedEMMorsels - Sean Fox

Extremities Hair tourniquet

Fractures

Sickle cell disease (dactylitis)

Septic joint

Post-vaccination (ex, DTaP especially)

Skin Cellulitis

Eczema

Petechiae, purpura, etc.

Toxidromes

adapted from PedEMMorsels - Sean Fox

10-26% of infants

Excessive crying for:

>3 hrs per day

>3 days per week

>3 weeks in duration

Can begin as early as 2nd week of life

Peaks around 6th week of life

Should resolve by 16th week of life

Diagnosis of exclusion!

Colic

Freedman, 2009 Pediatrics

Retrospective review of 237 afebrile

Bottom line If you and/or caregiver can calm the baby in the ED

and H&P is normal the baby is probably fine

If you do any tests, consider U/A and culture

www.pemcincinnati.com/orientation