Pedpourri – Pediatric Disorders II - acoep.org · Gastroenteritis Hernia, Incarcerated...
Transcript of Pedpourri – Pediatric Disorders II - acoep.org · Gastroenteritis Hernia, Incarcerated...
Pedpourri – Pediatric Disorders II Christopher S. Amato, MD, FACEP, FAAP
Emergency Medical Associates Goryeb Children’s / Morristown Medical Center
Director, Pediatric Emergency Medicine Fellowship Editor, ACEP PEER VIII, Pediatric EM
1
Case
7 male, diarrhea, fever x 2 days VS: WNL, looks well abd: soft, +/-diffuse tenderness, no peritoneal
sign Bloods, urine: non contributory Dx: ?Gastroenteritis
Case cont’d
Presents again next day, same symptoms exam: no change no bloods drawn seen by Gen Surg.
D/C with Gastroenteritis
Case cont’d
Presents 3rd time, abd pain increased rebound OR: perforated appendix
Case
24 months, male, crying, “bloated” no v/d, last bm 2 days ago vs: wnl, happy, looks well abd: no mass, nontender, +BS Abd. Series: stool+++ Dx: Constipation
Case cont’d
Presents next day lethargic pale, not responding, tachypneic protuberant abd 7.10/30/5 OR: intussusception
Which 2 diagnosis are found on emergency discharge records most frequently for missed
pediatric abdominal catastrophes in court cases?
Gastroenteritis Constipation
KIDS: VERBAL vs. NON-VERBAL
Differences? Similarities?
PRESENTATION:THE SPECTRUM
Stoic
H
Denies pain Fear of further medical attention
Histrionic Exaggerates pain
?missed diagnosis
1/3 of kids presenting with Abdominal Pain get no
specific diagnosis!!! (not good)
Abdominal Emergencies
Vomiting +/- abd pain – DDx 0 to 2 years
Appendicitis Colic Gastroenteritis Hernia, Incarcerated Hirschsprung’s Intussusception Malrotation/volvulus Testicular torsion
NEC Lactose intolerance Pyloric stenosis Toxins Neurogenic causes UTI CAH/adrenal crisis Inborn errors
Case
5 week old male infant with chief complaint of vomiting ◦ Has had almost daily emesis since birth ◦ Usually dribbles out of mouth ◦ Now more forceful and occurring with every feed ◦ No respiratory symptoms
◦ Now appears weak, eyes sunken
Radiology
Case Discussion: Hypertrophic Pyloric Stenosis (HPS) (1 of 2)
Background HPS: The most common surgical cause
of vomiting in infants. Hypertrophy of the circular musculature
surrounding the pylorus leads to obstruction of the gastric outlet.
Case Discussion: Hypertrophic Pyloric Stenosis (HPS) (2 of 2)
Background Infants with HPS present with nonbilious
projectile vomiting in the second to fourth weeks of life. Symptoms rarely occur before 2 weeks or
later than 4 to 6 months of age.
Your First Clue: HPS
• Male infant • Nonbilious, projectile emesis • Hungry appearing • Visible peristaltic waves • Palpable olive-shaped pylorus in
midepigastric region
Peristaltic Wave
Peristaltic Wave
Radiology Until recently, upper GI was the
"gold standard" for diagnosis of pyloric stenosis.
Positive upper GI signs for HPS are “string sign" (single streak of barium in lumen of elongated pylorus).
Ultrasonography
Indicative of pyloric stenosis
Length ≥ 1.6 cm wall thickness ≥ 0.4 cm Diameter ≥ 1.4 cm are
Management
ABCs Naso- or orogastric tube decompression Correct dehydration, metabolic and electrolyte
abnormalities with intravenous fluids. Ensure adequate urine output. Consult a pediatric surgeon. Surgery delayed until electrolytes stable
Case Progression/Outcome
Electrolytes: hypochloremic, hypokalemic, metabolic
alkalosis. Fluid resuscitation and gastric decompression
were initiated. A pediatric surgeon was consulted. Patient underwent a pyloromyotomy 2 days after
admission and was discharged 3 days later.
Case
18-month old infant ◦ Vomiting x 1 day, multiple times, nondescript ◦ Abdominal pain, nondescript, appears intermittent ◦ Lethargy afterwards ◦ Draws legs up into abdomen with discomfort
Radiology
Discussion: Intussusception
Intussusception is an invagination of the proximal portion of the bowel into an adjacent distal bowel segment.
Second most common cause of intestinal
obstruction in infants Approximately 80% to 90% involve
invagination of the ileum into colon (ileo-colic).
Background (1 of 2)
Peak age of occurrence is between 5 and 9 months, with most cases occurring from 3 months to 2 years.
10% to 25% occur in children older than 2
years.
Your First Clue: Intussusception (1 of 2)
Classic triad Intermittent colicky abdominal pain
(85%-90%) Vomiting (65%-80%) Emesis may be nonbilious, but may
become bilious or feculent. Bloody Stool with mucoid "currant jelly" stools---late finding
Your First Clue: Intussusception (2 of 2)
Only 20% have all three 70% have two of three
Radiology: Meniscus or Crescent Sign
Ultrasonography
Radiology: Barium or Air Contrast Enema
Management
ABCs Fluid resuscitation
Obtain surgical consultation. Perform barium or air contrast enema. Surgical reduction for: Signs of peritonitis Shock Pathologic lead point Unable to reduce with barium or air contrast enema
Case Progression/Outcome
After fluid resuscitation, Air contrast enema. Intussusception was
found and reduced. Lethargy quickly disappeared, and the
infant took oral fluids. The infant was discharged after
observation in ED.
Intussusception
Risk of recurrence Typically in the first 24 hours. Enema reduction 5-10% Surgical reduction 1-4%
Disposition Data shows safety with discharge from ED
36
WHAT if X-RAY Looked like this???
Malrotation with Midgut Volvulus
Malrotation is abnormal fixation of bowel mesentery
Volvulus is twisting of loop of bowel around mesenteric attachment Obstruction, ischemia, necrosis
Normal
Malrotation
Ladd bands
Midgut Volvulus
Malrotation with Midgut Volvulus
Usually presents in first year of life 75% < 1 mo; 90% <1yo Rarely may not present until childhood
Abdominal pain - nonspecific Bilious vomiting Abdominal distension and hematochezia
may be present Mortality up to 60%
Malrotation with Midgut Volvulus - Radiography
Plain films Normal to obvious SBO “Double-bubble” sign –
distension of stomach and first part of duodenum
UGI Study of choice “Apple core”, “corkscrew”, or
“coiled spring” sign Surgical consult prior to obtaining
UGI
Malrotation with Midgut Volvulus
Treatment IV hydration Correction of electrolytes NG tube Antibiotics Surgical correction
Acute Gastroenteritis
Gastroenteritis – Etiology
Bacterial: 10 – 20%
Shigella Salmonella E. coli Campylobacter Yersinia Vibrio cholera
Viral: 60%
Rotavirus Norwalk and Norwalk-
like (calicivirus) Adenovirus Astrovirus Coxsackie Echovirus
Treatment – Viral
Focus on oral hydration Antidiarrheals not recommended Antiemetics generally not needed ◦ Phenergan black box warning <2 years ◦ Ondansetron becoming more popular Good safety and efficacy profile
(AAP, Pediatrics 1996; Ramsook, Ann Emerg Med 2002. Freedman, N Engl J Med
2006)
Signs of Dehydration Summary
PE: ◦ Abnormal Cap refill
◦ Abnormal Skin turgor
◦ Abnormal Respiratory Pattern
Protective: Normal urine Output, Nl HCO3
ORT for mild/moderate dehydration vs. IV
End Tidal CO2 for HCO3 >37 torr
After hydration give Glucose fluid
Ondansetron helpful with vomiting
Dehydration in Children ORT vs IVRT in Current Practice
ORT IVRT
*Based on a national random survey of emergency physicians (N=176) selected from the American Academy of Pediatrics (AAP) Section on Emergency Medicine mailing list.3
1. AAP Practice Parameter Committee. Pediatrics. 1996;97:424-435. 2. World Health Organization. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers. 4th rev. Geneva, Switzerland: WHO Press; 2005; 3. Ozuah PO et al. Pediatrics. 2002;259-261; 4. Conners GP et al. Pediatr Emerg Care. 2000;16:335-338. 5. Humphrey GB et al. Pediatrics. 1992;90:87-91. 6. Cummings EA et al. Pain. 1996;68:25-31; 7. Frey AM. J Intraven Nurs. 1998;21:160-165; 8. Black KJL et al. Pediatr Emerg Care. 2005;21:707-711
Treatment Guidelines ORT is preferred in mild-to-moderate dehydration1
Use IVRT in severe dehydration or in children who cannot tolerate ORT1,2
Clinical Practice Realities
Use in Mild Dehydration*
71% always or almost always3 2% always or almost always3
Use in Moderate Dehydration*
15% always or almost always3 49% always or almost always3
Possible Contributing Factors Ongoing perception that ORT ineffective and takes too much time4
Parents expect an IV4
Catheter placement is one of the leading sources of pain and anxiety in children5,6
Often requires multiple attempts7-8
Is there another option?
SubCutaneous Hydration
Subcutaneous fluid administration for achieving hydration, to increase the dispersion and absorption of other injected drugs, and in subcutaneous urography for improving resaborption of radiopaque agents
Background
Subcutaneous (SubQ) administration of fluids was common from 1900 to 1950
IV route first developed in the 50s SubQ fluids safe and effective in mild to moderate
dehydration1
IV access may be difficult in dehydrated children and the elderly
Recombinant human hyaluronidase (rHuPH20) is FDA approved in subcutaneous fluid administration for
achieving hydration
1. Allen CH, Etzwiler LS, Miller MK, et al. Pediatrics. 2009;124:e858-e867.
Summary
ORAL HYDRATION THERAPY IS YOUR FRIEND!!! ◦ 5ml / 5 minutes and increase as tolerated
Alternatives? ◦ Nasogastric hydration ◦ Subcutaneous Hydration
GI – bloody diarrhea
Hemolytic uremic syndrome most common cause of ARF in children ◦Micronagiopathic hemolytic anemia ◦ Renal failure ◦ Thrombocytopenia ◦ Risk of seizures and hypertension
◦ Treatment of E.coli is risk for development
Inflammatory Bowel Disease
Crohn’s Disease ◦ Skip lesions ◦ Mouth to anus ◦ Cobblestoning ◦ Extra-intestinal manifestations
Ulcerative colitis ◦ Continuous from distal colon to proximal ◦ Significant risk of oncologic deterioration/conversion
Case
12 year male complains of abdominal pain ◦ Lasted 3 hours ◦ Obviously uncomfortable
◦ On exam, lower abdominal tenderness
◦ Further evaluation reveals…
Testicular Torsion
Salvage rate ◦ Less than 6 hours: 80-100% ◦ After 24 hours: <10%
Presence of a cremasteric reflex is possible Horizontal lie Vomiting Ultrasound with color flow
Colic / Crying – Differential
Infection: meningitis, otitis media, UTI Corneal abrasion / foreign body Intestinal obstruction Fracture Child abuse/increased intracranial pressure Incarcerated hernia Testicular torsion Hair tourniquet
Colic Criteria
Unexplained Crying for >3 hours for >3 days/week in >3 weeks
… In an otherwise healthy child.
“Neonatal bilious emesis is a surgical emergency until proven otherwise”
DIFFERENTIAL DIAGNOSIS
Infants: ◦ #1.inguinal hernia ◦ #2 intussusception
Case
3month old male presents with vomiting x1 hour ◦ can’t keep anything down
PE: small, protuberant abdomen, (+) tympanic belly
V.S. T 37.3, P 175, RR 50 PMHx: ex 33 weeker
Inguinal Hernia
INCARCERATED INGUINAL HERNIA
Most common in first year of life 30% of infant hernias present with incarceration
most manually reducible Dx by physical examination alone If abdomen distended or septic
obtain KUB to R/O free air
HERNIA REDUCTION POINTERS
Trendelenburg promotes spontaneous reduction ? Ice packs to limit edema Incarcerated bowel may be compromised
Temperature concerns Frog leg position to relax abdominal wall Quiet, calm environment limit fussiness /crying Sugar coated pacifier Keep NPO (tell parents!!)
HERNIA REDUCTION Transfix hernia, grasp testicle within scrotum Hand presses incarcerated mass through
inguinal canal Conscious sedation helpful Emergent surgery if hernia not completely
reduced, or postreduction obstruction, nonviable bowel, sepsis
If successful reduction, admit and repair when edema subsides in ≅ 24 hrs
Case Study: “Abdominal Pain”
8-year-old boy presents with 1 day of abdominal pain, fever, nausea, and vomiting.
Patient was previously healthy, although
several family members are ill. Boy is alert, has no retractions or tachypnea,
and color is normal.
Initial Assessment and Detailed Physical Examination
Initial assessment: –ABCDEs: Normal
Detailed physical examination: –Normal except for abdominal exam, which shows
tenderness in RLQ, voluntary guarding, and no rebound
–Pain had migrated from peri-umbilical area to RLQ
Management Priorities
Stop oral intake. Obtain vascular access. Begin fluid resuscitation with 20 mL/kg (500 mL)
NS.
Obtain blood and urine for laboratory analysis.
Administer pain medications. Consider antibiotics. Obtain surgical consultation.
Diagnostic Studies (1 of 2)
Laboratory There is no single specific laboratory
test that will diagnose appendicitis and rule out other causes for a child's illness. WBC is often normal.
Clinical Features: Your First Clue
Classic presentation in <50% of cases ◦ Periumbilical pain ◦ Anorexia, nausea, and vomiting ◦ Right lower quadrant pain ◦ Fever
Peritoneal irritation ◦ Percussion tenderness and rebound
Often a delay in diagnosis
Radiology: Plain Films
A fecalith is seen in 10% of cases.
May see evidence of bowel obstruction
Ultrasonography
Graded compression ultrasonography is particularly useful in the child with equivocal clinical signs.
No radiation exposure and accurate in experienced hands
Often nondiagnostic
CT Scan of Abdomen and Pelvis
High sensitivity and specificity rate Requires contrast Radiation exposure
Many institutions have elected to perform ultrasonography first.
Perform CT scan if highly suspicious of appendicitis and ultrasonography is non-diagnostic.
Case Progression/Outcome
Laboratory results showed a slightly elevated WBC.
Patient underwent ultrasonography, which showed a swollen appendix.
He was taken to the operating room. A non-perforated but inflamed appendix was removed.
TAKE HOME MESSAGE
rely on history very few physical findings (50% normal abd. exam)
TAKE HOME AND BRING TO WORK MESSAGE
HISTORY!!!! IF IN DOUBT RE-EXAMINE IF STILL UNSURE RE-EXAMINE LATER
AIRWAY / HEAD / ENT 79
Airway
Children’s airways different: Smaller = Increased resistance
More anterior/superior
Large, floppy glottis
Larger occiput = Affects patency
Large
Loss of tone with sleep, sedation, or CNS dysfunction
Frequent cause of upper airway obstruction
Anatomical differences in the airway- Tongue
Nose is responsible for 50% of total airway resistance at all ages
Infant: blockage of nose = respiratory distress due to
obligate nasal breather
Anatomical differences in the airway- Nose
Poiseuille’s Law
If radius is halved, resistance increases 16fold
R = 8 n l Π r4
Diagram of the Effect of Edema on the Cross-Sectional
Airway Diameter (R = radius)
Adult Airway Area = Π R2 = Π 102 = 100 Π mm2 (Normal) If have 1 mm Edema Area = Π 92 = 81 Π mm2
Or 81% of normal
Full Term Newborn Area = Π R2 = Π 32 = 9 Π mm2 (Normal) If have 1 mm Edema Area = Π 22 = 4 Π mm2
Or 44% of normal
1mm = 20% loss
1mm = 50% loss
20 mm
6 mm
W h e re ’s th e n o i se ?
ILBSET (I’ll Be Set)
Stridor Anatomy
Inspiratory Larynx
Bilateral (I/E) Subglottic
Expiratory Tracheomalacia
Signs of Respiratory Distress
Retractions Access muscles Wheezing Sweating Prolonged expiration Pulsus paradoxus Apnea Cyanosis
Tachypnea Tachycardia Grunting Stridor Head bobbing Flaring Inability to lie down Agitation
C AT E G O R I Z AT I O N O F R E S P I R AT O R Y E M E R G E N C I E S
Airway obstruction: ◦ Upper - stridor ◦ Lower – wheezing ◦ (where is the noise?)
Alveolar or interstitial conditions: ◦ Rales
Pediatrics ET tube
Internal Diameter mm: ◦ Uncuffed: (Age/4)+4 ◦ Cuffed ( > 1yr old): (Age/4) +3
Length (Age + 12)2= depth at the gumline/teeth ◦ Or 3 times the internal diameter
Airway positioning for children <2yrs
External laryngeal manipulation
Two person approach ◦ Assistant’s hand to Anterior neck
Improved POGO scores by 25% ◦ Cricoid Pressure-5% improvement ◦ BURP-4% improvement
Positioning of the Airway- Bimanual Laryngoscopy
Epiglottitis
Inflammation / swelling of epiglottis /surrounding tissues
H. Influenza with bacterial component
Hib vaccines have made this a rare occurrence.
Can cause complete airway obstruction, precipitated by gag reflex stimulation
Avoid examining or suctioning the upper airway
Clinical Presentation: Symptoms occur rapidly,
causing parents to seek medical attention within 24 hrs
Muffled voice Fever Stridor Labor breathing
(supraglotic edema) Drooling Usually anxious Tripod position
Epiglottitis Age Wide range: newborn to adults Average pediatric range 2 to 7 years
Etiology Now no predominant organism
S. aureus S. pneumoniae Beta-hemolytic Strep (group A and C) H. influenza B still possible
6/19 cases in 1 series 5 were fully immunized
(Shah, Laryngoscope 2004)
Epiglottitis – Symptoms Several hours of fever- Toxic child! Abrupt onset (< 12-24 hours)
Progressive sore throat Drooling Dysphagia Viral prodrome is absent Severe stridor usually absent Tripod / “Sniffing” position
Epiglottitis – Diagnosis Usually clinical 70-90% of blood cultures are positive Elevated WBC with bandemia Radiographs – consider only if sub acute
case
Epiglottitis vs. Normal
Treatment
Rapid recognition and treatment of airway obstruction Position of comfort Do not start IV or draw labs Mobilize OR team Intubate with smaller ETT BVM may need higher pressures Steroids not indicated
Retropharyngeal Abscess
Infection of paramedian lymphoid tissue Usually under 4 years old Organisms – usually polymicrobial GAS Anaerobes S. aureus
Fevers, sore throat, neck pain, drooling, stridor
Peri-Tonsillar Abscess Often Grp A Strep Severe Pharyngitis Hot-potato voice Dysphagia Trismus
Treatment Pain control Hydration Drainage-You or ENT
Case
A 3 year old is sent in by his pediatrician at 2 AM after listening to him coughing by phone ◦ URI for 2 days ◦ cough, hoarseness and what sounds like stridor ◦ In ED, Febrile (39), running around the room, without
stridor at rest ◦ RR 30, P 100, PulsOx 99%
CXR / labs ◦ Just say NO----the history and PE favor croup
Quick recheck of immunization status ◦ Epiglottitis still possible
Prior stenosis due to Trisomy 21 or Subglottic
www.andorrapediatrics.com
What can be done diagnostically?
What can be done therapeutically?
Mist therapy ◦ Doesn’t work!
Corticosteroids ◦ Effective in moderate to severe croup---PO/IM superior to
nebulized ◦ Dexamethasone (0.15 - 0.6 mg/kg) PO/IM
Racemic Epinephrine Racemic 0.05 mL/kg (max 0.5 mL) L-epinephrine (1:1,000 solution) 0.5 mL/kg (max 5 mL) Observe for 2hours—rebound unlikely afterward
◦ 2 strikes and you’re OUT! Admit
Don’t upset them!
Cochrane Review 2011
38 studies met the inclusion criteria (4299pts) Glucocorticoid treatment was associated with an
improvement in the croup severity score at 6 hours Fewer returns and ↓ Length of stay
Case
Mother of 2-month-old boy with 3days of a URI now with increasing work of breathing. EMS called
En route patient remained alert and they note a “waterfall of snot” from his nose
◦ P160, RR 60, BP: hahahaha ◦ T 38.4°C, O2 sat 93%, Wt. 5 kg
Affects Children <2yo
Viral, often RSV (may be metapneumovirus)
Differentiate upper vs. Lower in <5second
Other signs and symptoms include: o Upper airway: Stridor, respiratory or
cardiopulmonary arrest o Lower airway: Coughing, wheezing, retractions,
decreased breath sounds, cyanosis
Bronchiolitis
Albuterol?
Works in the 1st 24hrs only
Ribaviran
Costly, ?Efficacy, No AAP support since ‘03
Steroids?
No Help
Bronchiolitis
Hypertonic Saline?
Multiple studies (3%, NS, 5%, Racaemic)
Mixed Bag
Bronchiolitis
Case
A 6 year old presents with a 3 day history of cough, worse with activity
“No one smokes inside the house.” Strong family history of asthma
◦ T 37.2, RR 26, P 90, PulsOx 94%, Wt. 25 kg ◦ PE Mild tachypnea but no Distress
What can be done therapeutically?
Albuterol and Atrovent ◦ Indicated, often X3 ◦ Use spacers
Steroids ◦ give them EARLY, often for 3-5 days, may use
Dexamethasone ◦ Oral as effective as IV
Spacers vs. Nebulizers
No difference in admission rate 95% CI ( OR: 0.4 to 2.1 )
Children’s LOS in the ED shorter mean diff: -0.62 hours 95% CI ( -0.84 to -0.40 )
No difference for LOS in adults Decreased Pulse & tremor in spacer group Each spray = 108 microgram
Cochrane Review, 2009, Cates CJ
Spacers vs. Nebulizers
Conclude ◦MDI + holding chambers produced outcomes that
were at least equivalent to nebulizer delivery ◦ Holding chambers may have some advantages
compared with nebulizers for children with acute asthma
FYI ◦MDI comes out at 60MPH ◦ Spacer decreased med deposition to pharynx by 50%
IV and nebulized MgSO4 for treating acute asthma in adults and children: A systematic
review and Meta analysis:
25 Trials (16 IV, 9 Nebulized) 1754 patients IV MgSO4 (in addition to β2-agonist & Steroids) ◦ Improved pulmonary function and ↓ Admission for
Children ◦ Only improved lung function in adults
Shan Z, Rong Y Respir Med. 2013
CONCLUSIONS
Current therapy in children is based on variable levels of evidence ◦ Level 1 evidence to support steroids, Ipratropium
bromide, MgSO4 ◦ Level 2 evidence for HELIOX ◦ Level 3-5 evidence for ketamine, NO,
aminophylline, anesthetic agents
Otitis Media Update
Otitis media should be diagnosed based on TM: ◦ Mod/Severe Bulging or Otorrhea not related to OE ◦ Mild bulging and recent (<48hrs) otalgia in a non-verbal
NO AOM: ◦ Without effusion
Treatment with antibiotics: ◦ >6mos severe signs or T >39 ◦ Non-severe: B/L AOM 6-23mos
113
Otitis Media Update
Unilateral Otitis media 6-23mos w/o severe ◦ Prescribe antibiotics OR ◦ Offer close observation Need follow up if no improvement in 72hrs
Non-severe >24mos ◦ Prescribe antibiotics OR ◦ Offer close observation Need follow up if no improvement in 72hrs
114
Otitis Media Update
ANTIBIOTICS ◦ Amoxicillin if: NO allergy NO use in the past 30days NO concurrent purulent conjunctivitis
◦ Add β-lactamase Use in the past 30days Concurrent purulent conjunctivitis Hx of AOM unresponsive to Amox
115
Airway Foreign Bodies Age: 75% of patients are less than 3 years
Mortality ~200 deaths in children per year
Balloons Balls/marbles
Case Discussion: Foreign Body Aspiration
Often occurs in children younger than 5 years
Common offending agents: foods and home items
Balloons are the most common FB to result in death
Airway Foreign Bodies – Symptoms
Paroxysmal cough, wheezing and decreased breath sounds in 40% of patients
25% may be asymptomatic
39% may have no PE findings
50% diagnosed in first 24 hours, 30% in first week
Airway Foreign Bodies - Treatment Position of comfort with supplemental O2 Complete obstruction- remember BLS! Direct laryngoscopy with McGill forceps
available Bronchoscopy Intubation with mainstem bronchus
dislodgement Needle cricothyroidotomy Do you know where your difficulty airway
equipment is ???
Esophageal FB’s
3 likely regions to lodge ◦ Level of the thoracic inlet ◦ Level of the aortic arch ◦ At the lower esophageal sphincter
Plain radiographs to determine location Most items that pass the stomach are
appropriate for outpatient Observation. Corrosive (battery), sharp, length >4 cm
require removal.
Pneumonia Etiology Viral: all ages
Parainfluenza, RSV, influenza, adenovirus
Atypical: Mycoplasma: > 3 years old Chlamydia
C. trachomatis: infants < 3 months old C. pneumoniae: older children
Pneumonia Etiology Bacterial
Neonate Group B streptococcus E. coli Listeria monocytogenes
1 to 3 months S. pneumoniae Chlamydia trachomatis Bordetella pertussis S. aureus
(McIntosh, N Engl J Med 2002: LLSA 2005)
Pneumonia Etiology Bacterial
4 months to 4 years S. pneumoniae Mycoplasma (older children in this age group) S. aureus H. influenza (typable and non-typable)
5 to 15 years Mycoplasma S. pneumoniae Chlamydia pneumoniae
(McIntosh, N Engl J Med 2002: LLSA 2005)
Pneumonia Outpatient Treatment Suspected bacterial
3 months to 4 years Amoxicillin 80-100 mg/kg/day
5 to 15 years Macrolide
Erythro, Azithro, Clarithro Consider doxycycline if > 8 years old
(McIntosh, N Engl J Med 2002: LLSA 2005)
Chlamydia Pneumonia One of the most common types of
pneumonia in infants < 3-4 months Afebrile patient, with history of neonatal
conjunctivitis Staccato-like cough, wheezing Hyperinflation, increased interstitial markings
on CXR Oral erythromycin or a sulfonamide
Summary
Children are MUCH smarter than we give them credit to be Talk to everyone at the scene Keep everyone calm
Especially child!
Sleep when you can Eat when you can Pee when you can Never touch the pancreas!
Questions? 131
The END---GOOD LUCK! 132
Family Presence
Supported by ACEP and AAP Annals of Emergency Medicine, 2009
Family Presence at Resuscitation
Family present on even days, not on odd days Measured time to CT scan and total resuscitation time No delay in care from family presence
Family Contact and ICP 135
Presence, touch and voice of family / significant others...
Does not significantly increase ICP Has been demonstrated to decrease Measured time to CT and total resuscitation time
NO delay in care from family presence
Note: Visitors require education and preparation before spending time at bedside !
Bruya (1981) Journal of Neuroscience Nursing, 13
Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)
Mitchell (1985) Nursing Administration Quarterly, 9(4)
Treolar (1991) Journal of Neuroscience Nursing, 23(5)
Family Contact and ICP
Bruya (1981) Journal of Neuroscience Nursing, 13
Hendrickson (1987) Journal of Neuroscience Nursing, 19(1)
Mitchell (1985) Nursing Administration Quarterly, 9(4)
Treolar (1991) Journal of Neuroscience Nursing, 23(5)
Presence, touch and voice of family / significant others...
• Does not significantly increase ICP
• Has been demonstrated to decrease ICP
Family Centered Care
Bruya (1981) Journal of Neuroscience Nursing, 13
• Family Presence during Resuscitation: • Helped recognize the seriousness of condition
• They feel presence was beneficial
• They would choose to be present again
• Helps family adjust to grieving process
Family Centered Care
AAP & ACEP. Patient and family centered care and the role of the emergency physician providing care to a child in the emergency department, Pediatrics 2006
The “risk management literature indicates that patients and families are significantly less likely to initiate
lawsuits, even when mistakes are made, if there is open and effective communication and trusting relationships
between the practitioner and the patient and family”
• NO research has shown the family presence is harmful and evidence is growing that it is beneficial
The Nuclear Question: 2008
Adults age 45 or older
Very low risk of excess cancer for one scan
High prevalence of cancer in patients over 45
May not live long enough to express mutation
Usually past reproductive age
But for a 10 year old
Long lifespan in which to manifest mutation
Immature, rapidly developing body systems, more radiosensitive
May pass mutations to progeny
Radiation exposure from CT Scans in Childhood and subsequent risk of Leukemia and Brain Tumours: A
Retrospective Cohort Study. Lancet 2012
178,604 children (ages <22yo) in U.K. (‘98-’05) ◦ No Cancer prior to first CT ◦ 283,919 CT scans (64% Head CT) Leukemia = 74 Brain Tumors = 135
Compared to children with <5mGy RR Leukemia was 3.18 in those received >30mGy
Brain Tumor RR 2.82 in those received >50mGy
Risks of Ionizing Radiation from Diagnostic Imaging Bottom Line
Absolute risk is small (1/10,000 Head CT) Although the risk is small, it is cumulative ◦ Statistically significant increase in cancer risks
above 50mSv The benefits of an indicated CT far outweigh
the risks
Appropriate Utilization
CT should be avoided when an US or MRI is of comparable diagnostic utility ◦ Body MR: Liver, Pancreatic, and Renal imaging ◦ US vs. CT for appendicitis in children Amer. College of Radiology appropriateness criteria
• US 8/9: Relative Radiation Level= none • CT 7/9: Relative Radiation Level= high
Rating Scale 1,2,3 =not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
What Do Families Want to Know?
The exam is needed to best care for their child The risk of the exam is real, but very low The exam is being performed with the lowest
possible risk
Explaining Radiation Risk
Families are more interested in efforts to control the risk than the actual number
After reading a handout on radiation risk: ◦ preference for CT over no imaging decreased ◦ but no families refused CT
Larson, et al. Amer. Jrnl Rad. 2007
Summary
Ionizing radiation from diagnostic imaging may cause a small increase in the risk of cancer
For an indicated CT scan, the likely benefit is far
greater than the estimated risk We should work together to make the population
exposure ALARA