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Pediatrics Review Emergency

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  1. Pediatrics ReviewEmergency Gina Neto, MD FRCPC Division of Emergency Medicine

  2. Objectives • Review pediatric resuscitation guidelines • Recognize pediatric conditions that present to the emergency • Describe management of pediatric emergency cases

  3. 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

  4. Pediatric Resuscitation • Airway Management • Position, suctioning • Nasal/Oral airway • Endotracheal intubation • Cuffed tube size: age/4 + 3 (+/- 0.5mm) • Medications • Atropine (consider if< 6 yrs) • Paralytic - Succinylcholine, Rocuronium • Ketamine, Midazolam/Fentanyl, Propofol

  5. Pediatric Resuscitation • Bradycardia • Non-Cardiac causes (6 H’s, 5 T’s) • Hypoxia (Most Common) • Hypovolemia, Hypo/Hyperkalemia, Hypoglycemia, Hypothermia • Toxins, 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

  6. Pediatric Resuscitation • Tachycardia • Narrow • Wide • Stable or Unstable • Know what is normal for age

  7. Pediatric Resuscitation • Sinus Tachycardia • Rateusually < 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

  8. 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

  9. 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

  10. 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

  11. Case • 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.

  12. Asthma • 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)

  13. 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)

  14. Asthma • If not improving within 60 min or signs of impending respiratory failure: • Magnesium Sulfate50 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

  15. Case • 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?

  16. Bronchiolitis • 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

  17. 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

  18. Case • 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?

  19. Croup • 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

  20. Steeple Sign

  21. Case • 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?

  22. Retropharyngeal Abscess • < 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

  23. Retropharyngeal Soft Tissues* * Retrotracheal Soft Tissues * *

  24. Case • 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.

  25. Epiglottitis • Rarely seen • Strep pneumoniae • H. influenzae uncommon due to vaccine • Do not disturb patient • Consult Anesthesia, intubate • IV Ceftriaxone and Clindamycin

  26. Case • 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

  27. What investigation would you do next?

  28. Expiratory CXR

  29. Inspiratory Expiratory

  30. Foreign Body Aspiration • 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

  31. Case • 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?

  32. Fever < 1 month • 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

  33. Fever 1-3 months • 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%

  34. Low Risk Criteria “Rochester” for Febrile Infants • 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)

  35. Fever 3-36 months • 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

  36. Case • 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?

  37. Febrile Seizure • 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%

  38. 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

  39. Seizure Management • ABC's • IV access • Seizure treatment • 1st Line - Benzodiazepines • Lorazepam or Diazepam (Rectal or IV) • Midazolam (Intranasal or Buccal) • 2nd Line • Phenytoin, Fosphenytoin • Phenobarbitol

  40. 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)

  41. Case • 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.

  42. Case • What is the degree of dehydration of this child? • Management?

  43. Gastroenteritis • 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