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Pediatric Emergencies John D. Rowlett, MD, FAAP Associate Lecturer Fitzgerald Health Education Associates, Inc. No. Andover MA Georgia Emergency Associates Savannah, GA Disclosure: Baxter Pharmaceuticals

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pediatric emergencies

Pediatric Emergencies

John D. Rowlett, MD, FAAP

Associate Lecturer

Fitzgerald Health Education Associates, Inc.

No. Andover MA

Georgia Emergency Associates

Savannah, GA

disclosure baxter pharmaceuticals
Disclosure: Baxter Pharmaceuticals
  • Since signing the disclosure agreement, I have signed an agreement to be an investigator and occasional speaker for Hylenex©,, manufactured by Baxter. I own no individual stock in this company. This product will be mentioned briefly in this talk

 2009 Fitzgerald Health Education Associates, Inc.

goals for this talk
Goals for this Talk
  • Overview of Pediatric Assessment
  • Evaluation of the Acutely Ill Child
  • Review of fever, approach to the febrile child
  • Gastrointestinal Emergencies
  • Neurologic Emergencies
  • Respiratory Emergencies
  • Sudden Death/Cardiac Emergencies

 2009 Fitzgerald Health Education Associates, Inc.

lecture plan
Lecture Plan
  • 12:30-1:45 Lecture
  • 1:45-2:00 Break
  • 2:00-3:15 Lecture
  • 3:15-3:30 Break
  • 3:30-4:30 Lecture

 2009 Fitzgerald Health Education Associates, Inc.

emergency medicine rules
Rule # 1: The goal of emergency medicine is to ensure oxygen and glucose delivery to the brain.

Rule #2: Everything else is subordinate to Rule #1.

Rule #3: When in doubt, refer to Rule #1

Emergency Medicine Rules

 2009 Fitzgerald Health Education Associates, Inc.

the pediatric assessment triangle
The Pediatric Assessment Triangle*

*Pediatric Education for Prehospital Professionals.

Developed by the American Academy of Pediatrics

 2009 Fitzgerald Health Education Associates, Inc.

the pediatric assessment triangle pat
The Pediatric Assessment Triangle (PAT)*

Observational assessment

Formalizes the “general impression”

Establishes severity of illness or injury

Determines urgency of intervention

Identifies general category of physiologic abnormality

*Pediatric Education for Prehospital Professionals.

Developed by the American Academy of Pediatrics

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

pat appearance
PAT: Appearance
  • Does the child look sick or does the child look well?
    • May change with fever control
  • How is the child
    • Interacting with parent(s)
    • Interacting with provider
    • Interacting with environment

 2009 Fitzgerald Health Education Associates, Inc.

pat breathing
PAT: Breathing
  • Is the respiratory rate
    • Low, normal, or increased?
    • Is there accessory muscle use?
    • Are breath sounds normal or are there wheezes, rales, and/or ronchi?
  • Pulse oximetry? Capnography?
  • Nothing better than a loud cry

 2009 Fitzgerald Health Education Associates, Inc.

pat circulation skin color
PAT: Circulation/Skin Color
  • What is the capillary refill time?
    • Under 2 seconds
    • Under 1 second
    • Instant
    • I routinely discuss this with parents
  • Urine output?
  • Mental status?

 2009 Fitzgerald Health Education Associates, Inc.

vital signs by age
Vital signs by Age

 2009 Fitzgerald Health Education Associates, Inc.

a word about blood pressures
A word about blood pressures
  • Notoriously innaccurate
  • Minimum (mm Hg) should probably be 80 + twice age in years
  • Due to compensatory mechanisms in children (predominantly increased HR), may be “normal” in dire circumstances (until collapse)

 2009 Fitzgerald Health Education Associates, Inc.

slide13
The triage nurse sends you a phone call from the mother of a 6 week old infant. The mother states that the child “felt warm” so she took her temperature under the arm and it was 104.1o F. What should she do now?

 2009 Fitzgerald Health Education Associates, Inc.

slide14
Illness is caused by an imbalance in the four humors (blood, phlegm, yellow bile, and black bile. The purpose of fever is to “cook” the excess humor and bring the body back to normal homeostasis.

Hippocrates

 2009 Fitzgerald Health Education Associates, Inc.

slide15
“Fever is a mighty engine which Nature brings into the world for conquest of her enemies.”

Thomas Sydenham, 1600

 2009 Fitzgerald Health Education Associates, Inc.

slide16
“Humanity has but 3 great enemies: fever, famine, and war; of these, by far the greatest, by far the most terrible, is fever.

William Osler, 1896

The study of fevers of the South. JAMA 1896;26:999-1000

 2009 Fitzgerald Health Education Associates, Inc.

control of body temperature
Control of body temperature
  • Hypothalamus
    • Body’s “Thermostat”
    • Maintenance of “set point”
      • Autonomic
      • Endocrine
      • Behavioral

 2009 Fitzgerald Health Education Associates, Inc.

fever the good and the bad
Fever: The Good and the Bad

Benefits

Adverse effects

Hypermetabolism

Increased insensible fluid losses

Generalized malaise

You simply feel crummy when you have a temperature

Remember the last time YOU had a fever?

  • Increased leukocyte mobility and activity
  • Activation of T lymphocytes
  • Increased production of interferon

 2009 Fitzgerald Health Education Associates, Inc.

fever metabolic effects
Fever: Metabolic Effects
  • For each degree (C) increase over basal body temperature
    • Heart rate increases 10 to 15 beats per minute
    • Respiratory rate increase 3 to 5 breaths per minute

 2009 Fitzgerald Health Education Associates, Inc.

carl wunderlich
Carl Wunderlich
  • 1868
    • Reported the mean adult temperature was 98.6oF
    • Data was more than 1 million readings on 25,000 patients
      • Axillary temp, 1 foot long thermometer

 2009 Fitzgerald Health Education Associates, Inc.

sites for measuring temperature
Sites for Measuring Temperature

Central

Pulmonary artery, lower esophagus

Most accurate, difficult to access

Axillary

Inaccurate

Slow to change, affected by sweating, cooling

No role in modern pediatrics

 2009 Fitzgerald Health Education Associates, Inc.

sites for measuring temperature22
Sites for Measuring Temperature

Oral

Less lag time

Reasonably accurate for age 5 years +

Affected by oral fluid intake and mouth breathing

Rectal

Gold standard

Nobody likes a rectal temperature

 2009 Fitzgerald Health Education Associates, Inc.

sites for measuring temperature23
Sites for Measuring Temperature

Tympanic membrane

In theory, should be close to that of brain

Studies have shown wide variability (Cerumen, technique, acute otitis media)

Temporal artery

Well tolerated, just innaccurate, especially in sick infants < 3 months of age

 2009 Fitzgerald Health Education Associates, Inc.

the mometer
The MOMeter
  • “He just felt warm to me”
    • Subjective, varies by site of the infant touched by the examiner
    • Sensitivity range 71 to 89%
    • Specificity and positive predictive value < 50%

 2009 Fitzgerald Health Education Associates, Inc.

normal variation in body temperature
Normal Variation in Body Temperature

El-Radhi AS, Barry W. Thermometry in paediatric practice. Arch Dis Child 2006;91:351-6.

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

25

fever defined as a rectal temperature greater than or equal to 100 4 0 fahrenheit 38 o c
Fever:defined as a rectal temperature greater than or equal to 100.40 Fahrenheit (38o C)

 2009 Fitzgerald Health Education Associates, Inc.

antipyretic pharmacology
Antipyretic pharmacology

 2009 Fitzgerald Health Education Associates, Inc.

ibuprofen or acetaminophen
Ibuprofen or Acetaminophen
  • Both are effective
  • Both can have dosing errors
  • I prefer ibuprofen because:
    • Tastes better, works faster
          • Hay et al. BMJ 2008;337:a1302
  • APAP is safer in dehydrated children
    • ? increased asthma risk in children <1yr
          • Beasley R et al Lancet 2008;372:1039.

 2009 Fitzgerald Health Education Associates, Inc.

what do i do in the er
What do I do in the ER
  • It’s nice to get the temperature down
  • While there is significant difference between the response of serious vs. minor illness fever to antipyresis, the APPEARANCE may change
  • Seriously ill children still look sick when the temperature is normal

 2009 Fitzgerald Health Education Associates, Inc.

what about alternating ibuprofen and acetaminophen
What about alternating ibuprofen and acetaminophen
  • Widely practiced
    • 67% of parents
    • 50% of practitioners
  • No conclusive data to suggest that it is either safe or more effective
  • Potential risks include dosing error and theoretic renal & hepatic toxicity

 2009 Fitzgerald Health Education Associates, Inc.

rectal acetaminophen
Rectal Acetaminophen
  • Historically ineffective, likely secondary to improper dosing
  • New recommendation range from 25 to 45 mg/kg first dose with about ½ this for q six hour subsequent doses
    • Based on serum levels, most of the data are from anesthesia studies

 2009 Fitzgerald Health Education Associates, Inc.

fever phobia
“Fever Phobia”
  • Described by Schmidt in 1980
  • Parents view fever not as a symptom, but as a disease
    • About 30% of acute care pediatric visits are for fever
    • May lead to unnecessary testing and overuse of antibiotics
  • Parental education is key

 2009 Fitzgerald Health Education Associates, Inc.

selected references for fever
Selected References for Fever

Acute Fever

Avner J. Pediatrics in Review. 2009;30:5-12

Entire issue of Clinical Pediatric Emergency Medicine, December 2008

multiple articles on fever in children

 2009 Fitzgerald Health Education Associates, Inc.

slide35
Back to our case: The mother arrives with her infant, now asleep in the carrier. She states that he took a bottle (3 ounces) and has been sleeping quietly; he has had one wet diaper and one unusually loose and malodorous stool. His temperature is 101.6o (rectal)

 2009 Fitzgerald Health Education Associates, Inc.

chart review and physical examination
Chart Review and Physical Examination
  • Prenatal history
    • Negative
  • Birth
    • SVD at term
    • Apgars 9, 10
    • No problems in nursery
  • Mom healthy
  • No sick visits
  • HR 180, RR 30
  • Appears well
  • CRT 1 second
  • Vigorous cry
  • No focal findings on exam

 2009 Fitzgerald Health Education Associates, Inc.

the febrile infant work up
The Febrile Infant: Work-up
  • CBC
    • Part of all screening protocols, though independently not that useful
  • Urinalysis and culture
    • Catheterized specimen if at all possible
    • All specimens should be cultured
    • Most likely source of bacterial infection

 2009 Fitzgerald Health Education Associates, Inc.

the febrile infant work up38
The Febrile Infant: Work-up
  • CXR
      • Routine, though in the absence of physical findings rarely helpful
        • Indicated if patient is tachypneic, has rales, ronchi, grunting, retractions, wheezing, grunting, stridor, cough, nasal flaring
  • Other tests
      • Clinically suggested (RSV, Rotavirus, Flu)
    • Clinically helpful?
        • C-reactive protein, serum procalcitonin

 2009 Fitzgerald Health Education Associates, Inc.

to tap or not to tap that is the question whether tis nobler to
To Tap or Not to Tap, THAT is the question. Whether tis nobler to …

Given that:

  • Prevalence of bacterial meningitis is low
  • Marked decreased since advent of H. influenzae and S. Pneumonia vaccines
  • Best estimates (2 studies) = .5%

Should we tap every child < 60 days who has a documented fever?

 2009 Fitzgerald Health Education Associates, Inc.

for now the answer is yes
For now, the answer is YES
  • Some (including some well-respected clinicians) would disagree
  • The single most accurate and reliable test for meningitis is the lumbar puncture; any management strategy which omits this is inherently riskier than I choose to be

 2009 Fitzgerald Health Education Associates, Inc.

common strategies for management of febrile infants
Common Strategies for management of febrile infants

Modified from Baker MD, Avner JR. The Febrile infant: What’s new?

Clin Ped Emerg Med 2008;9:213-20.

 2009 Fitzgerald Health Education Associates, Inc.

common strategies for management of febrile infants42
Common Strategies for management of febrile infants

Modified from Baker MD, Avner JR. The Febrile infant: What’s new? Clin Ped Emerg Med2008;9:213-20.

common strategies for management of febrile infants43
Common Strategies for management of febrile infants

Modified from Baker MD, Avner JR. The Febrile infant: What’s new? Clin Ped Emerg Med 2008;9:213-20.

 2009 Fitzgerald Health Education Associates, Inc.

what about the child 30 days old
What about the child < 30 days old?
  • Incidence of serious infection much higher in this age group (compared to infants 30-60 days old
  • No strategy for risk stratification has been successful other than “they all get worked up, admitted, and place on antibiotics”

 2009 Fitzgerald Health Education Associates, Inc.

philadelphia and boston criteria and the febrile infant 30 days
Philadelphia and Boston Criteria and the febrile infant < 30 days

372 infants; SBI/ meningitis = 45 (12%)

  • Of these, misclassification as low risk
    • Philadelphia criteria = 13.3%
    • Boston criteria 17.8%
      • Kadish et al. Applying outpatient protocols in febrile infants 1-28 days of age. Clin Pediatr 2000;39:81-8.

254 similar infants (in Philadelphia)

    • inappropriately classified 15% of the infants with SBI/meningitis
      • Baker MD et al. Unpredictability of SBI in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med 1999;153:508-11.

 2009 Fitzgerald Health Education Associates, Inc.

what about the child 90 days of age with documented fever
What about the child > 90 days of age with documented fever
  • The older the child, the more discerning the physical examination
  • In fully immunized children, incidence of SBI/meningitis continues to decline
    • H. influenzae almost extinct, though recent outbreak (5 cases) in Minnesota
      • All were un/incompletely vaccinated
    • S. Pneumonia cases continues to decline

 2009 Fitzgerald Health Education Associates, Inc.

potential sources of infection
Potential Sources of Infection
  • Occult Bacteremia
  • Occult Pneumonia
  • Occult Urinary Tract Infection
  • Viral infection
  • Meningitis
  • Otitis media
  • Pharyngitis
  • Sinusitis

 2009 Fitzgerald Health Education Associates, Inc.

workup for the well appearing fully immunized child 90 days of age
Workup for the well- appearing, fully immunized child > 90 days of age
  • Disease specific testing
    • Influenza, RSV, Rotavirus, GAHBS
  • Urinalysis
    • Occult UTI most common source of SBI fever in this group; has not changed secondary to immunizations

 2009 Fitzgerald Health Education Associates, Inc.

urinalysis source is key
Urinalysis: Source is Key
  • Urine bag
    • High false positive rate; Only use if time permits the collection of second (cath) specimen if bag +
  • Urine Culture = Gold standard
  • Supapubic tap: Haven’t done one in 15 years
  • Clean-catch: if done right, it’s fine

 2009 Fitzgerald Health Education Associates, Inc.

utis treatment
UTIs: Treatment
  • Simple cystitis
    • 5-10 days
    • Antibiotic choice depends on age of patient, local resistance patterns, other complicating factors
      • Amoxicillin, tmp/smx, amox + clavulanate, cephalosporins
    • Oral therapy is fine, even if a little sick

 2009 Fitzgerald Health Education Associates, Inc.

utis treatment52
UTIs: Treatment
  • Febrile UTIs
    • New data suggest oral therapy okay, even for younger infants (if tolerating po therapy)
    • 10-14 days of therapy
    • Quinolones
      • Not approved, though safety data promising

 2009 Fitzgerald Health Education Associates, Inc.

utis follow up
UTIs: Follow-up
  • For decades, recommendation was VCUR (voiding cysto-urethrogram) on all children < 2 years of age with febrile UTI (after recovery)

Renal ultrasound recommended by AAP in 1999; recent study suggests that if normal prenatal u/s at post conceptual age >=30 weeks, additional study unnecessary

 2009 Fitzgerald Health Education Associates, Inc.

utis follow up54
UTIs: Follow-up
  • The efficacy of long-term prophylactic antibiotics for children (especially girls) is unclear
    • Recent study reported antibiotic prophylaxis in children younger than 30 months with VUR (vesiculoureteral reflux) and pyelonephritis was ineffective at preventing recurrent pyelonephritis or renal scarring
          • Pennesi M. Pediatrics 2008;121:1289-94

 2009 Fitzgerald Health Education Associates, Inc.

slide55
Meanwhile, back to our case

 2009 Fitzgerald Health Education Associates, Inc.

slide56
The child is sent to the emergency room for further evaluation. His work-up is completely normal and according to the Philadelphia criteria, he is discharged home and instructed to follow-up the next day. Fortunately, you office is open, in the words of the Beatles, “Eight days a week.”
slide57
The next day, the child is dutifully brought in by mother. He has been doing well except for the now frequent watery, malodorous, slightly green stools. His fever has been under 101.00 F (rectal). Mom notes that she stopped checking the temperature because “every time I do he boo boos all over everything!”
slide58
Physical examination reveals a happy, child with a HR of 140, RR 30, and temperature of 100.10 F (rectal). Capillary refill is about 1.5 seconds and the remainder of the examination is remarkable only for some redness of the perineum and yet another foul-smelling diaper.
dehydration in children definition and etiology
Dehydration in ChildrenDefinition and etiology
  • Loss of fluids and electrolytes due to:
    • Increased fluid output
      • Gastroenteritis (#1 cause)
      • Fever
      • Heat/exertion
      • Trauma (bleeding/burns)
    • Decreased fluid intake
      • Anorexia
      • Sore throat
      • Respiratory distress
          • Fleisher GR et al, eds. Textbook of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;234.

 2009 Fitzgerald Health Education Associates, Inc.

dehydration in children epidemiology of gastroenteritis
Dehydration in Children:Epidemiology of Gastroenteritis
  • Diarrhea is one of the leading causes of illness and death in young children
    • 1954-79 ~4.6 million children died/year1
    • 1980s: 3.3 million children died/year1
    • 1990s: 2.5 million deaths/year in children <5 years1
    • 2003: ~1.87 million children under 5 years died2
  • 1. Parasher UD et al. Bull World Health Organ. 2003;81:236 2. World Health Organization. The treatment of diarrhea: A manual for physicians and other senior health workers. 4th rev. Geneva, Switzerland: WHO Presss; 2005.

 2009 Fitzgerald Health Education Associates, Inc.

dehydration in children epidemiology of gastroenteritis62
Dehydration in Children:Epidemiology of Gastroenteritis
  • In the U.S., acute gastroenteritis in children annually accounts for
    • More than 1.5 million outpatient visits
    • 200,000 hospitalizations
    • ~300 deaths/year1
  • 1. King CK et al. Managing acute gastroenteritis among children. MMWR. 2003;52:1-16. www.cdc.gov.mmwr/preview/mmwrhtml/rr5216al.html

 2009 Fitzgerald Health Education Associates, Inc.

dehydration in children assessment
Dehydration in Children: Assessment

WHO Signs

Dry mucus membranes

Sunken eyes

Abnormal radial pulse

Tachycardia

HR > 150 bpm

Decreased urine output

  • Decreased skin elasticity
  • Capillary refill > 2 seconds
  • General appearance
  • Absent tears
  • Abnormal respirations

1-2 findings indicate deficit <5%; 3-5 findings indicate deficit 5-9%

6 or more findings indicate deficit of >=10%

Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

 2009 Fitzgerald Health Education Associates, Inc.

dehydration in children assessment64
Dehydration in Children: Assessment

Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

 2009 Fitzgerald Health Education Associates, Inc.

dehydration in children assessment65
Dehydration in Children:Assessment

Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99;e6.

 2009 Fitzgerald Health Education Associates, Inc.

gastroenteritis epidemiology
Gastroenteritis: Epidemiology

Severe Diarrheal Disease Requiring Hospitalization: Infants & Young Children

Developing Countries

Industrialized Countries

Unknown

Unknown

Rotavirus

Rotavirus

Parasites

Otherbacteria

ToxigenicEscherichia coli

Bacteria

Adenovirus

Adenovirus

Astrovirus

Calicivirus

Astrovirus

Calicivirus

From Kapikian AZ, Hoshino Y, Chanock RM. In: Knipe DM, Howley PM, Griffin DE, et al. Fields Virology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:1787–1825. Reprinted with permission.

Merckmedicus.com

rotavirus
Rotavirus

 2009 Fitzgerald Health Education Associates, Inc.

rotavirus gastroenteritis burden of disease in us children under 5 yr
20–60

1:200,000

55,000–70,000

1:70

205,000–272,000

1:7

410,000

4:5

2.7 M

Rotavirus Gastroenteritis: Burden of Disease in US Children Under 5 yr

Cumulative Risk by Age 5

Annual Events

Centers for Disease Control and Prevention. MMWR. 2006;55:(RR-12):1–13.

2008 Fitzgerald Health Education Associates, Inc.

Centers for Disease Control and Prevention. MMWR. 2006;55:(RR-12):1–13.

Merckmedicus.com

rotavirus infection cumulative probability by 24 months of age
Rotavirus Infection: Cumulative Probability by 24 Months of Age

1.0

1st infection

0.9

0.8

0.7

2ndinfection

0.6

Probability of

Rotavirus Infection

0.5

3rdinfection

0.4

0.3

4th infection

0.2

5th infection

0.1

0

2

4

6

8

10

12

14

16

18

20

22

24

Age, months

From Velázquez FR, Matson DO, Calva JJ, et al. N Engl J Med. 1996;335:1022–1028. Reproduced with permission by Massachusetts Medical Society.

© 1996 Massachusetts Medical Society. All rights reserved.

 2009 Fitzgerald Health Education Associates, Inc.

Merckmedicus.com

slide70
Image 114_02. Rotavirus Infections. Rotavirus, typical epidemiologic curve. Rotavirus disease is the leading cause of deaths from diarrhea in the world.

Red Book Online Visual Library, 2006. Image 114_02. Available at: http://aapredbook.aappublications.org/visual. Accessed December 10, 2007

Copyright ©2006 American Academy of Pediatrics

 2009 Fitzgerald Health Education Associates, Inc.

seasonal variation of rotavirus cdc
Seasonal variation of Rotavirus (CDC)

 2009 Fitzgerald Health Education Associates, Inc.

slide72
Rotavirus Gastroenteritis: Seasonality Burdens Healthcare Infrastructure

Influenza

Respiratory Syncytial Virus

Rotavirus

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

*Peak seasons may vary

1. Centers for Disease Control and Prevention. Influenza Fact Sheet. October 17, 2006. Available at: http://www.cdc.gov/flu/protect/keyfacts.htm.

Accessed November 29, 2006. 2. Centers for Disease Control and Prevention. MMWR. 2004;53:1159–1160. 3. Centers for Disease Control and

Prevention. MMWR. 2006;55( RR-12):1–13.

Merckmedicus.com

rotavirus gastroenteritis presenting symptoms among outpatients 36 months of age
Rotavirus Gastroenteritis: Presenting Symptoms Among Outpatients <36 Months of Age

Merckmedicus.com

rotavirus gastroenteritis presenting symptoms in hospitalized children
Rotavirus Gastroenteritis: Presenting Symptoms in Hospitalized Children

 2009 Fitzgerald Health Education Associates, Inc.

summary
Summary
  • Rotavirus gastroenteritis
    • In US children <5 years, associated with1:
      • ~2.7 million symptomatic episodes/year ~410,000 outpatient visits/year ~205,000–272,000 ED visits/year ~55,000–70,000 hospitalizations/year
    • An unpredictable disease that can lead to serious consequences, including hospitalization1
    • Affects parents and providers in terms of time, expense, and anxiety2

Merckmedicus.com

1. Centers for Disease Control and Prevention. MMWR. 2006;52(RR-12):1–13. 2. Coffin SE, et al. Pediatr Infect Dis J. 2006;25:584.

 2009 Fitzgerald Health Education Associates, Inc.

rotateq
RotaTeq
  • Liquid Vaccine
    • Contains multiple serotypes
      • G1 (76) (1% of disease)
      • G2 (11)
      • G3 (2.6)
      • G4 (1)
    • Other serotypes can cause disease
  • 3 dose series between 6 and 32 weeks of age; can be completed by as early as 4 months of age

 2009 Fitzgerald Health Education Associates, Inc.

rotateq77
Rotateq
  • Efficacy
    • 98% effective presenting severe rotavirus infection
    • 74% effective preventing mild, moderate rotavirus infection
  • Among vaccinated children, Hospitalizations/ ED visits from serogroups G1,G2,G3, and G4 reduced
    • 95% in United States
    • 90% in Latin America
    • 95% in Europe

 2009 Fitzgerald Health Education Associates, Inc.

rotarix glaxosmithkline
Rotarix (GlaxoSmithKline)
  • Monavalent vaccine derived from the most common human rotavirus strain (G1P)
  • Provides cross-protection to most human strains

 2009 Fitzgerald Health Education Associates, Inc.

rotarix
Rotarix
  • 90% protection following 1st dose
  • Significant reduction in hospitalizations
  • Significant protection sustained for two years

 2009 Fitzgerald Health Education Associates, Inc.

the big picture with rotavirus vaccines the third world
The Big Picture with Rotavirus Vaccines: The Third World
  • Will they be effective among the poorest children?
  • Will they be safe
  • Can they be made affordable

 2009 Fitzgerald Health Education Associates, Inc.

current treatment options oral rehydration therapy ort
Current Treatment Options:Oral Rehydration Therapy (ORT)
  • The American Academy of Pediatrics recommends ORT as the preferred treatment for fluid and electrolyte loss caused by diarrhea in children with mild-to-moderate dehydration
    • Less expensive than intravenous fluid therapy (IVT)
    • Can be administered in various settings
    • Fewer complications compared with IVFT
    • Requires ongoing attention from the caregiver

Practice Parameter Committee. Pediatrics 1996;97:424-35.

 2009 Fitzgerald Health Education Associates, Inc.

current treatment options oral rehydration therapy ort82
Current Treatment Options:Oral Rehydration Therapy (ORT)
  • Of 60 PEM fellowship directors surveyed on rehydration preferences, only 4 used ORT in all circumstances recommended by the AAP. Cited barriers to ORT include:
    • Disagreement with AAP recommendations
    • Moderate dehydration status
    • Belief that ORT is too time consuming
    • Expectation of parents
    • Expectation of referring physicians
    • Previous trial of ORT

Conner GP et al. Pediatr Emerg Care. 2000;16;335-8.

 2009 Fitzgerald Health Education Associates, Inc.

ort types of fluid
ORT: Types of Fluid
  • WHO fluid
    • Sodium 75 mmol/L
    • Potassium 20 mmol/L
    • Chloride 65 mmol/L
    • Citrate 10 mmol/L
    • Glucose 75 mmol/L
      • Prepared has osmolality of 245 mOsm/L

 2009 Fitzgerald Health Education Associates, Inc.

oral ondansetron zofran
Oral Ondansetron (Zofran®)
  • 106 patients aged 1-10 years
    • Moderate dehydration, failed oral hydration
    • Randomized to receive ODT ondansetron or placebo
    • Fluids/popsicles introduced in 30 minutes
  • IV therapy eventually required by
    • 21.6% of ondansetron group
    • 54.5% of placebo group
    • Number needed to treat = about 3
        • Roslund G et al. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy; a randomized controlled trial. Ann Emerg Med 2008;52:22-9.

 2009 Fitzgerald Health Education Associates, Inc.

ort the basics
ORT: The Basics
  • Use an appropriate fluid
  • Estimate fluid deficit
    • Ex: 5% dehydration in 15 kg child = estimated deficit of .05*15 = 750 cc
  • Begin at about 5 cc every 5 minutes; add 5 cc/feed as tolerated
  • Goal: Replace 10 cc/kg in first hour and entire deficit in 4 hours

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ng therapy
NG therapy
  • Effective
  • Cheaper
    • Less supplies, nursing time
    • Estimated about 20% less than IV
    • Labs largely unnecessary
        • Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002;109:566-72.
  • Despite this, it really hasn’t entered mainstream PEM practice

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key points for managing vomiting and diarrhea in children
Key Points for Managing Vomiting and Diarrhea in Children
  • Most children are not clinically dehydrated and do not require a PO challenge prior to discharge
  • ORT with appropriate fluid is preferred initial therapy
  • Rehydration should be performed rapidly (over < 4 hours)

Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

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key points for managing vomiting and diarrhea in children89
Key Points for Managing Vomiting and Diarrhea in Children
  • Once started, rehydration is continued in the ED and then continued at home by the parents
  • Successful ORT involves

Rehydration

Maintenance and prevention of dehydration

Realimentation

Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

 2009 Fitzgerald Health Education Associates, Inc.

key points for managing vomiting and diarrhea in children90
Key Points for Managing Vomiting and Diarrhea in Children
  • Laboratory testing seldom necessary
  • Medications usually not necessary
  • Following rehydration, rapid realimentation with age-appropriate unrestricted diet
    • Dilution of formula and milk restriction is not necessary

Modified from Hostetler MA. Gastroenteritis: An evidence-based approach to typical vomiting diarrhea and dehydration. Pediatric Emergency Medicine Practice. 2004;5:1-20.

 2009 Fitzgerald Health Education Associates, Inc.

pop quiz
Pop Quiz
  • What is the easiest way for me to get the nurse mad at me (for at least the rest of the shift, maybe longer?

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 2009 Fitzgerald Health Education Associates, Inc.

answer
Answer
  • Ask for an IV to be placed on a sick child.

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

barriers to iv access
Barriers to IV Access

Experience

Not all that common, even in busy ER

Technically difficult

Anxious parents

Staff

Need additional help, frequently not available

Host

Tired

Small

Cranky

Dehydrated

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

traditional iv access in children
Traditional IV Access in Children
  • Average time for nurse (and staff) is 20 minutes
  • Average attempts ranges from two to four per STAFF, frequently abandoned because of lack of access (for equivocal sticks)

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

some new and not so new toys
Some New (and not so new) toys
  • Vein illumination
  • Vein location
    • Ultrasound
    • Intravenous device
  • Intra-osseous
  • Subcutaneous hydration

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

vein illumination
Vein Illumination

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the vein viewer
The Vein Viewer

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in development at georgia tech
In Development at Georgia Tech

 2009 Fitzgerald Health Education Associates, Inc.

ultrasound view of vein artery
Ultrasound View of Vein, Artery

 2009 Fitzgerald Health Education Associates, Inc.

ultrasound machines
Ultrasound Machines

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vein entry indicator device veid
Vein Entry Indicator Device (VEID)
  • Attaches to the female end of standard catheter; Emits a “beep” when the vein is entered; Anesthesiologist study
    • No difference for easy veins
    • Intermediate veins (barely visible or palpable)
      • 6.4 vs 46.1 seconds, (VEID vs No VEID)
    • Difficult veins (neither visible nor palpable)
      • 22.2 vs. 97.1 seconds (VEID vs No VEID)
    • 1st attempt success (intermediate + difficult)
      • 89.7 (VEID) vs. 23.3 (no VEID)
    • `

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

101

slide104
Note that the 5 mm mark is NOT visible above the skin

Size matters!

Note that the 5 mm mark is NOT visible above the skin

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 2009 Fitzgerald Health Education Associates, Inc.

the right site
The Right Site

Site selection is dependent upon:

Absence of contraindications

Accessibility of the site

Ability to monitor and secure the site

Desired flow rates

Policy/Protocol specifications

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slide106
EZ-IO PD 15 mm Needle Set

5 mm mark

15 gauge

EZ-IO AD 25 mm Needle Set

EZ-IO LD 45 mm Needle Set

Length and color are the only differences between Needle Sets

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T430 RevA

intraosseous usage and pain
Intraosseous usage and pain

Insertion pain is specific,

local and of short duration

Infusion pain is general,

diffuse and protracted

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prepare equipment
Prepare Equipment

Inspect needle cartridge or packaging for damage and sterility (verify seal)

Open cartridge and attach driver to needle set (leave cap on needle until ready to insert)

Open EZ-Connect and prime w/saline (or lidocaine for conscious patients)

Leave syringe attached to EZ-Connect

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T430 RevA

slide109
DO NOT USE EXCESSIVE FORCE

Simply RELEASE the triggerwhen you feel the “POP” or “GIVE” to avoid possible recoil on 3-39 Kg patients

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T430 RevA

slide110
Any medication approved for peripheral IV injection

IO and IV doses are the same

Follow each med administration with 3-5ml fluid flush

Lab Testing:

> Draw 3-10ml for waste

> Aspirate IO blood for standardized labs

> May use heparinized syringe

 2009 Fitzgerald Health Education Associates, Inc.

slide111
 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

contraindications for ez io access
Contraindications for EZ-IO Access

Fracture (targeted bone)Previous orthopedic procedures near insertion site

Prosthetic Limb or joint

IO within past 24 hours (targeted bone)

Infection at the insertion site

Inability to locate landmarks or excessive tissue

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

T430 RevA

subcutaneous hydration
Subcutaneous Hydration
  • Old concept from the 1940s
  • Augmented with hyaluronidase
    • Previously animal product
    • Human recombinant product now available
      • Hylenex (Baxter, remember I have an affiliation with them)

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 2009 Fitzgerald Health Education Associates, Inc.

current treatment options intravenous fluid therapy ivft
Current Treatment Options:Intravenous Fluid Therapy (IVFT)
  • Treatment of choice for severely dehydrated child or those who cannot tolerate/take ORT
  • Immediate onset; can follow with ORT
  • Challenges
    • Intravenous access can be difficult and time consuming
    • Multiple attempts are often needed
    • Painful to child
    • Upsetting to parents
    • Consumes resources (staff, time, equipment)
    • May delay treatment and increase risks

 2009 Fitzgerald Health Education Associates, Inc.

infuse pediatric hydration study rehydration efficacy
Infuse Pediatric Hydration Study:Rehydration Efficacy
  • 51 patients, mean age 1.9 years
    • mild-moderate dehydration
    • admitted to hospital emergency departments
  • Inclusion criteria
    • Age 2 months to 10 years
    • Body weight <42 kgs
    • Need for parental fluids because of failed ORT or failed IV attempts
    • 1-5 points on dehydration scale
          • Allen CH, Et a. Subcutaneous hydration in children using recombinant Human hyaluronidase: Safety and ease of use. American College of Emergency Physicians, 2008.

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infuse pediatric hydration study rehydration efficacy116
Infuse Pediatric Hydration Study:Rehydration Efficacy
  • Exclusion criteria
    • Severe dehydration/shock
    • Substantial rehydration immediately prior to enrollment (ORT or IVFT)
    • Known hyponatremia, hypernatremia, or hypokalemia
    • Known hypersensitivity to hyaluronidase
          • Allen CH, Et a. Subcutaneous hydration in children using recombinant Human hyaluronidase: Safety and ease of use. American College of Emergency Physicians, 2008.

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infuse pediatric hydration study rehydration efficacy n 51
INFUSE Pediatric hydration Study:Rehydration Efficacy (N=51)

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infuse pediatric hydration study rehydration efficacy n 51118
INFUSE Pediatric hydration Study:Rehydration Efficacy (N=51)

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infuse pediatric hydration study other findings
INFUSE Pediatric Hydration Study:Other Findings
  • Baseline Gorelick dehydration score
    • Baseline=3.5 ±1.2
    • End of treatment = .5 ± 0.9
  • Catheter placement
    • 1st attempt successful 86%
    • 2nd attempt successful 12%
    • 1 patient required 3 attempts
        • All patients achieved successful placement of catheter on each attempt however they were kids and catheters dislodged and had to be replaced
  • 2 minutes = median time to initiate fluid therapy
  • No patient required change of infusion site

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moa subcutaneous hydration
MOA: Subcutaneous hydration
  • Subcutaneous hydration (hypodermoclysis) has been an alternative option to the traditional intravenous route for over 50 years.
  • Hydrostatic forces allow the subcutaneous administration of fluids via diffusion and perfusion.
  • Comparisons of subcutaneous fluid administration with intravenous fluid administration have found no significant differences in electrolyte measurements or osmolalities.

1 Barton, R., Fuller, & Dudley, N. (2004) Using subcutaneous fluids to rehydrate older people:current practices and future challenges. Q J Med 2004; 97:765–768.

2 Frisoli, A., de Paula, A., Feldman, D., & Nasri, F. (2000) Subcutaneous hydration by hypodermoclysis Drugs & Aging 16 (4) 313-319.

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advantages and disadvantages of subcutaneous fluid administration
Advantages and disadvantages of subcutaneous fluid administration

Adapted from Khan, M., Younger, G., Promoting safe administration of subcutaneous infusions. Nursing Standard, 2007, 21(31), page 51, table 1

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contraindications for subcutaneous infusion
Contraindications for subcutaneous infusion
  • Generalized edema or poor peripheral circulation
  • Bleeding or coagulation disorders
  • Should not be used when fluids must be administered rapidly and in large amounts (shock, severe dehydration)
  • Signs of infection or broken skin at infusion sites
  • Not suitable for administration of colloid or macromolecular fluids, blood or total parenteral nutrition.

Adapted from Khan, M., Younger, G., Promoting safe administration of subcutaneous infusions. Nursing Standard, 2007, 21(31), 52, table 2

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

mechanism of action of hyaluronidase
Mechanism of action of hyaluronidase
  • Hyaluronidase is a spreading or diffusing substance that modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid
  • The administration of hyaluronidase temporarily decreases the viscosity of the cellular cement and promotes diffusion of injected fluids, thus facilitating their absorption
  • Hyaluronidase causes rapid spreading, provided local interstitial pressure is adequate to furnish the necessary mechanical impulse

Reference: hylenex PI

 2009 Fitzgerald Health Education Associates, Inc.

infuse lr representative subject baseline and mid infusion
INFUSE-LR: representative subject: baseline and mid-infusion

Control

hylenex (rHuPH20)

Baseline

Baseline

200 cc

200 cc

Thomas, JR, Yocum, RC, Haller, MF, von Gunten, CF (2007). Assessing the role of human recombinant hylauronidase in gravity-driven subcutaneous hydration: The INFUSE-LR study. Journal of Palliative Medicine, 10 (6), 1312-1320. (Figure 3)

infuse lr representative subject end infusion and return to baseline circumference
INFUSE-LR: representative subject: end-infusion and return to baseline circumference

Control

hylenex rHuPH20

hylenex (rHuPH20)

400 cc

400 cc

Resolution

Resolution

Thomas JR, et al. hylenex recombinant hyaluronidase human injection dose comparison study of subcutaneous hydration: The Infuse-LR Study. Poster presented at: The American Academy of Hospice and Palliative Medicine (AAHPM), February 17, 2007, Salt Lake City, Utah.

hylenex recombinant for subcutaneous administrationsite selection
hylenex recombinant for subcutaneous administrationsite selection
  • Select an insertion site with adequate subcutaneous tissue
  • In adults, sites may include: supraclavicular area, anterior chest wall, lower abdomen, outer aspects of arms and thigh
  • Avoid sites that are:
    • Scarred / bruised
    • Contain areas of skin breakdown
    • Edematous
    • Hard, painful, or infected

Adapted from: Infusion Nurses Society. Policies and Procedures for Infusion Nursing. 3rd ed. Norwood, MA: Infusion Nurses Society; 2006 page 167.

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fluid selection for sq infusion
Fluid Selection for SQ Infusion

For infants and children < 3 years old, the volume of a single clysis should be limited to 200 mL; for premature infants or during the neonatal period, the daily dosage of the clysis should not exceed 25 mL/kg of body weight. The rate of administration should not be greater than 2 mL/minute

 2009 Fitzgerald Health Education Associates, Inc.

slide129
Meanwhile, back to our office

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slide130
Your next patient is also 6 months old and has a fever. The child hasn’t been feeding normally and mom states the baby “feels cool.” Past history is unremarkable; parents have “declined” immunizations for fear of autism.

 2009 Fitzgerald Health Education Associates, Inc.

slide131
On exam, the baby has a temp of 97.00F, pulse is 180. The child is lethargic and has a capillary refill of 4 seconds. He is offered a bottle but wants nothing to do with it. You are concerned about SBI and refer to ED.

An hour later, the ED physician calls to tell you that the child has purulent CSF.

 2009 Fitzgerald Health Education Associates, Inc.

cns defenses
CNS Defenses
  • Skull
  • Blood-brain barrier
    • Tight junctions between the cells in the cerebral vasculature
  • Vertebrae and dura matter
    • Protect from contiguous area infection

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routes of entry cns infection
Routes of Entry: CNS Infection
  • Direct CNS Penetration
    • Trauma
    • Surgery
  • Migration from neighboring site
    • Mastoiditis
  • Hematogenous spread from other location (including distant)

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slide134
Which of the following has had the greatest impact on the decrease in cases of bacterial meningitis in children in the past two decades?
  • Haemophilus influenzae type B vaccine
  • Heptavalent pneumococcal vaccine
  • Varicella vaccine
  • Meningococcal vaccine
  • Improved hand-washing for fear of MRSA

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median age of meningitis
Median Age of Meningitis
  • 1986 = 15 months
  • 1986, Haemophilus influenzae vaccine introduced
  • 1995, median age = 25 years
  • We fearmeningitis in children
  • We seemeningitis is adults

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meningitis causative organisms
Meningitis: Causative Organisms

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epidemiology of meningitis in children
Epidemiology of Meningitis in Children

2001-2004

2001-2006

Mongelluzzo, et al. JAMA 2008;299:2048-55

Nigrovic, et al. Acad Emer Med 2008;15:522-28

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clinical manifestations of meningitis 1954
Clinical Manifestations of Meningitis, 1954

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meningitis signs and symptoms
Meningitis: Signs and Symptoms

Fleisher GR, et al, Textbook of Pediatric Emergency Medicine, 2006 (page 791)

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viral vs bacterial meningitis signs and symptoms
Viral vs Bacterial Meningitis: Signs and Symptoms

Viral3

Bacterial1-3

  • Confusion and combativeness
  • Lethargy
  • Kernig/Brudzinski signs
  • Rigid arching of the back
  • Seizures
  • Loss of consciousness

• Alert and oriented

Headache

Low-grade fever

Stiff neck

Photophobia

Vomiting

Rash1-3

1. Ross GH, et al. In: Pharmacotherapy—A Pathophysiologic Approach. 2002:1831; 2. McGee ZA, Baringer JR. In: Principles and Practice of Infectious Diseases. 1990:741; 3. Farley JA, et al. In: Pathophysiology: The Biologic Basis for Disease in Adults and Children. 1994:587.

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physical examination
Physical Examination
  • Vitals
  • Neuro exam
  • Skin exam
  • Kernig & Brudzinski
    • Described in 1884, advanced bacterial or tuberculous meningitis
  • Nucchal rigidity

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brudzinski sign
Brudzinski Sign
  • Positive in 3/66 patients with meningitis
    • Sensitivity 4.5%
  • Negative in 162/170 patients without meningitis
    • Specificity 95%
  • Positive PV = 27%
  • Negative PV = 72%

Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

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kernig s sign
Kernig’s Sign
  • Positive in 3/66 patients with meningitis
    • Sensitivity 5%
  • Negative in 163/171 of 171 pt without meningitis
    • Specificity 95%
  • PPV = 27%
  • NPV = 72%

Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

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nuchal rigidity
Nuchal Rigidity
  • Positive in 24/80 patients with meningitis
    • Sensitivity 30%
  • Negative in 148/217 patients without meningitis;
    • specificity 68%
  • 24 of 93 patients with nuchal rigidity had meningitis,
    • PPV = 26%
  • 148 of 204 patients without nuchal rigidity did not have meningitis
    • NPV = 73%

Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. CID 2002;35:46-52.

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ct scan before lp
CT SCAN BEFORE LP?
  • New onset seizures
  • Immunocompromised patients
  • Moderate to severe impairments of consciousness
  • Suspicious for space occupying lesions
    • Seizures, papilledema
  • Focal neurologic abnormalities

Van de Beek, et al. NEJM 2006;354-44-53.

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successful pediatric lp
Successful Pediatric LP?
  • 1459 pediatric lumbar punctures
    • Traumatic = > 10,000 rbc/mm3,
    • Unsuccessful = failed initial attempt
  • Predictive of Failure
    • Lack of providor experience
    • Inadequate/no anesthesia
    • Pt movement
    • Failure to remove stylet after through dermis
            • Nibrovic, et al. Ann Emerg Med 2007;49:762-71.

Family member presence did not affect success rates

            • Nibrovic, et al. Pediatrics, 2007;120:e777-82.

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ultrasound assisted lumbar puncture
Ultrasound Assisted Lumbar Puncture
  • Adults: 22 normal, 24 ultrasound
    • 6/22 failed with traditional landmarks
    • 1/24 failed with ultrasound
    • In obese patients,
      • 4/7 traditional attempts failed
      • 0/5 ultrasound assisted attempts failed
            • Nomura, et al. J Ultrasound Med, 2007;26:1341-8.
  • Children < 60 days old (n= 43)
    • 80% successful without U/S
    • 100% successful with U/S
          • Gorn, Abstracts from SAEM 2008 (286)

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typical cerebrospinal fluid findings bacterial infection
Typical Cerebrospinal Fluid Findings: Bacterial Infection

Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

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typical cerebrospinal fluid findings viral infection
Typical Cerebrospinal Fluid Findings: Viral Infection

Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

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typical cerebrospinal fluid findings partially treated bacterial infection
Typical Cerebrospinal Fluid Findings: Partially treated Bacterial Infection

Modified from Sabella C. in Intensive Review of Pediatrics, 2006, p 407.

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predictors of bacterial meningitis when gram stain is negative or unavailable
Predictors of Bacterial Meningitis when gram stain is negative or unavailable

Bonsu, et al. Acad Emerg Med, 2008;15:437-4.

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meningitis treatment 1873
Meningitis: Treatment: 1873

“The treatment of meningitis ought to be very decisive. We should apply, early in the disease, two, four, or six leeches at the base of the maxilla; the application of refrigerant compresses to the head, the administration of calomel and other purgatives, and finally the application of several blisters to the legs or arms , should form the basis of the treatment”

Copeman E., The Cerebral Affections of Infancy, 1873 (p 88).

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slide156
A 5 year-old male presents to the emergency department with complaints of fever, stiff neck, and photophobia. Physical examination remarkable for temp 103.0, irritability, nuchal rigidity, and a purpuric rash on the extremities.

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slide157
Respiratory distress develops and the patient is intubated without difficulty. He is transferred to the ICU with droplet precautions and all healthcare workers don masks and gowns. Lumbar puncture reveals gram negative intracellular diplococci consistent with N. meningitidis.

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which of the health care workers require antibiotic prophylaxis
Which of the health care workers require antibiotic prophylaxis?

A. All staff present in the emergency department and ICU

B. All staff who examined the patient in the ICU and ER

C. The physician who intubated the patient in the emergency room

D. Prophylaxis is not required for any health care worker

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correct answer is c
Correct Answer is C
  • Person to person transmission occurs via the respiratory route
  • Routine prophylaxis of health care workers is not required if droplet precautions are observed
  • Always wear a mask with face shield when you intubate febrile patients
    • For that matter, Always wear a mask/shield

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neisseria meningitidis
Neisseria meningitidis

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clinically significant n meningitidis serogroups
Clinically Significant N meningitidis Serogroups

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1. Granoff DM, et al. In: Vaccines. 2004:959.

fatalities from meningococcal disease in the us 1997 2002
Fatalities From Meningococcal Disease in the US, 1997–2002

299

156

155

158

121

106

102

67

61

63

53

1. Centers for Disease Control and Prevention (CDC). National Vital Statistics Reports. 1999;47(19):52; 2. CDC. National Vital Statistics Reports. 2000;48(11):51; 3. CDC National Vital Statistics Reports. 2001;49(8):27; 4. CDC. National Vital Statistics Reports. 2002;50(15):28; 5. CDC. National Vital Statistics Reports. 2003;52(3):30; 6. CDC. National Vital Statistics Reports. 2004;53(5):29.

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common clinical presentations of meningococcemia
Common Clinical Presentations of Meningococcemia

Rash

Vascular damage

Disseminated intravascular coagulation

Multi-organ failure

Death can occur within 24 hours

Shock

5-20% of cases of meningococcal case

Up to 40% fatality rate

1. Rosenstein NE, et al. N Engl J Med. 2001;344:1378.

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common clinical presentations of meningococcal meningitis
Common Clinical Presentations of Meningococcal Meningitis

Flu like symptoms (fever, headache)

Stiff neck

Nausea

Altered mental status

Seizures

Represents about 50% of cases of meningitis

3-10% fatality rate

1. Rosenstein NE, et al. N Engl J Med. 2001;344:1378.

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morbidity in infants children and adolescents with meningococcal disease
Morbidity in Infants, Children, and Adolescents with Meningococcal Disease

*From 159 cases (19 years of age or younger) at 10 US children’s hospitals, Jan 1, 2001 to Mar 15, 2005

†From 146 surviving children during or after hospitalization

1. Kaplan SL, et al. Pediatrics. 2006;118:e979-e984.

late stage meningococcal infection in a 15 year old boy
Late-Stage Meningococcal Infection in a 15-Year-Old Boy

Reprinted with permission from Schoeller T, Schmutzhard E. N Engl J Med. 2001;34:1372.

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gangrene caused by n meningitidis infection
Gangrene Caused byN meningitidis Infection

 2009 Fitzgerald Health Education Associates, Inc.

Courtesy of R Rudoy, MD, Honolulu, Hawaii,

meningococcal disease incidence
Meningococcal Disease Incidence *

6

Male

Female

5

4

Incidence Rate (cases per100,000 population)

3

2

1

0

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

≥ 85

Age (years)

*In California, Georgia, Maryland, Tennessee, Connecticut, Minnesota, and Oregon, 1992–19961. Rosenstein NE, et al. J InfectDis. 1999;180:1894.

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most cases in adolescents and young adults are potentially vaccine preventable
Most Cases in Adolescents and Young Adults Are Potentially Vaccine-Preventable*

Potentially Vaccine-Preventable

65%

62%

41%

86%

70%

46%

72%

36%

*Serogroup distribution by age group, United States, 1999–2005; potentially vaccine-preventable was calculated assuming 100% efficacy using an A/C/Y/W-135 quadrivalent vaccine

1. CDC. Active Bacterial Core Surveillance (ABCs) Report. Neisseriameningitidis. 1999-2005.

Available at:. http://www.cdc.gov/ncidod/dbmd/abcs/reports.htm#reports

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impact of meningococcal vaccines in the us military
Monovalent (group C)

Bivalent(A/C)

Quadrivalent (A/C/Y/W-135)

Impact of Meningococcal Vaccines in the US Military

*Bars indicate hospitalization frequencies; line indicates rates

1. DeFraites RF. MSMR. 2000;6:2.

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disease risk for contacts of individuals with meningococcal disease
Disease Risk for Contacts of Individuals with Meningococcal disease

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corticosteroids and meningitis
Corticosteroids and Meningitis
  • In theory, steroids will inhibit or diminish the host inflammatory response to the debris from killed bacteria
    • Dog models support this
  • In turn, this may reduce
    • Increased ICP
    • Cerebral Edema
    • Altered cerebral blood flow
  • And hopefully, this will reduce CNS injury

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slide177
STEROIDS

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corticosteroids in meningitis
Corticosteroids in Meningitis?
  • Neonatal
    • Insufficient data though limited studies suggest no benefit on survival
  • Infants and Children
    • No effect on survival, length of hospital stay, or charges (Mongezzullo, 2008, Cochrane review (subgroup analysis, 2007)
      • 3rd study from Latin America which included 1/3 of cases from H. influenzae: no benefit on mortality

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corticosteroids and meningitis in children
Corticosteroids and meningitis in Children
  • Numerous studies have demonstrated decrease in hearing loss in children
    • Initially with H. influenzaebut subsequent studies have shown efficacy in S. pneumoniaemeningitis
  • Effects on other CNS damage and mortality are less dramatic
    • Trend towards beneficial but not statistically significant

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risks of corticosteroids
Risks of Corticosteroids
  • Decrease CNS penetration of some antibiotics, especially Vancomycin
    • Some advocate addition of rifampin until sensitivities (for cephalosporins) are available
  • Gastrointestinal bleeding
  • May mask infection related fever

 2009 Fitzgerald Health Education Associates, Inc.

aap red book 2006
AAP Red Book, 2006

Haemophilus influenzae Infection

“Dexamethasone may be beneficial for treatment of infants and children with HiB meningitis to diminish the risk of neurologic sequelae, including hearing loss, if given before or concurrently with the first dose of antimicrobial agent(s). There probably is no benefit if dexamethasone is given more than 1 hour after antimicrobial agent.”

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slide182
A 4-year old female who has a 3-day history of progressive earache and fever is hospitalized after becoming unresponsive. Medical history is otherwise unremarkable; she has no allergies and takes no medications.

 2009 Fitzgerald Health Education Associates, Inc.

slide183
On physical exam, her temperature is 103.0, pulse 170, bp 60/50, and respiratory rate 40. The patient is obtunded and has meningismus on examination. WBC is 25,000 with platelet count of 50,000 and 25% band forms.

Lumbar puncture is performed and reveals 2500 neutrophils, glucose of 20, and protein of 230 mg/dl.

Gram stain is shown on the next slide

 2009 Fitzgerald Health Education Associates, Inc.

best initial therapy is intravenous
Best initial therapy is (intravenous)
  • Penicillin + Vancomycin
  • Dexamethsone + Vancomycin
  • Dexamethasone + Vancomycin +cefotaxime
  • Dexamethasone + Ceftriaxone + Aminoglycoside
  • Chloramphenicol + Ampicillin

 2009 Fitzgerald Health Education Associates, Inc.

aap red book 2006187
AAP Red Book, 2006

Streptococcus pneumoniae Infection

“For infants and children 6 weeks of age and older, adjunctive therapy with dexamethasone may be considered after weighing the potential benefits and risks . . . Data are not sufficient to demonstrate a clear benefit in children. If used, dexamethasone should be given before or concurrently with first dose of antimicrobial.”

 2009 Fitzgerald Health Education Associates, Inc.

pneumococcal vaccine
Pneumococcal Vaccine
  • Model for success was conjugated HIB
  • 23 valent vaccine available since 1977 but ineffective in children younger than 2 years (polysaccharide)
  • Conjugate vaccine (PCV7) approved in 2000 and routine immunization began
    • Covered 7 serotypes + cross reactivity with two more, thereby covering 9 serogroups responsible for about 80% of invasive disease

 2009 Fitzgerald Health Education Associates, Inc.

pneumococcal vaccine189
Pneumococcal Vaccine
  • Marked decrease in pneumococcal disease
  • Still leading cause of bacterial meningitis in children
  • 50% of cases are “non-vaccine” serotypes
    • ?? Increasing antibiotic resistance in this subgroup (esp 19A)
        • (MMWR 2007;56:1077-80,
        • Ongkasuwan J et al . Pediatrics 2008;122:34-9.
  • Serotype “replacement” seen in otitis and this appears to be happening in meningitis

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delay in administering antibiotics
Delay in Administering Antibiotics
  • Frequent basis for action in malpractice suits, though data to support this are weak
  • Average time is to administration is between two and three hours
  • Concern for altering CSF findings if given before lumbar puncture performed (and the role of dexamethasone )
    • Since it is only clearly indicated for HIB, this shouldn’t be a concern in immunized children

 2009 Fitzgerald Health Education Associates, Inc.

fluid therapy
Fluid Therapy
  • Previous standard: restrict fluid to 2/3 maintenance to avoid SIADH
  • Cochrane meta-analysis review (2005) of 3 controlled studies
    • In sickest patients, those with maintenance fluids were less likely to develop spasticity, seizures, and neurologic deficits at 3 months
        • Extrapolation to other groups not feasible
          • Maconochie I, et al. Cochrane Database Syst Rev. 2005;(3)cd004786.

 2009 Fitzgerald Health Education Associates, Inc.

fluid therapy193
Fluid Therapy
  • My Conclusions
    • Isotonic fluids are the fluids of choice
    • Assess electrolytes frequently
    • Maintenance fluid if adequate to maintain blood pressure and urine output
    • Remember rule # 1—oxygen and glucose to the brain

 2009 Fitzgerald Health Education Associates, Inc.

future directions
Future Directions
  • Effective Group B (Neisseria) vaccine
    • Technically very difficult
    • New Zealand trials on going
    • Early studies suggest 73% efficacy with marked decrease in invasive disease
          • Kelly, et al. Am J Epidemiol2007;166:817-23
  • Increased serotypes in pneumococcal vaccine

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quick fire cases
“Quick Fire Cases”
  • A four-year old child is found unresponsive in the living room the morning after the parents had a party.
    • Exam:
      • cool, clammy, HR 80, rr 20
      • No signs of trauma
      • You get one test

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check the glucose
Rule # 1: The goal of emergency medicine is to ensure oxygen and glucose delivery to the brain.Check the glucose

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quick fire cases197
“Quick Fire Cases”
  • A four month-old child is presents to the office for lethargy and poor feeding. No other symptoms, past history unremarkable.

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slide198
On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count. What rhythm does the monitor show?

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 2009 Fitzgerald Health Education Associates, Inc.

supraventricular tachycardia
Supraventricular Tachycardia
  • History of
      • Irritability, poor feeding
  • Cardiac monitor
      • HR > 220 bpm, narrow QRS, R to R interval regular, no visible p waves

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treament priorities svt
Treament Priorities: SVT
  • Supplemental oxygen
  • Obtain IV access
    • IV or IO if necessary
  • Convert rhythm based on stability
    • Stable: vagal maneuvers or adenosine
      • Adenosine .1mg/kg (up to 6 mg); repeat at twice dose (up to 12 mg)
    • Unstable: synchronized cardioversion

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sinus tachycardia
Sinus Tachycardia
  • History of
      • fever, vomiting, diarrhea, hemorrhage
  • Cardiac monitor
      • HR < 220 bpm, narrow QRS, variable R to R interval, p waves present and upright

 2009 Fitzgerald Health Education Associates, Inc.

quick fire cases202
“Quick Fire Cases”
  • A four month-old child presents to your office for cough. Mother called for an appointment and said she would come in later “if the child didn’t get better.” She runs through the front door carrying her limp, pale child. Miraculously you get a monitor and an iv instantly.

 2009 Fitzgerald Health Education Associates, Inc.

slide203
The monitor shows the following rhythm.

What are your treatment priorities for this patient?

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

slide204
Patient’s heart rate improved to 70 beats/min with assisted ventilation.

Color, CRT and pulse quality improves.

After BVM, patient’s RR increases to 20 breaths/min, good chest rise

Rapid glucose check 100 mg/dL

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

conclusion
Conclusion

Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.

Management priorities for shock include airway management, oxygen and fluid resuscitation.

Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

rule number one
Rule Number One

Oxygen and Glucose to the Brain

 2009 Fitzgerald Health Education Associates, Inc.

slide207
A mother calls and states that her 6 week-old baby “stopped breathing” for “just a bit.” It was dark and she isn’t sure if she was “blue” or not. She calls to let you know she is on the way to the emergency room.

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

on arrival to the ed
On Arrival to the ED

Healthy appearing infant with a vigorous cry, normal vital signs, normal exam. Old records and office EMR reviewed; uncomplicated pregnancy, delivery, and newborn period, weight gain of 3 pounds thus far, no sick visits, no significant family or social history

 2008 Fitzgerald Health Education Associates, Inc.

 2009 Fitzgerald Health Education Associates, Inc.

apparent life threatening event
Apparent Life Threatening Event

“An episode that is frightening to the observer, that is characterized by some combination of apnea (centrally or occasionally obstructive), color change (usually cyanotic or pallid, but occasionally erythematous or plethoric), marked change in muscle tone (limpness), choking or gagging. In some cases, the observer feels that the infant has died”

(NIH Consensus development conference on infantile apnea and home monitoring. Pediatrics 1987;79:292-9).

 2009 Fitzgerald Health Education Associates, Inc.

 2008 Fitzgerald Health Education Associates, Inc.

similar appearing events that are not altes
Similar Appearing Events that are NOT ALTEs
  • Periodic breathing
    • Benign periodic pauses without changes
  • Apnea of infancy
    • Unexplained respiratory pauses lasting more than 20 seconds or less than 20 seconds if accompanied by pallor, cyanosis, bradycardia, or hypotonia
    • Term infants with no other problems

 2009 Fitzgerald Health Education Associates, Inc.

similar appearing events that are not altes211
Similar Appearing Events that are NOT ALTEs
  • Apnea of prematurity
    • Apnea lasting for 20 or more seconds
    • Accompanied by bradycardia, cyanosis, hypotonia, or other signs
    • Preterm, resolves by 37 weeks
  • SIDS

 2009 Fitzgerald Health Education Associates, Inc.

slide212
SIDS

“The sudden death of an infant under 1 year of age that remains unexplained after a thorough case investigation, including performance of an autopsy, examination of the death scene, and review of the clinical history”

Willinger M et al. Definining SIDS, Pediatr Pathol 1991;11:677-84.

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 2009 Fitzgerald Health Education Associates, Inc.

risk factors for sids
Winter Months

Young maternal age

Low birth weight

Poverty

Smoking

Drug use

Alcohol use

Male Gender

Prematurity

Single parenthood

Poor prenatal care

High parity

Multiple gestation

Prone/side sleeping position

Risk Factors for SIDS

Hunt, CE, Hauck FR. Sudden infant death syndrome; CMAJ 2006;20;174:1861-9.

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 2009 Fitzgerald Health Education Associates, Inc.

does breastfeeding reduce the risk of sids
Does Breastfeeding reduce the risk of SIDS?
  • 333 infants from Germany who died from SIDS and 998 age-matched controls
  • Breastfeeding at 2 weeks
    • 49.6% of cases, 82.9% of controls

 2009 Fitzgerald Health Education Associates, Inc.

slide215
FIGURE 1 Proportion of infants who were breastfed (both exclusively and partially) according to month of age for controls and cases

Vennemann, M.M. et al. Pediatrics 2009;123:e406-e410

Copyright ©2009 American Academy of Pediatrics

aap risk factors for alte
AAP Risk factors for ALTE
  • Previous cyanosis, apnea or ALTE
    • When in care of same person
  • Simultaneous or near simultaneous death of twin
  • Previous death of infants while in care of same unrelated person
  • Previous unexplained (or unexpected) death in sibling
  • Sibling who died when older than 6 months
  • Discovery of blood on infant’s nose or mouth in association with ALTE
    • Farrell PA, et al. SIDS, ALTE, and the use of home monitors. Pediatr Rev 2002;23:3.

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 2009 Fitzgerald Health Education Associates, Inc.

alte differential diagnosis
Cardiac

Gastrointestinal

Pulmonary

Infectious

Neurologic

Metabolic

Hematologic

Other

Trauma

ingestions

ALTE: Differential Diagnosis

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 2009 Fitzgerald Health Education Associates, Inc.

alte most common underlying diagnosis
ALTE: Most Common Underlying Diagnosis
  • Gastroesophageal Reflux (31%)
  • Seizure (11%)
  • Lower respiratory track infection (8%)
    • Pertussis, RSV
          • Kaji A, Gausche-Hill M. Managing infants after an apparent life threatening event. Emerg Med 2008; 15-19.

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alte history of present illness
Time & duration

Sleeping?

Feeding

Time of last feed

Type of feeding

What alerted caregiver there was a problem

Color change

Tone change

Resuscitative efforts

Recent illness

Change in behavior or activity

Sleeping conditions

ALTE: History of Present Illness*

*Adapted from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7)

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 2009 Fitzgerald Health Education Associates, Inc.

alte additional history
PMH

Similar episode

Monitoring

Prenatal course

Newborn course

Sick visits

H/o reflux

Social history

Caretakers

Smoking

medications

Medication

Prescription

OTC, Herbs, Supplements

Alternative

Family History

SIDS or other infant deaths

ALTE

Seizure

Illnesses in family (Seizures, cardiac, developmental delay, inborn errors)

ALTE: Additional History*

*Adapted from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7)

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alte ed workup
ALTE: ED Workup
  • Careful history
    • Most common components
      • Apnea
      • cyanosis
  • Careful physical examination
    • PE may be normal in the ED even in the setting of significant pathology

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alte diagnostic workup
ALTE: Diagnostic Workup
  • No evidence-based data on the ED workup of ALTE
  • No consensus on workup

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alte my ed workup
Chest xray

Literature reports ¼ abnormal

EKG

Cath Urinalysis

Basic chemistry

CBC

CRP

Other testing as dictated by pt

RSV

Pertussis

Influenza

Inborn errors of metabolism

Toxins (UDS)

ALTE: My ED workup

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alte disposition
ALTE: Disposition
  • No data on who can safely be discharged after ALTE
  • Observation in ED or admission should be considered
  • Even less clear what do to with patients with “marginal” history
  • Monitors change little if anything in this decision process

 2009 Fitzgerald Health Education Associates, Inc.

alte high risk
ALTE: High Risk
  • Age less than one month
  • Multiple episodes
  • Severe episodes
        • Claudis I, et al. Do all infants with apparent life-threatening events need to be admitted. Pediatrics 2007;119:267.

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alte okay to discharge if
ALTE: Okay to Discharge if?
  • Single brief, not severe, self-resolving episode
  • Evidence that the cause is non- progressive (e.g., GERD)
  • Infant appears well and has no co-morbidities
      • Fu LY, Moon RY. Apparent life-threatening events and the use of home monitors. Pediatr Rev 2007;28:203.

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alte sids and monitors
ALTE, SIDS, and Monitors
  • No data that monitoring prevents SIDS
  • AAP Consensus Statement, 2003

(Pediatrics, 2003;111:914-7.) http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/914)

“.. Monitors should not be prescribed to prevent SIDS”

“.. May be warranted for premature infants at high risk of apnea, bradycardia, and hypoxemia after discharge. . . Limited to 43 weeks PCA or until events stop. ..”

“parents should be advised that home monitoring has not been proven to prevent SIDS”

 2009 Fitzgerald Health Education Associates, Inc.

pitfalls to avoid alte
Appearance

Most look well

URI

RSV, pertussis

Repeat event

Why?

Tachypnea

May be acidotic

Minor trauma

What am I missing

Reflux

Monitors

Should not use to provide sense of “safety”

Pitfalls to AVOID: ALTE

Modified from DePiero AD. Apparent life-threatening events: An evidence-based approach. Pediatr Emerg Pract 2006,3(7

 2009 Fitzgerald Health Education Associates, Inc.

most frequent signs and symptoms of anaphylaxis
Most Frequent Signs and Symptoms of Anaphylaxis

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general descriptive definition anaphylaxis
General Descriptive Definition: Anaphylaxis

“Anaphylaxis is an acute, allergic systemic reaction, during which all or some of the following are present: urticaria/angioedema, upper airway obstruction, bronchospasm, and hypotension. In some cases, these manifestations may be accompanied by cardiovascular and/or gastrointestinal disturbances. Anaphylaxis can be fatal without evidence of cutaneous involvement.”

Adapted from Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. 1998.

 2009 Fitzgerald Health Education Associates, Inc.

causes of anaphylaxis
Foods:

Children: milk, eggs, wheat, soy

Adults: peanuts, tree nuts, fish, shellfish

Drugs:

antibiotics, NSAIDs, vaccines

Insect stings:

wasps, bees, fire ants

Latex

Idiopathic

Vaccines

Radiocontrast

Biologics

Rheumatologics, etc

Exercise

Causes of Anaphylaxis

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anaphylaxis the risk is increasing
Anaphylaxis: The Risk Is Increasing
  • The prevalence of peanut allergy has doubled in American children <5 years old in the past 5 years
    • The prevalence of food hypersensitivities is greatest during the first few years of life, affecting 6% of infants <3 years old
    • Food allergy remains a leading cause of anaphylaxis

Sampson HA. Update on food allergy. J Allergy Clin Immunol. 2004;113:805-819.

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fatal food induced anaphylaxis
Fatal Food-Induced Anaphylaxis

Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001;107:191-193.

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children may be different
Children may be different
  • Children present differently
  • Peds ED Study
    • 526 children with generalized allergic reactions; 57 with anaphylaxis
  • Respiratory symptoms most common
  • Cutaneous features present in only about 80% of patient

Arch Dis Child. Published Online First: 24 November 2005.

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diagnosing anaphylaxis
Diagnosing Anaphylaxis
  • Anaphylaxis may be difficult to diagnose, especially when patients present with
    • Bradycardia
    • Syncope

Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol. 1998;101(suppl):S464-S528. Sampson HA. Pediatrics. 2003;111:1601-1608.

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management of the acute anaphylactic event immediately
Management of the Acute Anaphylactic Event: Immediately
  • Place in recumbent position, feet elevated
  • Check airway and secure if necessary
  • Administer epinephrine
  • Initiate oxygen

Lieberman P. Annals Allergy Asthma Immunol. 2005;95:217.

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epinephrine the treatment of choice for anaphylaxis
Epinephrine: The Treatment of Choice for Anaphylaxis
  • Epinephrine is the treatment of choice for anaphylaxis
  • There is no absolute contraindication to epinephrine use in anaphylaxis

Sicherer S. J Respir Dis Pediatrician. 2003;5(5):191-198.

Simons FE. J Allergy Clin Immunol. 2004;113:837-844.

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time to demise
Time to Demise

35

Food Stings Drugs

30

25

20

15

10

5

0

<1 1-2 2.1-4.5 4.6-6.9 10-20 21-45 46st-99 100-214 >215

Minutes from First Exposure to First Arrest

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Pumphrey RSH. J Allergy Clin Immunol. 2003;112(2):451.

im vs sq epinephrine
IM vs SQ Epinephrine

Intramuscular Epinephrine (EpiPen®)

Subcutaneous Epinephrine

34 ± 14(5-120) minutes

p<0.05

5 10 15 20 25 30 35

Time to Cmax after Injection (minutes)

Simons. J Allergy Clin Immunol. 2004;113:838.

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myths regarding the administration of epinephrine
Myths Regarding the Administration of Epinephrine
  • Absolutely contraindicated in ischemic heart disease
  • Absolutely contraindicated in hypertension
  • Epinephrine reduces wheeze but has little effect on blood pressure
  • Other agents (e.g., antihistamines) should be be substituted in milder cases

 2009 Fitzgerald Health Education Associates, Inc.

slide241
Treatment of Anaphylaxis
  • Subsequent emergency care that may be necessary depending on response to epinephrine
  • Consider:
    • Placement in recumbent position
    • Establish airway
    • O2
    • IV fluids
  • Consider:
    • Epinephrine infusion
    • H1 and H2 Antihistamines
    • Inhaled bronchodilators
    • Corticosteroids
    • Glucagon
    • Vasopressors
    • Transport to emergency department or ICU

2005 Parameters. J Allergy Clin Immunol. 2005;115:s483.

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treatment of anaphylaxis
Treatment of Anaphylaxis
  • Repeat epinephrine if symptoms persist or increase after 10–15 minutes
  • Repeat antihistamine ± H2-blocker if symptoms persist
  • Observe for a minimum 4 hours
  • Discharge patient with an anaphylaxis protocol
    • Refer to allergist
  • Arrange follow-up care, provide EpiPen® or EpiPen® Jr Rx,and education
  • Office staff preparation

Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology.

J Allergy Clin Immunol. 1998;101(suppl):S464-S528.

 2009 Fitzgerald Health Education Associates, Inc.

epinephrine the treatment of choice for anaphylaxis243
Epinephrine: The Treatment of Choice for Anaphylaxis
  • Epinephrine is the treatment of choice for anaphylaxis
  • There is no absolute contraindication to epinephrine use in anaphylaxis

Sicherer S. J Respir Dis Pediatrician. 2003;5(5):191-198.

Simons FE. J Allergy Clin Immunol. 2004;113:837-844.

 2009 Fitzgerald Health Education Associates, Inc.

slide244
Epinephrine Is the Drug of Choice; Yet Underutilized
  • Only 49% of 79 children diagnosed in ED in Australia received EpiPen®
  • Only 32% of Canadian children with episodes were given EpiPen®
  • When patients know the antigen they are less likely to keep kit with them

J Allergy Clin Immunol. 2002:109,s181.

Allergy Clin Immun Int. 2003:18s.

 2009 Fitzgerald Health Education Associates, Inc.

take home message
Take home message
  • Anaphylaxis is real
  • Anaphylaxis is fatal
  • Anaphylaxis cannot always be prevented, but it can be treated
  • Health care providers can do better
  • Patients and parents can do better

 2009 Fitzgerald Health Education Associates, Inc.

slide246
So what happens when a patient gets exposed to an antigen in an unsuspecting manner, in an unsuspecting place, with an unprepared caregiver?

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categories of respiratory dysfunction
Categories of Respiratory Dysfunction
  • Respiratory distress:
    • Increased work of breathing to maintain adequate oxygenation and ventilation
  • Respiratory failure:
    • Compensatory mechanisms fail, inadequate oxygenation and/or ventilation
  • Respiratory arrest:
    • Absence of breathing

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etiology of respiratory problems
Etiology of Respiratory Problems

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hypotension and shock
Hypotension and Shock
  • Hypotension
    • Decreased systolic blood pressure
  • Shock
    • Inadequate tissue perfusion
    • Inadequate tissue oxygen delivery
    • Shock can occur with normal, low, or increased systolic blood pressure

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two types of shock
Two Types of Shock

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causes of pediatric out of hospital cardiopulmonary arrest
Causes of Pediatric Out-of-Hospital Cardiopulmonary Arrest* (%)

Table modified and compiled from Table 2 of Brown L. Pediatric Out-of-hospital cardiopulmonary arrest. . Pediatric Emergency Practice, September 2005

2008 Fitzgerald Health Education Associates, Inc.

initial cardiac rhythm identified in children with out of hospital cardiopulmonary arrest
Initial Cardiac Rhythm Identified in Children with Out-of-Hospital Cardiopulmonary Arrest
potential causes of pediatric out of hospital cardiopulmonary arrest
Anaphylaxis

Asthma

Auto vs. Pedestrian

Brain tumor

Burns

Cancer

Carbon monoxide

Cardiomyopathy

Complications of prematurity

Congenital heart disease

Dehydration

Drowning or near-drowning

Dysrhythmia

Electrocution

Foreign body aspiration

Heat stroke

Inborn errors of metabolism

Ingestions

Meningitis

Motor vehicle accidents

Myocarditis

Non-accidental trauma

Sepsis

Penetrating trauma

Pneumonia

SIDS

Status epilepticus

Traumatic Asphyxiation

Potential Causes of Pediatric Out-of-hospital Cardiopulmonary Arrest

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outcome of ventricular fibrillation in children
Outcome of Ventricular Fibrillation in Children
  • If recognized and treated promptly, survival may be up to 35% of the survivors, neurologic outcome may be favorable in the majority
      • Skewed in that this is a hospital study

Samson RA et AL. N Engl J Med 2006;354:2328-39.

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 2009 Fitzgerald Health Education Associates, Inc.

outcome of ventricular fibrillation in children255
Outcome of Ventricular Fibrillation in Children
  • Ventricular tachycardia or Ventricular fibrillation has a more favorable prognosis if it is the presenting rhythm than if it develops during the course of CPR

Samson RA et AL. N Engl J Med 2006;354:2328-39.

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 2009 Fitzgerald Health Education Associates, Inc.

key points for out of hospital cardiopulmonary arrest
Key Points for Out-of-Hospital Cardiopulmonary Arrest
  • Pediatric out-of-hospital cardiopulmonary arrest is uncommon
  • The most common initial rhythm is asystole
  • Most cases of cardiopulmonary arrest occur at home

Brown, L, Pediatric Emergency Practice, 9-2005

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key points for out of hospital cardiopulmonary arrest257
Key Points for Out-of-Hospital Cardiopulmonary Arrest
  • The majority of cases of pediatric cardiopulmonary arrest occur in the first year
  • Although AEDs are now available for children, PAD programs are unlikely to be effective

Brown, L, Pediatric Emergency Practice, 9-2005

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should family be present during invasive procedures resuscitation
Should family be present during invasive procedures/ resuscitation?

1200 physicians; 83% reported participation in resuscitations with family present

50% believed it helpful for the family

93% would allow families present

70% thought this would be stressful for residents though 80% thought residents should be trained in this

Gold KJ, Forenflow DW, Schwenk TL, Batton SL. Physician experieince with family presence during CPR in children. PediatrCrit Care Med 2006;7:428-33.

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end of presentation
End of Presentation!

Thank you for your time and attention.

John D. Rowlett, MD, FAAP

Website: www.fhea.com E-mail: john@fhea.com

 2009 Fitzgerald Health Education Associates, Inc.

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