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Pediatric Emergencies

Pediatric Emergencies

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Pediatric Emergencies

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

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. The Pediatric Assessment Triangle* *Pediatric Education for Prehospital Professionals. Developed by the American Academy of Pediatrics  2009 Fitzgerald Health Education Associates, Inc.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. Vital signs by Age  2009 Fitzgerald Health Education Associates, Inc.

  12. 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.

  13. 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.

  14. 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.

  15. “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.

  16. “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.

  17. Control of body temperature • Hypothalamus • Body’s “Thermostat” • Maintenance of “set point” • Autonomic • Endocrine • Behavioral  2009 Fitzgerald Health Education Associates, Inc.

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  23. 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.

  24. 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.

  25. 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

  26. Fever:defined as a rectal temperature greater than or equal to 100.40 Fahrenheit (38o C)  2009 Fitzgerald Health Education Associates, Inc.

  27. Antipyretic pharmacology  2009 Fitzgerald Health Education Associates, Inc.

  28. 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.

  29. Avner PIR

  30. 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.

  31. 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.

  32. 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.

  33. “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.

  34. 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.

  35. 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.

  36. 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.

  37. 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.

  38. 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.

  39. 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.

  40. 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.

  41. 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.

  42. 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.

  43. 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.

  44. 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.

  45. 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.

  46. 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.

  47. 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.

  48. 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.

  49. 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.

  50. Urinary Tract Infections