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Pediatric Emergencies
the 411 for ED Residents
Amy Buoncristiani, MDContra Costa Regional Medical CenterDepartment of Emergency Medicine
Topics Covered
• Upper Airway Emergencies
• Fever without Source
• Asthma
Pediatric Upper Airway Emergencies
DDx of stridor and fever: • Croup• Tracheitis• Retropharyngeal abscess• Epiglottitis
Croup aka viral laryngotracheobronchitis
Sx: Rhinorrhea, fever, barking cough, stridor, tachypnea, retractions, hypoxia
Dx: Clinical plus/minus lateral soft tissue neck to exclude epiglottitis in severe stridor
Path: parainfluenza mostly ; others adeno, influenza, rsv, mycoplasma
Peak: fall and winter
Age: 6 mos – 4 years
Evidence Based Croup Management
• Dexamethasone 0.6 mg/kg po (iv form) or IM x 1– Give to any severity of Croup– Reduces symptoms in 6 hrs– Fewer visits/hospitalizations– Decreased ED time and decreased use of Epi
• Racemic Epinephrine– For stridor at rest or severe Upper Airway obstxn– Dose 0.5 mL (0.05-0.1 ml/kg) – Observe 3-4 hrs and can d/c if no stridor at rest, good MS
*Cool Mist not considered helpful, but used for comfort
Tracheitis - watch for it!
• Due to Hib immunization and steroid treatment, tracheitis now exceeds epiglottitis and croup as the most common life-threatening infection of the upper respiratory tract in children
• Mortality high• Staph aureus most common
Tracheitis
• Sx: – Has features of epiglottitis and viral croup– Starts with viral upper respiratory symptoms, low
grade F, cough– Then rapid onset of high fever, respiratory
distress, variable stridor, and appears toxic. – Unlike patients with epiglottitis, these children
typically have a cough, are comfortable lying flat, and do not drool
TracheitisManagement
• Airway support • Contact ENT for endoscopic diagnosis and
intubation• Bug Juice: Vancomycin, Ampicillin-Sulbactam• Contact CHO ICU for transfer/transport
Retropharyngeal Infections:Abscess and Cellulitis
RP Space is potential space between pharynx and prevertebral fascia
Etiology: spread of infection from pharyngitis, tonsillitis, sinusitis, or cervical lymphadenitis
Age: < 6 years, peak age 3
RP Infections
Sx: feverneck and throat pain neck swellingdecreased movement of neck
(extension) drooling
decreased po intakeStridor and resp distress less common
RPI Management
Dx: CT of the neck soft tissues the standard if your attending insists, you may wind up ordering first a:lateral neck film that may (or may not)
show expansion of the prevertebral space = > 1 vertebral body width>7 mm at C2, and > 14 mm at C7
Tx: Broad Spectrum antibioticstransfer to CHO
Epiglottitis
Epidemiology: Rapid decline since 1990 Rise in Adults since that time Most likely caused by Staph and Strep now H. Influenza epiglottitis still rarely occurs in
vaccinated children
Epiglottitis Dx & Management
• Suspect in child with rapid progression of fever, stridor, drooling, throat pain, but young children may have more subtle course
• Lateral Neck film may show ‘thumbprint’• Contact ENT to take child to OR for direct
laryngoscopy and intubation• Broad Spectrum Antibiotics, no good evidence
for other Rx. Some try steroids, racemic Epi while considering DDx
Lateral Soft Tissue Neck ImagingEpiglottis
Normal Abby Normal
PediatricFever Management in ED
Initial and Basic Care:• Children under 36 months require a rectal
temperature• Triage nurse usually gives child given tylenol (15
mg/kg) or motrin (10mg/kg)• Ask nurse to start Oral Rehydration Therapy
(ORT) which is pedialyte administered by caregiver 5 ml every 5 min by syringe and recording this on sheet for Staff to review
Febrile Child Triage
• Infants < 3 months with – either a history of T> 100.4 by caregiver or – nurse identified T>100.4 or 38– are made a Triage Level 1 to facilitate physician
exam and ordering work up in under 30 minutes
• Any febrile child who is toxic – Triage Level 1 and needs to be seen by physician
within 10 minutes of triage
Fever Without a Source (FWS)
• Source not found in 20% febrile kids
• But, several percent have a Serious Bacterial Infection (SBI) or UTI
• Guidelines are AGE based due to differences in pathogens and immune function
Sources of Fever• Any obvious site of infection: – Pneumonia– bacterial diarrhea– cellulitis– overt otitis media (>1 month old)– abscess– clinical croup– Varicella
Sources of Fever
Viral sources– A positive rapid RSV, Influenza, Parainfluenza,
adenovirus test places child at much lower risk of SBI/UTI
– Still Strongly consider check for UTI in F < 24 mo and UCB < 6 mos
Despite positive test, or ‘source’:
**ALL NEONATES < 1 MONTH GET FULL SEPSIS WORKUP**
Pneumococcal Vaccine and Our Approach to Fever
• Heptavalent PNC Vaccine = Prevnar or PCV-7 added to immunization schedule in August 2000
• Infants receive at 2, 4, 6 and 12 – 15 mo
• Efficacy against IPD from vaccine serotypes is 97.3 % and from all types 89.1%
Pneumococcal Vaccine and Our New Approach to Fever
• Since IPD is responsible for majority of non UTI Serious Bacterial Infections in infants > 3 mo, the risk of SBI in vaccinated children is <1 % regardless of WBC count
– (translation: non toxic child over 3 months, don’t absolutely need CBC anymore!)
• IPD SBI’s still exist, so CLOSE FOLLOW UP
• ***Vaccine doesn’t change management of diagnosing UTI***
Facts about Fever in Neonates< 1 month old
• Incidence SBI/UTI = 4-12 %• UTI associated with up to 20 % bacteremia• Clinical exam unreliable • Even if viral test positive, UTI, or other
infection found, need to still do full sepsis work up because of high rate and risk of bacteremia and meningitis from source of infection, and high rate of concomitant SBI in virally infected neonates
FWS Management< 1 month
All get:• Cath UA and Culture• CBC, Blood Culture x 1• Lumbar Puncture for– Cell count, Gram Stain, Culture, HSV PCR if
pleiocytosis or infant ill appearing• IV Amp and Gent• Transfer to John Muir WC (CCHP-MediCal) or
CHO (straight MediCal) and depending on home town
FWS Epidemiology in 1 – 3 month old T> 38C, 100.4F
• UTI Prevalence High: UCBoys>girls>Cboys
• CBC helps place infant at low or high risk
• Rate of SBI (not UTI) in – Low risk infants = WBC between 5 and 15K= 1-3%– High risk infants WBC>15, <5 =20 %!
FWS Management in 1 – 3 month old T> 38
• Cath UA and Culture• CBC • Blood Culture• IM or IV Ceftriaxone if WBC >15, strongly
consider if <5• LP if irritable, lethargic, and strongly consider if
antibiotics are to be given.• Follow up in 24 hours, admit if unreliable
Risk Stratifying for FWS 3 – 36 months Unvaccinated = < 2 doses Prevnar
• Rate of Bacteremia 2.6 – 6 % in unvaccinated child regardless of WBC
• But, 2 large RCT’s tell us that WBC can be used to stratify into high and low risk groups when T>39.5– WBC > 15K Rate Bacteremia = 10% – WBC < 15 Rate Bacteremia = 1%
Pneumococcal Vaccinated 3-36 mo with fever > 39.5
A child is considered vaccinated if has at least 2 doses of pneumococcal vaccine, second dose more than 2 weeks before presentation
Risk of SBI drops to < 1% in this group, thus CBC or Blood Culture unlikely to change management in well appearing child
Pneumococcal Vaccine doesn’t protect against UTI
Prevalence of UTIand Risk Stratification
3-36 mo group:
Girls 6-8% in < 12 monthsGirls 5-10 % < 24 months
High Risk Girls = < 24 months
Boys< 6 mos: 2.7 % (mostly Uncirc)Circ Boys > 3 mo rate UTI very low <<1%
High risk boys are Uncirc = < 6 months old
Management for UTIof Febrile T > 39 and 3-36 months
High Risk Infants = F<24 mo, UCB<6 mo:All get Cath UA and Culture
Consider Screening Low Risk, especially if F> 48 hr (F > 24 mo, UCB to 12 mo, CB to 6 mo)
Options: 1. Cath UA and send Culture
or 2. Bag UA (don’t culture), but if LE/Nitrite +,
send Cath UA and culture
Management for SBIT > 39.5 (103.1), child 3-36 months
If child is NOT pneumococcal vaccinated CBC and Blood Culture, Treat IM/IV Ceftriaxone if WBC > 15
DO LP on any child with fever of any degree who is lethargic, irritable, ill appearing
Treatment of Febrile 3-36 mo child
UTI:– Oral as good as IV for UTI– First dose in ED– IM/IV Ceftriaxone– Oral Keflex, Cefixime
Unvaccinated with T > 39.5 (103.1) and WBC>15:– IM/IV Ceftriaxone
Any toxic appearing child:– IV amp + gent + vanco (if pneumococcal suspected)
Questions to ask about Febrile Children 3-36 mo
• Is the child toxic?• Is there a fever source?• Is the boy circumcised?• How many and when was most recent
Prevnar?• What is the likelihood of good follow up?
Final Notes
• Use your clinical judgment with children, and treat them not as a child, but as a little patient.
• If it is the right thing to do, then do it, even if it is invasive, or takes monitoring or more time, i.e., LP’s, IV pain meds when indicated
• Arrange closer follow up for children than others: 24 hr return is common in ED with febrile children FWS
Overview of ED Pediatric Asthma Management
Inhaled Beta AgonistsSupplemental Oxygen prn, Moniter prnCorticosteroidsSystemic Medications for Status AsthmaticusStep Up Home therapy in Persistent AsthmaticsEducationDisposition decision
Albuterol
Evidence:
– Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses
– Nebulized albuterol for severe disease, infants or when there is strong parent preference
Albuterol Dosing in ED
MDI+ Spacer: 1-8 puffs every 20 minutes x 3Spacers: Face Mask style for 1 – 10 years oldAlbuterol MDI 8 puffs = 2.5 mg UD nebulized
Albuterol Dosing in ED
Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h
>5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h
Nebulized Continuous: 5-10 mg/hr
calculate and caution <1 yr old0.3-0.5mg/kg/hr
Overview of ED Pediatric Asthma Management
Inhaled Beta AgonistsSupplemental Oxygen prn, Moniter prnCorticosteroidsSystemic Medications for Status AsthmaticusStep Up Home therapy in Persistent AsthmaticsEducationDisposition decision
Albuterol
Evidence:
– Multiple RCT’s and Expert Panel Report 3 conclude that MDI as effective as nebulizer for mild or moderate asthma at equivalent doses
– Nebulized albuterol for severe disease, infants or when there is strong parent preference
Albuterol Dosing in ED
MDI+ Spacer: 1-8 puffs every 20 minutes x 3Spacers: Face Mask style for 1 – 10 years oldAlbuterol MDI 8 puffs = 2.5 mg UD nebulized
Albuterol Dosing in ED
Nebulized UD 0-5 yrs: 2.5 mg (1 UD) Q 20 min x 3, then q1-2h
>5 yrs: 2.5 – 5 mg (1-2 UD) Q 20 min x 3, then q1-2h
Nebulized Continuous: 5-10 mg/hr
calculate and caution <1 yr old0.3-0.5mg/kg/hr
AtroventAnticholinergic
Nebulizer solution (0.25 mg/mL)
• < 20 kg : 0.25 mg = ½ UD
• < 20 kg : 0.5 mg = 1 UD every 20 minutes for 3 doses, then as needed q6h
Corticosteroids in ED
• Short bursts of steroids beneficial in acute asthma and reduce hospitalizations, duration
• Strongly consider corticosteroids for every asthma exacerbation or viral reactive airways.
• Down side is negligible and Benefits are evidence based.
The New FavoriteCorticosteroid
Oral Dexamethasone (T ½ 36-72 hr)
–May give tasteless IV form orally!!–0.6 mg/kg/day for 2 doses. –Give 2nd dose 24-36 hrs after the first. –May send home family with syringe of the
correct second dose of the IV form–Or Rx oral tablet form and crush in pudding
or jam
Adjunct Meds in Status Asthmaticus
Evidence: Magnesium is first line systemic bronchodilator
RCTs and Metas have established safety and efficacy in kids, reduces hospitalization
Single dose: 25-75 mg/kg (max 2 g) IV over 20 minutes
Adverse: flushing and nausea
Injectable Beta 2 Agonists: Terbutaline and Epinephrine
No proven benefit, but used when faced with
impending respiratory failure and possible intubation
Terbutaline
0.01 mg/kg SC every 20 minutes for 3 doses then every 2–6 hours as needed
Max dose 0.25 mg, or adult dose
Epinephrine 1:1000 =1 mg/mL
Dose Child and Adult: 0.01 mg/kg SC
Max dose 0.5 mg every 20 minutes x 3 doses
Step up Home Therapy
Send home patients with inhaled corticosteroids, who have persistent or not well controlled asthma**Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbationsJournal of Allergy and Clinical Immunology - Volume 124, Issue 2 Suppl (August 2009)
What is Uncontrolled Asthma?Rule of 2’s
More than 2 daytime/exercise symptoms/week or
>2 episodes of albuterol use/week, or >2 nighttime awakenings per MONTH or > 2 steroid courses or hospitalizations in last
YEAR