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Common Paediatric Emergency Referrals

Common Paediatric Emergency Referrals. Mark Anderson Consultant Paediatrician Great North Children ’ s Hospital. Case 1. Archie, 18 months. Unwell for 2 days with runny nose and cough Felt hot Difficulty breathing & wheezy today. Archie, 18 months. Examination Coryzal

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Common Paediatric Emergency Referrals

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  1. Common Paediatric Emergency Referrals Mark Anderson Consultant Paediatrician Great North Children’s Hospital

  2. Case 1

  3. Archie, 18 months Unwell for 2 days with runny nose and cough Felt hot Difficulty breathing & wheezy today

  4. Archie, 18 months • Examination • Coryzal • Mild subcostal recession • Quiet wheeze throughout chest

  5. Differential diagnosis?

  6. Differential diagnosis Viral induced wheeze (VIW) – episodic wheeze 1st presentation “asthma” – multi-trigger wheeze (Bronchiolitis)

  7. How to differentiate VIW from “asthma”?

  8. How to differentiate VIW from “asthma”? • Can be difficult! • Asthma more likely if • Multiple triggers for wheeze • Interval symptoms • Personal or family history of atopy • Absence of virus (!)

  9. Specific Therapy?

  10. Specific therapy • Inhaled bronchodilator • Salbutamol • Ipratropium bromide • ?Steroids

  11. Steroids in preschool VIW • Little evidence for efficacy • 120 children aged 1-5y given prednisolone or placebo • No effect on parental reported respiratory symptom score at 7 days • 700 preschool children given prednisolone or placebo • No effect on duration of hospitalisation • No effect on respiratory symptom score in first 24 hours

  12. Steroids in preschool VIW • Short burst therapy probably should be reserved for clinical features suggestive of atopic asthma • History of multi-trigger wheeze • Severe eczema • Family history of atopy

  13. What determines need for admission?

  14. What determines need for admission? Oxygen requirement (SpO2 <93%) Respiratory effort Hydration concerns Social complications

  15. Take home points Preschool wheeze appears to have multiple phenotypes Short burst oral steroids no longer the cornerstone of management for all preschool wheeze Questions?

  16. Case 2

  17. Micah, 2 years Unwell for 2 days with runny nose and cough Feels hot Mum noticed lump in neck

  18. What do you want to know?

  19. What do you want to know? Well/unwell Location Size Heat Other lymphadenopathy Spleen/liver

  20. Micah, 2 years • 4-5cm diameter firm swelling in upper cervical chain • Non-fluctuant • A few other small lymph nodes • No swallowing issues • Well otherwise

  21. Plan of action?

  22. Plan of action? Do nothing? Investigations? Oral antibiotics? Intravenous antibiotics?

  23. Causes of acute cervical lymphadenopathy • “Reactive” • Infection • Bacterial • Atypical mycobacterium • TB • Other

  24. Plan(s) of action • Fluctuant node • Incision & drainage/excision • Well • Oral antibiotics for 7-10 days – review in 48-72h • Unwell • IV antibiotics • Investigations probably only indicated for persistent adenitis (>2 weeks)

  25. Take home points • Acute adenitis • If collection suspected, needs I&D • Oral antibiotics & review appropriate for the majority of well children • Questions?

  26. Case 3

  27. Bethany, 6 years Awoke complaining of left hip and thigh pain Previously fit and well apart from an upper respiratory tract infection 7 days previously

  28. What else do you want to know?

  29. What else do you want to know? • Characteristics of the pain • Systemic features • Recent travel or systemic illness • Medication history • (Trauma)

  30. Bethany, 6 years • Refused to weight bear • Became very distressed at attempted examination • Temperature 38.7 • Flushed & tachycardic

  31. Differential diagnosis of the limping child?

  32. Differential diagnosis of the limping child • Transient synovitis/ ”reactive” arthritis • Septic arthritis/osteomyelitis • Perthes’ disease • Slipped Upper Femoral Epiphysis • JIA • Malignancy • Abdominal/testicular pathology • Discitis, Lyme disease, NAI

  33. Red flags • Severe & unremitting pain • Complete non-weight bearing • Pseudoparalysis • Night pain • Fever • Back pain • Features of malignancy

  34. Bethany, 6 years • Differential diagnosis • Septic arthritis • Reactive arthritis

  35. Investigations?

  36. Investigations • White cell count 11.5 x 109/L • CRP 30mg/L • ESR 15 mm/h • Plain X-ray normal • Urgent ultrasound – hip effusion

  37. Kocher’s clinical prediction rule • Factors • Fever >38 • Unable to weight bear • ESR>40mm/hr in the first hour • Serum WCC >12x106/L • Probability of septic arthritis • No factors present <0.2% • 2 factors present 40% • 3 factors present 93% • 4 factors present >99%

  38. Bethany, 6 years • Presumptive diagnosis septic arthritis • Joint aspiration & wash out • Gran stain negative • >50,000 white cells/mm3 on microscopy • IV antibiotics for 2 weeks, oral for 4 weeks

  39. Take home points • Limping is a common presentation • Limping is not a diagnosis • Not all children need excessive investigation • All children need clear follow up plans

  40. Thank you!

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