Pediatric Illnesses November 15, 2010

1. Pediatric IllnessesNovember 15, 2010 Keir Swisher, D.O.

2. 2008 National ChampionsKansas Jayhawks

3. Case 1 • 4 y/o male presents to Room 3 in ED with respiratory distress and speaks in 1-2 word sentences. H/o asthma with previous intubation for an asthma exacerbation, mom says he ran out of his meds last week (albuterol, advair, singulair). Respiratory rate 60, sats 87% (RA) with diffuse retractions and decr air movement.

4. Case 1 continued • Physical Exam • General: Severe respiratory distress without cyanosis • Airway: Speaks 1-2 word sentences • Breathing: Faintly audible expiratory wheezing, very diminished throughout with poor air movement, RR 60/min. • Circulation: Strong radial pulses, • What meds do you want? • Intern question?

5. Case 1 continued • Albuterol/atrovent • Subcutaneous epinephrine ?? • Solumedrol IV versus oral steroids? • Magnesium Sulfate 20mg/kg IV over 20 minutes (max 2 grams) • Terbutiline (my guess is only Grandpa/Allred is thinking of this medication) • RE: Taught in late 1800’s when he was in medical school • What if no response to these therapies? Can you try anything before intubation?

6. Case 1 continued • Bipap • Heliox • Minimal oxygen content is 60/40 • Can try prior to intubation • You try this but sats still 88% after 20 minutes and patient is getting very tired and becoming less responsive. • Meds for intubation/doses

7. Meds: • Ketamine 2mg/kg (+/- benzo’s to prevent emergence reaction) • Atropine 0.02mg/kg (min 0.1mg) or Robinul 0.005-0.01mg/kg IV (max 0.2mg) • Succinylcholine 1.5-2 mg/kg • Rocuronium 0.6-1mg/kg • Blade: miller vs. macintosh? • Tracheal tube size= (age + 16)/4 • 5.0 (also have available 0.5mm smaller and larger available • Cuff vs no cuff??

8. Asthma Quick Facts • Can see initial drop in sats after first neb (VQ mismatch) • If must RSI pt, remember permissive hypercapnia to minimize airway pressures and reduce barotrauma • Use albuterol (increases cAMP) and atrovent (decreases cGMP) together (first 3 treatments) • Alternative therapy: • Epinephrine 0.01mg/kg (max 0.5mg) SQ q20 minutes 1:1000 solution • Terbutaline 0.005-0.01mg/kg (max 0.4mg) SQ q20 min x 3 doses • Corticosteroids indicated for moderate-to-severe exacerbations (IV/PO absorption is equivalent) • Risk factors for death from asthma • H/o prior intubation or ICU admission • 2+ hospitalizations or 3+ E.D. visits in past year • >2 canisters of albuterol/month • Urban residency or low socioeconomic status

9. Dedication

10. Case 2 • 5 y/o male presents to Room 2 with stridor while chasing after his brother today outside. His mother states he has been congested with a runny nose x 2 days, and started with making this noise today. He also has a weird cough today on the ride to the hospital. When you get him to stop running around and sit still, the inspiratory stridor resolves. He is non-toxic appearing. • Differential Diagnosis for stridor?

11. Croup • Always think of F.B. with stridor • If any concerns for epiglottitis, obtain soft tissue x-rays unless toxic appearing (then call ENT/Anesthesia and leave the child in parents lap or wherever is comfortable • Typically parainfluenza virus in late fall/early winter • All children with croup (mild, moderate or severe) should receive decadron 0.6 mg/kg IV/IM/PO (max 10mg) as one time dose • Racemic epi (0.5ml of 2.25% solution) for patients with resting stridor • Cool mist, hydration and oxygen otherwise if does not need r.e. • Children receiving racemic epi must be observed for 3-4 hours to watch for rebound

12. Can repeat racemic epi every 15- 20 minutes (if 3+ doses in 2 hrs extended cardiac monitoring) • Can consider heliox if necessary to provide additional time for steroids and racemic epinephrine to work and postpone RSI • Will decrease work of breathing with improved laminar flow (decreased density of gas) • Most protocols employ 70:30 helium:oxygen ratio • Essentially depends on oxygen requirements

13. Bacterial Tracheitis • Symptoms similar to croup yet patient “takes turn for worse” • Toxic appearing • High fever, stridor, congestion, barking cough • Typically < 3y/o • O2 • ENT/anesthesia consult for endoscopy (will see pseudomembranes and purulent secretions) • S. Aureus most frequent pathogen • ICU admission

14. Case 3 • 18 month male presents to Room 11 with cyanosis to tongue and lips. His uncle states he turned this color after crying when his favorite team (Denver Broncos) got beat today, again. Apparently this has happened before with crying and the Broncos losing, and he was supposed to see a “heart doctor” but they missed the appointment. BP 84/40 HR 115 RR 20 Sats 86%. You note a harsh systolic ejection murmur in left sternal border 2nd IC space. He continues to cry yet between crying his lungs appear to be clear. His sats continue to be 86-87% on 15 L NRB and still has cyanosis to his lips. What is your differential and what is most likely going on?

15. DDX: • Respiratory etiology yet no resp distress and CTAB • Methemoglobinemia/Sulfhemoglobinemia • Hypoventilation • Foreign body? • Cyanotic heart disease

16. Cyanotic Heart Diseases • T.O.F. (most common in children > 1y/o) with four anatomic components “I.H.O.P.” • Interventric septal defect • Hypertrophy of RV • Overiding aorta • Pulmonary stenosis • Transposition of great vessels (most common in newborns) • Truncus arteriosus • Total anomalous pulmonary venous return • Tricuspid atresia • Pulmonary atresia • Ebstein’s anomaly of tricuspid valve

17. Tetrology of Fallot • CXR: Boot shaped heart with diminished pulm vascular markings (decr pulm blood flow) • ECG: R.A.D., RVH • CBC: polycythemia • Management: • Prone knee-chest position • Oxygen • Morphine 0.1mg/kg • If no response consider propranolol or phenylepherine after talking with peds cardiology

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19. Case 4 • 2 y/o male at circus, eating peanuts and watching performers. His mom states the bearded lady resembled a doctor she has seen before named David Dupy and went to check. Upon returning she noted her son to be coughing and turning blue. She ran to the ambulance nearby and they loaded up the boy and drove to the ED. Mom states both his brothers have bad asthma and he is kind of making the noise they do when they have problems.

20. Case 4 continued • The patient is placed in Room 15, the cyanosis has resolved yet he continues to cough. Vitals are normal except for RR of 32. Lung exam reveals wheezing in right lung and normal breath sounds in the left. The nurse asks if you want albuterol with atrovent, the steroids PO or IV, and hurry up with your decision. You pause to think what is going on? What next?

21. CXR • Inspiratory/expiratory • B/l decub if uncooperative child • Albuterol/atrovent?

23. Foreign Body Aspiration • If stridor FB is present in larynx or trachea • If wheezing the FB is in mainstem bronchus or further • MRI useful in confirming peanut or other vegetable matter • Bronchoscopy • IF radiopaque FB in trachea seen on edge (PA) and “en face” in lat, opposite for esophagus (per River’s, yet not always the case)

25. Case 5 • 15 month old male without h/o asthma presents to Room 8 with URI sx x 4 days and wheezing. Mom noted his “ribs are sucking in” when he breaths and he keeps making noises with breathing that interrupts Jerry Springer talking. RR 60, Sats 90%, HR 140, Temp 99.1 rectal. Patient in moderate respiratory distress, with intercostal/suprasternal retractions and diffuse wheezing. What next?

26. Oxygen • Nasal suction • CXR • RSV/Influenza A/B swabs? • Albuterol/atrovent neb • Steroids?

27. Steroids only indicated if pt with h/o asthma and requirement in past • Bronchodilator trial, continue if improvement • ?Nebulized epinephrine agent of choice, repeat in 30 minutes as needed • Chest x-ray in 1st time wheezers or clinically indicated • Saline drops/nasal suctioning for hospital and home care • Ribavirin for immunocompromised, mechanically ventilated, complicating illness and less than 6 weeks old • If < 6 months and RSV + what possible complication can occur? • 3rd year question?

28. Case 6 • 2 month 28 day old male presents to Lindsborg ED on your first shift moonlighting with fever 102.8 rectally. Pt without other signs of infections, irritable per family (appropriate tooth/tattoo ratio). Started that day, nobody else in family sick. HR 160, BP 82/55, sats 99RA, RR 40. Normal birth, home with mom. • What next?

29. Case 6 continued • Septic w/u (LP vs no LP) • According to Carol Rivers • Infants < 2 months old needs LP • Infants 2-3 months old, omit LP if infants: • Appears well • behaving normally • CBC normal, • F/u in 24 hrs and no antibiotics administered

30. Case 6 continued • What medications to start empirically? • Intern question? • What are the most common organisms in this nearly 3 months old that could cause sepsis? • 2nd year question?

31. Infancy and early childhood • Strep pneumoniae • N. Meningitidis • H. influenza • Neonatal period (0-4 wks) • GBS • E. Coli • Listeria monocytogenes

32. Case 7 • 4 yo male with fever 102, cough x 5 days with 2-3 episodes of post-tussive emesis and abdominal pain. Temp rectal 102.1, HR 125, BP 93/66, sats 99RA. Exam positive for rales in left base, chest x ray shows infiltrate.

33. You are going to send the patient home on antibiotics, what do you choose (NKDA)?

34. Case 7 continued • Outpatient • Amoxicillin (dose mnemonic for high dose 80mg/kg • 400mg/5ml dosing is weight in kilograms divided BID • Example 10 kg child (5ml BID) • Augmentin • Bactrim • Macrolide (zithromax/biaxin/erythromycin) • Cefixime • Cefaclor

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36. Case 8 • 4 yo female with fever 102 for past 6 days with “pink eye.” Mom concerned because rash on hands and seems to be peeling off. Vitals normal except temp 102.4 rectal, exam significant for b/l conjunctival injection with clear drainage, red tongue, rt anterior cervical lad 2cm and ttp. Lungs CTAB. What is in your ddx and how do you diagnose/exclude each?

38. DDx: • Endocarditis (always consider in persistant fever) • Janeway lesions, roth spots, pancarditis, osler’s nodes, fever, anemia, splinter hemorrhages • Rheumatic fever • Jones Criteria (1 major/2 minor or 2 major plus preceding GABH strep infection) • Major: polyarthritis, carditis, chorea, erythema marginatum, subcutaneous nodules • Minor fever, arthralgias, h/o RHF, pos labs • Plus recent strep infection (oropharynx, not skin), incr ASO titer, scarlet fever • Kawasaki’s • C.R.A.S.H. a motorcycle • Non purulent Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand rash/desquamation

39. Concerns for subacute phase (day 11-20 with development of coronary art thrombosis/aneurysm • Fever >5 days PLUS 4 of following • B/l nonsuppurative conjunctivitis • Changes of lips and oral mucosa (strawberry tongue, injected oropharynx, fissured lips) • Extremity features (palmar/plantar erythema, edema hands/feet, periungual desquamation) • Polymprphous rash • Cervical LAD (at least one > 1.5cm) • Prognosis determined by cardiac complications (20-30% of untreated children develop c.a. aneurysms) • Tx • IVIG 2grams/kg over 12 hrs • ASA 100mg/kg divided Q.I.D. • Treat with antibiotics while awaiting bld cultures??

40. Case 9 • 6 yo male with seizure at home witnessed by my baby’s daddy. “He was shaking all over.” Pt with h/o fever 103 at daycare, runny nose and cough x 2 days. Shaking lasted 5-10 minutes and stopped. Vitals 103.1 rectal, HR 120, bp 92/50, RR 22, sats 99 RA. Exam focal rales lt base, no retractions otherwise normal exam. What are the defining characteristics of a febrile seizure?

41. Children 3 months – 6 yrs • Last less than 10-15 minutes • Generalized seizure activity without focal postictal defecits • +/- family h/o febrile seizures • Single event in 24 hr time period • Rivers mentions LP in all children with nuchal rigidity (only consistant if > 2y/o), recurrent seizures, or prolonged post ictal period and all infants 3-12 months of age. What is the risk of a repeat seizure in the future? 3rd year question? Prophylaxis with tylenol/motrin the rest of his life?

42. Risk of recurrance: 30-40 percent (more likely if first seizure prior to 1 y/o • Prophylaxis with antipyretics not recommended.

43. Case 10 • 3.5 month old male with vomiting and decrease in wet diappers to ED at 11:59am and they of course call you and say “you have a patient here.” Vomiting started 24 hrs ago, throws up with and without feeds, bright green color, +/- projectile. No diarrhea, ROS neg, otherwise healthy child. Vitals normal/afebrile. Exam positive findings of dry mm, cap refill 3 seconds, crying so not sure if hear bowel sounds, diffusely ttp even with distraction, distended and ? palpable poopolith vs mass in RUQ area. DDX and work up?

44. Pyloric stenosis (too old typically 2-6 wks of life and nonbilious)) • Gastritis • Trauma/CHI • Midgut volvulus • Obstruction • Incarcerated hernia • Intussusception

46. Midgut volvulus • Congenital malrotation of bowel/inadequate attachment to mesentery • Children < 1y/o (typically first month of life) • Bilious vomiting, distention, ttp and palpable mass. • Tx • IVF, NGT, call surgery for emergent laparotomy • Dx • AAS/Upright abdomen • UGI or ultrasound will confirm dx

47. Intussusception • Most common cause of intestinal obstruction in 3mo-5yo • Illeocolic most common type • Triad of intermittent colicky abd pain, vomiting and currant jelly stools (21 % of patients) • Lethargy can be prominent feature • Abd pain child draws legs up (don’t all kids when crying?), screams followed by pain free intervals up to 20 minutes • Vomiting may become bilious • Absence of currant jelly stools doesn’t exclude the dx • Dx • Plain films (can be normal) • Air contrast enema (have peds surg available and ready incase of perf) • Can be diagnostic and theraputic (60-80% of cases)

48. Pyloric stenosis • Occurs at 2-6 wks of life • Nonbilious projectile vomiting • Evidence of dehydration and ftt • Palpable olive-shaped mass in RUQ • HYPOCHLOREMIC, HYPOKALEMIC METABOLIC ALKALOSIS • Dx sono or upper GI series

50. Bonus question • The last year the KC Chiefs won a playoff game? • A. 2001 • B. 1965 • C. 1997 • D. 1994