The Initial Evaluation and Stabilization of Routine Childhood Illnesses

1. The Initial Evaluation and Stabilization of Routine Childhood Illnesses Coburn H. Allen, MD, FAAP Pediatric Emergency Medicine Pediatric Infectious Diseases

2. Outline Review common childhood illnesses Discuss key questions to ask and findings to evaluate for each illness Know which cases can return to class and which need further care

3. Common Childhood Illnesses Allergies Asthma Depression Drug Abuse Fever Gastroenteritis Lice Pink Eye Rashes Sore Throat

4. Allergic Reactions 14 y/o young man in the cafeteria begins vomiting violently and is noted to have a red, swollen face, lips and tongue and his voice sounds raspy. He rapidly develops hives all over while walking to your clinic.

5. What is this? Anaphylaxis!

6. Allergic Reactions What to ask? What just happened? Difficulty breathing/swallowing, itching? History of allergies? What? How bad? Epipen? New foods, meds, stings or “products?”

7. Allergic Reactions What to examine? ABCs Airway Breathing (wheeze, stridor) Circulation (anaphylactic “SHOCK”) Skin Hives Angioedema

8. Hives (Urticaria)

9. Angioedema

10. Allergic Reactions What to do? Anaphylaxis Epipen, if available EMS if not Hives Antihistamine Stop exposure, if possible

11. Allergic Reactions Where to send them? Anaphylaxis EMS to nearest hospital Few exceptions Hives Depends Severity Number How itchy H/o anaphylaxis

12. Asthma A nine year old girl is rushed back to you complaining, “I can’t breath!” She is a known asthmatic who is admitted to the hospital almost every year. You have given her treatments many times in the past.

13. Asthma What to ask? “Count to 20” or “Say ABCs” What was she doing right before? How long has she been sick? Medications (missed)? Other complaint/concerns Chest pain Anxiety Drug use Exposures

15. Asthma What to examine? Look General condition Quality of breaths Respiratory rate Listen Air movement Wheezing Stridor Crackles

16. Asthma What to do? Depends on what you have Medications Albuterol treatments Nebulizer Metered dose inhaler WITH spacer Oxygen Inhaled steroids of minimal benefit during acute attack Preventative meds may be harmful EMS if respiratory distress

18. Asthma Where to send them? Back to class If rapidly respond to single treatment without worsening for 1 hour after completed If faking to get out of math test To doctor (me) Minimal or no response to treatment, or requiring more than one History of severe asthma (multiple ICU visits…)

19. Depression A 13 y/o girl is found crying in the bathroom using a razor to “cut” her forearm. She has 23 superficial wounds to the left forearm and quite a few old scars in the same area.

20. Depression What to ask? Why? Wants to die? If cutting, ask Friends doing it? Feels good? Prior history? Medications? Drugs? Abuse?

21. Depression “S I G- E- C A P S” S - Suicidal thoughts, sadness I - Interest (loss of interest) G - Guilt feelings E - Energy decline C - Concentration problems A - Appetite changes P - Psychomotor retardation S - Sleep disturbances

22. Depression What to examine? Wounds Evidence of substance abuse Neurologic exam Eyes Gait One sidedness (bad)

23. Depression What to do? First aid Build confidence

24. Depression Where to send them? EMS Suicidal Homicidal Medical emergency Toxidrome (“drugs on board”) Back to class Known depression, mild symptoms No drugs involved Home rarely an option (back to class or to ER) All need f/u confirmed

25. Drug Abuse Tripp Assyd, a 15 y/o young man, got in a fight with the gym teacher and is acting very “bizarre.” His heart is racing and he seems to be seeing things you don’t seem to see. Your sight is fine.

26. Top 10 “Street Drugs” TOBACCO : biggest killer (400,000 deaths/year) ALCOHOL : most widely abused legal substance PRESCRIPTION DRUGS : dangerously addictive, rising in popularity METHAMPHETAMINE : labeled an epidemic problem by the press MARIJUANA : most widely abused illegal substance MDMA (ECSTASY) : little research on long term effects, still popular CRACK COCAINE : cheap, destructive drug making a comeback HEROIN : highly addictive drug making a comeback in some areas STEROIDS : horrible side effects, the toll they're taking on athletics INHALANTS : abuse is on the rise among youth again www.streetdrugs.org

28. Drug Abuse What to ask? What did you take? Often don’t know Have them describe it Home made? Street name(s) Call Poison Center to help identify How much? When? Source? Medical history Medications Conditions Depression/psychiatric conditions

29. Drug Abuse What to examine? ABCs Smells Eyes Pupils (big or small) Nystagmus Speech Gait

30. Drug Abuse What to do? Where to go? Provide calm environment Police if aggressive/severe If any impairment, must be seen Significant via EMS Mild may be ok with family

31. Fever A 5 y/o girl with a history of epilepsy is found shaking on the floor of the outside art room closet with a fever of 105.4.

32. Fever What to ask? Recent illness? Heat exposure? Medications? Associated symptoms? Stiff neck Confusion Rash

33. Fever What to examine? Core temperature Vital signs HEENT Neck Chest Abdomen Skin

34. Fever What to do? Don’t panic = “Fever Phobia” Do: Cool them Remove excess clothing Luke warm “sponge bath” Antipyretics, if allowed Call home

35. Fever Where to send them? Doctor I’ll appearing Seizure Overheated Home Most Parents can discuss with PCP

36. Gastroenteritis Little Johny Stinkith, an 11 y/o boy, “pooped his pants” during recess and has vomited twice since. He is escorted to your office moaning and groaning saying “my tummy hurts.”

37. Gastroenteritis What to ask? When started? Describe the pain? How much V/D? Blood/Bile? Food poisoning/ill exposure? Dehydration? PMHx/Associated symptoms?

38. Gastroenteritis What to examine? General Abdomen RLQ, CVA, SP or diffuse pain Guarding/rigid Bowel sounds Dehydration

39. Gastroenteritis What to do? Hydrate- Slow and steady Gatoraid Sprite Water Call home

40. Gastroenteritis Where to send them? Doctor Localized pain Moderate to severe dehydration Underlying conditions Home Most Teach how to rehydrate

41. Lice The Principal’s 8 y/o daughter, Princess Purrfect, complains of her head “itching like crazy!” Your head starts to itch a bit too, come to think of it.

42. Lice What to ask? Where does it itch? How long? Exposures to lice? Treatment started? Other medical conditions?

43. Lice What to examine? Scalp Live lice Hair shafts Eggs (“Nits”) Just above the scalp Use magnifying glass, gloves

45. Lice What to do? Scratch your head, it’s natural. Live lice Need treatment Rid (over the counter) Malathion “Home remedies” “No nit policies” should be abolished Nits only do not need treatment

47. Lice Where to send them? Live lice Home for treatment Educate How contacted: Head to head, shared hats/brushes How to treat Resistance exists, if failure see PCP No live lice  back to class Unsure  PCP

48. Pink Eye Your two-time All-State Heavyweight Wrestling Champion, Penn Yufast, is seen wearing an eye-patch at practice and tries to hide when you approach him. The patch is stained with yellow-green goo. The big rivalry match is tomorrow, and his mom is your best friend. Oh yeah, and his dad is president of the school board. You pin him down, remove his patch and…

50. Pink Eye What to ask? How long? Injury? Itching vs. burning/pain? Visual changes? Associated symptoms? Fever, sore throat, cough, both eyes = viral One sided, pus, exposure history = bacterial