Category: Pediatrics

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The 3 Worst Causes of Neonatal Conjunctivitis

• Gonorrhea
  • Causes corneal ulcers and sepsis
  • Red flags
    • 1st week of life
    • Copious purulent drainage
  • Diagnose with cultures
  • Treatment
    • Cefotaxime (3rd generation cephalosporin)
    • Admit
• Chlamydia
  • Occurs in 1st month of life
  • Treat with PO erythromycin
• HSV
  • Can disseminate to the brain
  • Red flags
    • Mother tested positive (or had active lesions)
    • Vesicles on baby
  • Treatment
    • IV acyclovir
    • Admit

Other Causes of Conjunctivitis

• Viral/other bacterial
  • Treat with erythromycin ointment
• Chemical conjunctivitis
  • Caused by eye drops given after birth
• Dacryostenosis (closed eye ducts)
  • Watery eyes from tears not draining

Additional Reading

• Neonatal Conjunctivitis (CDC)

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The 4 Most Common Causes of Blood in Diaper

• Urinary crystals
  • Will be guaiac negative
  • Common in first few weeks of life
• Vaginal bleeding
  • Common in newborn females as they withdraw from maternal estrogen
• Maternal blood
  • Swallowed during birthing process
  • Breastfeeding with cracked/bleeding nipples
• Anal fissures
  • Common and will improve on its own

Basic Approach

• Step 1: Check if guaiac positive
  • If negative, it’s not blood
  • Urinary crystals, food coloring, etc
• Step 2: Consider vaginal bleeding
• Step 3: Perform apt test
  • Diagnoses maternal blood
• Step 4: Check for anal fissure
  • Self resolve
• Step 5: Expand the differential diagnosis
  • Necrotizing enterocolitis
  • Intussusception
  • Cow’s milk allergy
  • Colitis
  • Red Food Dye

Additional Reading

• Neonate With Bloody Stool (Pediatric EM Morsels)

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Physiology

• RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin
• Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin
• Conjugated (direct) bilirubin -> Eliminated in stool

Causes of Hyperbilirubinemia

• Increased RBC turnover
  • Sepsis
  • Rh incompatibility
  • RBC disorders
  • Maternal diabetes
  • Scalp hematoma
• Decreased/slow conjugation by the liver
  • Peaks around day 5 of life
  • Congenital liver disorders
    • Gilbert/Crigler Najjar Syndromes
  • Breast milk jaundice
    • Breast milk inhibits conjugation of bilirubin
• Decreased excretion
  • Bowel obstruction
  • Breast feeding failure (dehydration)
    • Decreased stool output results in reabsorbed bilirubin

Kernicterus

• Brain damage from severe hyperbilirubinemia (>25 mg/dL)
• Compare measured bilirubin to established nomogram
• Treatment is phototherapy
  • (Worst case scenarios require exchange transfusion)

Additional Reading

• Approach to Neonatal Jaundice (emDOCs)

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Non-Accidental Trauma

• Estimated 10% of pediatric patients are victims of abuse
  • Sexual abuse
  • Physical abuse
  • Neglect
• Common red flags
  • Changing story
  • Story that doesn’t make since
  • Delays in seeking care
  • Unusual bruising locations
    • Torso
    • Ears
    • Neck
• Common tests if non-accidental trauma suspected
  • Skeletal survey x-rays
  • Head CT
    • Especially if altered mental status
  • Abdominal CT
    • Especially if abdominal trauma
• Report to child protective services (CPS)

Tummy Ache

• Necrotizing enterocolitis
  • Classic presentation
    • Premature baby
    • 1st month of life
    • Ill appearing
  • Classic finding on x-ray
    • “Pneumatosis intestinalis”
• Volvulus
  • Classic presentation
    • 1st month of life but previously healthy
    • Distended abdomen
    • Bilious vomiting
  • Testing
    • Abdominal Xray
    • Upper GI Series (ideal test)
• Toxic megacolon
  • Complication of Hirchsprung Disease
  • Seen on x-ray
• Intussusception
  • Telescoping bowel resulting in ischemia
  • Classic presentation
    • 2 months – 2 years old
    • Intermittent abdominal pain followed by lethargy
  • Diagnose with abdominal ultrasound
• Pyloric stenosis
  • Classic presentation
    • Projectile vomiting
    • Normal appetite/hungry
    • Palpable “olive” in epigastrium
  • Testing
    • Electrolyte panel
      • Hypokalemia
      • Hypochloremia
      • Alkalosis
    • Abdominal ultraound

Additional Reading

• Pediatric Abdominal Pain (EM Clerkship)

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Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!!

Inborn Errors of Metabolism (IEM)

• Almost always result in one of the following three clinical abnormalities
  • Buildup of toxins
    • Ammonia
      • To test for this, obtain an ammonia level
  • Buildup of acids
    • Methylmalonic acidemia
      • To test for this, obtain electrolyte panel and look for decrease CO2
  • Shortage of glucose
    • Glycogen storage disorders
      • To test for this, obtain a blood glucose level

Congenital Adrenal Hyperplasia (CAH)

• Decreased 21-hydroxylase enzyme
• Physiologic abnormalities
  • Decreased aldosterone
    • Low sodium (hyponatremia)
    • High potassium (hyperkalemia)
  • Decreased cortisol
    • Low glucose level
    • Hyperpigmentation
  • INCREASED sex hormone (androgens)
    • Fused labia
    • Partial male genitalia

Additional Reading

• Congenital Adrenal Hyperplasia (Wikipedia)

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Common Chief Complaints

• Cyanosis
• Difficulty feeding
• Failure to thrive

Cyanotic Heart Lesions

1. Truncus arteriosus
   • Aorta and pulmonary artery are fused
   • Single vessel comes from both ventricles
2. Transposition of great vessels
   • Aorta comes off RIGHT ventricle
   • Pulmonary artery comes off LEFT ventricle
3. Tricuspid atresia
   • Blood unable to get from right atrium to right ventricle
4. Tetrology of fallot
   • Overriding aorta
   • Ventricular septal defect
   • Right ventricular outflow tract obstruction
   • Hypertrophy of right ventricle
5. Total anomalous pulmonary venous return
   • Pulmonary vein empties into the right ventricle

Ductal Dependent Lesions

• Classically presents in first 30 days of life
• Treatment = Prostaglandins
• Common lesions
  • Hypoplastic left heart
  • Aortic stenosis
  • Coarctation of the aorta

Congestive Heart Failure

• Common Presentation
  • Difficulty feeding
  • Organomegaly
  • Cardiomegaly on CXR
• Treatment
  • Furosemide
  • Vasopressors
• Admit

Additional Reading

• Congenital Heart Disease Emergencies (EM Cases)
• Ductal Dependent Congenital Heart Defects (CodeHealth)

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Pediatric “Sepsis”

• Consider in any toxic appearing child/neonate
  • Especially with fever (or hypothermia)
• Treatment
  • Early antibiotics
  • Fluid bolus

“Serious Bacterial Infections” (SBI)

• Consider in any baby with fever
• Three classic categories
  • Age <30 days
    • Introduction
      • Weak immune system
      • No immunizations
      • Very high risk for serious bacterial infections
    • Require a significant amount of testing
      • Urinalysis with Urine Culture
      • Blood Cultures
      • Lumbar Puncture with CSF Cultures
      • Chest X-Ray
    • Require admission and antibiotics
  • Age 30-60 days
    • ILL appearing
      • Treat same as fever in <30 day patient
    • WELL appearing
      • Testing and treatment differ by institution
      • Multiple criteria established to help in this age range
        • Rochester criteria
        • Philadelphia criteria
        • PECARN criteria
      • Choose one and use consistently
  • Age >60 days
    • (Assumes immunizations are up to date)
    • Workup is more targeted
      • Blood cultures, Urine cultures, Chest X-Rays still common

Additional Reading

• Rochester Criteria Febrile Infants (MDCalc)
• PECARN Rule for Low Risk Febrile Infants (MDCalc)

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Introduction

• In pediatric patients, have a low threshold to check blood sugar
• Undiagnosed diabetics commonly identified in ED during first episode of DKA
• HYPOglycemia is very common in multiple conditions, especially in ill children

Hyperglycemia

• DKA is different in kids
  • They get cerebral edema
    • Increased intracranial pressure with rapid fluid administration
  • Common symptoms
    • Headache
    • Altered mental status
    • Neurologic deficits
    • Cushings triad
      • Hypertension
      • Bradycardia
      • Irregular breathing
  • Treatment = mannitol

Hypoglycemia

• Multiple causes
  • Sepsis
  • Inborn errors of metabolism
  • Endocrine disorders
• Replace glucose using “Rule of 50s”
  • Dextrose % x Volume = 50
    • Neonates: 5ml/kg of D10
    • Pediatrics: 2ml/kg of D25
    • Teens/Adults: 1ml/kg of D50
  • 1 “amp” of D50 = 25g of sugar = 50ml

Additional Reading

• Rule of 50s (PEMBlog)
• Pediatric DKA (EM Cases)

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Applying oxygen is one of the first steps in treating any crashing child!!!

Airway Emergencies

• Foreign body (FB)
  • Patient presentation
    • Stridor
    • Choking episode
  • Testing
    • CXR
      • May directly show foreign body
      • May show secondary effects of a foreign body
        • Hyperinflated/collapsed lobes of the lung
  • Patient needs bronchoscopy if suspicion is high
• Peritonsillar abscess
  • Visible in the pharynx
• Bacterial tracheitis
  • HIDDEN IN the airway
• Epiglottitis
  • HIDDEN ABOVE the airway
• Retropharyngeal abscess
  • HIDDEN BEHIND behind the airway
• Common presentations of airway emergencies
  • Voice changes
  • Drooling
  • Stiff neck
• Testing
  • Most are seen on neck X-Ray
  • Peritonsillar abscess is clinical diagnosis
• Treatment
  • Manage the airway
  • IV Antibiotics
  • Peritonsillar abscess needs drainage

Breathing Emergencies

• Bronchiolitis = Badly breathing booger babies
  • Upper respiratory infection caused by virus
  • Signs of severe illness requiring admission
    • Grunting
    • Nasal flaring
    • Retractions
    • Hypoxemia
    • Unable to tolerate PO
  • Treatment
    • Deep suctioning
    • Can consider albuterol trial
    • Oxygen supplementation as needed
  • Generally avoid
    • Chest X-rays
    • Steroids
    • Antibiotics
• Asthma
  • Treatment
    • First line
      • Albuterol/ipratropium
      • Steroids
    • Additional options as needed
      • Magnesium
      • Ketamine
      • IV epinepherine
• Croup
  • Presentation
    • Barky cough
    • Stridor
  • Treatment
    • Steroids
    • Consider racemic epinephrine
• Pneumonia
  • Diagnosed by x-ray
  • Treat with antibiotics
• Cystic fibrosis
  • Albuterol/ipratropium
  • Nebulized saline
  • Antibiotics

Additional Reading

• Approach to Asthma (EM Clerkship)
• More Than a Sore Throat (emDOCs)

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When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!

Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies

• Foreign body
• Peritonsillar abscess
• Bacterial tracheitis
• Epiglottitis
• Retropharyngeal Abscess
• Bronchiolitis
• Asthma
• Croup
• Pneumonia
• Cystic Fibrosis

Hyper/Hypoglycemia- Check Blood Glucose

• Hypoglycemia
• DKA

Sepsis- Consider Sepsis and Serious Bacterial Infections

• Pediatric sepsis
• Fever <30 days of age
• Fever 30-60 days of age
• Fever >60 days of age

Heart- Consider Congenital Heart Abnormalities

• Truncus arteriosis
• Transposition of great vessels
• Tricuspid atresia
• Tetrology of fallot
• Total anomalous pulmonary venous return
• Ductal dependent lesions
• Congestive heart failure

Inborn Errors of Metabolism/Endocrinology

• Congenital adrenal hyperplasia

Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma

• Non-accidental trauma
• Necrotizing enterocolitis
• Volvulus
• Toxic megacolon
• Intussusception
• Pyloric stenosis

And never forget… If you feel flustered… GRAB THE BROSLOW!!!

Additional Reading

• Peds Oxygen, Airway, and Respiratory Disorders (EM Clerkship)
• Peds Hyper/Hypoglycemia (EM Clerkship)
• Peds Sepsis and Serious Bacterial Infections (EM Clerkship)
• Peds Heart Failure and Congenital Heart Disorders (EM Clerkship)
• Peds Inborn Error of Metabolism and Endocrinology (EM Clerkship)
• Peds Trauma and Tummy Ache (EM Clerkship)

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Mnemonic: ABCDEF

Appearance

• The ‘A’ in the pediatric assessment triangle
  • Interactive vs distant
  • Good tone vs floppy
  • Calm and happy vs inconsolable

Breathing

• The ‘B’ in the pediatric assessment triangle
  • Signs of respiratory distress
    • Nasal flaring
    • Retractions
    • Abnormal respiratory sounds

Color/Circulation

• The ‘C’ in the pediatric assessment triangle
• Pink = good
• Abnormalities
  • Pallor
  • Cyanosis
  • Mottling

Distraction

• Almost impossible to do a good peds exam in a crying kid
  • Easiest ways to keep kids distracted
    • Let parents hold/play with them
    • Toys
    • Stethoscope
    • Funny sounds/noises

ENT

• Many times the kids don’t localize the symptoms
• May present with vomiting, fever, irritability, etc
• If difficulty examining pharynx, consider triggering a gag reflex

Fully Undress

• Look for bruising, rash, blisters
• Signs of non-accidental trauma
• GU exam (especially in boys, check the testes!)

Additional Reading

• Peds Respiratory Disorders (EM Clerkship)
• Pediatric Assessment Triangle (Wikipedia)

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Always ask about pediatric patient’s ‘P-I-S-S’ status!!!

Core Function Questions (P-I-S-S Status)

• Peeing
  • Evaluates for dehydration
    • Number of wet diapers per day?
    • Same number as usual?
• Intake
  • Rule of 3s
    • Estimates how much milk/formula an average infant should be taking
    • 3oz of milk or formula every 3 hours
• Sleeping
  • Is the patient sleeping MORE than usual?
  • LESS than usual?
• Stooling
  • Normal stool
    • Changes from dark meconium to tans/yellows

Pediatric Medical History

• Prebirth
  • Did the patient have prenatal care?
  • Any issues with the pregnancy?
  • Was mom GBS positive?
• Peribirth
  • What gestational age was patient born at?
  • Vaginal delivery or c-section?
  • How long did baby have to stay in hospital after delivery?
• Postbirth
  • Diagnosed medical/surgical problems
  • Immunization status

Additional Reading

• The Truth About Baby Poop (WebMD)

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3 Categories: High Risk BRUE. Low Risk BRUE. Not a BRUE.

Step 1: Is This a BRUE?

• Brief
  • <60 seconds
• Resolved
  • Exam and vitals back to baseline in the ED
• Unexplained
  • No symptoms other than event itself
• Event
  • Concerning change in any of the following…
    • Tone
    • Color
    • Breathing
    • Mental status

Step 2: Is This Low Risk BRUE?

• Five low risk criteria
  • Age >2 months
  • Born at >32 weeks gestational age
  • First and only episode
  • No CPR by medical providers
  • No “Red Flags”

Step 3: Do They Have Red Flags?

• For abuse
  • History of SIDS/BRUE in sibling
  • Mental illness at home
  • Drug use at home
• For dysrhythmia
  • Family history of sudden unexplained death
• For infection
  • Fevers
  • Unimmunized
  • Sick contacts
  • Rash

Step 4: Examine for Non-Accidental Trauma

• Bulging fontanelle
• Petechia
• Torn frenulum
• Blood

Step 5: Place Patient Into One of Three Categories

• NOT a BRUE
  • Treat as you normally would
• HIGH risk BRUE
  • Admit
• LOW risk BRUE
  • Discharge without testing
  • May consider EKG and pertussis

Additional Reading

• Brief Resolved Unexplained Events (AAP)

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Don’t forget to do a thorough GU exam!

Step 1: Write Out Your Differential Diagnosis

• Remember 2-4-2-4
• (2) In the upper abdomen
  • Pyloric stenosis
  • Pneumonia
• (4) In the lower abdomen
  • Hirschsprung’s disease
  • Intussusception
  • Appendicitis
  • Hernia
• (2) Genitourinary
  • UTI
  • Testicular/Ovarian torsion
• (4) Generalized
  • Volvulus
  • Necrotizing enterocolitis
  • Henoch Schonlein Purpura
  • Diabetic ketoacidosis

Step 2: Do Pediatric History and Exam

• Pediatric assessment triangle
  • Appearance
  • Breathing
  • Color
• Birth history
  • Gestational age
  • Complications
• Eating/drinking/peeing/pooping
• Immunizations
• Physical exam
  • Don’t forget GU exam!

Step 3: Five Important Tests

• Finger stick blood glucose
• Urinalysis
• Chest x-ray
• Abdominal x-ray
• Abdominal ultrasound

Step 4: Common Treatments

• Fever/Pain
  • Acetaminophen
• Vomiting
  • Zofran
• Diarrhea
  • NOTHING
• Dehydration
  • Pedialyte

Additional Reading

• Pediatrics History (EM Clerkship)
• Pediatrics Exam (EM Clerkship)