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- 2. My stomach hurts 5 year old with vomiting and diarrhea – Arrives because of persistent fever – In general pain actually improved a couple of days ago – Looks very good. Watching TV (the advantage of having a new ED). In no distress – Abdominal diffusely and nonfocally tender – Ultrasound done to exclude appendicitis because pediatrician wanted one. – WBC normal Ultrasound negative – Patient discharged with diagnosis of gastroenteritis
- 3. Pediatric Appendicitis • Lifetime risk 7% • Misdiagnosis is common in young children – 100% around age 2 – 70% ages 3-5 – 40% ages 6-10 • Post-op complication from perforation increase from 8% to 39% QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 4. Why is appendicitis missed Most common misdiagnosis is GASTROENTERITIS Up to 33% of kids under age 3 have “diarrhea” • 40% of missed appy is called gastroenteritis • Pay CLOSE attention to exam. Gastro tenderness is diffuse, not localized. • BEWARE: Kids under 5 are less likely to wall off their appendix and more likely to present with diffuse peritonitis • CAREFUL physicians should not miss these
- 5. Diagnosis • Clinical judgment • Labs • Plain Xray • Ultrasound • CT scan Even in the best of hands the rate of normal appendix on operation in “classic” cases is over 10%. It is higher in more equivocal cases Up to 20% in pregnancy
- 6. Diagnosis • Clinical judgment • Labs • Plain Xray • Ultrasound • CT scan The peripheral WBC is of extremely limited use – Children with VERY common viral gastroenteritis or bacterial gastro often have high WBC counts – Children with early appendicitis are OFTEN normal
- 7. Diagnosis • Clinical judgment • Labs • Plain X-ray • Ultrasound • CT scan • Plain abdominal Xrays are useless – Obtained because often other diagnostic tests are unavailable – This does not make them any better • Not sensitive or specific • Do not discriminate • Fecalith is unreliable
- 8. Diagnosis Ultrasound • Limited radiation • Relatively sensitive – VERY dependent on the skills of radiologist – Up to 80% helpful with good reader • Does NOT exclude appendicitis CT Scan • More radiation • Expensive • Often unavailable • Extremely sensitive – Less operator dependent – Up to 95% sensitive • Excludes appendicitis if normal appendix seen – Avoids operation
- 9. What about our girl Came back 3 days later with perforated appendicitis • She was likely perforated on initial evaluation • She felt better when appendix ruptured a couple days earlier • Illustrates several pitfalls • Often misdiagnosed as gastroenteritis • Often has diarrhea • Often has normal WBC • Often has nonfocal exam • Ultrasound limited in EXCLUDING appendicitis
- 10. Pediatric hip pain • Septic arthritis • Toxic synovitis • Legg-Calve-Perthes • Aseptic necrosis • SCFE (Slipped Subcapital Femoral Epiphysis) QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 11. Septic hip vs toxic synovitis This is the REAL question Septic Arthritis • Average age 3-5 years • Time to presentation – 4+ days • May be afebrile – But most have low grade temperature • May not look clinically ill if early Toxic Synovitis • Average age 3-4 years • Time to presentation – 5+ days • May be very febrile – But most do not have a temperature • May be extremely uncomfortable and refuse any range of motion
- 12. Septic hip vs toxic synovitis Goal to identify EARLY before extensive damage Temperature and ESR are helpful in excluding septic hip – Most kids (66%) with septic arthritis with temperature over 37.5 °C – Most kids (80%) with septic arthritis with ESR over 20 – Combination picks up over 90% of sepsis
- 13. Septic hip vs toxic synovitis Problem with using temp and ESR – Up to 50% of kids with toxic synovitis have temperature OR a high ESR Step two: Imaging – Plain films – Ultrasound QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 14. Septic hip vs toxic synovitis Looking for fluid Plain films • Insensitive & will only show advanced cases with a lot of fluid Ultrasound • Sensitive and will find show small amounts of fluid seen in synovitis
- 15. Septic hip vs toxic synovitis Tapping the hip Up to now the evaluation has been working towards EXCLUDING cases of toxic synovitis. If there is a temperature or high ESR and fluid in the hip, you must do a diagnostic arthrocentesis – In the US this is an orthopedic procedure – There is some time urgency here – Diagnosis of septic hip should be washing out in the operating room – Antibiotics for staph and strep should be considered if ANY delays in operation or arthrocentesis are possible
- 16. Toxic synovitis After discharge Toxic synovitis is a viral reactive arthritis and is managed with ibuprofen or aspirin BUT…all cases require MANDATORY 12-24 hour follow to make SURE you are not missing septic arthritis
- 17. Other causes hip pain Legg-Calve-Perthes Idiopathic avascular necrosis of the femoral head – Other cases related to chronic steroid use or sickle cell disease School age children Early cases with normal Xray – Need MRI or bone scan
- 18. Slipped Capital Femoral Epiphysis Slipped growth plate at end of femoral head Adolescents Generally (not always) obese Early cases with normal Xray – Need MRI or bone scan
- 19. Slipped Capital Femoral Epiphysis Slipped growth plate at end of femoral head Adolescents Generally (not always) obese Early cases with nothing on Xray – Need MRI or bone scan K lein’s line ?
- 20. Slipped Capital Femoral Epiphysis Price of a missed case – Complete slip – Disrupted growth plate – Lost growth potential – Avascular necrosis of femoral hip – Chronic arthritis and DJD or hip Early pickups allow placement of a pin and potential recovery
- 21. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 22. The toxic neonate That kid looks BAD! Some illnesses present in the first two weeks of life with an abrupt deterioration A good clinician will understand that this is NOT always sepsis QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 23. The toxic neonate That kid looks BAD! Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 24. The toxic neonate Critical issues • Stabilization – Rapid IV access – Adequate fluid resuscitation – ETT and pressors? • Ampicillin/Gentamicin – Listeria – E coli – Group B strep Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
- 25. The toxic neonate Critical issues • Recognition • Stabilization – Rapid IV access – Adequate fluid resuscitation • Prostaglandin E1 – Antibiotics? – Pressors • Intubation? Yes but BEWARE Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
- 26. The toxic neonate Critical issues • Consideration - get a – Bicarb – Ammonia – Glucose • Stabilization – Rapid IV access – Adequate fluid – Glucose – Sodium Bicarb • Possible intubation Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
- 27. The toxic neonate Critical issues • Recognition – Low sodium – High Potassium • Stabilization – Rapid IV access – Adequate fluids • Hydrocortisone – Pressor-resistant shock Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congenital adrenal hyperplasia – Boys
- 29. Neonatal Vomiting • Gastroesophageal Reflux • Pyloric Stenosis • Volvulus Typical features – Gradual onset – Usually with each feed – Quantity can be large – Consists only of milk Do we really care? – Only if this is your misdiagnosis
- 30. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus • Onset in first 2-6 weeks – Boys ! • Early -- looks like reflux • Can have abrupt onset over 1-2 days • Late -- Vomits everything each feed
- 31. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus • Diagnosis – Ultrasound – The proverbial Olive – Classically projectile – Typical HUNGRY ! • Stabilization – Adequate fluids – Electrolyte correction • Over 1-2 DAYS • Then surgery QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 32. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus – The AAA of pediatrics – You miss this, they die – A true emergency • Onset usually acute • Onset at birth -- or anytime in first couple of weeks • Bilious emesis – Yellow or green • Exam – Toxic appearing infant – Shocky – Distended, tight abdomen
- 33. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus – The AAA of pediatrics – You miss this, they die – A true emergency • TIME IS BOWEL • Diagnosis – Immediate upper GI • TIME IS BOWEL • Stabilitization – Rapid IV access – Aggressive fluids • TIME IS BOWEL • IMMEDIATE surgery
- 34. One more time A missed volvulus is a death sentence QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 36. Pearl of Neonatal Wisdom • 6 week old infant • Fussy and not feeding quite as well – Decent urinary output • Well appearing on exam – Nonfocal, normal exam – Well hydrated – Normal vital signs • Discharged QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 37. Pearl of Neonatal Wisdom A Bad Physician Does not “hear” or listen to the parents Paternalistic Believes the parents are young, ignorant, uneducated QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 38. Pearl of Wisdom A Good Physician Listens carefully SOMETHING is different or they wouldn’t be there Be very careful ASSUMING nothing is wrong with an infant Parents know BEST ! QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 39. Pearl of Neonatal Wisdom Just before discharge, the next shift physician asked -- what about the feeding? Listening carefully, child really was changing. Subtle decreased sodium and increased potassium suggested CAH so admitted. Two days later, ruptured kidney unrecognized urethral obstruction Take home message: Always LISTEN to the parents
- 40. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 41. Pediatric Fever Well appearing 0-36 months of age The game we play -- Where is it hiding – Blood – Urine – CNS – Chest Risk is affected by – Age – Temperature – Appearance – Sex – Circumcision status – Immunization Status •This discussion is more germane to an urban population not at risk for zoonotic, typhoid, malaria, etc.
- 42. Appearance What should you do? Ill appearing Normal exam • CBC/Blood Culture • UA/Urine Culture • Lumbar puncture? • Chest Radiograph? Well appearing Normal exam It depends
- 43. The neonate 0-30 days Incidence of Serious Bacterial illness is high – Limited ability to localize or resist bacterial infection – Limited ability to express this illness • Cry more, eat less, less active • Fever tends to be LOW (38.0°C) • Delay in recognition – Rapid deterioration possible – This is true EVEN in the well appearing febrile infant – Don’t be cavalier with neonates
- 44. The neonate 0-30 days Judgment is limited: evaluation is empiric – Bacteremia: CBC/Blood culture • Prognostic value of CBC for bacteremia very limited – Urinary Tract Infection: Urinalysis and culture • 20% of bacterial UTI with normal urinalysis – Lumbar puncture: Meningitis • Social repertoire of young infants is so limited that clinical judgment useless • All children need a spinal tap – CXR: Pneumonia • Good thought but yield low without symptoms
- 45. The neonate 0-30 days Judgment is limited: evaluation is empiric – All children get antibiotics after cultures are drawn – Cover for typical organisms: from mother’s vaginal tract • Group B streptococcus • E coli • Listeria (extremely uncommon in US) – Empiric treatment with • Ampicillin • Gentamicin – Admit (if possible)
- 46. The young infant 0-30 days While judgment is extremely limited: – Children in first two weeks of life may be at greatest risk – Children with changes in behavior such as lethargy and poor feeding are very worrisome – Children with abnormal peripheral WBC (over 15,000 or under 5,000) – Positive urinalysis – Abnormal CXR
- 47. The young infant 30-90 days Judgment remains limited – This is a transitional age between newborns and older infants – They remain at risk for vaginal organisms from the mother but also to typical encapsulated organisms of older children – Social repertoire remains limited and difficult to assess – These children can also deteriorate quickly
- 48. The young infant 30-90 days Judgment remains limited: evaluation is empiric – Bacteremia: CBC/Blood culture – Urinary Tract Infection: Urinalysis and culture • 20% of bacterial UTI with normal urinalysis – Lumbar puncture: Meningitis • Social repertoire of young infants remains limited • A low threshold for empiric lumbar puncture – Many people empirically LP up to 6-8 weeks • Missing meningitis is the most devastating infection possible – CXR: Pneumonia • Again, yield low in absence of respiratory symptoms
- 49. The young infant 30-90 days Management Children at higher risk: – Children with changes in behavior such as lethargy and poor feeding are very worrisome – Children with abnormal peripheral WBC (over 15,000 or under 5,000) – Positive urinalysis (5-10 WBC) – Abnormal CXR
- 50. The young infant 30-90 days Children at higher risk should received empiric therapy until cultures back – The majority of pathogenic cultures will be positive within 24 hours • Typical organisms – Group B strep, E coli (neonatal organisms) – Pneumococcus, Haemophilus type B, meningococcus • Typical therapy – Third generation cephalosporin (ceftriaxone) – Lumbar puncture in the younger ages (6-8weeks) • Admission – If ill-appearing or if unreliable followup
- 51. Older Infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Children at highest risk of occult bacteremia are 12-24 months of age – 3-6 months are at less risk – But they deteriorate faster • This risk is due to a development immunodeficiency
- 52. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Risk and Temperature thresholds vary by age – 38°C represents real risk under 3 months – Very young children rarely have high temperatures – 39°C represents real risk over 3 months of age – Risk increases 2-3 fold as temperatures increase to 39.5°C and 40°C
- 53. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Boys are WEAK ! The main difference is found in risk of UTI Highest risk of UTI is in uncircumcised boys under 6 months of age Lowest risk is in circumcised boys over 12 months of age Girls are intermediate
- 54. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of occult bacteremia in well appearing infants in the U.S. in a fully immunized population (against pneumococcus and Haemophilus) is probably less than 0.5%
- 55. 3 months to 36 months Risk are affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of occult bacteremia in well appearing infants in the U.S. BEFORE universal immunization was on the order of 2-3% And this risk is modified by higher temperatures, ill appearance, etc.
- 56. The real question to is: what is the risk of progression of occult bacteremia to to meningitis? A recent meta-analysis showed that – 25/257 (9.7%) of untreated patients with pneumococcal bacteremia had persistent bacteremia or focal invasive infections at followup – The same study showed a 2.7% risk of progression to meningitis Pediatrics 1997;99:438 Pediatrics 2000;106:505
- 57. Older infants 3 months to 36 months Risk are affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of UTI in this age group is unaffected by immunization status and is on the order of 5%
- 58. Loose recommendations for 3- 24 (or 36) months Well-appearing fever without a source • UA/ Urine culture – All girls – Circumcised boys less than 6-12 months – Uncircumcised boys less than 12-24 months • Lumbar Puncture – If ill appearing • CBC/Blood culture – Consider strongly in the unimmunized – Address WBC count over 15-20,000 or less than 5,000 with empiric therapy – May defer in the fully immunized
- 59. Note on treatment Never administer parenteral (or oral) antibiotics without a reason – “Ear” infections are overdiagnosed. Do NOT use as an excuse to administer antibiotics – Always obtain cultures (blood or urine) prior to administering antibiotics (if possible) – NEVER administer antibiotics to a febrile infant (without an identified source of fever) less than 6-8 weeks without first performing an LP • Partially treated, unrecognized meningitis is a disaster
- 60. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 61. “Early” Pediatric meningitis Classic signs of meningitis – Kernig’s sign – Brudzinski’s sign – Stiff neck – Irritability – Lethargy These may NOT be present in early meningitis Of course one can simply wait until the diagnosis becomes obvious…
- 62. Pediatric meningitis Symptoms can be subtle Neonates – Well appearing with low grade fever – Poor feeding – “Not acting right” Infants 1-3 months – Fever and “a little fussy – Not feeding quite as well – Vomiting without diarrhea and looking more ill than typical gastroenteritis Older children – Consider meningitis in ALL children with a fever who complain of a bad headache – May be present in children with a bad headache, neck discomfort, or vomiting and NO fever
- 63. Febrile Seizures • Frequency 1:20-50 children • SIMPLE febrile seizures need NO special evaluation or treatment – Meaning no empiric spinal tap – Except for evaluating fever • “Simple” means: – Nonfocal - generalized – Short - less than 15 minutes – Single - only 1 in 24 hours – Return to NORMAL mental status • Beware the child already on antibiotics for partially treated meningitis
- 64. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for 5 days – Irritability • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
- 65. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
- 66. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
- 67. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
- 68. Kawasaki Disease Why this diagnosis is important Nobody every died of Kawasaki disease. Or did they? – Kawasaki’s is a vasculitis and myocarditis is present – Untreated, 13-40% develop coronary aneurysms – These giant aneurysms (8mm) thrombose, resulting in acute MI and death – This risk is greatest in the first year after the illness
- 69. Kawasaki Disease Why this diagnosis is important KD and prevention of coronary aneurysms are very responsive to treatment – But the correct diagnosis must be made – Treatment consists of • Aspirin • IVIG (Immunoglobulin) • Possibly corticosteroids
- 70. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 71. Vomiting and lethargy What do these 2 cases have in common? A 9 month old presents with 6 episodes of emesis for one day – No diarrhea – No fever – Last one bilious – No abdominal pain On exam, awake in no distress – Glassy-eyed and lethargic – Very soft abdomen You perform the LP but the results are negative A 5 year old presents with intermittent, severe abdominal pain – No fever – Emesis once – No diarrhea – History of a vasculitic rash for one week On exam, comfortable and well appearing – Abdominal exam benign – Petechiae, purpura on legs and buttocks
- 72. Intussusception Classic, text book presentation – Colicky severe abdominal pain – Acting normal between episodes – Vomiting – Current jelly stools • In reality, this presentation may be the exception QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 73. Intussusception A tale of two presentations Classic, text book presentation – Colicky severe abdominal pain – Acting normal between episodes – Vomiting – Current jelly stools • LATE finding! • Represents bowel ischemia Altered mental status – Lethargic, appears almost sedated with drugs – Meningitis often the primary misdiagnosis – Vomiting invariable – Abdomen general soft but may feel the mass
- 74. Diagnosis & Treatment • Barium or air contrast enema diagnoses AND reduces the intussusceptum • Refractory cases need surgery • Do not do enema until surgeon called – Risk of perforation by less experienced radiologist – Historically (1890s) up to 50% of children perforated and died QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 75. Diagnosis & Treatment If a barium enema seems invasive, consider CT or ultrasound for diagnosis and then enema if intussusception present
- 76. Diagnosis & Treatment In context of Henoch-Schonlein Purpura With HSP the intussusception – is NOT the typical ilio-colic intussusception – It is ILIO-ILIAL – Diagnosis will NOT be made with barium enema – Diagnosis is made on CT scan – Usual treatment is medical observation
- 77. Intussusception and HSP Henoch-Schonlein Pupura IgA mediated vasculitis similar to TTP in adults Diagnosis is clinical – Typical purpuric rash in dependent areas • Lower ext in children • Buttocks in infants – Arthralgias – Renal disease • May result in renal failure – Intussusception in some QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 78. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 79. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 80. Vomiting and tachypnea What do these two cases have in common? 8 year old with two days of vomiting – No fever – No diarrhea – Now bilious – Generalized abdominal pain – Recent history of weight loss On exam – Thin and ill appearing – Nonfocal abd tenderness – Candidal perineal rash 2 year old with two days of fast breathing – No cough – No fever – No feeding well – Spits up feeds On exam – Ill appearing – Dehydrated – Tachypneic – Clear lungs – Tachycardic
- 81. Diabetic ketoacidosis Diagnosed on a routine chemistry • Diagnosis DKA easy with history of diabetes • Classic presentation polydipsia, polyuria, weight loss -- but only if you ask • Atypical features – Altered mental status – Respiratory “distress” – Thrush / Perineal ‘diaper’ rash – Abdominal pain and vomiting
- 82. DKA Three problems in order of importance • Dehydration • Electrolyte disturbances • Insulin deficiency – While this is the underlying cause, it is NOT the immediate problem QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 83. DKA Dehydration They are dry, why not give them lots of fluids? – Give only a SINGLE bolus of 10- 20cc/kg UNLESS hemodynamically unstable – Theoretical risk of inducing cerebral edema – Correct dehydration over 12-24 hours – NEVER bolus with anything except NORMAL SALINE
- 84. DKA Electrolytes Potassium is the critical problem – They are profoundly depleted – Hypokalemia from both urinary loss and acid base shifts in the serum – Never give potassium until you prove there is no renal failure (urinate once) – If the starting serum potassium is low -- BEWARE -- it will drop quickly with fluids and insulin • Be prepared to aggressively replace (and monitor -- every 2 hours) potassium once therapy starts
- 85. DKA Serum glucose and insulin No one NEEDS insulin in first hours – Address fluid deficit and potassium – Glucose will drop significantly with simple fluid administration Principles of insulin administration – Do NOT bolus insulin • It does not act faster and simply results in overshoot hypoglycemia – Start with 0.1 unit/kg/hour – When serum glucose below 250mg/dl do NOT reduce insulin --- increase dextrose in IVFs
- 86. DKA Cerebral edema This is what kills kids with DKA • Occurs only in kids • Onset can be SUDDEN – Blown pupil – Apnea – Profound mental status change • Be prepared to administer Mannitol IMMEDIATELY – Intubate if necessary
- 87. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 88. Stiff neck and Stridor What do these two cases have in common? 23 month old leaving for Germany tomorrow with a stiff neck and fever – Fever 38.9°C – Holds neck stiffly – Decreased oral intake – Not particularly sick appearing 19 month old transferred for asthma attack – No wheezing but has stridor – Low grade fever – Poor response to racemic epinephrine – Progressive respiratory distress – Episodic apnea – Diagnosis made
- 89. Retropharyngeal abscess • Occurs in younger children – Adenoids involute with age • Multiple potential spaces in the neck • Clinical presentation resembles meningitis with stiff neck • Clues are there – Without altered mental status – Subtle swelling of face – Dysphagia/drooling QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 90. Retropharyngeal abscess Diagnosis and treatment • Textbook diagnosis is a lateral neck film – Not particularly sensitive and may miss early cases – Not particularly specific if poor technique • Money is on the CT scan for diagnosis – Delineates extent of disease – Helps decide whether therapy is medical or surgical QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 91. Look-a- likes A 9 month old presents with 6 episodes of emesis for one day – No diarrhea – No fever – Last one bilious – No abdominal pain On exam, awake in no distress – Glassy-eyed and lethargic – Very soft abdomen You perform the LP but the results are negative A 7 month old presents with 4 episodes of emesis for one day – No diarrhea – No fever – No abdominal pain – Lethargic all day On exam – Lethargic – Ill-appearing – Non-focal exam You perform the LP but the results are bloody 6 month old with one day lethargy – Tactile fever – Sleeping – Little oral intake – Decreased urination – Vomited twice On exam – Tachypneic – Lethargic – Dry – Low grade temperature
- 93. Child abuse Shaken baby syndrome Presents as altered mental status – In younger infants as lethargy and poor feeding – Vague story – Nonfocal exam
- 94. Same fracture Two stories My 1 year old was playing with a toy my 4 year old wanted The older one tackled the younger one His leg got twisted under his leg He screamed and won’t walk on his leg and we rush him down here as fast as we could My 1 year old was fine yesterday Now he won’t walk He fell off the couch yesterday. That might be it.
- 95. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 96. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 97. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 98. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 99. Conscious sedation in kids Agents – Midazolam – Midazolam/Opioid – Pentobarbital – Propofol – Etomidate – Ketamine Problems – Paradoxical reaction – Respiratory – Respiratory/hypotension – Hypotension – Respiratory – Laryngospasms (rare)
- 100. Ketamine • Useful in all ages – Concern about use in older kids misplaced • Inexpensive • Reliable – Does not provide analgesia per se – DISSOCIATIVE agent and therefore unaware of pain – Also amnestic to procedure
- 101. Ketamine • Useful in all ages • Inexpensive • Reliable • Risks are low – Protects airway – No respiratory depression – No hypotension – Rare cases of laryngospasm • Adverse effects – Vomiting (up to 20%) – Emergence reaction (uncommon) QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
- 102. Ketamine Administration practicalities • Dosing – 2mg/kg IV – 4mg/kg IM • Side effects NOT dose related • Duration IS dose related – 0.5 - 1.0 mg/kg for short procedures – May repeat multiple doses if procedure prolonged • Pretreat with ATROPINE – Reduces secretions and laryngeal irritation • No need to pretreat with midazolam – Does not prevent emergence reaction – Can treat afterwards if needed • Laryngospasm – Almost all kids can be bagged through the event
Notes de l'éditeur
- This is a case of a child that looked very good and had an evaluation for appendicitis that I did not think she had. I only did the studies because she was a referral from a private pediatrician. The ultrasound did not show appendicitis, she still had some tenderness, but don’t a lot of children and we discharged her looking good. The case will illustrate the pitfalls of diagnosing appendicitis and how easy it is to miss -- even when you are actually looking for it. This concept MUST BE EMPHASIZED. Less skilled physicians are more likely to miss appendicitis as the next slide will show
- Misdiagnosis is almost the rule in very young children. Between the ages of 3-5 years of age, appendicitis presents as a PERFORATED APPENDIX. This means that either the parents or the physicians waited to long before making the correct diagnosis. Take home…it is DIFFICULT to diagnose appendicitis in young children and a high index of suspicion must be maintained. Even in older children, the diagnosis of appendicitis is frequently missed or delayed.This is important because morbidity increase with perforation.
- Why is it missed? Many children have “diarrhea”. Family and physicians then think that this is acute gastroenteritis. Beware: what people call “diarrhea” may really just be loose stools and not really diarrhea. You must ask what the parents mean by diarrhea. Also, gastroenteritis should not have FOCAL tenderness, or should not have impressive generalized tenderness (which would suggest perforation and peritonitis). Pay close attention to ANY child with a diagnosis of stomach infection and focal tenderness. Children less than age five are less likely to wall off their ruptured appendix and will not form an abscess. They will develop peritonitis.
- Clinical judgment is the time honored way to diagnose acute appendicitis. But even the most skilled surgeons. A good surgeon will have a 10% false positive rate (10% unnecessary surgeries). A bad surgeon will either do more surgeries or wait too long and have more perforations.
- This slide illustrates the different aids in the diagnosis of appendicitis. Beware: the white blood cell count has VERY LIMITED utility. Remember to teach about positive and negative predictive value. Appendicitis OFTEN presents with a NORMAL white count (especially when early). MANY OTHER more benign problems such as gastroenteritis present with an elevated white count for which surgery is NOT indicated. It is is valuable but very LIMITED in it’s usefulness.
- The diagnostic utility for plain Xrays in diagnosing acute appendicitis is USELESS and should almost never be done. The theory is that a visible fecalith means that acute appendicitis is present. There may be an association but there are much better ways to diagnosis appendicitis, including clinical judgment. Xrays have NO ability to discriminate appendicitis as the cause of abdominal pain over other causes.
- When the clinical picture is unclear, diagnositic imagingg may be helpful. Ultrasound is attractive because of the limited exposure to radiation. The cost is generally less. It can diagnose acute appendicitis in skilled hands. However, unless the radiologist is very skilled they may miss the diagnosis. So ultrasound is good when appendicitis is seen. But when it is NOT seen, you can’t be sure that you just aren’t missing it. A negative study does not guarantee that the patient does not have appendicitis. CT scan has several advantages. They are easier to read and less operator dependent. They are extremely sensitive, meaning they will pick up most cases (if the radiologist is good) and miss very few. So a “normal” CT scan is unlikely to have a missed appendicitis. Often a normal appendix is actually seen on the radiograph, PROVING that the patient does not have appendicitis. Disadvantages are that there is radiation exposure. They can be expensive. They are not available everyone. Also, early appendicitis can be missed, especially if a normal appendix is not actually seen on the scan. But while it is not perfect, it is VERY good.
- So going back to my case. Just to show how difficult it can be: This child had a perforated appendix on the first visit which was misdiagnosed until later. Her initial diagnosis was gastroenteritis because she had diarrhea. She had a normal WBC which was relied on inappropriately. Once the appendix is perforated it may become nonfocal (and not severe). The ultrasound is far from perfect when the reading is negative.
- Pediatric hip pain can be a high risk problem because two of the causes are time dependent for a good outcome: SCFE and septic arthritis.
- Few issues are as time dependent as the septic hip. A missed septic hip can result in rapid joint destruction and life long disability. The far more common look alike is toxic synovitis, a reactive arthritis following a viral infection that can be moderately severe but is benign and self-limiting. These two conditions, with very different outcomes, can look very similar. They affect the same age group of children. They have the same time course. They can both have fever (or not). They can both look quite ill with a lot of pain (or not). Bottom line: Just because the child does not look very ill or have a high fever, do NOT assume that the hip is not infected. If you wait and find out later, irreversible damage has been done.
- What is helpful is the most (not all kids) with sepsis have a fever (not particularly high). Also, most have and elevated sed rate (but not all). However, what is helpful is that fact that almost all have either a temperature OR a sed rate. Those with neither are unlikely to have a septic hip (Here you are using the negative predictive value.)
- If a temperature OR an ESR is elevated, you will need to look further. Plain films are NOT sensitive to picking up fluid in the joint and are rarely helpful (other than to exclude trauma or other bony problems). Ultrasound is necessary to look for joint fluid (or you can simply tap the joint)
- All hips require CLOSE followup because… you might be wrong.
- Other causes of hip pain. Legg-Calve-Perthes is a sort of aseptic necrosis of the hip. See on the left hip. Not much you can do about this. Just recognize it and refer it.
- SCFE on the other hand MUST be recognize. You can see on the left there is a slippage at the growth plate that is significant. Once it progresses this far, the vascular supply is disruptive and the outcome may be poor. The goal is to pick this up BEFORE there is a significant slip so that the epiphysis can be surgically pinned. Early cases can be quite subtle and easily missed. However, missed cases suffer lifelong disability.
- Here is Klein’s line. This case is obvious and does need this method, but more subtle cases may benefit from using this method.
- A missed case has lifelong consequences. Here the epiphysis has been surgically pinned, but late.
- This is near Aspen Colorado, a few hours from where I grew up.
- A number of things can cause a very young infant to look terrible. The assumption is almost always infection and sepsis. But the cause is not always sepsis and these other causes do not respond to antibiotics.
- Other causes of critical illness in the first month of life without obvious causes: I.e. they just look bad. Volvulus is a critical illness in neonates but there are specific findings, e.g. vomiting. The above kids just look shocky and may have only subtle findings that point to the underlying cause.
- Sepsis is the one everyone thinks about first, because it is the most common. While antibiotics are important, they are not enough. As noted in the cardiac lecture, AGGRESSIVE management of shock is NECESSARY for survival. Rapid iv access in minutes (intraosseous if necessary) with aggressive fluid resusciation ( up to 60-80cc/kg in the first how if needed. Cover with appropriate antibiotics.
- Congenital heart disease may look much like sepsis. The child may have a ductal dependent cardiac lesion and be doing just fine until the ductus closes. An example may be coarctation of the aorta or hypoplastic left heart syndrome. When the ductus closes, critical blood flow to the lungs or body are disrupted and the child goes into fulminant shock. The only way to save these children is often to open the ductus arteriorus back up with intravenous prostglandins and transfer them to a children’s hospital. But to do this, you must first recognize that it is a cardiac lesion. Sometimes CXR can help. Sometimes just an ECHO. Sometimes a murmur. You will want to intubate these critical children. Beware: they may be MAXIMALLY COMPENSATED and intubation may tip them over the edge and they will arrest when paralyzed and intubated. Only intubate if necessary.
- Another cause of shock in the neonate is an inborn error or metabolism: a genetic disorder that results in profound metabolic acidosis. One must first consider the diagnosis to get the right answer. The bicarb and glucose will often identify these kids. But sometimes, an elevated ammonia is the only finding and you will only find this if you look for it. This is obviously not a routine lab. Stabilization is treatment of the shock with IV fluids and glucose and perhaps bicarbonate to normalize the sugar and improve the acidosis (Don’t correct the acidosis)
- Congenital adrenal hyperplasia results in a critical lack of endogenous corticosteroids and mineralocorticoids and children present in shock at about two weeks. Girls are picked up at birth before they get sick because they have ambiguous genitalia. The clue it the low sodium and the high potassium on the chemistry. Treatment is hydrocortisone, which you won’t give unless you think of the diagnosis.
- From where I grew up in Colorado.
- Neonatal vomiting can be a critical problem, primarily because of the concern of volvulus and pyloric stenosis. Gastroesophageal reflux is added because this is the most COMMON cause, even if not the most serious. Also, it is what patients with volvulus and pyloric stenosis are diagnosed with. In general, children with reflux do not suddenly begin to vomit. They have been spitting up all along. But they can progress to the point of vomiting with each feed and a significant amount of each feed, making severe reflux difficult to differentiate from the more serious pyloric stenosis. It will always be nonbilious. When I ask the question, do we really care? I am referring to us as EMERGENCY PHYSICIANS. Of course we care, but we don’t need to address the problem with the same urgency as the other two diagnoses. Also, we care because it is bad if we misdiagnose volvulus or pyloric stenosis as GER.
- Pyloric stenosis is more serious and can look like more severe reflux. The characteristic group is the BOY between the ages of 2-4 weeks. Why boys? I don’t think anyone knows. One of the confusing aspects is that early on, it resembles reflux -- vomiting with some but not all feeds. Vomiting a lot but not all feeds. What is different is frequently that these are not kids who have been vomiting prior to this. Something has changed. Always worry when you diagnose ‘sudden onset gastroesophageal reflux”. Don’t worry, it will get worse! As pyloric stenosis progresses, vomiting will occur with each feed and will remain nonbilious. Kids will feed well because they are quite hungry. Eventually however, they become lethargic and poor feeders as they become more dehydrated.
- Diagnosis is NOT on exam. The proverbial olive is extremely late in the course and I have never felt one. Diagnosis is made on the size of the pylorus on ultrasound. If ultrasound is not available, admit these kids for IV fluids and sono the patient in the morning. These kids need to be rehydrated and their electrolytes corrected before what is othewise a very simple surgery.
- Volvulus is the one true miss. It is the aortic aneurysm of neonates. Neonates should NOT vomit green or yellow. Onset is typically around birth or the first few weeks, but can occur later. These kids look sick. Volvulus of the arterial supply of the gut results in intestinal ischemia, acidosis, shock and translocation of bacteria through a leaky intestinal barrier with sepsis. You have only a few hours to intervene or these children will die. Even with a rapid response, bowel is invariably lost.
- Definitive diagnosis is an upper GI to show the twisting. But do not wait for this test to call the surgeon. These kids should go to the operating room if a radiologic study is delayed. They need stabilization of their shock: IV fluids, antibiotics, perhaps pressors and or bicarb
- This is not a medical slide per se. It is a case that illustrates a lesson. A six week old was seen by a general (well trained and skilled) emergency physician. The chief complaint was simply that the child was not feeding as well. The child looked good on exam and labs were relatively unremarkable. Not finding anything wrong, the child was discharged to home. The picture is a pearl -- we say a “pearl of wisdom” for a specially important and wise fact.
- This is to remind physicians to be diligent and not sloppy or lazy. A bad physician or clinician does not listen well or is paternalistic. They may believe they listen but they do not actually hear what the patient’s parents are trying to say, only what they think is right. They may think the parents are young, ignorant, that they do not understand, and are overly worried. Physicians should only disregard what parents have to say at their own peril as well as that of the child. I have seen this kind of arrogant practice over the years and this is especially a problem for neonatal patients where all clues are subtle (until it is too late)
- A good physician listens carefully (like this baby). Parents don’t bring in their kids because they are acting funny. They bring them in because something has changed. Something new is going on. Sure, parents bring their kids in for colic because the crying never ends. But usually, the child is one who is fussy and SUDDENLY is crying much more. Parents may bring them in for reflux, but often they bring their kids in because they are SUDDENLY vomiting EVERYTHING (I.e. not reflux but pyloric stenosis). Something has changed. Physicians must be good listeners and careful not to ASSUME that nothing is wrong. Start with the premise that the parents are right. PROVE that nothing is wrong, don’t make the child prove that something IS wrong.
- So as the above case progressed. The parents noted that they never got an answer to why the child had changed their feeding behavior. Listening carefully, the child really had changed the amount of feeding and was admitted to the hospital without a clear diagnosis. Within two days, the calyx of the kidney ruptured from obstruction and everything became obvious. Had the child been discharged, this would have happened at home.
- The next set of slides are the approach to fever in the infant in the United States. It must be recognized that we have had a very aggressive approach in infantile fever and have favored laboratory evaluation over simply clinical judgment because judgment will miss a few cases of occult bacteremia which progresses to meningitis. Since the introduction BOTH haemophilus AND pneumococcal vaccine, this approach has lessened somewhat. However, pneumococcal vaccination is not universal. Sick kids look sick and get an evaluation and admission. In many places the WELL APPEARING child is assumed to have nothing wrong and is discharged. THIS is the child we are talking about. It has been recognized for 20-30 years now that a small percentage of WELL APPEARING infants with fever and no apparent source of infection have a “hidden” bacterial illness. Usually this is urine (and cannot be diagnosed clinically). But it can also be occult bacteremia, pneumonia, or even meningitis in the very young. In other words WELL APPEARING infants with fever can harbor serious or life threatening bacterial illnesses. So how can you tell which ones these are?
- Obviously, ill appearing children get everything done. Well appearing children often get no further examination and discharge. But should they? It depends on your resources and your understanding of pediatrics and how much risk you accept.
- For children who are under a month of age, fever is a BIG deal. Neonates have almost no behavioral cues to help physicians decide which ones have bacterial illness -- as noted in the previous slides, when they do have clues they are often extremely subtle. They may cry less, eat less, be less active. The fever may be very low at 38. OR…they may simply look the same and have a fever. The problem is that with missed infections, they can deteriorate rapidly because of their age.
- Clinical judgment is extremely limited in this age group to see who has bacterial illness and who does not. Limited meaning judgment is not helpful.(Remember, we are not talking about obviously sick children). All children under a month of age should have a CBC and a blood culture (although the CBC is also of limited value and may be falsely normal). They also need a urinalysis and urine culture. (But 20% of urinary tract infections with positive urine cultures will have a falsely negative urinalysis in young children). Lumbar puncture is routinely performed in ALL children with fever less than a month because it is widely accepted that one cannot clinically EXCLUDE meningitis. (You can clinically diagnosis it but you cannot clinically exclude it in these young children because they may look well). Standard of practice in the US is to LP all these children. The data on who needs a CXR is less clear. Certainly anyone with respiratory symptoms.
- In the US ALL children under 30 days of age get antibiotics and admitted after the above workup. The chance is having serious bacterial illness even if well appearing and with normal labs is too high. Empiric treatment is ampicillin and gentamicin for the above organisms. Ceftriaxone should not be used under two months of age.
- In a place where resources are limited, one can make some LOOSE statements about who is at greatest risk. Note above.
- Again, I am emphasizing the point that judgment is limited in this age group. Physicians may make judgments about the very young. They may be lucky from a statistical standpoint, but judgement is imperfect.
- We treat children after the first 30 days a little differently. They are a little easier to assess clinically. In general the laboratory evaluation is the same except for the lumbar puncture part. They are a little easier to assess and meningitis can be excluded based on good clinical appearing in the older kids. Most emergency physicians in the US perform lumbar puncture for the first 6-8 weeks, while many of the pediatric specialists may push this down to four weeks of age.
- For ages 30-90 days, children who look sick are at higher risk of having serious bacterial illness (but remember, we are really talking about well appearing infants). So for well appearing infants, those at lowest risk are those with “normal” labs. Note that I am saying lowest risk. In these very young infants, “normal” labs are not a guarantee that bacteremia or a UTI is not present, but it reduces the chance of this greatly.
- Those with abnormal labs should receive empiric antibiotics until cultures come back negative (a day later). Cover the above organisms with a third generation cephalosporing after two months of age. Not the comment about an LP. The reason is that the LP is often omitted after four weeks of age. But if labs are abnormal and antibiotics are given, then an LP should be performed before giving antibiotics to prevent accidentally partially treated meningitis.
- After 3 months of age, clinical judgment and epidemiologic factors become much more important and each child approached individually. Risk is affected by age. Children between 3-36 months of age are at risk for occult bacteremia. Let me define this: Occult bacteremia is bacteria in the bloodstream in an infant who is well appearing and CLINICALL INDISTINGUISHABLE from a simple viral infection. In other words it is IMPOSSIBLE to clinically identify occult bacteremia in any individual child. We know from large studies who is at risk. Children 0-36 months of age are at risk. The greatest age group at risk for Haemohilus and Pneumococcal bacteremia are children 12-24 months of age. Physicians are much more likely to draw labs on children between 3-6 months than 12-24 months of age thinking them at greater risk. The reality is the opposite. Children 3-6 months of age still have residual protective antibodies from their mothers. These are gone in the second year of life, but the still have a developmentally immature immune system. Having said this, younger children tend to deteriorate faster and should still be assessed closely. The developmental immunodeficiency I refer to is the fact that children in the first 3 years of life are UNABLE to effectively develop immunity to polysaccharides (sugars). The capsules of pneumococcus, haemophilus, and other ENCAPSULATED organisms are made of sugars
- Risk is affected by the temperature (rectal). For children under 3 months of age, the risk of a hidden bacterial infection becomes very real at 38C. But for children over 3 months of age, risk really goes up after 39C, meaning that higher temperatures can be tolerated. Risk increases progressively the higher the temperature, but is never excessive, even at very high temperatures.
- THE HIGHEST risk of urinary tract infection is in BOYS under 3-6 months of age, and this most specifically mean boys who are UNCIRCUMCISED. This risk drops off dramatically in after 12 months of age (earlier at 6 months of age for circumcised boys). Girls are at risk of “occult” or “hidden” UTIs up to 24 months of age (until they are toilet trained). The means that ALL girls get urine studies for the first couple of years for fever without a source and all boys under 12 months of age who are uncircumcised or under 6 months of age who are circumcised.
- Obviously immunization status is important. The aggressive laboratory evaluation of WELL APPEARING children with fever WITHOUT AN OBVIOUS SOURCE made financial sense in United States when pneumococus and haemophilus were still causing disease. Immunization for Haemophilus made a critical difference in the amount of meningitis and serious illness in children but not until pneumococcal vaccination became widespread did we begin to change our practice. If children are COMPLETELY immunized, then the risk of occult bacteremia becomes extremely low and blood work is likely unnecessary. BUT…..this does not affect the risk of urinary tract infection.
- As noted the risk of bacteremia in WELL APPEARING CHILDREN WITH FEVER WITHOUT A SOURCE was a respectable 2-3%. This was important because some of these children became septic and some developed meningitis.
- As noted the risk of bacteremia in WELL APPEARING CHILDREN WITH FEVER WITHOUT A SOURCE was a respectable 2-3%. This was important because some of these children became septic and some developed meningitis. These children were then devastated. The thinking was to catch bacteremia while it was still occult rather than waiting until they became critically ill.
- Remember, the risk of UTI is unaffected by immunizations and often has no obvious signs on exam (until it becomes advanced and they look sick with pyelonephritis and vomiting).
- Here is a summary slide of some general recommendations as practiced in the US. As noted, we are doing much less blood work in children because they tend to be completely immunized. But OFFICIAL recommendations have not changed yet.
- Physicians worldwide over prescribed antibiotics. This is simply bad medicine. It is PHYSICIANS who have driven serious bacterial resistance worldwide. This is a reminder that we overdiagnose ear infections as an excuse to give antibiotics for fever. Antibiotics should never be given parenterally unless cultures are obtained. The reason is that if cultures are not necessary, then neither are antibiotics. Also, NEVER administer intravenous antibiotics to the very young infants less than 6-8 weeks of age without also obtaining an LP first (if you are not treating a focal infection such as UTI, cellulitis, ear infection).
- Where I went to college. Boulder Colorado
- Meningitis is easy to miss in the very young. Textbooks talk about the classic signs noted above. But the reality is much different in young children.
- Neonates may have ABSOLUTELY not signs or symptoms other than fever. They may have no fever and just be acting funny. As they get older they get easier to clinically assess. Infants 1-3 months of age may have very subtle signs and symptoms and a VERY LOW THRESHOLD FOR LUMBAR PUNCTURE should be maintained. Infants older the 3 months of age and older children can be better assessed clinically. But some children may present with headache and fever and not have a stiff neck.
- Physicians who are not pediatricians often worry too much about febrile seizures. SIMPLE febrile seizures need no special evaluation (other than what you normally would for the fever). They certainly do not need a spinal tap. This is only for SIMPLE febrile seizures. This means generalized, nonfocal, short duration, only one in 24 hours and a return to COMPLETELY normal mental status. If these criteria do not ALL apply, then the seizure is considered a complex febrile seizures and needs an aggressive evaluation including a spinal tap. The one exception is the child with a simple febrile seizure WHO IS ALREADY ON ANTIBIOTICS. These children may have meningitis that is modified by the antibiotics and may present differently.
- Kawasaki Disease is seen worldwide but can be difficult to recognize. They just look sick with several subtle findings noted above. First they feel bad and are NOT happy. A generally well appearing infant or child who is febrile but is otherwise happy is unlikely to have Kawasaki Disease.
- They can have skin changes such as peeling of the digits. This is usually late in that course. But RASH is extremely common and is generally nonspecific in appearance. Just rash.
- They often have conjunctivitis without discharge (such as you might see in measles, which can EASILY be confused with Kawasaki). The will have lips and a tongue that are more bright red than usual.
- Lymph nodes must be large and over 1.5cm to count. The can also have a nonspecific swelling of the hands and feet.
- Why is this important not to miss? Because of the underlying vasculitis that is present. These children are developing coronary vasculitis and large coronary aneurysms that can ultimately cause fatal myocardial infarction at any time. This is only true if the diagnosis is unrecognized and the child remains untreated.
- Here are some pictures of these aneurysms.
- Colorado National Monument
- These two cases illustrate the same case. The first should be easier to recognize as intussusception. The second would only be recognized as intussusception if one could first recognize that this child has Henoch Schonlein purpura and then that the two conditions were related.
- Everyone should remember and know the classic textbook presentation of intussusception. As with most things in medicine, the “classic” presentation may be the exception rather than the rule.
- The classic presentation is colicky, intermittent abdominal pain. Severe one minute and normal the next. These episodes of pain strike the child suddenly, last for 10-20 minutes and resolve for minutes or even hours at a time; the child acts normal in the meantime. Eventually, vomiting from the obstruction is invariably present. Eventually, current jelly stools occurs from intestinal ischemia. This is a late and bad finding. One should never wait for this to make the diagnosis. (However, the stools are frequently guaiac positive for heme long before they are visibly current jelly). As frequently (or more so) is the child whose PRIMARY presentation is one of altered mental status. The child is not obtunded but appears quite sedated. Lethargic and limp. The less sophisticated physician frequently puts meningitis at the top of their list; but these children do not look like they have a ‘cloudy’ mental status so much as they are very “relaxed” appearing. This is a difficult concept to place in words. The point is that CNS symptoms frequently predominate in intussusception.
- Definitive diagnosis (and treatment) is by a barium enema. Often the obstruction is not reducible and the patient must go to surgery. While the risk is small (in very skilled hands), barium enema has been known to cause intestinal perforation requiring an emergent operation. It is recommended that the surgeon be informed before this procedures takes place for this reason.
- Often, a barium enema seems invasive to the family and is discouraged, particularly in equivocal cases. In situations where the physician or the family does not want to subject the child to this test, in situations where a physician skilled in doing a barium enema in a small child is not available, or when other diagnoses are being considered such as acute appendicitis, other studies may be done. Intussusception can be visualized on both CT and ultrasound
- Intussusception with HSP is a little different. First of all, the children who get this are a bit older. Secondly, the location is different. In primary intussusception, the “lead point” or primary lesion is the Peyer’s patch lymph nodes in the terminal ilium, leading to an ilio-colic intussusception. With HSP, the lesion is more proximal, resulting in and Ilio-ilial intussusception. This significance is two fold. These ilio-ileal lesions are not easily seen (and diagnosed) by ultrasound and they CANNOT be reduced by barium enema.
- Just a reminder of what HSP is. It is a transient (usually) vasculitis. Typical signs and symptoms include a purpuric rash in the lower extremity (buttocks and back in babies), arthralgias, and evidence of renal disease. Intussusception is not common but well described.
- Sand Dunes of Colorado
- Two more cases of very different children who have different presentations of the same diagnosis. I use cases a lot to engage my audience. By making them think about what the diagnosis is, they ACTIVELY engage in the learning process, sifting through their knowledge of what this could be compared to their own experiences. If they are right, the will learn more. If they are wrong, they will pay even closer attention. Either way, teaching with cases will cause the learner to ACTIVELY incorporate information into their own clinical knowledge base.
- These cases were both DKA. Especially easy to miss in the two year old. DKA is easy to diagnose when you know the child has preexisting diabetes. But is may be the presenting event that makes the diagnosis. And it may present in an atypical fashion as noted with intussusception. These children may have altered mental status from cerebral edema and advanced DKA. They may be perceived to be in respiratory distress due to the tachypnea -- this is especially true in preverbal children. Older children who are past the infant stage should not have candidal rashes of the perineum or thrush. This implies an immune deficiency which is often diabetes. And finally, children may have serious abdominal pain that mimics an acute abdomen.
- Physician frequently get their priorities out of order and focus on the blood sugar. This is the LEAST of your problems. First and foremost is hemodynamic stability. THEN it is electrolytes, I.e. potassium (in the silver vial). Finally, address the sugar.
- Dehydration is typically profound. It SHOULD NOT be corrected rapidly. The only thing that needs to be addressed rapidly is hemodynamic STABILITY. If the patient is not shocky, go slow. If the patient is in shock (compensated with normal blood pressure or decompensated with hypotension), bolus until stable and then resume a slow hydration protocol. You are NOT in a hurry. Rapid or excessive hydration has been linked to the develop of cerebral edema, the most lethal of consequences in childhood DKA that is rarely seen in adults. (This linkage is recently somewhat controversial and not clearly proven. NO FLUIDS OTHER THAN NORMAL SALINE should be given initially. While the free water deficit is greater then the sodium deficit, both are present and hypotonic fluids should not be given in the initial treatment phase in the emergency department.
- Potassium is the next most critical issue. They are PROFOUNDLY depleted. But frequently because of acid-base shifts, the serum potassium is initially normal with a significant acidosis. As the acidosis resolves and as insulin is given, potassium is driven into the cells, driving the serum potassium down which can cause conduction problems in the heart. If the initial serum potassium is already low, you can assume the potassium will drop quickly and you could be in serious trouble as soon as fluids and insulin are started. Aggressive potassium replacement should begun immediately. (The only caveat is that the patient needs to prove they are not in renal failure by urinating prior to giving intravenous potassium)
- Finally, address the glucose issues. The initial fluids management will rapidly and significantly drop the presenting serum glucose without the need for insulin, sometimes by half. Start insulin as soon as is practical. There is no advantage to giving a bolus and then a drip. They do not get better faster but frequently develop hypoglycemia from overshoot. What is the hurry? Start a drip at 0l.1 unit per hour. Check serum glucose hourly and as it gets low you can increase the dextrose in the IV fluids to D5/NS or D5 1/2NS to D7.5 to D10. If you are still have a problem then ease down on the insulin but try not to stop it.
- If children die from DKA they will die from cerebral edema. Be prepared for this. Onset can be without warning and will just need to be reacted to. Clear signs of cerebral edema/herniation must immediately receive mannitol and intubation without the benefit of a CT. Only half of children will give warning that this is developing. The other half will show you by herniating. Prognosis is extremely guarded.
- Again, two different presentations of the same diagnosis. These cases are both of retropharyngeal abscess. The first presentation is the more common and physicians frequently make the mistake of fever + stiff neck = meningitis and do a spinal tap (which is normal)
- Retropharyngeal abscess occurs in younger children from adenitis of the adenoids. It resembles meningitis as described. But these children usually have a normal mental status that does not fit the diagnosis of meningitis. They may have dysphagia or drooling or swelling of the neck. The X-ray shows classic prevertebral swelling which is not seen until late. So don’t presume that a normal film excludes retropharyngeal abscess
- Don’t rely heavily on a normal plain film. CT scan is really the study of choice. It confirms the diagnosis with high sensitivity and specificity. (Plain film is not as sensitive, it misses milder cases and it is not specfic - a child who is filmed in flexion has a falsely increased prevertebral tissue mass on the film). The CT also identifies the size of the abscess and whether surgical or medical management is necessary, as well as the extent of the infection, I.e. does it track into the mediastinum
- More look-alikes. These kids are all vomiting and could be diagnosed as meningitis with vomiting. The first case was the case of the intussusception. The second case really does have meningitis. The third case looks a little similar. The child is vomiting and has a sick, CNS appearance like meningitis. The LP is bloody, but not from infection….
- Child abuse and intracerebral bleeding will present in young children as a MEDICALLY ILL APPEARING CHILD WITHOUT A STORY OF ABUSE. Abuse is common in all cultures. The third case looked like meningitis but this was not confirmed by LP. Therefore, a child with a CNS presentation that is not infectious needs a CT scan. In this case it may have confirmed actually bleeding or just diffuse cerebral edema from shaking.
- In cases of child abuse, whether it be CNS or an extremity fracture, the answer lies in the details. When there IS a history of trauma in a very sick child it will make sense. The first child above has a very good and consistent story for a broken leg. The second child may have a broken leg but no good story. Good parents almost ALWAYS know what has happened to their child. Parents who have abused their children will try to deflect suspicion. Yes, it was traumatic but we are not sure why.
- It is impossible to condense a whole field into 4 or 5 slides. Suffice it to say that the above type of fracture is typical or almost pathognomonic of abuse. It is a “corner” or “chip” fracture, not a typical Salter fracture. These fractures occur from traction is the limb of the child is violent pulled on.
- This is a bucket handle fracture which is essentially the same thing from another view.
- These are EASILY missed unless you are extremely thorough. Why? Because you are not looking for them. These are posterior rib fractures from squeezing by powerful adult hands.
- Denver International Airport in Colorado near my home.
- Finally, a note on procedural sedation. There are many choices and many problems.
- Ketamine is a great drug and perhaps the safest choice. It can be used in all age groups, even adults. There is some concern that the possibility of “emergence reaction” can occur more frequently in older children and adults, but this is generally not dangerous. The drug is reliable, has good pain relief and amnestic features.
- The picture refers to its abuse potential. Also called kit kelly or special K or numerous other things, it is chemically related to PCP. But this is an aside and not related to the discussion at hand. Just interesting background. Ketamine is useful because it is effective and the risks are low. But not zero. The primary side effects that all patients need to be informed about are: vomiting during or after the procedure in 10-20%, emergence reaction as the drug wears off where the child is confused, fearful, and inconsolable. Treatment is midazolam and time. And beware of LARYNGOSPASM, an uncommon but potentially life threatening effect. It is more common if the child has an upper respiratory infection or if the procedure is near the throat inside the mouth. In general, it can be bagged through but sometimes the child will need rapid sequence induction to paralyze the vocal cords.
- Here is some dosing information. Pretreat with atropine. Ketamine causes increased secretions that may be difficult to handle and perhaps trigger laryngeal irritation. Patients are commonly treated with benzodiazepines to prevent emergency reaction, but evidence suggests that this practice is unnecessary.