Chapter 50. Pediatric Emergencies

General Considerations

Epidemiology

Children constitute one of the most diverse and challenging patient populations facing the emergency physician. While comprising almost 30% of emergency department patients, critical illness and injury are present in only approximately 5%. The majority of pediatric emergency visits are evaluated not in pediatric hospitals, but community emergency departments. Early recognition and aggressive management of illnesses and injuries effecting pediatric patients is of utmost importance.

The epidemiology of pediatric emergency medicine changes with the clinical setting. In the prehospital environment, the common presenting complaints are trauma, seizures, respiratory distress, and toxicologic emergencies. In the emergency department, the most common complaints are fever, trauma, injury, respiratory distress, vomiting, diarrhea, or upper respiratory tract infection.

Assessment

Assessment of the pediatric patient in the emergency department requires an age-specific approach. A calm, reassuring, and gentle manner on the physician's part will facilitate information collection and encourage patient cooperation in examining and testing.

Knowledge of the child's growth and development often is required for the diagnosis, management, and disposition of the pediatric patient. Severity of acute pediatric illness and injury is often difficult to discern. Recognition of anatomic and physiologic differences remind the examiner of large surface area to weight ratio leading to heat loss and trauma to internal organs may exist with little signs of external injury. Airway differences are important to understand in order to manage respiratory distress and failure. Observational methods of assessment may be more sensitive to illness and injury acuity in children taking into account such variables as quality of cry, reaction to parent stimulation, state variation, skin color, hydration status, and response social overtures such as talking and smiling. Such observations appear to be more predictive of serious illness than anatomic physical examination using standard palpation, percussion, and auscultation techniques.

Assessment and management of the distressed pediatric patient requires appropriately sized equipment. Table 50–1 provides equipment sizes for invasive procedures in children of different age groups.

Vital signs may vary by age (Table 50–2). A rapid formula for estimating normal systolic blood pressure is 80 + (2 × age [in years]). The maximum effective heart rate in infants is 200 beats/min, in young children 150 beats/min, and in school-aged children 120 beats/min. Respiratory rate decreases with advancing age (Table 50–2). The use of vital signs to assess vital functions in pediatric patients, however, is hazardous. Appropriate-sized measuring equipment is imperative, techniques must be applied carefully, and interpretation must be age-related. Furthermore, even accurately obtained, age-adjusted vital signs may be insensitive and are often affected by fever, pain, and ambient features of the emergency department environment. Instead, other measures of cardiopulmonary function, such as skin color, temperature, and capillary refill, are often better triage and assessment tools.

Concept of the Distressed Family

The emergency department physician must appreciate the intimate relationship of the child to the family. Acute pediatric illness and injury are inextricably part of the family environment and dynamics. The child as well as the entire nuclear and extended family may experience major psychological, emotional, and financial consequences of pediatric emergencies. Effective care requires appropriate consideration of the child within the distressed family, enlistment of parental assistance in evaluation and management, and provision of psychological support.

Pain and Sedation

Too often, the inexperienced physician neglects pain control or procedural sedation because of misunderstanding the significance of pain in the young child, unwarranted fear of addicting children to narcotic agents, or ignorance of appropriate agents. When a painful procedure is necessary, an effective approach integrates careful explanation directly to the child and enlistment of parental understanding and assistance. Whenever conscious or deep sedation procedures are performed, the emergency department physician must ensure patient's safety by strict adherence to the guidelines of monitoring. This includes preparation for any potential airway complications, such as aspiration or apnea. In general, only previously healthy or mildly chronically ill children should be considered candidates for sedation procedures in the emergency department. Sometimes a restraint apparatus will facilitate the procedure.

The guidelines for a variety of clinical situations are given next.

Topical Anesthetics

(Table 50–3)

For Wound Repair

The formulation LET (2% lidocaine, 1:1000 epinephrine, and 2% tetracaine) is easily applied and has a favorable safety profile. It is available as gel or solution. The onset of action is approximately 30 minutes; thus it should be applied early in the laceration evaluation process. TAC (tetracaine, adrenaline, and cocaine) is occasionally used as well; however caution should be used as seizures have been reported secondarily to systemic cocaine absorption. Any anesthetic containing epinephrine (such as LET or TAC) should be avoided on end-arterial structures, such as the ears, nose, digits, or penis. (See Table 50–3.)

For IV Line Placement, Blood Draws

Eutectic mixture of local anesthetics (EMLA) or Elamax 4%, ethyl chloride spray preparations, J-tip lidocaine applicators have been advocated for local analgesic use on intact skin.

Sedation and Analgesia for Painful Procedures

There are numerous agents (Table 50–4) which are useful in sedation and pain management in the pediatric patient. Familiarity with several of these is useful for the emergency physician, allowing tailoring of the most appropriate agent to the clinical situation. The most commonly used agents are discussed next.

Midazolam

Midazolam is a relatively fast acting benzodiazepine providing anxiolysis, sedation, and antegrade amnesia, commonly used in emergency department sedation. It is commonly used in conjunction with a narcotic analgesic such as morphine or fentanyl. Some children will have a paradoxical excitation to midazolam and will experience agitation instead of sedation. There is some evidence that this unpleasant reaction may be reversed with flumazenil. Patients may also respond favorably to additional administration of benzodiazepines.

Ketamine

Ketamine, IM/ may be used for procedural situations involving children of any age, especially burn debridement, foreign body removal, deep wound care, abscess incision and drainage, or orthopedic reductions. Some clinicians recommend adding atropine, 0.01 mg/kg (maximum, 0.5 mg), or glycopyrrolate, 0.005 mg/kg (maximum 0.25 mg), to avoid hypersalivation, although current literature has not demonstrated a clear benefit. Intravenous administration is better for longer procedures. Ketamine may elevate intracranial and intraocular pressure, induce emesis, and occasionally precipitate laryngospasm. Ketamine use in older children may also cause an adverse behavioral reaction upon emergence from sedation. Some clinicians recommend the concomitant use of midazolam in children over 5 years. Studies, however, have not demonstrated a clear benefit to administering midazolam with ketamine to prevent emergence phenomenon.

Propofol

Propofol, 0.5–1.0 mg/kg by slow IV injection over 3–5 minutes, followed by an infusion of up to 0.5 mg/kg over 2–3 minutes with at least 1 minute between infusions. The advantage to this drug is the rapid onset of sedation and quick recovery time. Propofol is easily titrated to appropriate level of sedation. As with other agents, respiratory depression can occur and therefore ability to manage the airway and assist ventilation is extremely important when using this agent. Common uses of propofol include sedation for orthopedic reduction and suturing. Because of the potential for allergic reaction, the drug is contraindicated in patients with egg or soy allergies. Although the clinical significance of the effect is often not apparent, blood pressure frequently drops during propofol infusion. For this reason, most clinicians avoid propofol in patients who have been hypotensive and/or are significantly hypovolemic.

Sedation for Imaging Studies

For individuals requiring imaging studies such as computed tomography (CT) scan or magnetic resonance imaging (MRI), pentobarbital intramuscularly, midazolam, etomidate , methohexital or dexmedetomidine are commonly and safely used with proper monitoring as for any procedural sedation.

Precautions

Sedation agents should only be used by those with appropriate training and familiarity with the agents used. Proper precautions should be taken such as constant vital sign and pulse oximetry monitoring. End-tidal CO2 monitoring is advised to more closely assess the adequacy of a patient's ventilation. Rescue airway equipment and reversal agents such as naloxone, 0.01–0.1 mg/kg IV, and flumazenil, 0.01 mg/kg IV should be readily available.

Outpatient Analgesia

Outpatient analgesia ordinarily includes a nonsteroidal, anti-inflammatory drug such as ibuprofen, 10 mg/kg every 6–8 hours. This drug can also be used in combination with oral narcotic agents for the treatment of severe pain. Acetaminophen, 10–15 mg/kg every 4–6 hours, can also be used for the treatment of mild pain on an outpatient basis. Narcotics as hydrocodone/acetaminophen combination or codeine/acetaminophen every 4–6 hours may be used for severe pain.

Drug and Fluid Administration

All parenterally and orally administered agents should be given strictly on a per-kilogram basis, until maximum adult doses and volumes are reached. Over dosing and over hydration are dangerous errors in emergency pediatrics. Under dosing is also frequent, especially in infants and small children. Initial treatment of dehydration should include isotonic fluids (normal saline or lactated Ringer's). Physicians and nurses should meticulously review drug and fluid orders to ensure that they are age and weight corrected.

Vascular access is often the rate-limiting step in provision of life-saving therapy to critically ill and injured children. The emergency department physician must be familiar with a variety of techniques for access into the cardiopulmonary system.

Endotracheal Tube

In critically ill, intubated patients, the endotracheal route is an effective conduit for administration of a variety of life-saving drugs, including epinephrine, atropine, lidocaine, naloxone, and diazepam. Epinephrine is by far the most commonly used. When administered through the endotracheal tube, higher doses, up to 10 times the IV dose, must be used to obtain adequate serum concentrations. The pharmacokinetics of endotracheal epinephrine administration may be optimized by delivery of the drug directly into the highly vascular trachea and proximal tracheobronchial tree instead of directly into the endotracheal tube. The preferred technique required is the insertion of a nasogastric tube or a size 5F umbilical catheter past the distal tip of the endotracheal tube with direct instillation of drugs through the tube. Because endotracheal drugs may be more effective if aerosolized, dilute the drug with normal saline to a maximum volume of 0.5–1.0 mL/kg, and then inject rapidly to achieve a partially aerosolized form.

IV Access

In infants, the scalp is an ideal site for cannulation; use a size 24 gauge IV catheter. In children past the neonatal period, the dorsal veins of the hand, antecubital fossa, or dorsum of the foot are usually accessible with a 24 or 22-gauge IV catheter. The external jugular vein is a large vein, usually easily visualized and readily cannulated with a 20-gauge catheter if the child is properly restrained and the head is held in a dependent position.

Intraosseous Infusion

(See also Chapter 8.) For patients under age 5 years in extremis and requiring life-saving drug and fluid administration, intraosseous infusion is an alternative method of administration. This method of access is also a viable alternative in older children and adults; however, successful cannulization is more difficult in this population. A short, thick needle with a trocar tip is inserted into the intramedullary space of the bone. The richly vascularized intramedullary space allows for direct entry of drugs into the central circulation through emissary veins. The easiest insertion sites are the medial proximal tibia or the distal midline femur. Intraosseous infusion is a rapid and effective technique of achieving therapeutic serum concentrations of almost all important drugs; moreover, a large fluid volume can be rapidly administered in injured or dehydrated patients. The most common complication of this procedure is osteomyelitis.

Death in the Emergency Department

The sudden and unexpected death of an infant or child in the emergency department constitutes one of the most difficult situations in emergency practice. Chaplin and social services should be made available to aid in support to the family. Careful and compassionate dialogue between the physician and parents, and between the physician and emergency department staff, is essential to minimize chaos in the clinical setting and to reduce confusion and anger among bereaved families and department personnel. Provide the parents with a hospital contact should questions arise after their return home. Debriefing for health-care workers may also be appropriate within 48–72 hours to alleviate stress that may impair work performance or cause psychological disability.

1This chapter is a revision of the chapter by Eric Yazel, MD, & Sandra Herr, MD from the 6th edition.

Evaluation of cardiopulmonary function in children, especially in infants and younger children, requires special techniques. Vital signs are generally insensitive and nonspecific. Blood pressure poorly reflects volume status. In children, hypovolemia triggers compensatory tachycardia and intense peripheral vasoconstriction, which effectively maintains blood pressure until volume loss exceeds about 50% of intravascular volume.

Tachycardia, while sensitive to cardiopulmonary duress, is nonspecific. Normal heart rate also varies with age, and tachycardia is a common response to many types of stress (eg, fever, anxiety, hypoxia, hypovolemia). In children, assessment of volume status should focus primarily on skin signs (temperature, color, capillary refill, turgor) in combination with heart rate. Rate of urine output may be the next best measure of core perfusion. Adequate core blood flow results in 1–2 mL/kg/h of urine production. Therefore, in the unstable child with suspected perfusion abnormalities, a urinary bladder catheter is imperative to monitor output. Also, close monitoring of mental status and interaction with the surrounding environment is important indicators of adequate cardiopulmonary perfusion.

Cardiac rhythm disturbances in children are unusual. The most common disturbance is bradycardia, usually secondary to hypoxia. Properly applied pulse oximetry, at the triage desk or part of an initial clinical assessment, is an easy and useful method for rapid evaluation of oxygen saturation in patients with slow or rapid heart rates. When a primary tachycardia occurs, it is usually supraventricular in origin. In the distressed child, ECG monitoring will assist in evaluating cardiovascular status and in judging response to therapy.

Dehydration

Essentials of Diagnosis

• Commonly occurs after severe or prolonged episodes of diarrhea and vomiting
• Significant signs include acute weight loss, listlessness, sunken eyes, dry mucous membranes, poor capillary refill, and tachycardia

General Considerations

Acute dehydration is a common pediatric emergency. Diarrhea and vomiting are the most frequent causes. Other common causes are burn wounds, open wounds, fever or hyperthermia, sweating, inadequate fluid intake, polyuria, and poisoning.

Clinical Findings

The smaller the child, the greater the risk for developing dehydration secondary to the high water body requirement resulting from their surface area/volume ratios. Clinical evaluation of the dehydrated child requires assessment of hydration status. Comparison of presenting weight with recent weights may be useful. Management is dictated by degree of acuity (mild, 3–5% weight loss; moderate, 10%; severe, 15%). Formulate initial treatment on the basis of clinical evaluation of degree of dehydration. Only three clinical signs have been found to be specific for diagnosis of 5% dehydration: prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. Laboratory assessment of type of dehydration assists the physician in later strategies for specific electrolyte replacement. Serum sodium concentration is the most important laboratory parameter. Serum sodium concentration does not indicate degree of hydration but does provide a useful measure for titrating sodium repletion (ie hyponatremic, isotonatremic, or hypernatremic dehydration).

Treatment

After rapid assessment of degree of dehydration, management must match severity of illness.

Oxygen and IV Access

For severely dehydrated patients, provide supplemental oxygen, attach pulse oximeter and cardiac monitor, and establish IV or intraosseous access with one or two secure catheters.

Volume Resuscitation

For a severely dehydrated infant or young child, rapidly infuse a balanced isotonic solution (eg, normal saline or lactated Ringer's). Infants and children have limited glycogen stores and are prone to hypoglycemia when stressed; rapid blood glucose analysis (eg, fingerstick blood sugar) should be performed, and glucose should be replaced if less than 60 mg/dL. Administer 5–10 mL/kg 10% dextrose in water for infants and young children and 2–4 mL/kg 25% dextrose in water for older children.

Administer an isotonic fluid bolus of 20 mL/kg, and then repeat boluses of 20 mL/kg until physical signs (heart rate, skin temperature, and capillary refill) indicate improved perfusion. After 60 mL/kg of isotonic fluid have been administered, if vital signs have not normalized, consider administration of albumin. Packed red blood cells, 10–20 mL/kg, should be considered in cases of blood loss from trauma.

Other Measures

After stabilizing the patient, slow IV infusion to a maintenance rate (Table 50–5) and devise a therapeutic plan. Insert a urinary bladder catheter if the child has uncertain volume replacement requirements. Send blood for complete blood count (CBC); electrolytes; and glucose, blood urea nitrogen (BUN), and creatinine measurements. Obtain a urinalysis. Blood gas determination is indicated for the child who remains unstable after 60 mL/kg of volume administration.

When laboratory data are available, titrate sodium and water repletion accordingly. For hyponatremic and isonatremic dehydration, replace the calculated volume deficit over 24 hours, giving 50% of the deficit in the first 8 hours and the remaining 50% over the following 16 hours. Ongoing losses and maintenance requirements must also be included. Control fever, because insensible water losses are significantly increased by temperature elevation. Add small amounts of potassium to the ongoing infusion, once urination is observed, and replace calculated potassium deficits over 48 hours. The minimum daily maintenance requirements for water, sodium, and potassium are noted in Table 50–5. For hypernatremic dehydration, divide fluid and electrolyte replacement evenly over 48 hours to avoid rapid osmolal shifts and CNS complications.

Oral Rehydration Therapy

Use oral rehydration therapy (ORT) in most dehydrated patients. Children can usually take fluids by mouth. Vomiting does not contraindicate the use of ORT. Unless shock, altered mental status, or severe weakness is present, ORT may be used as part of early emergency department and inpatient management for most dehydrated patients. Other patients not requiring hospitalization can be easily rehydrated using this technique. ORT in the ED has been underutilized in favor of IV fluid therapy. Recently oral ondansetron (dose 0.15 mg/kg/dose) has been shown to reduce vomiting and facilitate successful ORT. The composition of ORT as set by the World Health Organization includes 90 mEq/L of sodium, 20 mEq/L potassium, 30 mEq/L of citrate, and 1–2% glucose concentration. Commercial preparations that provide approximately these constituents include Pedialyte®, Lytren®, and Infalyte®. Other commonly used clear liquids, such as colas, have too few electrolytes (Na, K, Cl), and their high sugar content may contribute to worsening of osmotic diarrhea. If the child can be discharged, prescribe home fluid replacement that is appropriate for the age of the child, the calculated deficit, and ongoing losses.

Shock

Essentials of Diagnosis

• Altered mental status
• Tachypnea, tachycardia
• Hypotension is a late sign in children

Clinical Findings

Shock is inadequate oxygen delivery to tissues (See Chapter 11). Most causes of shock in children (eg, gastrointestinal fluid losses, burns, blood loss from acute injury) involve decreased stroke volume usually from hypovolemia (hypovolemic shock). Septic shock, a form of distributive shock, occurs usually in the patient under 2 years of age and must always be considered in the sick-appearing, febrile child. Anaphylactic shock, another form of distributive shock, may develop after bee stings or after in-hospital use of parenteral drugs or contrast agents. Cardiogenic shock is extremely rare in children but may complicate congenital heart disease or toxicologic emergencies. Neurogenic shock occurs in trauma, presenting with hypotension and bradycardia (Table 50–6).

Shock is not hypotension. Successful management includes early recognition of the compensated, normotensive phase of shock. During the compensated phase of hypovolemic shock, vital signs in the supine patient are usually normal, except for mild tachycardia. Skin signs of hypoperfusion are usually evident, and laboratory testing may disclose metabolic acidosis. Intervention is usually successful during this phase. When the hypotensive, de-compensated phase develops in the absence of recognition and effective treatment, irreversible shock and death may result.

Treatment

Rapid clinical assessment should disclose a shock category so that focused treatment can be immediately instituted. Failure to act expeditiously and aggressively is a common error and may significantly increase mortality risk. Figure 50–1 is an algorithm for the treatment of uncompensated shock in neonates and Figure 50–2 is an algorithm for treatment of infants and children with uncompensated shock.

General Management

Consider immediate endotracheal intubation. In the ill-appearing child with signs of shock and sepsis or the frankly hypotensive child, intubation should be accomplished either immediately or after the patient fails to respond to first-line resuscitation with oxygen and fluids. After intubation, insert a nasogastric tube.

Apply supplemental oxygen, attach pulse oximeter and cardiac monitor, establish two secure IV catheters, check fingerstick blood glucose, and insert urinary bladder catheter.

Volume Resuscitation

Initiate volume resuscitation. Start with 20 cc/kg of isotonic saline administered as rapidly as access will allow. The bolus may be repeated up to two times if no clinical response. If there remains no response after 60 mL/kg, consider colloid or packed red blood cell transfusion or administration of an inotropic agent. When inotropic agents are used, the intravascular volume must be adequate. Inotropic infusions used are dependent on etiology of shock. They can then be titrated at bedside, often using multiple infusions (dopamine, epinephrine, dobutamine), until perfusion is restored. Start with epinephrine at 0.1–1.0 μg/kg/min or dopamine 10–20 μg/kg/min, and then add a second inotropic agent if cardiovascular response does not occur. If physical examination is equivocal for hydration status, a chest X-ray may help: dehydration or overhydration is reflected in the appearance of pulmonary vessels.

Other Measures

Obtain arterial blood gases, CBC, electrolytes, platelets, coagulation studies, blood, urine, and spinal fluid cultures (if infection is suspected), and urinalysis. A urine drug screen may also be considered. A chest X-ray is also necessary in most cases. Administer broad spectrum antibiotics if infection suspected.

Congestive Heart Failure

Essentials of Diagnosis

• Sweating during feeding or crying; failure to thrive
• Tachypnea, tachycardia
• Hepatomegaly

Clinical Findings

Congestive heart failure (CHF) is unusual in childhood. When it does present, it is usually as a manifestation of congenital heart disease and is seen in the first year of life. Table 50–7 lists the structural conditions causing CHF at different times during infancy. The classic triad of symptoms for pediatric CHF is tachypnea, tachycardia, and hepatomegaly. There may also be a history of poor feeding, sweating or color change with feeding, and poor weight gain. Lower extremity edema and jugular venous distention are less likely in the pediatric population.

Evaluation of the Neonate with Cyanosis

Cyanosis in neonates is usually due to either pulmonary or cardiac disease. A CXR, ECG, and hyperoxia test should be obtained in all neonates with unexplained cyanosis. The hyperoxia test is performed by obtaining an initial ABG from the right radial artery on room air. A second ABG is obtained after 10 minutes of breathing 100% FiO2. In general, the pao2 will rise on 100% FiO2 to greater than 80 mmHg in neonates with pulmonary disease. In contrast, it will remain unchanged or only slightly increase in those with cyanotic heart disease (Table 50–8).

Treatment

When CHF has progressed to frank pulmonary edema, the treatment is as follows.

General Management

Apply supplemental oxygen as necessary including endotracheal intubation in the severely distressed, hypotensive, or hypoxic patient (pulse oximetry < 85% on 100% oxygen). Apply a pulse oximeter and cardiac monitor. Establish secure IV access. Insert urinary bladder catheter and check fingerstick blood sugar.

Pharmacologic Treatment

Pharmacologic treatment can be critically important for patients with left heart obstructive lesions such as hypoplastic left heart syndrome, severe coarctation of the aorta, interrupted aortic arch, and critical valvular aortic stenosis. The newborn is extremely dependent on a patent ductus arteriosus to supply systemic flow. Initial management may require administration of prostaglandin E1 (.05–0.1 μg/kg/min) if a ductal-dependent cardiac lesion is suspected. Apnea is the main side effect of prostaglandin E1; therefore consider intubation prior to transport of a patient during an infusion. In other cases, first-line pharmacologic management is furosemide, 1 mg/kg IV.

Other Measures

Obtain chest X-ray, ECG, CBC, and serum electrolytes, with additional studies if indicated. Consider digoxin in refractory cases. Occasionally, patients with severe pulmonary edema unresponsive to initial therapy require dopamine, dobutamine, or both.

Cardiac Dysrhythmias

Clinical Findings

Dysrhythmias are relatively rare in the pediatric population, with the most common being sinus tachycardia, supraventricular tachycardia, and bradycardia. Atrial flutter may be present in patients having undergone cardiac shunting surgeries (ie Fontan procedure) These can present a diagnostic challenge to the emergency physician as vague and nonspecific symptoms may be the rule. Evaluation of dysrhythmias includes a rapid cardiopulmonary assessment and ECG interpretation using a systematic approach and comparison with age-specific norms.

Treatment

See Table 50–9.

General Management

Apply supplemental oxygen; attach pulse oximeter and cardiac monitor. Establish a secure IV line. Obtain an ECG.

Cardioversion

Unstable patients with tachydysrhythmias require immediate electrical cardioversion or defibrillation. Unsynchronized mode is recommended for ventricular fibrillation and pulseless ventricular tachycardia, synchronized for the remaining rhythms. Exact energy levels are dictated by the nature of the dysrhythmia (see Table 50–9).

Ensure that paddles are held firmly against chest wall and a good conductive agent is employed. If standard 4.5-cm pediatric paddles are unavailable for sternoapical placement, use adult paddles in an anteroposterior configuration.

Pretreat conscious patients requiring cardioversion with light sedation, and be prepared to perform endotracheal intubation and full cardiopulmonary resuscitation if necessary.

In children, normal ventilation and oxygenation occurs with minimal visible effort. Evaluation of respiratory function includes assessment of rate, work of breathing, skin and mucous membranes color, and mental status. Respiratory rate alone is an insensitive means of evaluating for respiratory distress. Rates vary greatly with age, anxiety, excitement, or fever, and interobserver reproducibility is often poor. Tachypnea may be an early manifestation of respiratory distress, or it may result from respiratory compensation for metabolic acidosis caused by shock, diabetic ketoacidosis, inborn errors of metabolism, salicylism, or chronic renal insufficiency. A slow respiratory rate may indicate impending respiratory failure.

Observation alone will usually disclose distress or increased work of breathing. Increased work of breathing is also evidenced by nasal flaring and by suprasternal, intercostal, and subcostal retractions. Retractions become more pronounced cephalad to caudad with increasing hypoxia. Grunting is produced by premature glottic closure and usually represents alveolar collapse and loss of lung volume, which develops in patients with pulmonary edema, pneumonia, or atelectasis. Auscultation will provide further differentiation of disease possibilities. Wheezing, rales, or decreased breath sounds may be present. Cyanosis, when present, represents severe distress and is best seen on mucous membranes of the mouth and nail beds. Peripheral cyanosis is more likely due to circulatory failure than a primary pulmonary source. Finally, mental status changes may be a clue to gas exchange abnormalities. Hypoxic patients are restless and agitated; hypercapnic patients are drowsy or even comatose.

Rapid evaluation of respiratory function is imperative in all distressed pediatric patients. Respiratory failure and respiratory arrest due to a wide spectrum of causes (eg, head trauma, coma, poisoning, pneumonia, asthma, foreign body aspiration) are the most common causes of cardiac arrest in childhood. Timely, aggressive intervention in the early stages as well as meticulous respiratory monitoring by means of pulse oximetry and continuous observation will avert preventable adverse patient outcomes. Children with respiratory distress should not be sent for imaging studies without qualified personnel in attendance. Early hospital admission is usually warranted for such patients.

Pulse oximetry should be used liberally in the emergency department setting in order to disclose undetected oxygen desaturation states. Pulse oximetry is noninvasive, simple, and reasonably accurate. Readings may be difficult to obtain in patients with poor perfusion or cold sites of placement. In selected patients, especially those with significant tachypnea or work of breathing, pulse oximetry may underestimate degree of distress, and it provides no indication as to the adequacy of ventilation. In such patients, it may be necessary to obtain arterial blood gas levels to help measure the severity and nature of the ventilation or oxygenation disturbance.

Apnea

General Considerations

Apnea is defined as an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia. Ordinary sleep will sometimes cause breathing irregularities easily confused with apnea. There are two classifications of apnea: central and obstructive. Central apnea is characterized by an absence of respiratory effort secondary to diminished muscular activation. It occurs in newborn infants, most commonly in preterm infants. Infection, metabolic abnormalities, anemia, hypoxia, or CNS injury may be associated with newborn apnea. Obstructive apnea occurs in later infancy and childhood and is related to obstructive upper airway conditions. This results in cessation of airflow despite respiratory effort, as can be seen with chest and abdominal movement. Apnea may be accompanied by color change, marked change in muscle tone (usually limpness), choking or gagging which is frightening to the observer. This is the definition for apparent life-threatening event (ALTE).

Treatment

Apnea in Infants

Apnea in infants may be symptomatic of life-threatening illness. Such patients ordinarily require hospital admission for observation and full workup for infections and for CNS, metabolic, and feeding problems. Initial management in the emergency department is discussed here.

Oxygenation and Ventilation

Place child on supplemental oxygen, and apply pulse oximeter and cardiac monitor or apnea monitor.

Volume Resuscitation

If evidence of dehydration is present, establish IV access and replete with an isotonic fluid bolus.

Laboratory and Imaging Studies

Obtain blood for CBC with differential, electrolytes, BUN, creatinine, ionized calcium and magnesium, and cultures. Obtain urinalysis and urine cultures as well as toxicology studies. CT of the head should be strongly considered for evaluation of any infant with abnormal mental status, bulging fontanelle, or focal neurological examination. Spinal fluid analysis should also be considered in any lethargic- or toxic-appearing infant.

Other Measures

Admit for observation and further evaluation on an apnea monitor.

Apnea in Children

Obstructive apnea may be serious. Focus evaluation on obstructive upper pharyngeal lesions such as tonsillitis and pharyngitis or laryngomalacia. Chest X-ray and lateral neck films are often necessary. Emergency department evaluation may be insufficient to exclude a serious diagnosis, such as airway masses, and hospital admission may be indicated.

ALTE

The evaluation for ALTE is primarily dependent upon the history and physical exam. Currently, in-hospital observation and monitoring remain an accepted treatment, especially in infants less than 48 weeks postconceptional age.

Upper Airway Obstruction

Essentials of Diagnosis

• Inspiratory stridor
• Suspect foreign body aspirations if symptoms develop rapidly without associated signs of infection
• Anteroposterior and lateral neck X-rays are helpful to differentiate croup from epiglottitis and foreign body

Clinical Findings

Upper airway obstruction is usually readily apparent. Inspiratory stridor is the hallmark. The child is dyspneic and shows signs of respiratory distress, including tachypnea, nasal flaring, and supraclavicular, intercostal, and subcostal retractions. Ventilation and oxygenation abnormalities are sometimes present. If obstruction is severe, hypercapnia will be present, usually along with depressed mental status, cyanosis, and decreased air movement. Arterial blood gases will demonstrate carbon dioxide retention and often hypoxemia. Pulse oximetry will be abnormal in most advanced cases but normal in typical cases (see Figure 50–3).

Differential Diagnosis

In children, the common causes of stridor and upper airway obstruction are croup, epiglottitis, and foreign body aspiration (see Table 50–10). Other less common conditions producing stridor are bacterial tracheitis (usually Staphylococcus aureus, Streptococcus pneumoniae, or Haemophilus influenzae), retropharyngeal or peritonsillar abscess, trauma, caustic ingestions, neoplasm, or angioneurotic edema.

Treatment

Clear the airway using procedures recommended in Table 50–11 for the patient with complete airway obstruction. Avoid airway clearance maneuvers in the patient with partial airway obstruction as this may result in further progression to a complete obstruction. Allow the child to adopt a position of comfort, usually on a parent's lap. Apply supplemental oxygen, and attach pulse oximeter and cardiac monitor. Avoid procedures or interventions that cause agitation or worsening symptoms.

Anaphylaxis

Anaphylaxis is a life-threatening manifestation of immediate hypersensitivity. It is an IgE-mediated reaction that occurs after re-exposure to an antigen. Symptoms develop within 30 minutes of exposure to the inciting agent. Manifestation may be mild, demonstrating urticaria or severe involving upper airway obstruction resulting from edema of the larynx, epiglottis, and surrounding structures. Hypotension, secondary to profound vasodilatation and seizures may occur.

Management consists of maintenance of airway and oxygenation. Attach a pulse oximeter and cardiac monitor. Initial pharmacologic management consists of administration of epinephrine (1:1000), 0.01 mL/kg (max 0.5 mL) IM. For bronchospasm (wheezing), administer albuterol by metered-dose inhaler (MDI) or nebulizer. For stridor, racemic epinephrine 2.25% solution dosed 0.05 mL/kg (max 0.5 mL) diluted with normal saline to volume of 3 mL for nebulization. For hypotension, administer 20 mL/kg bolus isotonic fluids with the addition of inotropic agents if needed. Other therapies include: H-1 receptor-blocking antihistamines, such as diphenhydramine (1 mg/kg) IV/PO/IM; corticosteroids (1–2 mg/kg methylprednisolone IV, max 125 mg, or oral prednisone 1–2 mg/kg (max 80); H-2 receptor-blocking antihistamines such as cimetidine (5 mg/kg, max 300 mg) or ranitidine (1–2 mg/kg, max 50 mg) work synergistically with H-1 blocking antihistamines. Children with airway involvement should be monitored for 24 hours. Discharge instructions must involve instruction and dispension of epinephrine auto-injector use.

Epiglottitis

Epiglottitis has become much less common since the introduction of the H. influenzae type B vaccine. The epidemiology has now changed to more commonly involve older children and adolescents, with Staphylococcus and Streptococcus being the most common etiologic agents. The patient often presents with dysphonia and dysphagia and sits in the sniffing position. The findings on oropharyngeal examination are typically unimpressive. However, the patient may rapidly progress to stridor and complete airway obstruction. In such cases, early airway management is essential, preferably in the operating room. In the meantime, minimize all invasive procedures in order to avert patient agitation and potential precipitous airway obstruction, and ensure that equipment for airway management is readily available. The patient should not be left unattended at any point.

Once the airway is secured, obtain blood and throat cultures and begin antibiotic therapy with second or third generation cephalosporins plus coverage for the treatment of possible methicillin-resistant Staphylococcus with vancomycin.

In a patient with a lower likelihood of epiglottitis, a soft tissue lateral film of the neck may be useful to help demonstrate the swollen epiglottis (Figure 50–4).

Bacterial Tracheitis

Bacterial tracheitis is also known as psuedomembranous croup, is characterized by prodromal viral upper respiratory symptoms with low grade fever, cough, and stridor similar to croup. Unlike epiglottis, a cough may be present. Typically, the child is without drooling and may be comfortable lying flat. Routine laboratory data are not indicated. The diagnosis is made endoscopically by visualizing normal supraglottic structures with prominent subglottic edema, ulcerations, and copious purulent secretion. Patients with severe distress are best managed in the operating suite for endoscopic diagnosis and intubation. If emergency department intubation is required, an endotracheal tube smaller that the calculated size for the patient may be necessary. Antibiotic coverage should be initiated with a third generation cephalosporin plus vancomycin.

Croup (Laryngotracheobronchitis)

Croup is infection and inflammation of the subglottic airway causing upper airway obstruction. It is characterized by barking cough, hoarseness, and inspiratory stridor. The physician must note that symptoms are typically more severe at night; thus the presentation may not be as impressive in daytime hours. Therapy includes the following:

Initial Steps

Attach pulse oximeter and cardiac monitor. Keep the child in a position of comfort, usually on the parent's lap. Cool humidified mist, although frequently administered, has not been shown to be effective in improving clinical symptoms in children presenting to the ED.

Pharmacologic Treatment

Give glucocorticoids to any child who presents with croup symptoms and demonstrates increased work of breathing. Give PO/IM/IV dexamethasone, 0.6 mg/kg (max 10 mg) once. In more severe cases, nebulized epinephrine should be considered. This can provide immediate improvement though reduction in edema and secretions. Dosage for nebulization is 0.5 mL/kg (maximum of 5 mL) of 1:1000 preparation of epinephrine, or racemic epinephrine 2.25% is dosed at 0.05 mL/kg (maximum 0.5 mL) diluted with normal saline to a total volume of 3 mL. In severe croup, consider administration of heliox (a mixture of helium and oxygen). In patients unresponsive to nebulized epinephrine, steroids or heliox, endotracheal intubation and ventilation may be necessary. Using a tube with a diameter smaller than recommended for patient age and size should be used.

For the minimally distressed child, treatment with steroids may be adequate. For patients who receive nebulized epinephrine, caution must be taken because the clinical effects of epinephrine wane after 2 hours. All patients should be monitored during this time period for worsening or return of symptoms. Those who remain without stridor or hypoxia, appear comfortable, and tolerating oral fluids may be discharged with a reliable parent. All others should be hospitalized for observation and further treatment.

Foreign Body Aspiration

Foreign body aspiration can have a constellation of physical findings depending on the degree of occlusion of the airway. The presentations can range from a complete obstruction managed by the Heimlich maneuver to a protracted course of wheezing not responsive to bronchodilators. The history can be highly suggestive, with a brief asymptomatic interval followed by severe dyspnea, coughing, and gagging, after the child has handled a small object. In 20% of cases, the object is in the upper airway; in 80% it is in the main-stem or lobar bronchus. Stridor is present if the object is lodged high, at the level of the larynx; wheezing and decreased breath sounds occur if it is lodged below the larynx. Mild tachypnea may be the only clinical sign in some instances. Useful X-ray views include the lateral neck, chest, and bilateral lateral decubitus end-expiratory chest, which may show hyper-inflation in the affected lung.

Complete Obstruction

If obstruction is complete and airway clearance maneuvers (see Table 50–11) fail, perform laryngoscopy immediately, and attempt to remove the foreign body with Magill forceps under direct visualization. After removal of a foreign body, insert a properly sized endotracheal tube to prevent later inflammatory obstruction.

Partial Obstruction

In most patients, obstruction is partial. Apply supplemental oxygen, and attach pulse oximeter and cardiac monitor. Allow the patient to assume a position of comfort, usually on parent's lap. Obtain airway and chest X-rays. Maintain constant observation of the patient by nurse or physician. Arrange for rigid bronchoscopy, under general anesthesia, to remove the foreign object.

Lower Airway Disorders

Lower airway disorders are a disparate group of conditions with varying clinical presentations that may affect oxygenation and ventilation. Lower airway disease includes both obstructive conditions and parenchymal or alveolar disease. The clinical hallmarks are dyspnea and tachypnea, often with cough. Wheezing denotes an obstructive process.

In children, the most common causes of lower airway obstruction are bronchiolitis, asthma, and foreign body obstruction. In infants, congenital abnormalities of the airway (tracheal web, cysts, vascular rings, lobar emphysema) must also be considered. Pneumonia is the most frequent pediatric alveolar disorder, although pulmonary edema, pneumonitis, inhalation injury, and cystic fibrosis must also be excluded.

Bronchiolitis

Clinical Findings

Bronchiolitis is a clinical syndrome characterized by the acute onset of respiratory symptoms in a child younger than 2 years of age. The typical course consists of an upper respiratory tract infection progressing within 4–6 days to involve the lower respiratory tract with the onset of cough and wheezing. Respiratory syncytial virus (RSV) is the most common underlying viral infection. More than half of the affected children are between 2 and 7 months of age. Clinical signs of respiratory distress are variable. The white blood cell (WBC) count may be slightly elevated or normal. Hyperinflation, patchy infiltrates, and atelectasis may all be seen on chest X-ray.

Treatment

General Management

Supportive care is the mainstay of therapy. Ensure hydration, oxygenation, and clearing of secretions with nasal suction. Intubation may be required for respiratory failure. Attach pulse oximeter, apply supplemental oxygen for saturations < 92%.

Medical Therapy

There is conflicting evidence as to the efficacy of bronchodilator therapy in bronchiolitis.

If wheezing is present, a trial of nebulized epinephrine or albuterol can be considered. Bronchodilators should be continued only if there is a documented clinical response. Deep nasal suctioning is helpful. Nebulized 3% hypertonic saline seems to provide a beneficial effect as an adjunct to aid in clearance of thickened secretions. Recent reviews recommend that steroid therapy not be given. Heliox (a mixture of helium and oxygen), high flow nasal oxygen, or nasal continuous positive airway pressure (CPAP) may be trialed prior to intubation for severe or refractory disease.

Other Measures

Obtain a chest X-ray and consider a nasopharyngeal swab for RSV viral testing.

Disposition

Infants younger than 2 months of age, former premature infants, any history of apnea or cyanosis, and those with underlying chronic medical conditions or congenital abnormalities should be strongly considered for admission, as well as any patient with persistent tachypnea, hypoxia, or toxic appearance.

Asthma

Clinical Findings

Asthma is one of the most common diseases of childhood and accounts for over 15% of all emergency department visits. It is characterized by bronchial hyperreactivity, airway inflammation, and reversible airway obstruction. The overall prevalence of asthma is increasing. Despite significant efforts in treatment and management, mortality rates have not improved, especially in urban areas.

Pulmonary function tests are also of great importance in assessing the severity of an exacerbation. Peak flow testing is relatively easy to perform and has been shown to be relatively successful even in young children. The patient's baseline value is especially useful, if known; otherwise comparison can be made with the patient's predicted value. Chest X-rays are usually not indicated in afebrile patients with known disease, but may be of assistance when the etiology is unclear. Arterial blood gas is indicated in more severe exacerbations. Close monitoring of pco2 should occur as normalization or elevation can indicate impending respiratory failure.

When a patient presents during and asthma exacerbation, important historical information includes recent steroid use, prior intensive care unit admissions, prior intubations secondary to asthma, preceding triggers, medications and frequency of their use, and baseline peak expiratory flow rates (PEFRs).

Treatment

See Figure 50–5.

General Management

Attach pulse oximeter, provide supplemental oxygen therapy, if required.

Pharmacologic Therapy

Inhaled β2-Agonists

These are the first-line agents for the treatment of the acute asthma exacerbation, causing the rapid relaxation of bronchial smooth muscle. Albuterol is typically the agent used (0.15 mg/kg; maximum 5 mg). Both metered dose inhaler and nebulizer have been shown to be equally efficacious. Nebulizer is the method of choice in young children who may have difficulty with proper inhaler use.

Glucocorticoids

Glucocorticoids are indicated for all children with asthma who present in an acute exacerbation. The initial dose of prednisone is 1–2 mg/kg, with a maximum of 60 mg. Oral and IV routes have been shown to be equivalent.

Ipratropium Bromide

Ipratropium is used as an adjuvant therapy to β-agonist therapy. It has been shown to decrease ED treatment time and improve pulmonary function testing. Dosing is 250 mcg per nebulized treatment for patients' weights less than 15 kg and 500 mcg for weights greater than 15 kg.

Epinephrine or Terbutaline

In severe exacerbations where nebulizer or MDI treatments may not be tolerated or rapid decompensation occurs, subcutaneous epinephrine or terbutaline (0.01 mg/kg up to 0.3–0.5 mg) or IV terbutaline (10 μg/kg over 10 minutes followed by infusion of 0.4 μg/kg/min) may be considered.

Magnesium

Several conflicting studies exist but data have been shown that magnesium sulfate has improved pulmonary function and reduce hospitalizations in certain subgroups. Dosage is 25–50 mg/kg (maximum of 2.0 g) over 20 minutes. Close monitoring for hypotension is indicated.

Adjunctive Treatments

Bi-level positive airway pressure (BiPaP) in treating pediatric status asthmatics is safe and effective with resulting prevention of intubation.

Ketamine intravenous infusions have also been controversial in the management of severe asthma exacerbations. However, infusion at a bolus dose of 0.2 mg/kg followed by an infusion of 0.5 mg/kg was not found beneficial.

Intubation

The only absolute indications for intubation in an asthma exacerbation are coma and respiratory arrest. Worsening ventilatory status despite maximized treatment is a relative indication. Clinical judgment must be used on a patient by patient basis. Due to significant difficulty attaining adequate ventilation and oxygenation while avoiding barotraumas, permissive hypercarbia by means of low tidal volumes and a prolonged expiratory phase has been used.

Disposition

There are no absolute guidelines for admission or discharge of a pediatric asthma patient and the decision is highly dependent on response to therapy. Intensive care unit admission is required for patients with an altered level of consciousness, hypotension, or respiratory failure. Hospitalization is highly recommended for patients with poor social situation, history of near-fatal asthma, or inability to tolerate oral medications. If the clinical decision is made to discharge the patient home, an inhaled β2-agonist should be prescribed. In addition, steroids (eg, prednisone 2 mg/kg/d) should be strongly considered and close follow-up should be arranged.

Pneumonia

Clinical Findings

There is a wide spectrum in presentation of pediatric pneumonia, ranging from the classic fever, productive cough, and tachypnea to nonspecific presentations such as lethargy, vague abdominal pain, and poor feeding. Physical examination may reveal crackles, rhonchi, or dullness to percussion. Often adventitious lung sounds are difficult to discern secondary to the ambient noise level in the emergency department. Chest X-rays show various patterns from lobar consolidation to diffuse interstitial patchy opacities depending on the etiologic agent.

The exact etiologic agent causing pneumonia is not known in a majority of cases. It is typically inferred from factors such as age, season, and clinical characteristics. Table 50–12 summarizes the most common pathogens in each pediatric age bracket. While clinical practice typically involves chest X-rays, blood counts, and cultures, these tests are of limited utility in pathogen identification. However, certain clinical or laboratory features suggest specific causes. Rapid onset of lobar pneumonia is often Streptococcus pneumoniae. Empyemas are frequently associated with Streptococcus or Staphylococcus, including methicillin-resistant staph. Nonspecific symptoms with patchy interstitial infiltrates are consistent with atypical pneumonias such as Mycoplasma or Chlamydia. A newborn with staccato cough, eosinophilia, and bilateral diffuse infiltrates on radiograph is likely to have Chlamydia trachomatis pneumonia. A paroxysmal cough followed by posttussive emesis combined with a lymphocytosis on peripheral blood smear is suggestive of pertussis.

Treatment

Rapid evaluation of respiratory status, in combination with pulse oximetry and, in more severe cases, arterial blood gas determination, will direct the immediate therapy.

General Management

Provide supplemental oxygen, and attach pulse oximeter and cardiac monitor. Evaluate degree of respiratory distress.

Laboratory and Imaging Studies

Obtain a chest X-ray (posteroanterior and lateral). Consider CBC with differential, RSV studies, and blood culture. If a pleural effusion is suspected, a lateral decubitus X-ray is useful.

Antimicrobial Therapy

Administer antimicrobial therapy based on age and clinical appearance. See Table 50–12 for guidelines.

Disposition

Most cases may be treated on an outpatient basis with close follow-up. Hospitalization is appropriate for any child appearing toxic, dehydrated, hypoxic, or in respiratory distress, any child failing outpatient therapy, and child less than 1 month old, and those with chronic medical conditions or preexisting pulmonary disease. Close follow-up is mandatory for all pediatric pneumonia patients who are discharged.

Objective neurologic evaluation of the emergency department patient involves recognition of age-appropriate differences in cognitive function. For patients with altered mental status, an objective scale, such as the pediatric Glasgow Coma Scale (Table 50–13) will help reduce interobserver differences in assessment and provide a measure for comparison during serial examinations.

Seizures

General Considerations

Seizures are common pediatric emergencies in both the prehospital environment and the emergency department. Approximately 5% of all children have had one or more seizures by the age of 16. Epilepsy is a chronic condition of recurrent seizures that develops in only a small percentage of patients who have a single seizure. Most seizures in childhood are single, generalized, tonic-clonic events, lasting a few minutes. Seizures may be generalized or focal. Status epilepticus is defined as continuous seizure activity for 30 minutes or as recurrent seizures without intervening return of consciousness. Status epilepticus may be the first presentation of seizures in childhood.

The causes of seizures and status epilepticus in children are multiple and age-dependent. Children under age 3 years presenting with status epilepticus are most likely to have serious conditions, for example, CNS infections or vascular disorders, anoxia, trauma, intoxications, or metabolic abnormalities. Many of these conditions are treatable. In older children, however, status epilepticus is usually the result of chronic epilepsy with noncompliance for anticonvulsive medications, chronic progressive encephalopathy, or idiopathic encephalopathy. The likelihood of serious underlying disease in a child with status epilepticus is inversely proportional to age.

Febrile seizures are also common in childhood. The peak age is 8–20 months, although they may occur in children from approximately 6 months to 6 years of age. Often, underlying diseases are simply upper respiratory tract infections or gastroenteritis. Febrile seizures may be simple or complex. A simple febrile seizure typically occurs as a generalized self-limited tonic-clonic seizure of several minutes' duration. Complex febrile seizure denotes a seizure with high-risk features, including focal onset, postictal neurologic abnormalities, or duration greater than 15 minutes. Other high-risk features include prior neurologic or developmental abnormalities or a history of epilepsy in the nuclear family. The simple febrile seizure is usually benign and requires no therapy; however, children presenting with high-risk features are a greater risk for recurrent afebrile seizures.

Clinical Findings

Many children will present in the postictal state. In such patients, search for a specific cause. A thorough history is of extreme importance. Information must be obtained about potential precipitating factors such as fever, trauma, ingestions, the patient's medical history, and family history. A detailed description of the event is necessary, including length of event, movements during the event (including eye movements), incontinence, and the presence of a postictal state. Exclude head trauma and alcohol/drug intoxication and hypoglycemia. Consider syncope, hysteria, breath holding, and night terrors as alternative causes. Several drugs are well known to cause seizure activity, including tricyclic antidepressants, sympathomimetics (cocaine, amphetamines), theophylline, isoniazid, phenothiazines, camphor, antihistamines, anticholinergics, and lindane. Physical examination should specifically exclude head trauma, bulging fontanelle, papilledema, meningeal irritation, focal neurologic signs, cutaneous lesions, and systemic disease.

Treatment

A well-organized approach to seizure management minimizes the complications of the acute electrical and metabolic derangements and averts iatrogenic complications. Ensure adequate ventilation and oxygenation in the patient with active seizures, and then address termination of the seizure and reversal of metabolic imbalances. Finally, attempt to establish the cause in order to implement specific therapy.

General Management

Initial Steps

Open the airway, use suction to clear secretions or foreign bodies, and then administer oxygen. Reserve intubation for failure of medical management, or respiratory depression from medication administration.

Laboratory Studies

Establish IV access, and draw blood for immediate bedside glucose determination and other appropriate laboratory investigations, which may include CBC, glucose, lead, calcium, and magnesium levels; liver and renal function; and electrolytes, ammonia, and pertinent drug levels. Send urine for toxicologic screening. Consider obtaining an arterial blood gas if significant acidosis is suspected.

Volume Resuscitation

If rapid bedside glucose determination is less than 70 mg/dL, administer 25% dextrose in water, 2 mL/kg per dose slowly. If evidence of dehydration is present, provide lactated Ringer's solution or isotonic normal saline. Otherwise, if the patient is euvolemic, start 5% dextrose in normal saline at maintenance rate for weight.

Pharmacologic Therapy

If the child is febrile, administer rectal acetaminophen, 15 mg/kg. If fever fails to respond to acetaminophen, ibuprofen may be administered at a dose of 10 mg/kg to infants greater than 6 months of age. Consider pyridoxine (vitamin B6) if the child could have been exposed to isoniazid in the setting of refractory seizures.

Other Measures

After a febrile seizure, children who appear toxic or do not return to baseline mental status (after a brief postictal period) should undergo a full septic workup including a lumbar puncture. In addition, a lumbar puncture should be strongly considered in all children less than 1 year of age with seizures associated with fever.

Specific Management

If seizures continue after first-line supportive care, consider immediate anticonvulsive therapy (Figure 50–6). Duration of seizure activity may be related to ultimate neurologic outcome, particularly in patients with severe underlying disease. In patients with difficulty obtaining IV access, alternatives include rectal diazepam, 0.5 mg/kg, or intramuscular midazolam 0.2 mg/kg, phenytoin, barbiturates, and benzodiazepines also may be given intraosseously.

For treatment of status epilepticus in neonates use of benzodiazepines (lorazepam, midazolam) and phenobarbital loading at 10–20 mg/kg is recommended. For older infants and children, administer benzodiazepines, then loading with fosphenytoin at 20 mg/kg. Consider use of phenobarbital or levetiracetam as secondary intravenous medicatious for status epilepticus.

Encephalitis

Encephalitis is an inflammation of the brain parenchyma. Etiologies include postinfectious, viral and arthropod–borne. Acute disseminated encephalomyelitis (ADEM) is an immune-mediated disorder of the central nervous system, also identified as postinfectious.

Clinical Findings

Symptoms range from headache to a severe presentation with seizures, coma or death. Focal neurologic deficits may be seen with Herpes simplex virus infections. ADEM typically appears with abrupt onset of neurologic symptoms 2-3 weeks after the occurrence of a preceding infection or vaccination. CNS white matter demyelination is the pathologic hallmark of this disease.

General Management

Initial Steps

Manage the airway. Intubate if needed for altered mental status.

Laboratory Studies

Establish IV access, and draw blood for immediate bedside glucose determination and other appropriate laboratory investigations, which may include CBC, glucose, liver and renal function; and electrolytes, ammonia. Send urine for toxicologic screening. Perform lumbar puncture after obtaining a brain CT to ascertain any existing intracranial pathology. Consider emergent MRI to determine if white matter disease is present.

Specific Management

Neurologic consultation is appropriate. Current management is the administration of high-dose glucocorticoid therapy with dexamthasone (1 mg/kg) or methyprednisolone (10–30) mg/kg/day.

Management of encephalitis is mainly supportive care. Acyclovir should be initiated if there is a suspicion of viral herpetic encephalitis. In the case of ADEM, intravenous immunoglobulin has been used in combination with high-dose steroids.

Fever

Fever is one of the most common presenting complaints in the pediatric patient. Despite the regularity with which it is seen, appropriate management is one of the most difficult dilemmas facing the emergency physician. While a vast majority will have benign infections, a few will have significant bacterial infections that, when untreated, can lead to morbidity or even death. The identification of this subset of patients at increased risk is of extreme importance. Most authorities agree that two primary risk groups for managing fever in young children are (1) those younger than 2 months (fever in infants) and (2) those aged 2–24 months (fever in young children).

Fever in Infants

General Considerations

Fever in infants under age 2 months is typically managed by a conservative clinical approach. This is secondary to the fact that younger children are at greater risk of serious infections and the relative immaturity of their immune system leaves them at risk for invasive disease. Numerous studies have shown that identifying patients at increased risk by means of physical examination findings and laboratory results lacks the necessary sensitivity. This leads to a more cautious approach with generous use of laboratory testing. Common organisms causing infection in this age group that should be considered include Group B Streptococcus, Listeria, Escherichia coli, Strep. pneumoniae, herpes, and congenital infections such as cytomegalovirus, rubella, and syphilis.

Clinical Findings

Initial evaluation begins with a detailed history, including the length of gestation, any complications, maternal infections during pregnancy including Group B Streptococcus, and Herpes simplex status of mother, whether antibiotics were administered, and hospital course after delivery. Examine the patient for general signs and symptoms of sepsis such as grunting, respiratory distress, lethargy, irritability, fever or hypothermia, hypo- or hyperglycemia, apnea, poor feeding, cyanotic spells, petechiae, and unexplained jaundice.

Laboratory Findings

The laboratory evaluation of febrile infants under age 2 months often includes the following:

• CBC with differential and blood culture—High-risk infants include those with WBC count of <5000 or greater than 15,000 and/or a total band count of 1500 or more, or a band/neutrophil ratio of 0.2.
• Lumbar puncture—Lumbar puncture is mandatory for all infants under 1 month of age and should be strongly considered in those aged 1–2 months. There are no conclusive data to support omission of lumbar puncture from routine evaluation in infants 4–8 weeks of age. Nevertheless, for a selected group of older well appearing infants who meet all low risk criteria both clinical and diagnostic, some experienced clinicians will elect to delay or omit the LP, provided follow-up can be arranged and the provider is confident the parents have appropriate skills. Immediate lumbar puncture may be deferred in patients who are hypotensive or have respiratory failure. Spinal fluid studies include Gram stain and culture, glucose and protein, cell count and differential, and antigen testing dependent on local laboratory capabilities.
• Urinalysis—Obtain urine dipstick and microscopic analysis. Clues to the diagnosis of UTI include urine nitrate, leukocyte esterase, bacteria, or WBCs. Less than 10 WBCs per high-powered field are considered normal.
• Urine culture—Urine culture is the most accurate means to diagnose UTI in infants. A bagged specimen is not adequate because of the high incidence of contamination. Bladder catheterization is the preferred method of obtaining urine.

X-Ray Findings

Findings of pneumonia may be present on chest X-ray even in infants without cough tachypnea or rales.

Treatment

General Management

Management must be conservative. If evaluation discloses a local infection (eg, meningitis, pneumonia, or urinary tract infection [UTI]), hospitalize the infant and promptly institute IV antibiotic therapy. Most clinicians recommend IV coverage with either ampicillin 50–100 mg/kg or cefotaxime 50–100 mg/kg, plus gentamycin 2 mg/kg, and acyclovir 20 mg/kg for treatment of neonatal sepsis.

Treatment of Fever Without Clear Cause

Emergency department treatment of febrile infants less than 1 month of age without clear evident source of infections after history, physical examination, and diagnostic workup requires admission to the hospital and IV antibiotics until blood, urine, and CSF cultures are negative or reveal a source that can be more specifically treated. The shift in management over the last few years is that febrile infants between 1 and 2 months of age who are well appearing and have a normal sepsis workup can be considered for discharge and close outpatient follow-up. This is a decision that should be made in consultation with the patient's primary physician and be reserved for reliable parents with readily available follow-up access. Reevaluation should occur within 12–24 hours. All other infants should be admitted and managed in a similar fashion to those less than 1 month of age.

Fever in Children

General Considerations

Febrile illness is an extremely common presenting complaint for children aged 2–36 months. While careful history and examination can elicit a source in many of these subjects, there is a small risk of occult bacteremia—unsuspected presence of bacteria in the bloodstream. The current prevalence of occult bacteremia among febrile children aged 2–36 months is thought to be between 0.5 and 1%. Less than 1% will later develop serious complications such as septic arthritis, osteomyelitis, meningitis, or sepsis. The widespread use of the H. influenza type b (Hib) and 7-valent pneumococcal vaccines have decreased the incidence of occult bacteremia but some risk remains.

Clinical Findings

A thorough history and physical examination is essential in the febrile child aged 2–36 months. A precise fever history should be elucidated including maximum temperature, method of temperature obtainment, timing, antipyretic use, and any associated symptoms. Past medical history, ill contacts, and immunization status should all be included in the routine history. As Strep. pneumoniae remains the most common organism isolated in occult bacteremia, history of the pneumococcal vaccine is of importance. Physical examination should include close inspection of the tympanic membranes, oropharynx, auscultatory findings of the lungs, and abdominal and genitourinary examination. UTIs are a common culprit in this age range and must be considered as dysuria, frequency, and urgency are difficult and often impossible symptoms to screen for in this age group

Treatment

General Management

A rapid cardiopulmonary survey should be performed. Any patient appearing toxic or in distress should be managed aggressively (see below). Antipyretics should be administered early in the emergency department course to improve the patient's comfort level. However, response to antipyretic medication does not change the likelihood of a child having serious bacterial infections and should not be used for clinical decision making. If a source of infection can be elucidated, it should be addressed.

Fever Without an Apparent Source

The management of infants over 3 months of age with fever and no apparent source on physical examination remains controversial. Current clinical guidelines suggest children with fever < 39°C and a nontoxic appearance may be managed on an outpatient basis with antipyretic therapy only. Children > 6 months of age with fever ≥ 39°C and history of three doses of both the pneumococcal and Hib vaccine should be screened with a urinalysis and urine culture and discharged with antipyretic therapy if negative. The rate of bacteremia in these children is determined to be < 1%. Some clinicians advocate that children < 6 months of age and/or less than three doses of the aforementioned vaccines should be screened with a urinalysis and urine culture, CBC and blood culture, and chest X-ray. Others will take a less aggressive approach and trust clinical judgment to determine if an extensive laboratory evaluation is indicated in infants and children with fever. Regardless of the approach employed by the ED physician, febrile infants and children should have follow-up in 12–24 hours for reexamination and to check on any cultures that were obtained.

Management of the Child Appearing Seriously Ill

Any child on rapid cardiopulmonary survey appearing seriously ill requires aggressive diagnostic evaluation and prompt institution of parenteral antibiotic therapy within 1 hour of arrival to the emergency department. Obtain cultures of blood, urine, and CSF (if clinical status allows), and begin antibiotics. If physical examination or laboratory evaluation does not disclose a source of infection, use third-generation cephalosporin IV, or piperacillin/tazobactam, + vancomycin. Regardless of whether a source of infection is found, hospitalize seriously ill febrile children for continued antibiotic therapy and observation.

Meningitis

Essentials of Diagnosis

• Fever, headache, stiff neck, mental status changes, or excessive irritability
• CSF Gram stain or culture may be diagnostic for a specific organism

General Considerations

Meningitis is defined as inflammation of the membranes that surround the brain and spinal cord. Potential pathogens include bacteria, viruses, fungi, and parasites. These organisms reach the CNS by either hematogenous spread or by direct extension from a contiguous site. In neonates, pathogens are acquired from nonsterile maternal genital secretions such as Group B-Beta Streptoccus(GBBS) and Herpes Simplex Virus (HSV). In infants and children, many of the organisms that cause meningitis colonize the upper respiratory tract. Direct inoculation can occur from trauma, skull defects with CSF leaks, congenital malformation, or extension from nearby suppurative foci. Bacterial meningitis typically presents acutely as bacterial penetration of the blood–brain barrier elicits an intense inflammatory response. Prompt diagnosis and aggressive treatment is paramount as delays can lead to significant morbidity and possibly death.

Clinical Findings

Symptoms and Signs

Manifestations of meningitis depend on the age of the patient. Symptoms may be subtle in infants such as poor feeding, decreased interactiveness, increased crying, and lethargy. Other signs include fever, apnea, seizures, a bulging fontanel, and a rash. Neck stiffness and mental status changes may be apparent in older children. Kernig's and Brudzinski's signs are useful signs of meningeal irritation, but their presence is not specific for meningitis. Headache, focal neurologic deficits, persistent vomiting, and seizures are commonly seen. Petechiae and purpura may be seen with several etiologic agents, but are most common in patients with meningococcal meningitis.

Laboratory Findings

Lumbar Puncture

Lumbar puncture is necessary for the definitive diagnosis of bacterial meningitis. Neuroimaging (Head CT) should occur before lumbar puncture in patients with signs or symptoms of increased intracranial pressure or focal neurologic deficits. This should occur on an emergency basis and antibiotic administration should not be delayed for imaging. Analysis should include Gram stain and culture, cell count and differential, and glucose and protein levels. A herpes PCR can be considered as well as a viral battery panel. Table 50–14 demonstrates typical findings associated with bacterial, viral, fungal, and tubercular meningitis.

Other Tests

CBC and blood cultures are indicated. A comparison of serum to CSF glucose is often useful. Urinalysis, urine culture, and chest X-ray should be strongly considered. If septic shock is evident, add PT/PTT and a Basic Metabolic Panel.

Treatment

General Management

The initial focus of attention remains the primary survey. Assess the airway, including elective intubation if indicated. Apply supplemental oxygen, place the child on a monitor, and perform a rapid cardiovascular assessment.

Volume Resuscitation

Assess the child's intravascular volume by means of blood pressure, heart rate, and capillary refill. Hypovolemia can compromise perfusion of the CNS. Aggressive rehydration with isotonic fluid is indicated if signs of hypovolemia are present.

Steroid Therapy

The administration of steroids (dexamethasone) in patients with bacterial meningitis is controversial. Studies have shown a benefit in reducing hearing loss in patients with H. influenzae meningitis. However, the decrease in H. influenzae meningitis due to the advent of the Hib vaccine makes this data less significant. Studies have suggested benefit for pneumococcal meningitis if steroids are given before antibiotics. Further complicating recommendations, steroids may decrease antibiotic penetrating through the blood–brain barrier. Current recommendations support the use of steroids in infants and children with Hib meningitis. For infants and children 6 weeks and older with pneumococcal meningitis, steroids should be considered after weighing risks and benefits. Steroids for neonates with bacterial meningitis are not recommended. The dosing of dexamethasone ranges from 0.6–0.8 mg/kg daily in two or three divided doses for 2 days to 1 mg/kg in four divided doses for 2–4 days.

Antimicrobial Therapy

In critically ill children suspected of having meningitis, administer antibiotics rapidly without delay prior to lumbar puncture. In neonates, during the first month of life, ampicillin with either an aminoglycoside or cefotaxime is typically used as initial empiric therapy. For children older than 1 month, vancomycin plus a third-generation cephalosporin (ceftriaxone or cefotaxime) is recommended as initial therapy (see Table 50–15). Acyclovir should be considered for suspected herpetic CNS infections.

Other Measures

Treat seizures aggressively with anticonvulsants. Attempt to maintain euvolemic status. Hyperglycemia and hypoglycemia should be avoided. Electrolytes should be closely monitored and any abnormalities should be corrected.

Disposition

Children with proven or clinically suspected meningitis require prompt hospitalization, ideally in a pediatric intensive care unit.

Acute Otitis Media

Essentials of Diagnosis

• Redness and bulging of the tympanic membrane is highly suggestive of otitis media
• Loss of tympanic membrane landmarks and decreased mobility are sensitive indicators

General Considerations

Otitis media is one of the most common pediatric infectious diseases and accounts for a large number of emergency department visits. A large majority of pediatric patients will have an episode of otitis media at some point during childhood. Otitis media most commonly occurs during the period of speech and language development in children, making appropriate management essential to assist the child in reaching appropriate developmental milestones.

Impaired eustachian tube function is key in the pathogenesis of otitis media. This often occurs after an upper respiratory infection. Serous fluid accumulates behind the tympanic membrane and often becomes inoculated with organisms from the nasopharynx. In infants and children, Strep. pneumoniae, H. influenzae, and Moraxella catarrhalis are the most common pathogens.

Clinical Findings

The classic symptom complex for otitis media is ear pain and hearing loss. This may occur after antecedent upper respiratory infection or may occur spontaneously. Fever is often associated with this presentation, but may be absent. Younger children typically present with more nonspecific signs, such as poor feeding, decreased activity level, and irritability. Very young infants with otitis media associated with fever are at increased risk for hematogenous spread of disease and must be managed aggressively.

On otoscopic examination, a red bulging tympanic membrane provides an easy diagnosis. The absence of this finding does not rule out otitis media, however. The loss of tympanic membrane landmarks on visual inspection and decreased movement by pneumatic otoscopy often will facilitate the diagnosis.

Most cases of otitis media are self-limited and will resolve with symptomatic treatment only. In recent years, some clinicians have advocated a more watchful waiting approach to decrease the administration of antibiotics, which may not ultimately be necessary for all cases of otitis media. Although rare, complications do occur and include brain abscess, cavernous sinus thrombosis, mastoiditis, as well as progression to meningitis and sepsis. Any focal neurologic signs on physical examination should alert the physician to the potential for these complications. The mastoid area should be inspected carefully for swelling, tenderness, or erythema.

Otitis media is a clinical diagnosis and typically no ancillary tests are needed to assist the diagnosis. Treatment is directed at the most common bacterial pathogens. Further testing is necessary when complications are a clinical concern. CT scan of the head may be indicated when intracranial pathology or mastoiditis is suspected on basis of physical examination.

Treatment

Antimicrobial Therapy

While controversy exists, typical clinical practice includes administration of antibiotics at the onset of symptoms, especially in children less than 2 years and those with severe symptoms. Figures 50–7 and 50–8 indicate appropriate antibiotic selection. Typical treatment length is 10 days. If symptoms persist, alternative antibiotic treatment may be necessary. Table 50–16 lists the various antibiotics commonly used to treat otitis media. The “observation option” for treatment entails deferring antibiotic prescription for 48–72 hours. If the child improves clinically in that time frame, no prescription is required. Close follow-up is a necessity for this treatment option.

Treatment of Pain and Fever

The pain and fever associated with otitis media may be quite significant and are managed with acetaminophen and ibuprofen. Topical anesthetic agents may also be useful, but cannot be used if perforation has occurred.

Treatment for Infants under Age 4 Weeks

Due to the risk of hematogenous spread of infection in this age group, any febrile or ill-appearing neonate should undergo a full sepsis evaluation.

Disposition

A vast majority of children with uncomplicated otitis media can be appropriately discharged home. However, an emergency department presentation of otitis media is an excellent time to discuss risk factor modification with parents, including passive tobacco smoke exposure, allergens in the household, and pacifier use.

A reevaluation is necessary in 1–2 days if no improvement in condition occurs and again at the conclusion of antibiotic therapy.

If complications such as cavernous sinus thrombosis, brain abscess, or mastoiditis occur, admission to the hospital and IV antibiotics are indicated.

Pharyngitis

General Considerations

Acute pharyngitis is one of the most common illnesses for which children present to the emergency department. There are a wide range of viral and bacterial pathogens which may cause pharyngitis. Group A β-hemolytic streptococcus (GABHS) is the most significant of the bacterial pathogens. Discerning between the more common viral causes and GABHS, for which antibiotic treatment can prevent significant morbidity, is essential. Other important bacterial causes of pharyngitis include Corynebacterium diphtheriae, which may present with a gray–white membrane (now rare due to immunization practices), and gonococcal/chlamydial pharyngitis which may be seen in sexual abuse and must be considered in sexually active patients. Pharyngitis by the Epstein-Barr virus (EBV), the causative agent in infectious mononucleosis, can also cause a significant exudative pharyngitis. It can be associated with hepatitis and splenomegaly which should preclude the patient from contact activities.

Clinical Findings

The clinical findings associated with pharyngitis overlap between viral and bacterial causes. Typical presentation includes sore throat, pain on swallowing, and fever. Other symptoms that may be present include headache, nausea, vomiting, abdominal pain, an inflamed swollen uvula, and rash. The associated abdominal pain may be quite significant and distract the physician from the true diagnosis. These may be present in both viral and bacterial causes including GABHS. The four most reliable clinical features for diagnosis of GABHS are tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and temperature of at least 100.4°F.

While the diagnosis of pharyngitis is on a clinical basis, ancillary testing may be considered to determine the necessity of antibiotic therapy. The decision to perform a test should be based upon clinical characteristics that may indicate GABHS or other bacterial cause is likely. Prevalence of GABHS in the community as well as close contacts with known GABHS pharyngitis can be useful in this decision.

The most commonly used ancillary test is the rapid antigen detection test followed by a throat culture. While rapid antigen tests are convenient, the sensitivity remains approximately 80–90%, necessitating the confirmatory throat culture when rapid test is negative. CBC may show an elevated WBC count with pharyngitis, but is nonspecific and does little to guide management. Leukocytosis with predominantly atypical lymphocytes is common with EBV pharyngitis. Screening with the monospot test can be useful but has limited sensitivity. In patients for whom a confirmatory diagnosis is essential, EBV antibody titers should be obtained.

The complications of pharyngitis are classified as suppurative (peritonsillar abscess and retropharyngeal abscess) and nonsuppurative (rheumatic fever and poststreptococcal glomerulonephritis). Peritonsillar abscesses (PTA) occur when pharyngitis progresses to cellulitis followed by abscess formation. Patients may present with drooling, muffled voice, and trismus. It is most commonly seen in adolescents. Retropharyngeal abscesses (RPA) typically occur from suppuration of retropharyngeal lymph nodes from adjacent pharyngitis and present similarly to PTAs. This complication is more commonly seen in toddlers and school-aged children. Imaging may include a plain lateral soft tissue study of the neck to evaluate RPA and to rule out epiglottitis. It is rare that more extensive imaging such as a CT with contrast of the neck would be required. Appropriate diagnosis and treatment of GABHS pharyngitis has led to a dramatic decrease in the incidence of rheumatic fever. Treatment does not appear to prevent poststreptococcal glomerulonephritis.

Treatment

Symptomatic Therapy

Symptomatic therapy can be used to decrease the discomfort from an inflamed pharynx, including acetaminophen, NSAIDs, and saltwater gargles in age appropriate patients. In severe cases, dexamethasone can be used to decrease pharyngeal edema.

Antimicrobial Therapy

If pharyngitis is determined to be GABHS by rapid antigen test, or is later confirmed by throat culture after negative rapid antigen test, administer antimicrobial therapy immediately. Treatment of patients with a high clinical suspicion of GABHS pharyngitis before test results are available is an option, provided a mechanism is in place to discontinue antibiotics if GABHS infection is not confirmed. Penicillin, which has never shown resistance to GABHS, remains the drug of choice for treatment of GABHS. In patients diagnosed with GABHS and acute otitis media amoxicillin appears to be efficacious. Penicillin V is administered orally at 250 mg b.i.d. or t.i.d. in children and 250 mg t.i.d. to q.i.d. in adolescents. A 10-day course is recommended. A single intramuscular injection of benzathine penicillin is dosed at 6 million units for children less than 27 kg and for 1.2 million units for all others. For patients allergic to penicillin, erythromycin and possibly cephalosporin drugs are reasonable alternatives.

Treatment of Peritonsillar Abscesses and Retropharyngeal Abscesses

The definitive treatment of PTAs and RPAs includes broad-spectrum antibiotics and abscess incision and drainage. Antibiotic choices include penicillin and a β-lactamase inhibitor, carbapenem, or clindamycin. PTAs often require aspiration or incision and drainage, while RPAs are often managed nonoperatively.

Disposition

Most patients with pharyngitis can be safely discharged with close follow-up. Patients in whom there is suspicion for potential airway difficulty or who are unable to tolerate oral intake with dehydration should be admitted for observation and fluid resuscitation. In noncomplicated cases where the abscess is minimal and easily visualized, bedside drainage of PTAs may occur in the emergency department, with close otorhinolaryngology follow-up. The remainder of patients should be hospitalized for IV antibiotics, airway monitoring, intravenous fluid resuscitation, and definitive incision and drainage.

Cellulitis and Subcutaneous Abscesses

General Considerations

Simple superficial cellulitis in the pediatric population is routinely treated for the basic skin flora organisms of streptococcus and staphylococcus aureus. In recent years, however, subcutaneous abscess and cellulitis management have become more common and complex due to the increase of infections caused by community acquired methicillin resistant staphylococcus aureus (CA-MRSA). With the outbreak of CA-MRSA, there has been a sharp increase of emergency department visits for abscess management in the healthy pediatric population nationwide. One study found a sevenfold increase in CA-MRSA from 1999 to 2006. Many emergency departments are seeing over 50–60% of all abscesses in children culture positive for CA-MRSA. CA-MRSA is spread via direct contact with skin surfaces. Increased risk factors associated with the spread of CA-MRSA include: (1) close skin-to-skin contact, (2) open wounds in the skin, (3) crowded living conditions, and (4) poor hygiene.

Clinical Findings

Classic findings of superficial cellulitis are also hallmark signs of an early abscess infection. These can include redness, swelling, warmth, pain, and tenderness. Unique to abscess formation, the patient will commonly complain of a preceding “spider bite.” As the infection worsens, fluctuance will become apparent with a white or yellow center and can spontaneously drain pus. CA-MRSA infections are more commonly found on the buttocks, legs, and thighs. In some cases, CA-MRSA can evolve into bacteremia, empyema, and sepsis. It can also be found in conjunction with “super-infections” with preceding viral or influenza infection.

Treatment

When treating superficial cellulitis, one must consider antimicrobial therapy with coverage for Streptococcus as well as other basic skin flora organisms. Antibiotic choice can include cephalexin, dicloxicillin, or cefazolin. If an abscess is present, simple incision and drainage is the treatment of choice. Needle aspiration is also an option for draining a small subcutaneous fluid collection. Currently there are mutiple antimicrobial options for out-patient management of CA-MRSA which include: (1)trimethoprim-sulfamethoxazole(TMZ), (2) clindamycin, (3) rifampin (not used in montherapy), and (4) linezolid. Some strains of CA-MRSA have an inducible resistance to clindamycin. If the culture sensitivities show CA-MRSA susceptibility to clindamycin but resistance to erythromycin, the strain could have an inducible resistance to clindamycin. Definitive efficacy can be confirmed with a D-test through the laboratory. The regional rates and types of inducible CA-MRSA resistance should be evaluated to determine the best out-patient antimicrobial choice. Some physicians consider adding a second antimicrobial agent to treat both superficial cellulitis and early CA-MRSA in the patient who has a history of previous infection or exposure to CA-MRSA or if there is significant cellulitis surrounding the abscess.

Severe infections with large abscesses and patient symptoms consistant with systemic bacteremia need emergent surgical consultation for operative incision and drainage as well as IV antimicrobial therapy, usually vancomycin. Supportive and aggressive management of the septic pediatric patient is a necessity with IVF resuscitation, laboratory evaluation including CBC, BMP, blood and urine cultures as well as possible CSF evaluation and inpatient admission.

Disposition

Close follow-up is a necessity for patients that receive abscess incision and drainage to evaluate for resolution of infection as well as any culture results and antimicrobial sensitivities. If CA-MRSA infection becomes a recurring problem, refer the patient to pediatric infectious disease specialist.

Periorbital and Orbital Cellulitis

Essentials of Diagnosis

• Erythema and swelling around the eye
• Pain with limitation of ocular motility and decreased visual acuity differentiates orbital from periorbital cellulitis

General Considerations

Periorbital cellulitis, also commonly referred to as preseptal cellulitis, is an infection anterior to the orbital septum. This is an important distinction as the orbital septum provides a barrier to spread of infection into the orbit and breach of this barrier may provide access to intracranial structures. It is often secondary to eyelid infections, sinusitis, upper respiratory infection, otitis media, or eye trauma. H. influenzae, Staphylococcus sp., and Streptococcus sp. are the most common pathogens. Orbital cellulitis differs in that it is an infection of the contents of the orbit posterior to the septum. It usually results from severe sinusitis and is also typically caused by Staphylococcus and Streptococcus sp. as well as H. influenzae.

Clinical Findings

Patients with periorbital cellulitis present with erythema and edema of the eyelid and surrounding skin and may be associated with chemosis, conjunctivitis, fever, and nasal discharge.

Periorbital cellulitis is often a clinical diagnosis; blood and wound cultures may be of assistance in pathogen identification. In orbital cellulitis, physical examination often demonstrates unilateral proptosis, pain with limitation of ocular motility, decreased visual acuity, or an afferent papillary defect. This can indicate progression past the orbital septum. Orbital cellulitis is evaluated by CT scan of the orbits to determine extent of infection and to evaluate for a periosteal abscess. CBC and blood cultures should also be obtained.

Treatment

Mild periorbital cellulitis is typically treated on an ambulatory basis with dicloxacillin, 25 mg/kg/d divided four times daily, or cephalexin, 25–100 mg/kg/d divided four times daily. For children who do not respond to outpatient therapy, have severe infection, or are ill appearing, use IV ceftriaxone, 100 mg/kg/d divided twice daily, or IV cefuroxime, 100 mg/kg/d divided three times daily. IV antibiotic treatment is indicated for orbital cellulitis (second- or third-generation cephalosporins or ampicillin–sulbactam are appropriate choices).

Disposition

Children with mild periorbital cellulitis can be managed on an outpatient basis with close follow-up. Patients with extensive cellulitis, toxic appearance, or those who do not respond to outpatient management require admission. A nasal decongestant and warm compresses may also be beneficial to patients.

Management of orbital cellulitis should include blood cultures and CBC if the patient is febrile or appears bacteremic. Infants under age 3 months with these symptoms should be worked up as outlined previously. Obtain a CT scan without contrast for all patients suspected of having orbital cellulitis. Mild cases may be managed with daily ceftriaxone injections. More severe cases should receive inpatient IV antibiotics (second or third-generation cephalosporins or ampicillin–sulbactam are appropriate choices). Consultation with ophthalmology is highly advised.

Urinary Tract Infection

General Considerations

Similar to adults, UTIs are relatively common in the pediatric populations. However, the implications of UTIs in pediatric population differ significantly. UTI in the pediatric population may be a hallmark of an anatomic anomaly, such as obstruction or vesicoureteral reflux. Children also have a greater risk of renal scarring after a UTI.

Among children 2 months to 2 years of age with a fever without a source, ∼5% are diagnosed with a UTI. Premature infants have greater risk of UTI as well. Males have a higher rate of UTI in the first months of life. From that point forward, the incidence is higher in females than males, and is lowest in circumcised boys. Studies have shown a 5–20% increase risk of UTI in uncircumcised males versus circumcised males under age 2. Recurrence rates are similar between the sexes, but recurrence in males greater than 1 year after primary infection is rare.

In the healthy child, pathogens typically reach the urinary tract as a result of retrograde migration of enteric bacteria colonizing the periurethral area, most commonly E. coli. Other common pathogens include Klebsiella, Proteus, other Enterobacteria, Staphylococcus saprophyticus (especially in sexually active females), and Staph. aureus. In neonates, hematogenous seeding of the urinary tract may occur during sepsis. Infants and children with recurrent infections, abnormal urinary tract anatomy, or frequent urinary instrumentation are at greater risk for Enterococcus or Pseudomonas.

Clinical Findings

Nonspecific presentations are typical in patients under 2 years of age. Symptoms may include fever, fussiness, vomiting, diarrhea, abdominal pain, or poor feeding. A caretaker may notice foul-smelling or cloudy urine. In this population, fever is often the only presenting symptoms and UTI should be in the differential for any febrile patient without an apparent source. Older children may present with the more classic symptoms of dysuria, urgency, frequency, and suprapubic or low back pain. Incontinence and enuresis should raise suspicion for the presence of UTI as well. In adolescents, the presence of dysuria and other associated symptoms may be a hallmark of sexually transmitted disease (STD) and should be evaluated by the physician.

The key to diagnosis of UTI is the demonstration of bacteria in the urine. Obtaining an appropriate specimen in the pediatric patient is of great importance and may be quite difficult. Urine specimens may be obtained by suprapubic bladder aspiration, urethral catheterization, or midstream clean catch in a toilet-trained child. A urine bag collection technique in a nontoilet-trained child can be considered as a screening tool, however, due to the high rate of contamination, it is only useful if negative for signs of infection. A urine sample collected via urine bag technique should never be sent for a culture. If the urine is positive for infection, further confirmatory testing should be done by one of the other collection techniques listed. Once collected, the urine specimen should be processed as rapidly as possible.

Urine specimens should be sent for culture and microscopy. Culture results are typically not available until at least 12–24 hours from initial processing; thus urinalysis by microscopy is commonly used for a presumptive diagnosis. The presence of bacteria on urinalysis can be due to infection or contamination, but the presence of greater than 10 WBCs per high-powered field has a relatively high positive predictive value. The presence of nitrites (a by-product of bacterial metabolism) is 98% specific for UTI. Positive leukocyte esterase (produced by activated leukocytes) is 83% sensitive and 78% specific for UTI.

Neonates with UTI on urinalysis or culture should have CBC and blood cultures drawn and CSF studies considered. Blood cultures should also be obtained for any infant or young child with high fever or toxic appearance. Diagnostic imaging tests are seldom indicated in the acute setting.

Treatment

Outpatient Treatment

Patients older than 2 months with a nontoxic appearance and ability to tolerate oral intake may be managed on an outpatient basis. Initial therapy should be broad spectrum and cover the most common pathogens. Common oral antibiotics used include TMP-SMX, amoxicillin (although E. coli resistance is increasing), nitrofurantoin (unless pyelonephritis is a consideration), or oral cephalosporins. The choice can be further tailored when results of the urine culture are available. Physicians may consider an IV or intramuscular dose of antibiotic, such as ceftriaxone, while the patient is in the emergency department followed by oral antibiotics upon discharge. A 7–10-day course is recommended for un-complicated UTI and 14 days for complicated infections or suspected concomitant pyelonephritis. For patients requiring inpatient treatment, IV ampicillin with gentamycin or ceftriaxone are commonly administered antibiotics.

Inpatient Treatment

Neonates and any additional patients who do not meet criteria for outpatient management should be admitted for IV antibiotics.

Evaluation for Urinary Tract Anomalies

Because of the frequency of urinary tract anomalies in children who have UTIs, renal and bladder ultrasound is recommended for all children younger than 2 years with first UTI. It should also be considered in males older than 2 years with UTI and girls with repeated UTIs. Vesicocystourethrogram is also recommended in this subset of population to evaluate for vesicourethral reflux. Imaging is not typically necessary in the emergency department and may be done after admission or on an outpatient basis if the patient meets discharge criteria.

Disposition

Hospital admission for IV antibiotics is indicated for patients younger than 2 months with UTIs, as well as toxic, vomiting or dehydrated patients. Patients with urosepsis, who are immunocompromised, have decreased renal function, or who appear to be failing outpatient management should also be admitted. Nontoxic, febrile, older infants, and children with UTI can receive treatment on an outpatient basis with follow-up at 24–48 hours. Urine cultures results should be evaluated to ensure appropriate antibiotic selection.

Gastroenteritis

General Considerations

Diarrhea is a common reason for bringing a child to medical attention. Dehydration frequently complicates diarrhea in children, particularly young children who experience a greater net fluid and electrolyte loss. Acute diarrhea in children most commonly results from infectious gastroenteritis. Keys to management include identification of children who will benefit from antimicrobial therapy, prevention and treatment of dehydration, and identification of children with diarrhea secondary to other processes (eg, intussusception, hemolytic uremic syndrome). In the United States, rotavirus is the most common cause of acute diarrhea, particularly in winter months.

Clinical Findings

Symptoms and Signs

Information regarding the duration of diarrhea, number of stools per day, frequency of urination, presence of tears when crying, and most recent weight of the child are helpful in assessing the risk of dehydration. A history of frequent vomiting, particularly early in the course of the disease, suggests a viral cause. High fever, lack of vomiting, abdominal pain with bowel movements, and the presence of gross blood and mucus in the stool suggest a bacterial cause. A history of recent antibiotic use suggests the possibility of pseudomembranous colitis. A history of recent travel suggests the possibility of a parasitic infection or traveler's diarrhea. Children in daycare are particularly susceptible to infections with Giardia lamblia. Inquire about a common outbreak of symptoms in family members that may suggest food poisoning. When more than one family member has symptoms of nausea, vomiting, or headache, explore the possibility of carbon monoxide poisoning. Assess the child's hydration status, and look for signs of appendicitis or intussusception. Serial abdominal examinations are recommended to rule out surgical conditions. Gastroenteritis is one of the most common diagnoses listed in cases of missed appendicitis.

Laboratory Findings

Stool Culture

A stool culture is the most reliable means of identifying a bacterial cause. It is not cost effective, however, to culture the stool of every child with diarrhea. Obtain cultures from children at highest risk for bacterial disease. Stool cultures for Shigella, Salmonella, E. Coli 0157:H7, and Campylobacter should be obtained in the following circumstances:

• If the child presents with obvious symptoms of acute bacterial dysentery (ie, fever, watery stool, fecal leukocytes, and gross blood in the stool).
• If the child has abrupt onset of frequent stools without the initial vomiting common to viral gastroenteritis. Perform methylene blue slide examination for the presence of fecal leukocytes. A positive result (>5 WBCs per high-power field) is a sensitive indicator of a bacterial pathogen. Trophozoites of G. lamblia may also be identified.
• If the child has hemoglobinopathies or immunodeficiencies.

Peripheral WBC Count

While not necessary in most cases, a peripheral WBC count may be helpful, because Salmonella and Shigella can cause leukocytosis. Some patients with Shigella infection may have a low WBC count with a marked shift to the left.

Other Laboratory Tests

If the child appears dehydrated, check serum electrolytes, BUN, creatinine, and fingerstick blood sugar. Blood cultures are also indicated in febrile young infants with bloody diarrhea and any child who appears significantly ill. If the child is in day-care or has a recent history of travel, consider examination of the stool for ova and parasites.

Treatment

Rehydration

The use of oral rehydration solutions for children with mild to moderate dehydration and of IV fluids for children with more severe dehydration is critical to prevent severe morbidity and mortality. Breast-feeding infants should continue to breast feed while taking oral rehydration.

Antiemetics and Antidiarrheal Agents

Antiemetic and antidiarrheal drugs occasionally worsen symptoms in children with gastroenteritis. Promethazine is contraindicated in children younger than 2 years. Some recent studies have seen improvement with tolerating oral rehydration after dosing a patient with ondansetron and it is frequently used to control vomiting in children with gastroenteritis.

Antimicrobial Therapy

Antibiotic therapy is not indicated for a majority of gastroenteritis infections, as most are self-limited. The empiric use of antibiotic therapy can be considered for obvious symptoms of most bacterial dysentery. TMP-SMZ (TMP, 8–12 mg/kg/d, and SMZ, 30–60 mg/kg/d, in divided doses every 12 hours) can be given empirically until culture results are available. Regarding pediatric specific treatment of salmonella, antibiotics are only indicated in patients < 2 months old, in those with sickle cell disease, patients with extra intestinal infection or in those who are immunocompromised.

Disposition

Hospitalize children with moderate to severe dehydration, particularly if vomiting prevents oral rehydration, and young infants with fever and bloody diarrhea. Young infants are at increased risk for Salmonella bacteremia.

Instruct parents about the signs of dehydration and the proper use of oral rehydration solutions. Parents should encourage children to continue small but frequent amounts of liquids at home and to resume a low-fat diet as tolerated.

Infants under 6 months of age should be followed up by telephone or be seen in 24 hours. Reevaluate older children if diarrhea persists longer than 3 days. Stable children with bloody diarrhea should be reexamined in 24 hours.

Septic Arthritis

Essentials of Diagnosis

• Patients usually febrile
• Involved joint is tender, swollen, erythematous, with painful range of motion
• Aspiration with fluid analysis is diagnostic

General Considerations

Septic arthritis is the bacterial invasion of a joint space and the subsequent inflammatory response. The synovium is highly vascular and prone to bacteremic seeding. Contiguous spread and direct inoculation from penetrating trauma may also lead to this condition. Patients with sickle cell disease (SCD) and diabetes mellitus are at increased risk. The knees and hips are the most commonly affected joints.

Most cases of septic arthritis are caused by gram-positive organisms, particularly Staph. aureus. GABHS and Strep. pneumoniae are also noted causes. Patients with sickle cell anemia are at increased risk for septic arthritis due to Salmonella sp. In the neonatal population, Staph. aureus remains the most common, but group B Streptococcus and gram-negative enteric organisms are also seen. Neisseria gonorrhoeae should be considered as a causative agent in sexually active adolescents.

Clinical Findings

Symptoms and Signs

Patients typically present with focal findings at the infected joint. Warmth, erythema, swelling, and pain with range of motion are common findings. Systemic symptoms, such as fever and malaise, are often present. Children will usually keep the affected joint in a position that maximizes comfort. Any sudden onset of refusing to move a limb or joint should raise concern for this condition. In neonates and infants, discomfort may be noted during manipulation of the knees and hips during diaper changes. Toxic synovitis can closely mimic septic arthritis. These patients may have similar complaints but in general have a lower-grade temperature, less pain on joint manipulation, and a more indolent course.

Laboratory Findings

Joint Aspiration

Definitive diagnosis is established by joint aspiration. Examine joint fluid for Gram stain and culture, cell count and differential, glucose, and protein. In general, the WBC count for septic arthritis will be over 50,000 (with greater than 75% PMNs) as compared to transient synovitis in which the WBC count in the synovial fluid is usually between 5000 and 15,000 (with less than 25% PMNs). The glucose level is usually low at less than 40 mg/dL in septic arthritis.

Blood Tests

CBC with differential, C-reactive protein, and erythrocyte sedimentation rate are often elevated in septic arthritis. When normal, these do not rule out septic arthritis, but are helpful when considering other etiologies. Blood cultures should also be obtained.

Imaging

X-rays may show a widened joint space in septic arthritis, especially when comparing the hip joint space, and are useful to rule out fractures and other conditions. If septic arthritis is suspected, obtainment of plain films should not delay joint aspiration and treatment. Ultrasound is useful in identifying location and size of effusions, especially in deeper joints such as the hip, and may be used to guide aspiration. Bone scan and MRI are often helpful diagnostic adjuncts, but are more typically used in the inpatient setting.

Treatment

Antibiotic therapy should be initiated without delay. A list of the typical organisms involved in septic arthritis can be found in Table 50–17. If Gram stain is available, results can be used to guide antibiotic selection. Traditionally, if gram-positive cocci are seen, a penicillinase-resistant penicillin (eg, oxacillin, 150 mg/ kg/d, divided in four doses) has been appropriate. In the current era of increasing community-acquired MRSA, however, vancomycin or clindamycin should be strongly considered. If gram-negative or no organisms are seen on Gram stain, a third-generation cephalosporin, such as cefotaxime or ceftriaxone, should be used. This will also provide coverage for gonorrheal septic arthritis. Neonates are often treated with oxacillin or nafcillin plus cefotaxime or gentamicin. Coverage can be tailored once culture results are available. Despite the early initiation of antibiotics, septic arthritis remains a surgical emergency. Timely orthopedic consultation and drainage are essential. Pain management can be addressed though the use of NSAIDs and narcotic medication as needed.

Disposition

Hospitalize children with suspected septic arthritis for IV antibiotic therapy. Obtain orthopedic consultation to evaluate the need for surgical drainage of the affected joint.

Acute Osteomyelitis

Essentials of Diagnosis

• Usually warm, tender, swollen area
• Initially X-rays tend to be normal

General Considerations

Acute osteomyelitis is a pyogenic infection of bone that occurs in about 1 in 5000 children before the age of 13 years. Although any bone may be involved, in children, the long bones are more frequently infected. Infection usually is the result of seeding, although spread from a contiguous focus or through direct traumatic inoculation can also occur.

Over 90% of cases of acute hematogenous osteomyelitis are caused by Staph. aureus. Group A streptococci and H. influenzae are less common causes. In neonates, osteomyelitis may also be caused by group B streptococci and gram-negative enteric organisms. Children with SCD are at risk for Salmonella and Strep. pneumoniae osteomyelitis. Puncture wounds to the plantar surface of the foot may result in Pseudomonas aeruginosa osteomyelitis.

Clinical Findings

Symptoms and Signs

The clinical hallmarks are fever and well-localized bone tenderness. Chills, malaise, and ill appearance are frequently present. Lower extremity disease will frequently result in a limp. Point tenderness is usually evident on careful examination. There may also be swelling, warmth, redness, and focal induration at the site of infection. The young infant is usually irritable when the affected extremity is touched or moved. Pseudoparalysis is common, and occasionally significant swelling of the extremity will occur.

Laboratory Findings

Draw blood for culture, CBC with differential, C-reactive protein, and erythrocyte sedimentation rate. Blood cultures are positive in about 30–50% of patients with osteomyelitis.

Imaging

Obtain plain X-rays of the affected extremity. Radiographic changes are usually not evident until 7–10 days after disease onset. However, soft tissue swelling and obliteration of the tissue planes may be the initial radiographic findings. Later findings include periosteal reaction and osteolysis.

After the child has been admitted to the hospital, technetium bone scans or MRI may be helpful. Bone aspiration under CT or ultrasound guidance may reveal the etiologic agent.

Treatment

The mainstay of treatment of acute osteomyelitis is parenteral antibiotics. Because culture results are usually not available when the diagnosis is first made, empiric therapy depends on the patient's age. In children with puncture wound osteomyelitis of the foot, surgical debridement is an important part of therapy and parenteral antibiotics active against Pseudomonas should be started.

Disposition

Hospitalize children in whom acute osteomyelitis is suspected.

Abdominal Pain

General Considerations

Abdominal pain and gastrointestinal disturbances are frequently encountered in the care of the pediatric patient. There are a vast number of conditions that appear in the differential diagnosis of abdominal pain and differentiating the benign causes from the true emergencies can be a challenging and extremely difficult task. The causes of abdominal pain vary by the age of the patient (see Table 50–18). Gastroenteritis is the most common medical complaint, appendicitis the most common of a surgical nature.

Abdominal pain occurs via three separate pathways: visceral, parietal, and referred. Visceral pain occurs when stimuli such as tension, stretching, or ischemia affect a viscus, such as the stomach or intestines. Visceral pain fibers are bilateral and enter the spinal cord at multiple levels. Irritation of these fibers causes pain that is dull, poorly localized, and midline in location. Parietal pain results from irritation of the parietal peritoneum. These fibers transmit to the same side and dermatomal level of the site of irritation. This pathway leads to sharp, intense, well-localized pain. Referred pain is similar to parietal pain with the exception that the pain is felt in remote areas supplied by the same dermatome as the site of local irritation.

Clinical Findings

Symptoms and Signs

A thorough history is essential; the character of the pain, onset, duration, severity, and location should be elicited. Aggravating and relieving factors, associated symptoms, gynecologic and sexual history, and medical history are also important information.

Rapid cardiopulmonary assessment is the initial step in the physical examination. If the patient appears toxic or has unstable vital signs, aggressive resuscitation should coincide with history and further physical examination. Much can be learned by simple direct observation before manual examination. Is the patient active and playful or lying in bed avoiding any movement? The abdomen should be inspected for distention, masses, or peristaltic waves. Auscultate the abdomen in all quadrants to evaluate the nature of the bowel sounds. If the child is able to indicate the area of maximal tenderness, start with gentle palpation away from the site and move slowly to the area. Percussion should be used to elicit rebound tenderness. Deeper palpation is used to discover masses or organomegaly.

A thorough extra-abdominal examination is indicated. Lower lobe pneumonia can be a cause of referred abdominal pain, as can Streptococcal pharyngitis. Genitourinary examination may reveal a testicular torsion or hair tourniquet. In sexually active females, pelvic examination is indicated. Rectal examination can be helpful in numerous conditions, including retrocecal appendicitis, intussusception, gastrointestinal bleeding, abscess, or impaction. Signs associated with appendicitis such as Rovsing's sign (palpation of left lower quadrant causes pain in right lower quadrant), iliopsoas (reproduction of pain with extension of right hip and flexion of right thigh), and obturator (pain reproduced with rotation of flexed right hip) should be checked and documented. A modified heel tap sign can be performed by having a child stand and jump, then evaluate for right lower quadrant discomfort/peritoneal signs upon landing. When considering a pediatric specific abdominal pathology differential, one should include intussusception, Hisrchsprungs Disease, malrotation resulting in a midgut volvulus, streptococcal pharyngitis, lower lobe pneumonia and pain from trauma or abuse.

Laboratory Findings

Urinalysis

Look for evidence of a UTI. More than five white or red blood cells per high-power field can occasionally be seen in patients with appendicitis.

CBC with Differential

CBC with differential may be useful in suggesting an infectious cause for abdominal pain. The WBC count is an insensitive and nonspecific test and cannot be used to rule out appendicitis.

Other Laboratory Studies

Electrolytes, BUN, and creatinine measurements should be obtained for children who appear dehydrated after protracted vomiting or diarrhea. Consider lipase and hepatic function tests if biliary disease, pancreatitis, or hepatitis are possible causes. Obtain a pregnancy test in adolescent girls.

Imaging

Obtain a chest X-ray for any patient with abdominal pain and respiratory symptoms to evaluate for the presence of a lower lobe infiltrate. Plain film abdominal X-rays are helpful in identification of intestinal obstruction, perforated viscus, constipation, and some types of kidney stones. CT scan of the abdomen is a sensitive test to evaluate for a variety of abdominal pathologies and may be indicated in acute abdominal pain where etiology is unclear. This must be balanced with the risks of radiation exposure, use of contrast agents, and possible need of sedation. Ultrasound may be helpful in diagnosing testicular, gynecologic, and biliary pathology, and it may also show periappendiceal inflammation and intussusception.

Treatment and Disposition

Treatment is directed at the underlying cause. Often repeat physical examinations by the same physician are necessary to elicit the cause. IV fluid hydration may be necessary. Analgesics should be given for patient comfort. Recent studies indicate that appropriate pain management may assist diagnosis by allowing a more thorough examination on a comfortable patient. Any patient with an acute abdomen should remain on nothing-by-mouth status and have an immediate surgery consult. Broad-spectrum antibiotics should be given without delay if a perforated viscus is suspected. Patients with significant abdominal pain but no signs of acute abdomen may be admitted for serial abdominal examinations. In cases of mild abdominal pain with no additional concerning signs or symptoms, or known nonsignificant causes of abdominal pain, outpatient management is acceptable. Strong precautions should be given upon discharge and follow-up for reexamination should be arranged in 12– 24 hours.

Vomiting

General Considerations

Causes of vomiting in children may be categorized due to direct irritation to the gastrointestinal tract, intestinal or gastric outlet obstruction, effect of a toxin or other noxious stimulus on the CNS, or elevated intracranial pressure.

Clinical Findings

Look for precipitating factors including trauma, medications, feeding techniques, and recent illness. It is helpful to know the nature of the vomitus (eg, bilious, bloody, coffee ground, bright red, or feculent), the relationship to eating and position, and whether projectile vomiting occurs. The absence of passage of stool or gas implies obstruction. Inspect the abdomen for signs of obstruction, and look for evidence of a systemic illness (eg, otitis media, UTI, strep pharyngitis).

Vomiting in the Newborn

Infants commonly regurgitate a portion of feedings. Nonforceful regurgitation is usually benign. Forceful vomiting, however, often indicates serious disease. Causes of gastrointestinal obstruction in newborns include:

Intestinal Atresia

Intestinal obstruction will occur in the first days of life with emesis. Emesis will often be nonbilious in duodenal atresia and bilious of atresia occurs distal to the duodenum. Patients will often have abdominal distention and failure to pass meconium. Diagnosis is made by presenting symptoms and abdominal X-ray. Early surgical intervention is necessary.

Meconium Ileus

Obstruction due to thick meconium can lead to ileus and perforation if unrecognized. A vast majority of these patients will have cystic fibrosis.

Meconium Plug Syndrome

The distal colon becomes obstructed with a plug of meconium. A barium enema shows the plug and usually relieves the obstruction. This entity is suggestive of Hirschsprung disease.

Midgut Volvulus

This abdominal emergency typically presents in the first month of life as a result of malrotation during development. Midgut volvulus must be considered in the presence of emesis in this age range. The emesis is classically bilious in nature, but nonbilious emesis may occur in up to 20% of patients. Abdominal X-rays should be performed but a normal pattern does not rule out volvulus. An upper gastrointestinal tract contrast study is the choice for definitive diagnosis. Immediate pediatric surgery consult is essential.

Hirschsprung Disease

This condition is characterized by aganglionosis of the distal colon. It presents most commonly in the newborn with abdominal distention and bilious vomiting. There is often a delay in passing meconium beyond in the first 24 hours of life. Diagnosis is made by barium enema.

Pyloric Stenosis

This condition results from thickening of the antral-pyloric muscle resulting in gastric outlet obstruction. Pyloric stenosis usually presents between the third and sixth week of life, with an increased frequency in first born males, with progressive nonbilious vomiting, often described as projectile. The diagnosis can be made on physical examination with the observation of a gastric peristaltic wave, or palpation of an olive-shaped mass in the epigastrium. Diagnosis can be confirmed by ultrasound. Definitive treatment is surgical pyloromyotomy.

Vomiting in Infants and Children

A majority of infants and children with emesis have gastroenteritis. More serious causes of vomiting include the following:

• Intussusception—Intussusception is the prolapse of one section of the intestine into the distal adjoining section, often seen between 3 months and 5 years of age. It often presents as gastrointestinal obstruction. The classic triad consists of colicky abdominal pain, vomiting, and bloody mucous stools, and is variably present. On physical examination, an elongated mass in the right upper or right lower quadrant may be present. Rectal examination may reveal either occult blood or bloody, foul-smelling stool, often referred to as “currant jelly” stool. This is often a late finding.
• Duodenal hematoma—Consider if a history of trauma is present, traumatic pancreatitis as well as abuse should be considered.
• Appendicitis—May begin with a history or nausea and vomiting prior to the appearance of right lower quadrant abdominal pain. Associated with anorexia and classically starts with periumbilical pain that progressively localizes to the right lower quadrant.
• Hepatitis—Commonly associated in children with anorexia and vomiting as well as in teenagers and preteen population who have infectious mononucleosis.
• Incarcerated inguinal hernia—Common in children with abdominal pain and vomiting, often will have a palpable firm, indurated groin mass with an increased frequency in premature born males.
• Intracranial pathology—A mass or lesion, hemorrhage, or hydrocephalus can lead to increased intracranial pressure and should be considered as an etiology of vomiting.

Treatment

Administer fluids if the child is dehydrated or if an obstruction is present. Obtain upright and supine X-rays and if signs of obstruction are present, insert a nasogastric tube for decompression. An air-contrast enema is indicated for both the diagnosis and treatment of intussusception. Perform an upper gastrointestinal series on an emergency basis in the infant with bilious emesis who may have a midgut volvulus. Obtain urinalysis, CBC, platelet count, and electrolyte measurement as indicated by the child's clinical condition. Imaging with ultrasound or CT is dependent on the presumed etiology of the vomiting.

A pediatric surgery consult is essential for any child with an acute abdomen and vomiting, or surgically correctable condition that cannot clinically tolerate outpatient treatment.

Gastrointestinal Bleeding

General Considerations

Gastrointestinal hemorrhage in children can result from numerous sources. The first step in evaluation is to determine if the bleeding is from an upper or lower source. Patients with hematemesis (vomiting of blood) usually have a lesion proximal to the ligament of Treitz (upper source). Bleeding from sources distal to the ligament of Treitz is referred to as lower gastrointestinal bleeds. The appearance of stool may also indicate the site of bleeding. If stools are dark or black in appearance (melena), this typically indicates a longer transit time for stool, such as upper gastrointestinal, small bowel, or slow right colon bleeding. Patients with bright red blood per rectum (hematochezia) typically have distal colon or rectal lesions. There are exceptions to this as profuse bleeding from an upper gastrointestinal source may lead to hematochezia, while slow transit from a distal colon source may lead to melena.

Clinical Findings

The patient's age and the amount and type of bleeding help determine the most likely etiology. Bleeding in neonates is usually benign and self-limited. Profuse, painless bleeding may indicate Meckel's diverticulum. Bleeding associated with colicky pain may occur with intussusception. Diarrhea associated with bleeding per rectum may indicate bacterial dysentery.

Obtain vital signs to detect cardiovascular compromise. Clinical signs of liver disease may indicate a coagulopathy or esophageal varices as a possible cause of bleeding. Elicit a careful history for nonsteroidal anti-inflammatory drug use or exposure to warfarin containing drugs.

Occasionally what appears to be gastrointestinal hemorrhage is not truly from the gastrointestinal tract. Epistaxis, nasopharyngeal trauma, oral or pharyngeal postoperative bleeding (eg tonsillectomy) and hemoptysis may result in coffee-ground emesis. Some substances may color the emesis or stool red (eg, food colorings, beets, red gelatin, artificial fruit drinks, and antibiotic elixers such as cefdinir). The stool should be routinely checked with a guaiac test for occult blood.

Bleeding in the Newborn

Maternal Blood Ingestion

Swallowed maternal blood at delivery or from a bleeding nipple can result in hematemesis or melena in the newborn. These infants usually appear otherwise healthy. An Apt-Downey test can differentiate infant from maternal blood by identifying fetal hemoglobin.

Hemorrhagic Disease

Newborns with hemorrhagic disease may present with melena or hematochezia. However, other evidence of a generalized bleeding disorder is usually present. Maternal medications such as aspirin or anticoagulants may result in neonatal hemorrhage. Consider vitamin K deficiency if the neonate did not receive an intramuscular injection after birth.

Stress Ulcers

Stress ulcers can be secondary to sepsis, asphyxia, intracranial pathology, or heart disease. These ulcers may cause significant gastrointestinal bleeding.

Other Causes

Consider necrotizing enterocolitis, anal fissures, malrotation or midgut volvulus, and Hirschsprung disease with enterocolitis.

Upper Gastrointestinal Bleeding in Infants and Children

The most common cause of upper gastrointestinal bleeding is esophagitis or gastric and duodenal ulceration. Esophageal varices are an uncommon cause of bleeding in young children but may develop with severe liver disease. With forceful vomiting, tears of the distal esophagus (Mallory–Weiss syndrome) can occur, causing upper gastrointestinal hemorrhage.

Lower Gastrointestinal Bleeding in Infants or Children

Anal Fissures

Anal fissures are the most common cause of hematochezia in infants. This usually is from constipation and passing a large, firm stool. In pediatric patients with rectal trauma or fissures, one must also consider abuse in the differential diagnosis.

Cow's Milk Sensitivity

Sensitivity to cow's milk protein can result in severe colitis with bloody stools.

Intussusception

Always consider intussusception in a child who presents with colicky abdominal pain followed by vomiting. Typically, these children may appear well between episodes of vomiting. Bloody stool helps establish the diagnosis but is often a late finding.

Meckel Diverticulum

Patients with Meckel diverticulum may present with painless appearance of bright red blood per rectum. Sufficient blood loss may result in cardiovascular compromise. The gastric mucosa within the diverticulum can be identified on technetium scan.

Bacterial or Viral Infection

Fever and diarrhea associated with blood per rectum are usually secondary to an invasive bacterial infection of the colon. Culture stool for E. Coli, Campylobacter, Shigella, and Salmonella. Viral pathogens such as rotavirus and Norwalk virus must also be considered as possible causes.

Hemolytic Uremic Syndrome (HUS)

HUS is characterized by acute renal failure with thrombocytopenia, hemolytic anemia, and bloody diarrhea. Children with this syndrome are usually quite ill and require hospitalization and close observation.

Intestinal Polyps

Intestinal polyps are sometimes found in young children and may result in bright red blood per rectum. A diagnosis can be established by colonoscopy.

Henoch-Schonlein Purpura (HSP)

This disorder is characterized by small vessel vasculitis of the skin, gastrointestinal tract, and kidneys. Patients will at times have palpable purpura of the skin, joint swelling and pain, and colicky abdominal pain. Gastrointestinal bleeding may be secondary to submucosal hemorrhage. Abdominal pain and gastrointestinal bleeding may occur before the classical skin findings, complicating the diagnosis. Children with HSP are also at increased risk for intussusception.

Inflammatory Bowel Disease

Patients with inflammatory bowel disease may present with evidence of gastrointestinal bleeding associated with anemia, poor growth, abdominal pain, and diarrhea.

Thrombocytopenia

Children can present with low platelets resulting in gastrointestinal bleeding from new onset leukemia or secondary to the side effects of chemotherapy, as well as Idiopathic Thrombocytopenia (ITP)

Treatment

Evaluate cardiovascular status. Obtain IV access and initiate blood volume as indicated by cardiovascular assessment. Send blood for CBC, coagulation studies, and type and crossmatch. Consider stool evaluation for fecal leukocytes, bacterial culture, ova, and parasites.

Place a nasogastric tube to determine if the site of bleeding is in the upper gastrointestinal tract. Lavage with saline (10 mL/kg) until active bleeding stops. Unstable patients are at risk for aspiration and may require intubation.

Disposition

Admit children with acute and persistent upper gastrointestinal bleeding to the hospital for stabilization and endoscopic evaluation. Children with lower gastrointestinal bleeding can be evaluated as outpatients as long as they appear well and are hemodynamically stable with no active bleeding. Patients with abnormal hemodynamics need to be stablized prior to performing diagnostic procedures. Emergency surgical intervention may be necessary to identify the site of bleeding.

Foreign Body

Esophageal Foreign Bodies

Foreign bodies within the esophagus become lodged at the cervical esophagus, aortic arch, or lower esophageal sphincter. Esophageal obstruction secondary to a foreign body may result in substernal chest pain and increased salivation secondary to inability to swallow. The physical examination is usually normal unless perforation has occurred. X-ray examination of the chest usually will identify the foreign body; in the esophagus it is best seen on an anteroposterior film (Figure 50–9). A radiolucent foreign body (eg, plastic) may not be visible on X-ray.

Gastric and Small Bowel Foreign Bodies

Most foreign bodies, regardless of shape, that successfully pass through the esophagus will navigate the remainder of the gastrointestinal tract without difficulty. The occasional object that is unable to pass through the stomach after a period of 3 days should be removed by endoscopy. Intestinal obstruction may occur if a foreign body becomes lodged in the region of the ileocecal valve. Small disc batteries or “button” batteries need to be removed emergently via upper endoscopy if they have not passed within 24–48 hours. If two or more magnets are ingested, endoscopy or surgical consultation is warranted.

Anemia

General Considerations

In children, over 75% of anemias are due to iron deficiency or thalassemia minor, both of which are characterized by microcytosis. The most common cause of anemia in children aged 6 months to 2 years is nutritional iron deficiency. Typically, this results from excessive cow's milk intake. Less commonly iron deficiency anemia will occur secondary to chronic blood loss, usually from the gastrointestinal tract (eg, duodenal ulcers, Meckel diverticulum, and polyps).

Anemias not due to iron deficiency may occur as a result of either of the following two: (1) Decreased erythrocyte production or release from the bone marrow, for example transient erythorblastopenia of childhood (TEC). TEC typically occurs in children aged 1–2 years. Severe anemia and reticulocytopenia spontaneously resolve in 1–2 months. (2) Increased destruction, sequestration, or acute loss of circulating red cells owing to sickle cell disease, autoimmune hemolytic anemia, or hemolytic uremic syndrome, or blood loss due to trauma, surgery, or peptic ulcer disease.

Clinical Findings

Symptoms and Signs

With rapid onset of anemia from blood loss or hemolysis, signs of cardiovascular compromise as well as impending cardiac failure may be present. With slow onset of anemia, children typically show pallor and decreased exercise tolerance but no evidence of cardiovascular compromise even with extremely low levels of hemoglobin. Hemolytic anemias may cause jaundice and splenomegaly. Petechiae may indicate hemolytic uremic syndrome and thrombocytopenia.

Laboratory Findings

Laboratory evaluation should include a CBC with hemoglobin, red blood cell indices, WBC, and platelet counts, peripheral smear, and reticulocyte counts. Anemia with microcytosis in a young child strongly suggests iron deficiency. If the stool is negative for occult blood, further tests are not necessary if the child is not severely anemic.

Treatment

Iron Therapy

Treat iron deficiency with elemental iron at 3–6 mg/kg/d. Continue iron therapy for 2 months after the anemia is corrected. Restrict cow's milk intake.

If anemia has developed slowly, patients can often tolerate remarkably low hemoglobin levels, even to 4–5 g/dL, without the need for transfusion if other effective therapy is available.

Transfusion

Transfuse children who experience a rapid decline in hemoglobin to less than 7 g/dL, particularly if signs of cardiovascular compromise are present.

In patients with gradual onset of anemia who require transfusion, slow transfusion is recommended, because these children are at risk for CHF with rapid transfusion. Consider use of a diuretic to prevent fluid overload.

Disposition

Consult with a hematologist for anemias requiring transfusion, anemias associated with hemolysis, and anemias without obvious cause.

Recheck the hemoglobin level in children receiving iron therapy in 2–4 weeks to document response.

Sickle Cell Disease

General Considerations

SCD is a group of inherited disorders of hemoglobin structure characterized by hemolysis, unpredictable acute complications, and chronic organ damage. SCD is an autosomal recessive genetic disorder that results in an abnormally (sickle) shaped hemoglobin molecule. This leads to hemolysis and intravascular sludging, particularly in times of oxidative stress.

Clinical Findings

Symptoms and Signs

Vaso-occlusive events are associated with fever, leukocytosis, joint effusions, and local tenderness. These symptoms may not be apparent at initial presentation but develop gradually during the course of the illness. The location is most often in the long bones or joints. Vasoocclusive events may also occur in the scalp, jaw, abdomen, pelvis, and various other locations. Pain in these areas may mimic numerous other medical conditions.

Splenic sequestration results from an accumulation of sickled red blood cells within the spleen. This can lead to rapid enlargement of the spleen, and precipitous drops in hemoglobin. Progression to shock and death can occur. Over time, sludging of red blood cells in the splenic vasculature leads to infarcts, causing abdominal pain and progressive decrease in splenic function. Any patient with SCD should be managed as if they are asplenic and are vulnerable to overwhelming infection by encapsulated bacteria.

Vaso-occlusive crises affect numerous other organs such as the chest, CNS, and penis. Acute chest syndrome is characterized by an infiltrate on chest X-ray, combined with lower respiratory tract symptoms and/or hypoxemia. This may be an isolated presentation or develop 2–3 days after a pain crisis. Any neurologic symptom more severe than a minor headache requires urgent evaluation, as occlusion of the CNS blood supply may be occurring. Symptoms may be significant (aphasia, hemiparesis) or more subtle (developmental delay, poor school performance). Occlusion of the vascular supply of the penis can lead to priapism (prolonged painful erection of the penis).

Laboratory Findings

Obtain a CBC and reticulocyte count. A decrease in hematocrit from baseline may indicate the need for transfusion. The absence of reticulocytosis indicates an aplastic crisis (often due to parvovirus B19 infection) and heralds an abrupt decrease in the hematocrit.

Obtain cultures of blood and urine if fever is present. Obtain electrolyte studies if dehydration is a concern.

If bone pain is associated with high fever, chills, toxicity, and leukocytosis, orthopedic consultation and bone aspiration is indicated to evaluate for osteomyelitis.

Imaging

Obtain X-rays of the chest if hypoxemia, cough, tachypnea, or dyspnea is present. Infiltrates may be present in patients with acute chest syndrome.

Treatment

General Management

Administer oxygen if the patient is hypoxemic or in respiratory distress. IV fluid hydration is important in reversing the sickling process.

Venous Access

Begin an IV line if need for fluids or parenteral pain medications is anticipated. For patients with acute splenic sequestration, give bolus with IV fluids and perform exchange transfusion when available.

Antimicrobial Therapy

Due to increased risk for severe infection from encapsulated organisms, febrile SCD patients should be managed aggressively. CBC, blood cultures, urinalysis, urine culture, and chest X-ray should be performed, and CSF studies strongly considered. Empiric antibiotics should be administered while cultures are pending.

Pain Management

Effective pain management is essential in sickle cell crises. Patient's self-report is often the most accurate way to assess pain level. Patients may be able to use an objective scale or compare the current episode to prior crises. Even younger patients are often capable of relating the pain management regimen that has worked for them in past episodes. Acetaminophen with or without codeine can be used for mild pain. For severe pain, give IV morphine sulfate, 0.1 mg/kg every 2–4 hours. The patient should be reassessed frequently and medications adjusted according to pain level.

Treatment of Acute Chest Syndrome

Treatment of acute chest syndrome includes hospitalization, IV antibiotics, and supplemental oxygen to keep oxygen saturation above 95% on pulse oximetry. Administer IV fluids judiciously to maintain hydration. Over-hydration can lead to pulmonary edema. Frequent chest X-rays are necessary as radiologic appearance often lags behind clinical appearance. If hypoxemia worsens or respiratory distress occurs, exchange transfusion may be required to improve oxygen-carrying capacity and reduce the cardiac workload.

Disposition

Children who can maintain adequate oral fluid intake and whose pain is controlled with oral medication can be managed as outpatients with close follow-up.

Hospitalize children who require continued parenteral therapy for pain, those who cannot maintain adequate oral hydration, or those who have required more than two visits for treatment of the same painful crisis. Any febrile child with SCD should be considered for admission.

Idiopathic Thrombocytopenic Purpura

Essentials of Diagnosis

• Usually children present with petechia, purpura, or spontaneous bleeding involving the mucous membranes
• Platelet counts usually less than 100,000

General Considerations

There are three mechanisms by which thrombocytopenia occurs: (1) increased destruction (idiopathic thrombocytopenia purpura [ITP], hemolytic uremic syndrome, or disseminated intravascular coagulopathy), (2) decreased production (aplastic crisis, marrow infiltrating neoplasms), and (3) splenic sequestration (sickle cell disease). ITP is an autoimmune disorder from increased destruction of platelets causing severe isolated thrombocytopenia. It commonly follows a viral illness. It is usually benign and self-limited; approximately 80–90% of cases resolve within 6 months.