Pediatric Illnesses November 15, 2010 Keir Swisher, D.O

Pediatric IllnessesPediatric IllnessesNovember 15, 2010November 15, 2010

Keir Swisher, D.O.Keir Swisher, D.O.

2008 National Champions2008 National ChampionsKansas JayhawksKansas Jayhawks

Case 1Case 1

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

Case 1 continuedCase 1 continued

Physical ExamPhysical Exam General: Severe respiratory distress without cyanosisGeneral: Severe respiratory distress without cyanosis Airway: Speaks 1-2 word sentencesAirway: Speaks 1-2 word sentences Breathing: Faintly audible expiratory wheezing, very Breathing: Faintly audible expiratory wheezing, very

diminished throughout with poor air movement, RR diminished throughout with poor air movement, RR 60/min.60/min.

Circulation: Strong radial pulses, Circulation: Strong radial pulses, What meds do you want?What meds do you want?

Intern question?Intern question?

Case 1 continuedCase 1 continued Albuterol/atrovent Albuterol/atrovent Subcutaneous epinephrine ??Subcutaneous epinephrine ?? Solumedrol IV versus oral steroids?Solumedrol IV versus oral steroids? Magnesium Sulfate 20mg/kg IV over 20 minutes Magnesium Sulfate 20mg/kg IV over 20 minutes

(max 2 grams)(max 2 grams) Terbutiline (my guess is only Grandpa/Allred is Terbutiline (my guess is only Grandpa/Allred is

thinking of this medication) thinking of this medication) RE: Taught in late 1800’s when he was in medical schoolRE: Taught in late 1800’s when he was in medical school

What if no response to these therapies? Can you try What if no response to these therapies? Can you try anything before intubation?anything before intubation?


BipapBipap HelioxHeliox

Minimal oxygen content is 60/40Minimal oxygen content is 60/40 Can try prior to intubationCan try prior to intubation

You try this but sats still 88% after 20 minutes You try this but sats still 88% after 20 minutes and patient is getting very tired and becoming and patient is getting very tired and becoming less responsive.less responsive.

Meds for intubation/dosesMeds for intubation/doses

Meds:Meds: Ketamine 2mg/kg (+/- benzo’s to prevent emergence Ketamine 2mg/kg (+/- benzo’s to prevent emergence

reaction) reaction) Atropine 0.02mg/kg (min 0.1mg) or Robinul 0.005-Atropine 0.02mg/kg (min 0.1mg) or Robinul 0.005-

0.01mg/kg IV (max 0.2mg)0.01mg/kg IV (max 0.2mg) Succinylcholine 1.5-2 mg/kgSuccinylcholine 1.5-2 mg/kg Rocuronium 0.6-1mg/kgRocuronium 0.6-1mg/kg

Blade: miller vs. macintosh?Blade: miller vs. macintosh? Tracheal tube size= (age + 16)/4Tracheal tube size= (age + 16)/4

5.0 (also have available 0.5mm smaller and larger available5.0 (also have available 0.5mm smaller and larger available Cuff vs no cuff??Cuff vs no cuff??

Asthma Quick FactsAsthma Quick Facts Can see initial drop in sats after first neb (VQ mismatch)Can see initial drop in sats after first neb (VQ mismatch) If must RSI pt, remember permissive hypercapnia to minimize airway If must RSI pt, remember permissive hypercapnia to minimize airway

pressures and reduce barotraumapressures and reduce barotrauma Use albuterol (Use albuterol (increases cAMPincreases cAMP) and atrovent () and atrovent (decreases cGMPdecreases cGMP) together ) together

((first 3 treatmentsfirst 3 treatments)) Alternative therapy:Alternative therapy:

Epinephrine 0.01mg/kg (max 0.5mg) SQ q20 minutes 1:1000 solutionEpinephrine 0.01mg/kg (max 0.5mg) SQ q20 minutes 1:1000 solution Terbutaline 0.005-0.01mg/kg (max 0.4mg) SQ q20 min x 3 dosesTerbutaline 0.005-0.01mg/kg (max 0.4mg) SQ q20 min x 3 doses

Corticosteroids indicated for moderate-to-severe exacerbations (Corticosteroids indicated for moderate-to-severe exacerbations (IV/PO IV/PO absorption is equivalentabsorption is equivalent))

Risk factors for death from asthmaRisk factors for death from asthma H/o prior intubation or ICU admissionH/o prior intubation or ICU admission 2+ hospitalizations or 3+ E.D. visits in past year2+ hospitalizations or 3+ E.D. visits in past year >2 canisters of albuterol/month>2 canisters of albuterol/month Urban residency or low socioeconomic status Urban residency or low socioeconomic status

DedicationDedication

Case 2Case 2

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

CroupCroup Always think of F.B. with stridorAlways think of F.B. with stridor If any concerns for epiglottitis, obtain soft If any concerns for epiglottitis, obtain soft

tissue x-rays unless toxic appearing (then tissue x-rays unless toxic appearing (then call ENT/Anesthesia and leave the child in call ENT/Anesthesia and leave the child in parents lap or wherever is comfortableparents lap or wherever is comfortable

Typically parainfluenza virus in late Typically parainfluenza virus in late fall/early winterfall/early winter

All children with croup (mild, moderate or All children with croup (mild, moderate or severe) should receive decadron 0.6 mg/kg severe) should receive decadron 0.6 mg/kg IV/IM/PO (max 10mg) as one time doseIV/IM/PO (max 10mg) as one time dose

Racemic epi (0.5ml of 2.25% solution) for Racemic epi (0.5ml of 2.25% solution) for patients with resting stridorpatients with resting stridor

Cool mist, hydration and oxygen otherwise Cool mist, hydration and oxygen otherwise if does not need r.e.if does not need r.e.

Children receiving racemic epi must be Children receiving racemic epi must be observed for 3-4 hours to watch for observed for 3-4 hours to watch for reboundrebound

Can repeat racemic epi every 15- 20 minutes (if 3+ Can repeat racemic epi every 15- 20 minutes (if 3+ doses in 2 hrs extended cardiac monitoring)doses in 2 hrs extended cardiac monitoring)

Can consider heliox if necessary to provide additional Can consider heliox if necessary to provide additional time for steroids and racemic epinephrine to work and time for steroids and racemic epinephrine to work and postpone RSIpostpone RSI

Will decrease work of breathing with improved Will decrease work of breathing with improved laminar flow (decreased density of gas)laminar flow (decreased density of gas)

Most protocols employ 70:30 helium:oxygen ratioMost protocols employ 70:30 helium:oxygen ratio Essentially depends on oxygen requirementsEssentially depends on oxygen requirements

Bacterial TracheitisBacterial Tracheitis Symptoms similar to croup yet patient “takes turn for Symptoms similar to croup yet patient “takes turn for

worse”worse” Toxic appearingToxic appearing High fever, stridor, congestion, barking coughHigh fever, stridor, congestion, barking cough Typically < 3y/oTypically < 3y/o O2O2 ENT/anesthesia consult for endoscopy (will see ENT/anesthesia consult for endoscopy (will see

pseudomembranes and purulent secretions)pseudomembranes and purulent secretions) S. Aureus most frequent pathogenS. Aureus most frequent pathogen ICU admissionICU admission

Case 3Case 3 18 month male presents to Room 11 with cyanosis to tongue 18 month male presents to Room 11 with cyanosis to tongue

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

DDX:DDX: Respiratory etiology yet no resp distress and Respiratory etiology yet no resp distress and

CTABCTAB Methemoglobinemia/SulfhemoglobinemiaMethemoglobinemia/Sulfhemoglobinemia Hypoventilation Hypoventilation Foreign body?Foreign body? Cyanotic heart diseaseCyanotic heart disease

Cyanotic Heart DiseasesCyanotic Heart Diseases T.O.F. T.O.F. (most common in children > 1y/o) with four anatomic components (most common in children > 1y/o) with four anatomic components

“I.H.O.P.”“I.H.O.P.” IInterventric septal defectnterventric septal defect HHypertrophy of RVypertrophy of RV OOveriding aortaveriding aorta PPulmonary stenosisulmonary stenosis

Transposition of great vessels (most common in newborns)Transposition of great vessels (most common in newborns) Truncus arteriosusTruncus arteriosus Total anomalous pulmonary venous return Total anomalous pulmonary venous return Tricuspid atresiaTricuspid atresia Pulmonary atresiaPulmonary atresia Ebstein’s anomaly of tricuspid valveEbstein’s anomaly of tricuspid valve

Tetrology of FallotTetrology of Fallot

CXR: Boot shaped heart with diminished pulm CXR: Boot shaped heart with diminished pulm vascular markings (decr pulm blood flow)vascular markings (decr pulm blood flow)

ECG: R.A.D., RVHECG: R.A.D., RVH CBC: polycythemiaCBC: polycythemia Management:Management:

Prone knee-chest position Prone knee-chest position OxygenOxygen Morphine 0.1mg/kgMorphine 0.1mg/kg If no response consider propranolol or phenylepherine after If no response consider propranolol or phenylepherine after

talking with peds cardiologytalking with peds cardiology

Where do you place the EZ IO?Where do you place the EZ IO?

Case 4Case 4

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


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

CXRCXR Inspiratory/expiratoryInspiratory/expiratory B/l decub if uncooperative childB/l decub if uncooperative child

Albuterol/atrovent?Albuterol/atrovent?

Foreign Body AspirationForeign Body Aspiration If stridor FB is present in If stridor FB is present in

larynx or trachealarynx or trachea If wheezing the FB is in If wheezing the FB is in

mainstem bronchus or furthermainstem bronchus or further MRI useful in confirming MRI useful in confirming

peanut or other vegetable peanut or other vegetable mattermatter

BronchoscopyBronchoscopy IF radiopaque FB in trachea IF radiopaque FB in trachea

seen on edge (PA) and “en seen on edge (PA) and “en face” in lat, opposite for face” in lat, opposite for esophagus (per River’s, yet esophagus (per River’s, yet not always the case)not always the case)

Case 5Case 5

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

OxygenOxygen Nasal suctionNasal suction CXRCXR RSV/Influenza A/B swabs?RSV/Influenza A/B swabs? Albuterol/atrovent nebAlbuterol/atrovent neb Steroids?Steroids?

Steroids only indicated if pt with h/o Steroids only indicated if pt with h/o asthma and requirement in pastasthma and requirement in past

Bronchodilator trial, continue if Bronchodilator trial, continue if improvementimprovement

?Nebulized epinephrine agent of ?Nebulized epinephrine agent of choice, repeat in 30 minutes as choice, repeat in 30 minutes as neededneeded

Chest x-ray in 1Chest x-ray in 1stst time wheezers or time wheezers or clinically indicatedclinically indicated

Saline drops/nasal suctioning for Saline drops/nasal suctioning for hospital and home carehospital and home care

Ribavirin for immunocompromised, Ribavirin for immunocompromised, mechanically ventilated, complicating mechanically ventilated, complicating illness and less than 6 weeks oldillness and less than 6 weeks old

If < 6 months and RSV + what If < 6 months and RSV + what possible complication can occur?possible complication can occur?

33rdrd year question? year question?

Case 6Case 6

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

What next?What next?


Septic w/u (LP vs no LP)Septic w/u (LP vs no LP) According to Carol RiversAccording to Carol Rivers

Infants < 2 months old needs LPInfants < 2 months old needs LP Infants 2-3 months old, omit LP if infants:Infants 2-3 months old, omit LP if infants:

Appears wellAppears well behaving normallybehaving normally CBC normal, CBC normal, F/u in 24 hrs and no antibiotics administeredF/u in 24 hrs and no antibiotics administered


What medications to start empirically?What medications to start empirically? Intern question?Intern question?

What are the most common organisms in this What are the most common organisms in this nearly 3 months old that could cause sepsis?nearly 3 months old that could cause sepsis? 22ndnd year question? year question?

Infancy and early childhoodInfancy and early childhood Strep pneumoniaeStrep pneumoniae N. MeningitidisN. Meningitidis H. influenzaH. influenza

Neonatal period (0-4 wks)Neonatal period (0-4 wks) GBSGBS E. ColiE. Coli Listeria monocytogenesListeria monocytogenes

Case 7Case 7

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

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


Outpatient Outpatient Amoxicillin (dose mnemonic for high dose 80mg/kgAmoxicillin (dose mnemonic for high dose 80mg/kg

400mg/5ml dosing is weight in kilograms divided BID400mg/5ml dosing is weight in kilograms divided BID Example 10 kg child (5ml BID)Example 10 kg child (5ml BID)

AugmentinAugmentin BactrimBactrim Macrolide (zithromax/biaxin/erythromycin)Macrolide (zithromax/biaxin/erythromycin) CefiximeCefixime CefaclorCefaclor

2009 Masters Golf Tournament2009 Masters Golf Tournament

Case 8Case 8

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

DDx:DDx: Endocarditis (always consider in persistant fever)Endocarditis (always consider in persistant fever)

Janeway lesions, roth spots, pancarditis, osler’s nodes, fever, anemia, Janeway lesions, roth spots, pancarditis, osler’s nodes, fever, anemia, splinter hemorrhagessplinter hemorrhages

Rheumatic feverRheumatic fever Jones Criteria (1 major/2 minor or 2 major plus preceding GABH strep Jones Criteria (1 major/2 minor or 2 major plus preceding GABH strep

infection)infection) Major: polyarthritis, carditis, chorea, erythema marginatum, subcutaneous Major: polyarthritis, carditis, chorea, erythema marginatum, subcutaneous

nodules nodules Minor fever, arthralgias, h/o RHF, pos labsMinor fever, arthralgias, h/o RHF, pos labs Plus recent strep infection (oropharynx, not skin), incr ASO titer, scarlet feverPlus recent strep infection (oropharynx, not skin), incr ASO titer, scarlet fever

Kawasaki’sKawasaki’s C.R.A.S.H.C.R.A.S.H. a motorcycle a motorcycle Non purulent Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand Non purulent Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand

rash/desquamationrash/desquamation

Concerns for subacute phase (day 11-20 with development of coronary art Concerns for subacute phase (day 11-20 with development of coronary art thrombosis/aneurysmthrombosis/aneurysm

Fever >5 days PLUS 4 of followingFever >5 days PLUS 4 of following B/l nonsuppurative conjunctivitisB/l nonsuppurative conjunctivitis Changes of lips and oral mucosa (strawberry tongue, injected oropharynx, Changes of lips and oral mucosa (strawberry tongue, injected oropharynx,

fissured lips)fissured lips) Extremity features (palmar/plantar erythema, edema hands/feet, periungual Extremity features (palmar/plantar erythema, edema hands/feet, periungual

desquamation)desquamation) Polymprphous rashPolymprphous rash Cervical LAD (at least one > 1.5cm)Cervical LAD (at least one > 1.5cm)

Prognosis determined by cardiac complications (20-30% of untreated Prognosis determined by cardiac complications (20-30% of untreated children develop c.a. aneurysms)children develop c.a. aneurysms)

TxTx IVIG 2grams/kg over 12 hrsIVIG 2grams/kg over 12 hrs ASA 100mg/kg divided Q.I.D.ASA 100mg/kg divided Q.I.D. Treat with antibiotics while awaiting bld cultures??Treat with antibiotics while awaiting bld cultures??

Case 9Case 9

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

Children 3 months – 6 yrsChildren 3 months – 6 yrs Last less than 10-15 minutesLast less than 10-15 minutes Generalized seizure activity without focal postictal defecitsGeneralized seizure activity without focal postictal defecits +/- family h/o febrile seizures+/- family h/o febrile seizures Single event in 24 hr time periodSingle event in 24 hr time period Rivers mentions LP in all children with nuchal rigidity (only Rivers mentions LP in all children with nuchal rigidity (only

consistant if > 2y/o), recurrent seizures, or prolonged post ictal consistant if > 2y/o), recurrent seizures, or prolonged post ictal period and all infants 3-12 months of age.period and all infants 3-12 months of age.

What is the risk of a repeat seizure in the future?What is the risk of a repeat seizure in the future?33rdrd year question? year question?

Prophylaxis with tylenol/motrin the rest of his life?Prophylaxis with tylenol/motrin the rest of his life?

Risk of recurrance: 30-40 percent (more likely Risk of recurrance: 30-40 percent (more likely if first seizure prior to 1 y/oif first seizure prior to 1 y/o

Prophylaxis with antipyretics not Prophylaxis with antipyretics not recommended.recommended.

Case 10Case 10 3.5 month old male with vomiting and decrease in 3.5 month old male with vomiting and decrease in

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

Pyloric stenosis (too old typically 2-6 wks of Pyloric stenosis (too old typically 2-6 wks of life and nonbilious))life and nonbilious))

Gastritis Gastritis Trauma/CHITrauma/CHI Midgut volvulusMidgut volvulus ObstructionObstruction Incarcerated herniaIncarcerated hernia IntussusceptionIntussusception

Midgut volvulusMidgut volvulus Congenital malrotation of bowel/inadequate attachment to Congenital malrotation of bowel/inadequate attachment to

mesenterymesentery Children < 1y/o (typically first month of life)Children < 1y/o (typically first month of life) Bilious vomiting, distention, ttp and palpable mass.Bilious vomiting, distention, ttp and palpable mass. TxTx

IVF, NGT, call surgery for emergent laparotomyIVF, NGT, call surgery for emergent laparotomy

DxDx AAS/Upright abdomenAAS/Upright abdomen UGI or ultrasound will confirm dxUGI or ultrasound will confirm dx

IntussusceptionIntussusception Most common cause of intestinal obstruction in 3mo-5yoMost common cause of intestinal obstruction in 3mo-5yo Illeocolic most common typeIlleocolic most common type Triad of intermittent colicky abd pain, vomiting and currant jelly stools Triad of intermittent colicky abd pain, vomiting and currant jelly stools

(21 % of patients)(21 % of patients) Lethargy can be prominent featureLethargy can be prominent feature Abd pain child draws legs up (don’t all kids when crying?), screams Abd pain child draws legs up (don’t all kids when crying?), screams

followed by pain free intervals up to 20 minutesfollowed by pain free intervals up to 20 minutes Vomiting may become biliousVomiting may become bilious Absence of currant jelly stools doesn’t exclude the dxAbsence of currant jelly stools doesn’t exclude the dx DxDx

Plain films (can be normal)Plain films (can be normal) Air contrast enema (have peds surg available and ready incase of perf)Air contrast enema (have peds surg available and ready incase of perf) Can be diagnostic and theraputic (60-80% of cases)Can be diagnostic and theraputic (60-80% of cases)

Pyloric stenosisPyloric stenosis Occurs at 2-6 wks of lifeOccurs at 2-6 wks of life Nonbilious projectile vomitingNonbilious projectile vomiting Evidence of dehydration and fttEvidence of dehydration and ftt Palpable olive-shaped mass in RUQPalpable olive-shaped mass in RUQ HYPOCHLOREMIC, HYPOKALEMIC HYPOCHLOREMIC, HYPOKALEMIC

METABOLIC ALKALOSISMETABOLIC ALKALOSIS Dx sono or upper GI seriesDx sono or upper GI series

Bonus questionBonus question

The last year the KC Chiefs won a playoff The last year the KC Chiefs won a playoff game?game?

A. 2001A. 2001 B. 1965B. 1965 C. 1997C. 1997 D. 1994 D. 1994

Jan. 16, 1994Jan. 16, 1994 AFC Divisional AFC Divisional Kansas City 28, Houston Kansas City 28, Houston

20 20

Case 11Case 11 9 y/o male MVA to Trauma 2. Unrestrained 9 y/o male MVA to Trauma 2. Unrestrained

passenger, thrown from car traveling 40 mph after passenger, thrown from car traveling 40 mph after mom went into ditch trying to miss a deer. GCS 3, mom went into ditch trying to miss a deer. GCS 3, airway intact, RR 30, Sats 93% HR 130, BP 95/60. airway intact, RR 30, Sats 93% HR 130, BP 95/60. No Gag reflex and CTAB. You ask for meds for RSI No Gag reflex and CTAB. You ask for meds for RSI (70kg), Lidocaine 100mg, Etomidate 20mg, (70kg), Lidocaine 100mg, Etomidate 20mg, Rocuronium 70mg. Attempt RSI and note diffuse Rocuronium 70mg. Attempt RSI and note diffuse blood in posterior oropharynx, unable to visualize blood in posterior oropharynx, unable to visualize cords and unsuccessful attempts x 2. Pt still cords and unsuccessful attempts x 2. Pt still chemically paralyzed for 40 more minutes (oops, chemically paralyzed for 40 more minutes (oops, should have used suc?), sats slowly falling with should have used suc?), sats slowly falling with bagging patient, need airway now. What do you do?bagging patient, need airway now. What do you do?

You recall that percutaneous You recall that percutaneous needle cricothyroidotomy is needle cricothyroidotomy is indicated for children <12 indicated for children <12 yrs oldyrs old

You get your supplies ready You get your supplies ready and ask for the nurse to get and ask for the nurse to get you a diapper for you to put you a diapper for you to put onon 14 gauge angiocath.14 gauge angiocath. 3ml syringe3ml syringe 3.0 ETT adapter3.0 ETT adapter

Percutaneous needle Percutaneous needle CricothyroidotomyCricothyroidotomy

Identify the cricothyroid membrane just Identify the cricothyroid membrane just below the thyroid cartilagebelow the thyroid cartilage

Stabilize trachea with thumb and Stabilize trachea with thumb and forefingerforefinger

14 G angiocath to puncture skin midline 14 G angiocath to puncture skin midline over membraneover membrane

Apply neg pressure to syringe and direct Apply neg pressure to syringe and direct caudally and posteriorly at 45 degree anglecaudally and posteriorly at 45 degree angle

Once air aspirated, advance catheter Once air aspirated, advance catheter further and withdraw the needlefurther and withdraw the needle

Connect 3.0 ETT adapter to syringe with Connect 3.0 ETT adapter to syringe with plunger outplunger out

Will have exaggerated resistance to Will have exaggerated resistance to bagging (due to turbulence)bagging (due to turbulence)

Must occlude pop-off valve due to high Must occlude pop-off valve due to high pressures requiredpressures required

If using jet ventilation, connect IV tubing If using jet ventilation, connect IV tubing to end of angiocath, cut small hole and to end of angiocath, cut small hole and provide 1 second burst with 3 seconds of provide 1 second burst with 3 seconds of exhalationexhalation

Case 12Case 12 You are on your first OB/Gyn month and in the delivery suite. You are on your first OB/Gyn month and in the delivery suite.

There was a prolonged delivery, the patient was a Gravida 1 There was a prolonged delivery, the patient was a Gravida 1 at 39 2/7 weeks with Gestational Diabetes. Dr. Allred had to at 39 2/7 weeks with Gestational Diabetes. Dr. Allred had to use forceps and Apgars were 6/7 at 1 and 5 minutes. You hear use forceps and Apgars were 6/7 at 1 and 5 minutes. You hear someone say “is that a seizure” and turn to see the neonate someone say “is that a seizure” and turn to see the neonate seizing. You begin your ABC’s and astutely ask for an seizing. You begin your ABC’s and astutely ask for an accucheck. You see GTC activity, apply oxygen and after 3 accucheck. You see GTC activity, apply oxygen and after 3 minutes of seizing hear the accucheck is 81. What are causes minutes of seizing hear the accucheck is 81. What are causes of seizures in neonatal period? What next?of seizures in neonatal period? What next?

Causes:Causes: Hypoxic-ischemic encephalopathy (most common)Hypoxic-ischemic encephalopathy (most common) ICHICH TORCHS infectionTORCHS infection Pyridoxine deficiencyPyridoxine deficiency CVACVA Drug withdrawalDrug withdrawal Hypoglycemia or electrolyte abnormalitiesHypoglycemia or electrolyte abnormalities Development/inborn errors of metabolismDevelopment/inborn errors of metabolism

Types of neonatal seizuresTypes of neonatal seizures Subtle, Tonic, Focal clonic, Multifocal clonic, MyoclonicSubtle, Tonic, Focal clonic, Multifocal clonic, Myoclonic

Treatment of Neonatal SeizuresTreatment of Neonatal Seizures

Phenobarbitol initial D.O.CPhenobarbitol initial D.O.C.. 15-20mg/kg IV over 10 minutes, may be redosed 5mg/kg 15-20mg/kg IV over 10 minutes, may be redosed 5mg/kg

(max 40 mg/kg)(max 40 mg/kg) Phenytoin Phenytoin

20 mg/kg IV20 mg/kg IV AtivanAtivan

0.05-0.1mg/kg at rate 2mg/min0.05-0.1mg/kg at rate 2mg/min Diazepam Diazepam

0.20.3mg/kg at rate 1mg/min0.20.3mg/kg at rate 1mg/min Or rectally 0.5mg/kg (diastat)Or rectally 0.5mg/kg (diastat)

Documents

Pediatric Illnesses November 15, 2010 Keir Swisher, D.O