Transcript Pediatrics in Review - University of Kentucky Emergency Medicine

Pediatrics in Review
Craig T. Carter, D.O.
Associate Professor
Department of Emergency Medicine and Pediatrics
University of Kentucky
2/2013
Some Pictures Do Not Require
Captions ….
“Ringworm”

Ringworm often causes itchy, red, scaly, slightly
raised, expanding rings on the skin of the trunk
of the body, face, groin or thigh fold. The ring
grows outward as the infection spreads, and the
center area becomes less actively infected.
Tinea…
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Athlete's foot (tinea pedis). This form affects
the moist areas between your toes and
sometimes on your foot itself.
Jock itch (tinea cruris). This form affects your
genitals, inner upper thighs and buttocks.
Ringworm of the scalp (tinea capitis). This
form is most common in children and involves
red, itchy patches on the scalp, leaving bald
patches.
Q: How are kids
airways different?
Anatomical airway issues in kids
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big tongue, soft tissue 
obstruction
soft trachea  no cuff
soft VC  no stylet
anterior larynx
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short trachea
narrowest at subglottis
nose breathers
< 6 mos
big occiput
big epiglottis  straight
blade
Airway positioning for children
<2yrs
Chalazion
Chalazion
Chalazions may be treated with any one of the following
methods:
 1) Antibiotics and/or steroid drops of injections;

2) Warm compresses;
Warm compresses can be applied in a variety of ways,
The simplest way is to hold a clean washcloth, soaked in
hot water, against the closed lid for five to ten minutes,
three to four times a day. Repeatedly soak the washcloth
in hot water to maintain adequate heat.
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3) Massage of expression of the glandular secretions;
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4) Surgical incision or excision.
Pre-septal and Orbital Cellulitis
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Bacterial infection
usually results from local
spread of adjacent URTI
Preseptal usually follows
periorbital trauma or
dermal infection
Orbital most commonly
secondary to ethmoidal
sinusitis
Preseptal
Staphylococcus aureus
and Staphylococcus
epidermidis
Streptococcus
Orbital
Strep pneumoniae
and pyogenes,
Staph aureus
Haemophilus
influenzae,
anaerobes
Answers when you do not know the
answers…
What is this?
Burn Depth
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Superficial partial
thickness burn
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Pink, moist,thin
walled blisters
Intact sensation
Heal in 2-3 weeks
No scarring
Burn Depth
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Deep partial thickness
burn
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Red or Blanched
Thick walled blisters
Decreased two point
discrimination
Mild or exquisitely painful
May heal by
epithelialization 3-6 weeks
High scar and contracture
potential
Burn Depth
Burn Depth
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Full thickness burn
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White, charred leathery
Capillary and nerve
beds destroyed
Less painful/ insensate
Only 1-2cm lesions can
heal by contraction
Grafting required
High complication rates
and prolonged recovery
Burn Depth
Extent of Burn

What is the Rule of Nines?
Itchy, stayed at friends house
overnight, woke with pet in bed
Flea Bites
Rash
Rash w/ fever and abd pain
So what is it?
Get your clickers…
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1. Meningococcemia
2. ITP/TTP
3. HUS
4. HSP
5. Petichial hemorrhages
6. RMSF
Henoch-Schonlein Purpura

Clinical Presentation

Effects predominantly young children, but adults
are also affected
Peak incidence is 4-5 years of age
There is a slight male predominance
The condition is more prevalent in the winter and
early spring
The onset of illness is usually sudden and is
preceded by a URI in at least 1/3 of cases
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HSP - Clinical Presentation
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Classic Triad of symptoms is the most common
presentation
Purpura
 Colicky abdominal pain
 arthritis
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50% of children may present with symptoms
other than purpura
Risk of Intuss
Q: How much of
their blood volume
can a kid lose, and
still have a
NORMAL bp?
Q: How much of
their blood volume
can a kid lose, and
still have a
NORMAL bp?
40%
Lymphadenitis
Spontaneous subconjunctival
haemorrhage
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Painless red eye without discharge
VA not affected
Clear borders
Masks conjunctival vessels
Check BP and body for other hemorrhages
No treatment (lubricants)
10-14 days to resolve
If recurrent: clotting, FBC
Always consider abuse…
Liver Laceration from ATV
What is it?
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1. ECM
2. EM
3. Fifths disease
4. No clue
5. Erythema Nodosum
What is it?
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1. ECM
2. EM
3. Fifths disease
4. No clue
5. Erythema Nodosum
Erythema Multiforme
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Symmetrically distributed, erythematous, expanding macules or
papules evolve into classic iris or target lesions, with bright red
borders and central petechiae, vesicles, or purpura.
Lesions may coalesce and become generalized.
Vesiculobullous lesions develop within preexisting macules,
papules, or wheals.
Rash favors palms and soles, dorsum of the hands, and extensor
surfaces of extremities and face.
Postinflammatory hyperpigmentation or hypopigmentation may
occur.
Eye involvement occurs in 10% of EM cases, mostly bilateral
purulent conjunctivitis with increased lacrimation.
Mucous membrane blistering occurs in about 25% of cases of
EM, is usually mild, and typically involves the oral cavity.
Varicella
Varicella
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Agent: varicella zoster virus
Transmission: respiratory
Period of communicability: 1 day before
eruption of vesicles.
Prodromal phase: slight fever, malaise, pruritic
rash; macular to papular to vesicular.
Management of Varicella
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Isolation
Skin care: tepid bath, calamine lotion, clip finger
nails.
Keep from scratching
Antihistamines for itching - Benadryl
No ASA – acetaminophen only.
Varicella vaccine now available.
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97% immunity in 2m-12 y
78% immunity in 13y-adult
2% can have attenuated disease
Parent of the year…NOT!
What is it and what is next best
test?
Seat Belt sign
What is it?
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1. Mumps
2. Measeles
3. Ruebella
4. Small pox
5. No clue
Measles: Diagnosis / Clinical
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Clusters of children with
fever, cough, conjunctivitis,
coryza, morbilliform rash
Measles: Signs and Symptoms
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Peak of Illness
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Other signs and symptoms
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Anorexia, malaise, HSM
Resolution
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2-4 days after onset of rash
Rapid improvement at end of febrile period (1 week)
Complete recovery in 10-14 days
Pearl: darker-skinned children
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Sandpaper feel to rash may be helpful
Measles or Rubeola
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Agent: Virus
Transmission: respiratory, blood and urine
Incubation period: 10 to 20 days
Period of Communicability: 4 days before and 5
days after rash appears.
Prodromal stage: fever, cough, conjunctivitis,
Koplik spots.
Can get same rash/illness up to 10 d after MMR
Measles: Signs and Symptoms
Rash
Hairline
Behind Ears
Face
Trunk
Limbs
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Erythematous papular
eruption
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Travels inferior over 2-3
days
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Coalesces into macular
“splotches”
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Often desquamates at end
of illness
Nothing here
Parent of the year…NOT
Down Syndrome
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Described by John Landon Down in 1866
Etiology: nondisjuction mutation resulting in
Trisomy 21
Prevalence 1:700
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Most common chromosomal anomaly
Associated with Maternal age > 35
Down Syndrome
Characteristics
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Macroglossia
Micrognathia
Midface hypoplasia
Flat occiput
Flat nasal bridge
Epicanthal folds
Up-slanting palpebral fissures
Progressive enlargement of lips
Hands: Simian crease (continuous line in the palm of the
hand), short broad hands, underdevelopment of middle
portion of the 5th finger resulting in the finger bending
towards the outside of the hand.
Name 4 medical issues to consider in Down
Syndrome patients…especially in ED!
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Atlantal-axial dislocation – be wary in traumas or
downs patient with neck pain or inability to ambulate
Cardiovascular anomalies (40%)
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GI anomalies (10-18%)
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ASD, VSD, Tetralogy of Fallot, PDA
Pyloric stenosis, duodenal atresia, TE fistula
Malignancy
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20 fold higher incidence of ALL
Gonadal tumors
Q: What’s the
formula for minimal
systolic bp for age?
Q: What’s the
formula for minimal
systolic bp for age?
70 + (Age x 2)
Eg for 5 yo: 70+5x2 = 80
MCAD ?
Group effort - Tell me everything you know
(I am certain this will be a very short conversation!)
Medium chain acyl-CoA dehydrogenase
deficiency (MCAD)
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Fatty acid oxidation defect
Disorder of ammonia detoxification
Most common mitochondrial β oxidation disorder 1/10,000
5% of 313 cases SIDS
Screen all infants of mothers with HELLP syndrome
Results in acute toxic encephalopathy with episodes of nonketotic
hypoglycemia in the 1st 2 years of life provoked by fasting
v/lethargy after fasting , usually with URI/AGE
 In ED: coma, hypoglycemic hypoketotic, hyperammonemia,
LFTs
 TX: D10
 Avoid fasting
 Carnitine 100mg/k/d
Mulluscum Contagiosum
Dictation goofs and gaffs..
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“Unsure the etiology of this left upper shimmy pain.”
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“He had reported that he slipped and fell landing
primarily with his hip on the patient's right knee. The
child did not lose consciousness and did not appear
to strike any other body parts. They report a car
immediately afterwards”
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“History of present illness: Six-year-old nontender by
mother mother reports intermitten…”
Febrile Seizures
CRITERIA FOR THE DIAGNOSIS OF
SIMPLE FEBRILE SEIZURE
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Between 6 months and 5 years of age
Seizure lasting less than 15 minutes
Fever present prior to the onset of the seizure
No other neurologic diagnoses
Non-focal, generalized seizure, involving all limbs
No severe metabolic disturbance
No more than a single seizure per 24-hour period
No evidence of intracranial infection
Febrile SZ work-up
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Clinicians evaluating infants or young
children after a simple febrile seizure
should direct their attention toward
identifying the cause of the child's fever.
In general, a simple febrile seizure does
not usually require further evaluation,
specifically EEGs, blood studies, or
neuroimaging.
Febrile Seizures – Parental
Education
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The risk of febrile seizure in the general
population is between ?
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2% and 5%
There is no evidence that treating
simple febrile seizures with antiepileptics decreases the incidence of
epilepsy later in life or results in
improved cognitive outcomes.
Febrile Seizures – Parental
Education
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If a patient is less than 12 months of age at the
time of the first simple febrile seizure, the risk of
second simple febrile seizure is 50%.
If a patient is over 12 months of age at the time
of the first simple febrile seizure, the risk of a
second simple febrile seizure is 30%.
Following a second simple febrile seizure, the
risk of future simple febrile seizures is 50%,
regardless of the age of the initial simple febrile
seizure.
The risk of epilepsy is minimally increased from
1% to 2.4% in patients who have a simple febrile
seizure
Mumps Clinical Features
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Incubation period 14-18 days
Nonspecific prodrome of low-grade fever,
headache, malaise, myalgia
Parotitis in 30%-40%
Up to 20% of infections asymptomatic
May present as lower respiratory illness, particularly
in preschool-aged children
Mumps Pathogenesis
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Respiratory transmission of virus
Replication in nasopharynx and regional lymph
nodes
Viremia 12-25 days after exposure with spread
to tissues
Multiple tissues infected during viremia
?
Human Bites-ABUSE
Q: Name 4 things that
can result in an
agitated pediatric
trauma patient.
Causes of agitation…
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Head Injury
Decreased Oxygenation
Shock
Altered LOC due to Alcohol, drug etc
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What is this rash?
Drug Reaction/Eruption
Treatment ?
Differential Dx ? List 3…
Hand edema – What is
it?

How about now?
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Coronary artery
aneurysms -
Kawasaki Disease - Clinical
Manifestations
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High fever
Conjunctivitis
Strawberry tongue
Edema of hands and feed
Reddening of palms and soles
Lymph node swelling
Kawasaki Disease - Clinical Tests
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LFTs/TBili
Albumin
ESR
CRP
Urine
CBC
Thrombocytosis
 Leukocytosis
 Anemia (normocytic)
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A 4yo boy presents with painful rectal bleeding. Mom
describes the blood as “bright red, my son is going to
bleed to death!” The most common etiology of
painful rectal bleeding in this age group is?
a. Juvenile polyposis
b. Anal fissure
c. Crohn’s Disease
d. Meckel’s diverticulum
A 4yo boy presents with painless rectal bleeding. Mom
describes the blood as “bright red, my son is going to
bleed to death!” The most common etiology of painless
rectal bleeding in this age group is?
a. Juvenile polyposis
b. Anal fissure
c. Crohn’s Disease
d. Meckel’s diverticulum
Dictation goofs and gaffs…
What???

“I discussed this with the family and felt as
though he most likely had some dry skin no
switching off in this area”
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“She is taken to court Riche already performed
chest x-ray”
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“Patient presents with bruising the posterior
thighs which appears consistent with Niceville
trauma”
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Salter 1
Salter 2
Salter 3
Salter 4
Salter 5
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Salter 1
Salter 2
Salter 3
Salter 4
Salter 5
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Salter 1
Salter 2
Salter 3
Salter 4
Salter 5
Salter Fracture I and II
Salter Fracture III, IV and V
?
Abnormal bruising patternsABUSE
Bowden & Greenberg
Tripod position
Epiglottitis Symptoms
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Acute inflammation of supra-glottic structures.
Medical Emergency
Sudden onset
High fever
Dysphasia and drooling
Epiglottis is cherry red and swollenDiagnosis made on
presenting symptoms
No tongue blade in mouth
Emergency tracheostomy set
No procedures until in the operating room
Keep quiet
Purple Rash
Bowden & Greenberg
Characteristic purpuric lesions.
Meningococcemia
Necrosis of skin
Bacterial Meningitis Pathogens
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Under 2 months :E-coli, Group B
streptococcus, Listeria, Haemophilus influenza
type B, and Streptococcus pneumonia
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Beyond neonate: Strep, Haemophilus, Neisseria.
Clinical Manifestation
Severe abdominal pain
Currant jelly-like stool is a
classic sign.
Bowden & Greenberg
Intussusception
Telescoping of part of
intestine into an adjacent
distal portion.
Bowden Text
Barium Enema
Ball & Bindler
Gas filled
loops of
bowel
Necrotizing Enterocolitis
Necrotizing = damage and death of cells
Entero = refers to intestines
Colitis = inflammation of the colon60 to 80% are premature infants
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Feeding of concentrated formulas
Infants who have received blood transfusion
Infants with GI infections
Infants with polycythemia: congenital heart disease
Q: List 3 trauma
considerations that we
often forget about,
especially in children?
Q: List 3 trauma
considerations that we
often forget about?
1.
2.
3.
Hypothermia
Child Abuse
Hazardous Environments
Myelomeningocele

A protruding saclike structure
containing meninges, spinal fluid and
neural tissue.
Bulging anterior fontanelle
Eyes deviated downward
“Setting” Sun sign
Bates: Physical Assessment
Severe Hydrocephalus
Hydrocephalus
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Greek meaning water on the brain
Dilation of the ventricles
Two primary causes:
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Congenital .5 to 1%
Acquired:
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Lesion, tumors, infection, intracranial bleed,
myelomeningocele
Retinal Hemorrhages
Normal retinal
Retinal hemorrhage
What is it?
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MRSA
Burn
Grp A strep
Yeast
No clue
Erysipelas
Streptococcal Skin Infections
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Group A Streptococci (Strep. pyogenes), which
cause erysipelas, an infection affecting the
superficial layers of the skin, and which
classically has sharply defined borders.
Clostridium tetani
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Anaerobic gram-positive, spore-forming bacteria
Spores found in soil, dust, animal feces; may
persist for months to years
Multiple toxins produced with growth of
bacteria
Tetanospasmin estimated human lethal dose =
2.5 ng/kg
Tetanus Clinical Features
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Incubation period; 8 days
(range, 3-21 days)
Three clinical forms: Local (not common), cephalic (rare),
generalized (most common)
Generalized tetanus: descending symptoms of trismus (lockjaw),
difficulty swallowing, muscle rigidity, spasms
Spasms continue for 3-4 weeks; complete recovery may take
months
Pathogenesis of Lyme Borreliosis
 Lyme disease characterized by three stages:
i.
Initially a unique skin lesion (erythema chronicum
migrans (ECM)) with general malaise
 ECM not seen in all infected hosts
 ECM often described as bullseye rash
 Lesions periodically reoccur
ii. Subsequent stage seen in 5-15% of patients with
neurological or cardiac involvement
iii. Third stage involves migrating episodes of nondestructive, but painful arthritis
 Acute illness treated with phenoxymethylpenicillin
or tetracycline
Diagnosis of Lyme Borreliosis
Rickettsia rickettsii Rocky mountain spotted fever
Q: What are the risk
factors for child abuse?
Child Abuse
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History
story  injuries
history changing
injury  development
delay seeking help
inappropriate level of
concern
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Physical Exam
multiple old and new
bruises
posterior rib #, sternum
#,
spiral # < 3 yo
immersion burns,
cigarette
Impetigo

Impetigo contagiosa
The most common form of impetigo is impetigo
contagiosa, which usually starts as a red sore on
your child's face, most often around the nose
and mouth. The sore ruptures quickly, oozing
either fluid or pus that forms a honey-colored
crust. Eventually the crust disappears, leaving a
red mark that heals without scarring. The sores
may be itchy
Staphylococcus aureus

Topical antibiotics. Your doctor may prescribe an antibiotic that you apply
to your child's skin (topical antibiotic), such as mupirocin ointment
(Bactroban). Topical antibiotics avoid side effects such as diarrhea that can
result from some oral medications, but as with oral antibiotics, bacteria can
become resistant to them over time.

Oral antibiotics. Your doctor is likely to prescribe an oral antibiotic for
ecthyma and severe cases of impetigo contagiosa. The specific antibiotic will
depend on the severity of the infection and any allergies or conditions your
child might have. Be sure to finish the entire course of medication even if
your child seems better. This helps prevent the infection from recurring and
makes antibiotic resistance less likely.
Pityriasis Rosea
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It most often develops in the spring and the fall, and seems to
favor adolescents and young adults.
The skin rash follows a very distinctive pattern. In 3/4 of the
cases, a single, isolated oval scaly patch (the "herald patch")
appears on the body, particularly on the trunk, upper arms, neck,
or thighs.
These patches often form a pattern over the back resembling the
outline of an evergreen tree with dropping branches. Patches
may also appear on the neck and, rarely, on the face. These spots
usually are smaller than the "herald" patch. The rash begins to
heal after 2-4 weeks and is usually gone by 6-14.
Aveeno oatmeal baths, anti-itch medicated lotions and steroid
creams may be prescribed to combat the rash. Lukewarm, rather
than hot, baths , ERYC, Famvir
Fractures of Abuse
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FIGURE 6. Multiple healing posterior
rib fractures (arrows) from a
compression injury of the chest.
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FIGURE 7.
Metaphyseal or "buckethandle" fracture (arrow)
of the tibia.
1. Parvovirus B19
2. Chilblans (cold)
3. Fifths Disease
4. Sixth disease
5. SLE butterfly rash
6. Erythema Infectiosum
7. No clue
Erythema Infectiosum (Fifth
Disease)
History:
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Erythema infectiosum typically has an incubation period of 4-14
days and is spread primarily via aerosolized respiratory droplets.
Transmission also occurs through blood products and from
mother to fetus.
The prodromal phase often is mild enough to be noticed only
rarely but may include headache, coryza, low-grade fever,
pharyngitis, and malaise.
Infrequently, nausea, diarrhea, arthralgias, and abdominal pain
may occur.
In hosts who are immunocompetent, the patient is viremic and
capable of spreading the infection only during the incubation
period.
Classic cutaneous findings follow within 3-7 days for some
patients, while other patients may manifest no findings.
Erythema Infectiosum (Fifth
Disease)
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Physical:

Pertinent physical findings predominantly are limited to the skin and joints.
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Skin (first stage): The exanthem begins with the classic slapped-cheek appearance.
The bright red erythema appears abruptly over the cheeks and is marked by nasal,
perioral, and periorbital sparing. The exanthem may appear like a sunburn,
occasionally is edematous, and typically fades over 2-4 days.
Skin (second stage): Within 1-4 days of the malar rash, an erythematous macularto-morbilliform eruption occurs primarily on the extremities. While the eruption
tends to favor the extensor surfaces, it can involve the palms and soles. Pruritus is
rare.
Skin (third stage): After several days, most of the second stage eruption fades into
a lacy pattern, with particular emphasis on the proximal extremities. Despite its
synonym, slapped-cheek disease, the reticulate pattern is distinctly characteristic
for erythema infectiosum and may be the only manifestation of the illness. The
third stage lasts from 3 days to 3 weeks. After starting to fade, the exanthem may
recur over several weeks following physical stimuli, such as exercise, sun exposure,
friction, bathing in hot water, or stress.
Erythema Infectiosum (Fifth
Disease)
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Complications of PV-B19 infection include the
following:
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Aplastic crisis: The parvovirus infects erythroid cells, causing
a reticulocytopenia that lasts 7-10 days. A healthy host
experiences no consequences, since the normal lifespan of a
red blood cell is 120 days. In patients with a background of
shortened red blood cell survival, such as hemolytic anemia,
an acute aplastic crisis ensues.
Congenital infection: PV-B19 can cross the placenta during
pregnancy and have a direct cytotoxic effect on fetal red
blood cells. Infection
For a 24-kg child, the daily maintenance
fluid requirement is approximately which
of the following?
a.
b.
c.
d.
1440cc/24hrs
1536cc /24hrs
2400cc/24hrs
1223cc/24hrs
“4-2-1 rule”
0-10 kg 4cc/hr x wt
11-20 kg 2cc/hr x wt
>20 kg 1cc/hr x wt
Easy method
Anyone >20kg =wt + 40
Proper fluid bolus for a 9kg infant
who presents as a severe trauma with
unstable vitals is?
a. 180 cc LR x 2, then 90cc/kg pRBCs
b. 180cc NSS, then 90 cc NSS
c. 180 cc LR, then 180cc pRBCs
d. 180cc LR x 2, then 90cc 5% albumin, then 90cc pRBCs
Scarlet fever / scarlatiniform rash
Background:
 Scarlet fever is a syndrome characterized by exudative
pharyngitis, fever, and scarlatiniform rash. It is caused by
an infection with a pyogenic exotoxin-producing group A
beta-hemolytic streptococci
 Infections occur year-round, but the incidence of
pharyngeal disease is highest in school-aged children (515 y) during winter and spring and in a setting of
crowding and close contact. Person-to-person spread by
means of respiratory droplets is the most common mode
of transmission.
 The incubation period for scarlet fever ranges from 12
hours to 7 days. Patients are contagious during the acute
illness and during the subclinical phase.
Scarlet fever / scarlatiniform rash

The rash appears 1-2 days after onset of illness, first on the neck and then
extending to the trunk and extremities.

Scarlatiniform rash





Exanthem texture is usually of coarse sandpaper, and the erythema blanches with
pressure.
The skin can be pruritic but usually is not painful.
A few days following generalization of the rash, it becomes more intense along skin
folds and produces lines of confluent petechiae known as the Pastia sign. These lines
are caused by increased capillary fragility.
The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This
phase begins with flakes peeling from the face. Peeling from the palms and around the
fingers occurs about a week later and can last up to a month.
TX

Treat patients with a standard 10-day course of penicillin or erythromycin. This
regimen prevents acute renal failure if antibiotics are initiated within 1 week of the
onset of acute pharyngitis
Centor Criteria

1. Exudative pharyngitis

2. Fever

3. Anterior Cervical Lymphadenopathy

4. No “cold” symptoms (ie no cough or runny nose)
? (Hint – Not E.T.’s Finger)
Clubbing of Finger/Cystic fibrosis


Background: Cystic fibrosis (CF) is the most common lethal inherited
disease in white persons. CF is an autosomal recessive disorder, and most
carriers of the gene are asymptomatic. CF is a disease of exocrine gland
function, involving multiple organ systems and chiefly resulting in chronic
respiratory infections, pancreatic enzyme insufficiency, and associated
complications in untreated patients. Pulmonary involvement occurs in 90% of
patients surviving the neonatal period. End-stage lung disease is the principal
cause of death.
Gastrointestinal tract manifestations (intestinal)


Neonates: Infants may present with intestinal obstruction at birth and a variety of
surgical findings, for example, meconium ileus (7-10% of patients with CF),
volvulus, intestinal atresia, perforation, and meconium peritonitis. Less
commonly, passage of meconium may be delayed (>24-48 h after birth) or
cholestatic jaundice may be prolonged.
Infants and children: Patients present with increased frequency of stools, which
suggests malabsorption (ie, fat in stools, oil drops in stools), failure to thrive,
intussusception (ileocecal), or rectal prolapse.
Stevens-Johnson syndrome (SJS)


Pathophysiology: SJS is an immune-complex–
mediated hypersensitivity disorder that may be
caused by many drugs, viral infections, and
malignancies. Cocaine recently has been added
to the list of drugs capable of producing the
syndrome. In up to half of cases, no specific
etiology has been identified
In 3-15% of cases, patients with severe SJS die
Stevens-Johnson syndrome (SJS)

The 4 etiologic categories are (1) infectious, (2) drug-induced, (3)
malignancy-related, and (4) idiopathic.








Viral diseases that have been reported include herpes simplex virus (HSV),
AIDS, Coxsackie viral infections, influenza, hepatitis, mumps, mycoplasmal
infection, lymphogranuloma venereum (LGV), rickettsial infections, and
variola.
Bacterial etiologies include group A beta streptococci, diphtheria, Brucellosis,
mycobacteria, Mycoplasma pneumoniae, tularemia, and typhoid.
Coccidioidomycosis, dermatophytosis, and histoplasmosis are the fungal
possibilities.
Malaria and trichomoniasis have been reported as protozoal causes.
In children, Epstein-Barr virus and enteroviruses have been identified.
Drug etiologies include penicillins and sulfa antibiotics. Anticonvulsants
including phenytoin, carbamazepine, valproic acid, lamotrigine, and
barbiturates have been implicated. Mockenhapupt et al stressed that most
anticonvulsant-induced SJS occurs in the first 60 days of use. In late 2002,
the US Food and Drug Administration (FDA) and the manufacturer
Pharmacia noted that SJS had been reported in patients taking the
cyclooxygenase-2 (COX-2) inhibitor valdecoxib.
Various carcinomas and lymphomas have been associated.
SJS is idiopathic in 25-50% of cases
?
TOF




Pulmonary stenosis (a narrowing of the blood
vessel to the lungs)
Overriding aorta (the main blood vessel from
the heart to the entire body is somewhat
displaced)
A ventricular septal defect (hole in the wall
between the lower two chambers of the heart)
Right ventricular hypertrophy (a thick muscle in
the right pumping chamber)
TOF

First presentation may include poor feeding,
fussiness, tachypnea, and agitation.

Emergency Department Care:

The ED physician should be able to recognize and treat a hypercyanotic episode as one of the
very few pediatric cardiology emergencies that may present to the ED.
Hypoxic tet spell: Hypercyanotic episodes are characterized by paroxysms of hyperpnea,
prolonged crying, intense cyanosis, and decreased intensity of the murmur of pulmonic
stenosis.



Mechanism - Secondary to infundibular spasm and/or decreased SVR with increased right-to-left
shunting at the VSD, resulting in diminished pulmonary blood flow
If left untreated, may result in syncope, seizure, stroke, or death

Treatment for the acute setting of hypercyanosis includes the
following:
 Knee-chest position: Place the baby on the mother's shoulder
with the knees tucked up underneath. This provides a calming
effect, reduces systemic venous return, and increases SVR.

Oxygen is of limited value since the primary abnormality is
reduced pulmonary blood flow.

Morphine sulfate, 0.1-0.2 mg/kg IM/SC, may reduce the
ventilatory drive and decrease systemic venous return.

Phenylephrine, 0.02 mg/kg IV, is used to increase SVR.

Treat acidosis with sodium bicarbonate, which may reduce the
respiratory center stimulating effect of acidosis.

General anesthesia is a last resort.
?
1.
2.
3.
4.
5.
Candida
EBV
CMV
Diptheria
No clue
Infectious mononucleosis





History:
IM may have a varied clinical presentation, but the
symptoms usually consist of fever, pharyngitis, and
lymphadenopathy.
The incubation period of IM is 4-6 weeks. Patients
usually do not recall a history of possible exposure.
Prodromal symptoms consisting of 1-2 weeks of
fatigue, malaise, and myalgia are common
In more than 90% of cases, IM is secondary to EBV
infection
Infectious mononucleosis - Labs




Liver function tests (LFTs) are abnormal in more than 90% of
patients with IM.
 Serum transaminase and alkaline phosphatase levels usually are
modestly elevated.
 The serum bilirubin may be increased in approximately 40% of
patients, but jaundice only occurs in approximately 5% of IM
cases.
CBC : differential that demonstrates greater than 50% lymphocytes,
an absolute lymphocyte count greater than 4500, or an elevated
lymphocyte count with greater than 10% atypical lymphocytes
Also can have thrombocytosis
Splenic rupture is a serious complication of IM, but it occurs in
fewer than 0.5% of cases. More than 90% of splenic rupture cases
occur in male patients.
?
The Limping Child
Slipped Capital Femoral Epiphysis
What is the red line called?
Slipped Capital Femoral
Epiphysis

Klein’s line



Superior femoral necklateral portion femoral
head
Mild widening, lucency,
irregularity of physis
Blurring of junctionmetaphysis/physis (early)
Radiograph
Legg-Calvé-Perthes Disease




Avascular necrosis leading to collapse,
fragmentation, and then reossification
Most frequent between 4 and9 years
Boys more often than girls
Bilateral in 10% of cases
Management - LCP




Disease is self-limited – limp can last 2 to 4 years
Nonsteroidal anti-inflammatory agents
Limit activities
Crutches/braces occasionally needed


May help maintain spherical femoral head
Better outcomes in younger children
?
Clinical Features: Your First Clue





Irritability
Fever
Erythema
Limp/refusal to walk
Decreased range of motion of limb
Septic Arthritis of ankle
Management

Once the diagnosis of septic joint is made,
surgical intervention should proceed ASAP.

Needle aspiration or open surgical drainage required
Synovial Fluid Findings
Septic Arthritis Treatment by Age
Kerion


This is a vigorous inflammatory reaction to
dermatophyte infection, occasionally associated
with secondary bacterial infection, that occurs
on the scalp, resulting in a boggy inflammatory
swelling
Untreated tinea capitis
Dictation Gaffs and Goofs…
“Patient is a 3-year-old male who presents after a
fall from a trampoline heart about an hour and
half ago”
“Patient
presents to emergency department on
orders from right ear CBS worker”
“7-year-old
male female presents to emergency
department with complaints of pain or right ankle.
Mom prospective about 57 concrete steps last
night”
Oral thrush

Signs and symptoms

Oral thrush usually produces creamy white
lesions on your tongue and inner cheeks and
sometimes on the roof of your mouth, gums and
tonsils. The lesions, which resemble cottage
cheese
Rubella/German Measles


Background: The name rubella is derived from a Latin term
meaning "little red." Rubella is generally a benign communicable
exanthematous disease.
The major complication of rubella is its teratogenic effects when
pregnant women contract the disease, especially in the early
weeks of gestation. The virus can be transmitted to the fetus
through the placenta and is capable of causing serious congenital
defects, abortions, and stillbirths
Rubella
Incubation period: The incubation is usually 14-21
days after exposure to a person with rubella.
 Prodromal phase: Prodromal symptoms are unusual
in young children but are common in adolescents
and adults.

Rubella

The following signs and symptoms usually appear 1-5 days before the
onset of rash:
 Eye pain on lateral and upward eye movement (a particularly
troublesome complaint)
 Conjunctivitis
 Sore throat
 Headache
 General body aches
 Low-grade fever
 Chills
 Anorexia
 Nausea
 Tender lymphadenopathy
Sturge-Weber Syndrome



Sturge-Weber syndrome is a neurological
disorder indicated at birth by seizures
accompanied by a large port-wine stain
birthmark on the forehead and upper eyelid of
one side of the face.
Some children will have developmental delays
and mental retardation; most will have glaucoma
(increased pressure within the eye) at birth or
developing later.
“Port wine stain”
Peds GCS/EMV - ?

1 year old, MVC,
cries during exam,
opens eyes
spontaneously when
saying Dr says
name, localizes pain
but not following
commands
1.
2.
3.
4.
5.
6.
7.
15
14
13
12
11
10
No clue
1 year old, MVC,
cries during exam = 3 or 4
1. opens eyes spontaneously = 4
localizes pain but not following
commands = 5
Total = 12 or 13


Eye Opening
 4 Spontaneously
 3 To voice
 2 To pain
 1 No response
Verbal Response
 5 Appropriate words,
spontaneous cooing
 4 Inappropriate words
 3 Cries
 2 Incomprehensible
sounds, grunts
 1 No response

Motor Response
 6 Obeys
 5 Localizes pain
 4 Flexion withdrawal
 3 Flexion abnormal
(decorticate posturing)
 2 Extension (decerebrate
posturing)
 1 No response
Peds ICI/BHT

Found significant ICI is unlikely in a child who
does not exhibit at least 1 of the high-risk criteria







Evidence of significant skull fx
Altered level of alertness
Neuro deficit
Persistent vomiting
Scalp hematoma
Abnl behavior
coagulopathy








Headache
Dizziness
Depression
Confusion
Nausea/vomiting
Sensitivity to light or
noise
Anxiety
Poor memory








Lethargy
Slow response to
questions
Decreased energy
Irritability
Blurred or double vision
Poor concentration
Poor balance
Insomnia
Severity
Symptoms
Management
Grade 1 (Mild)
No LOC, ringing, headache,
dizziness, or memory loss
Observation
May not return to competition
until symptom-free upon
exertion
Grade 2 (Moderate)
LOC <5 min or PTA >30
min
Observation
May not return to competition
for 1 wk after symptom-free
upon exertion
Grade 3 (Severe)
LOC >5 min or PTA >24 h
Admit
Refer for neurocognitive
testing prior to resumption of
contact sports
LOC=loss of consciousness; PTA=posttraumatic amnesia
Eczema / Atopic Dermatitis
The most common surgical cause of vomiting in
infancy is
a. Intestinal atresias
b. Malrotation
c. Pyloric stenosis
d. Meconium ileus
Pyloric Stenosis





Pathophysiology: Marked hypertrophy and hyperplasia of the 2 (circular and
longitudinal) muscular layers of the pylorus occurs, leading to narrowing of the
gastric antrum.
Frequency:
In the US: The incidence of IHPS is 2-4 per 1000 live births
Sex: IHPS has a male-to-female predominance of 4:1, with 30% of patients
with IHPS being first-born males
Age: The usual age of presentation is approximately 3 weeks of life (1-18 wk).
History:
Classically, the infant will have nonbilious vomiting or
regurgitation,
which may become projectile (up to 70%), after
which the infant is still
hungry.
Emesis may be intermittent or occur after each feeding
Branchial cleft remnants present most
commonly as a(n)?
a.
b.
c.
d.
pain
airway obstruction
intraoral mass
infection
Pediatric Cardiopulmonary
Arrests
10% 10%
1° Respiratory
Shock
80%
1° Cardiac
Age distribution of arrests
40
35
# Arrests
30
25
20
15
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12 1314 15
Age (years)
Arrive in ER in
cardiac arrest
(N = 80)
Admit PICU
(N=43) 54 %
Mod Deficit
(N=3)
PVS at
12 mos
(N=2)
Died in ER
(N=37) 46%
Dead at Died in ICU
12 mos (N=37) 46%
(N=1)
Schindler M, et al. Outcome of out-of-hospital cardiac or
respiratory arrest in children. N Engl J Med
1996;335:1473-1479.
List at least 10 signs
of pediatric
Respiratory distress

Signs of Respiratory Distress








Tachypnea
Tachycardia
Grunting
Stridor
Head bobbing
Flaring
Inability to lie
down
Agitation
•
•
•
•
•
•
•
•
Retractions
Access muscles
Wheezing
Sweating
Prolonged
expiration
Pulsus paradoxus
Apnea
Cyanosis
List signs of impending respiratory failure
Impending Respiratory Failure






Reduced air entry
Severe work
Cyanosis despite O2
Irregular breathing / apnea
Altered Consciousness
Diaphoresis
1.
2.
3.
4.
5.
Bruising from abuse
Petechial rash
Mongolian spots
HSP
No clue
Specificity of Fractures for Abuse

High specificity






Moderate specificity

Metaphyseal
Posterior rib
Scapula
Spinous process
Sternal






Multiple fractures
Fractures of diff. age
Epiphyseal
Vertebral body
Digital
Complex skull
Low specificity



Clavicle
Long bone shaft
Linear skull
Radiographic Dating of Injuries
Soft tissue
findings
Periosteal new
bone
Loss of Fx line;
soft callus
Hard callus
Remodeling
Early
2-5d
4-10d
Peak
4-10d
10-14d
Late
10-21d
14-21d
10-14d
14-21d
14-21d
21-42d
42-90d
3 mos
1 yr
2 yr
Peds Clin
NA 1996


Candidiasis -Signs and symptoms

Oral thrush
usually produces creamy white lesions on your
tongue and inner cheeks and sometimes on the roof
of your mouth, gums and tonsils. The lesions, which
resemble cottage cheese
 Nyastatin - works by contact!


Perineal/diaper rash candidiasis
antifungal cream
 Keep dry and open to air

Speed Round Rashes
Go Interns!!

Name the rash and everything you know about
it
Cause
 Treatment
 Prevention

Question #1

A 1-week-old infant presents for his first newborn evaluation. He had been
discharged apparently well and thriving at 48 hours of age. He now exhibits
grouped vesicles on an erythematous base that were not present at birth.
Wright stain of scrapings from the floor of the vesicles reveals multinucleated
giant cells and balloon cells.
Of the following, the MOST likely diagnosis is:





A) bullous impetigo
B) congenital varicella
C) herpes simplex virus infection
D) incontinentia pigmenti
E) recessive dystrophic epidermolysis bullosa
Skin Lesions (photos: University of California, Australian
Herpes Management Forum, and eMedicine)