Pediatric Pearls SRPC. Jock Murray April 2019
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1 Pediatric Pearls SRPC Jock Murray April 2019
2 Case 1 Sore Ear 9 y male Cough and Runny nose x 1 week Eating and drinking well Not able to sleep due to right ear pain T 38.6 P 100 BP 90/60 RR 16
3 Case 1A
4 Case 1A Acute Otitis Media
5 Treatment? Case 1A
6 Case 1A Treatment Amoxicillin 90 mg/ Kg/24h po BID Alternative Macrolide Clarithromycin 15 mg/kg/24h po BID 10 days under 2years or 5 days if over 2 years Pain relief Acetaminophen 15mg/kg/dose q 4 h or Ibuprofen 10mg/kg/dose q 6h Ciprofloxacin Otic drops 2 drops BID if TM ruptured or Tube in addition to oral antibiotic
7 Case 1A
8
9 Case 1A NNT David Neuman NNT 20 NNH 9 No benefit
10 Case 1A
11 Case 1A Cochrane review Very limited benefit for Antibiotics in Otitis Media
12 Case 1B 9 y male Cough and Runny nose x 1 week Eating and drinking well Not able to sleep due to right ear pain T 38.6 P 100 BP 90/60 RR 16
13 Case 1B
14 Case 1B Serous Otitis Media
15 Treatment? Case 1B
16 Case 1B Treatment Acetaminophen Ibuprofen Valsava Nasal Steroid
17 Case 2 A Sore Throat 12 y f Sore throat x 24 h still drinking Not SOB No cough T 39C P 110 BP 85/60 RR18
18 Case 2A Sore Throat
19 Diagnosis? Case 2A
20 Case 2A Diagnosis Step Throat
21 Case 2A Sore Throat
22 Treatment? Case 2A
23 Case 2A Treatment Penecillin V 600mg po BID adult Liquid not palatable Amoxicillin 50mg/KG/24H Acetaminophen 15mg/kg/dose Ibuprofen 10mg/kg/dose
24 Case 2A
25 Case 2A NNT Culture positive 3.7 NNT culture negative 6.5 NNT not cultures 14.4 Resolution 16 hours earlier
26 Case 2A
27 Case 2A NNT For Steroids in Pharyngitis = 3
28 Case 2B Sore Throat 12 y f Sore throat x 24 h still drinking Not SOB No cough No drinking Severe pain Posterior chain adenopathy Hot potato voice
29 Case 2B
30 Diagnosis Case 2B
31 Case 2B Diagnosis Monoucleosis Treatment? Monospot or Epstien Barr Serology
32 Case 2B Diagnosis Monoucleosis Treatment Monospot or Epstien Barr Serology Pain medication Steroids (Dexamethasone 0.3mg/kg po) up to 16mg maximum
33 Case 2B Disposition Avoid Abd trauma Recheck before return to sports Return if SOB or not drinking
34 Case 2 C Sore Throat 12 y f Sore throat x 24 h still drinking Not SOB No cough Decreased Drinking looks unwell T 39C P 110 BP 85/60 RR18
35 Case 2C
36 Diagnosis? Case 2 C
37 Case 2 C Diagnosis Peritonsilar Abcess or Cellulitis Treatment?
38 Case 2 C Diagnosis Peritonsilar Abcess Treatment IV Penecillin G or Clindamycin IV steroids
39 Disposition? Case 2C
40 Case 2C Disposition Admit IV antibiotics Consult Otolaryngology
41 Case 3D 07 year female Sore neck Fever Not drinking Dental caries Swollen anterior Neck T39 P 120 BP 95/60 RR22
42 Case 2D
43
44 Case 2D
45 Diagnosis? Case 3D
46 Case 3D Diagnosis Cellulitis Ludwig s Angina Treatment?
47 Case 3D Ludwig s Angina Vs Cellulitis Tongue raised in mouth Trismus Looks unwell
48 Case 3D Diagnosis Ludwig s Angina Treatment IV antibiotics (clindamycin) IV steroids Consult Otolaryngology and or Oral Maxillofacial Surgery
49 Dispostion? Case 3D
50 Case 3C Disposition Admit IV antibiotics Consult Oral Maxillofacial Surgery and/or Otolaryngology
51 Case 4A 3 y male Cold x 3 days Fever, cough runny nose Awakes in middle of night with barking Cough T 38.5 P130 BP 90/50 RR 22 Looks well
52 Case 4A Differential for Stridour
53 Case 4A Differential for Stridour Croup Foreign body Layngomalacia Epiglotitis Prevertebral abcess Bacterial tracheitis
54 Croup
55 Case 4A Steeple Sign
56 Case 4A
57 Croup Case 4A
58 Case 4A Treatment? Disposition?
59 Case 4A Treatment? Dexamethaone mg / Kg up to 12 mg Racemic Epinephrine 0.5mg mg nebulized
60 Case 4A Disposition Observe for 2 hours after Epinephrine If requiring 3 doses then admit
61 Croup
62 Croup Fever Rhinorrhea Nasal Congestion Barking Cough Stridour Respiratory Distress Worse at night
63 Case 4B Leave child with parent Portable lateral neck Call for help Otolayngology and Anesthesia Avoid IV or other distressing interventions if possible
64 Case 4B 3 y male Cold x 3 days Fever, cough runny nose Awakes in middle of night with barking Cough T 38.5 P130 BP 90/50 RR 22 Looks unwell sitting forward and drooling Not drinking
65 Differential? Case 4B
66 Case 4B Differential? Croup Epiglotitis Tracheomalacia Prevertebral abcess Bacterial tracheitits
67 Approach? Case 4B
68 Croup Gradual onset of cold Mild fever, hoarseness, barking cough Sudden Stridour Dyspnea and Tachypnea
69 Case 4B IV antibiotics if IV access IV Steroids if IV access
70 Case 4B
71 Case 4C 5 year Male Sore throat Fever Stridour Drooling not drinking T 39C P120 BP 95/60 RR24 Looks unwell RESP no wheeze
72 Case 4C
73 Case 4C
74 Diagnosis? Case 4C
75 Case 4C Diagnosis Retropharyngeal Abcess Treatment?
76 Case 4C Diagnosis Retorpharngeal Abcess Treatment Same approach as Epiglotitis
77 Retropharngeal Abcess Similar to Epiglotitis No Stridour Gradual onset Fever drooling Tripod position Respiratory Distress
78 Retropharyngeal Abcess Presentation Same as epiglotis Problem is posterior no anterior
79 Case 4C Diagnosis Retropharngeal abcess Leave with parent Avoid IV Otolaryngology and Anesthesia
80 Case 4D 9 year male Cough runny nose x 1 week Fever Increased work of breathing Drooling not drinking T39 C P 130 BP 95/60 RR 40 Noisy breathing +/- stridour RESP no wheeze
81 Case 4D
82 Diagnosis? Case 4D
83 Case 4D Diagnosis Bacterial Tracheitis Treatment?
84 Case 4D Diagnosis Bacterial Tracheitis Treatment?
85 Case 4D Diagnosis Bacterial Tracheitis Treatment? Same as Epiglotitis and Retropharngeal Abcess
86 Case 4D
87 CASE B,C and D Epiglotitis, Retopharngeal abcess and Bacterial Tracheitits if child is mordibund then take control of airway If child is mildly symptomatic IV Antibiotics Clindamycin or Ceftriaxone if IV Dexamethaone 0.3mg iv if IV Consult Otolaryngology (immediatlely) and admit If the child is distressed then limit intervention
88 Case 5 10 y M 2 days post tonsilectomy Spitting up spots of blood Looks well T 36 P 100 BP 100/60 RR 18 HEENT post surgical changes (white film)
89 Diagnosis? Case 5
90 Case 5 Diagnosis Post tonsilectomy Bleed Treatment?
91 Case 5 Diagnosis Post Tonsilectomy bleed Treatment IV Cross Match Consult Otolaryngology
92 Pediatric Airway Passive Flexion due to Large occiput Relatively large tongue Relatively large adenoids Floppy Epiglotitis Anterior Larynx
93 Pediatric Airway Cicoid ring is the smalles diameter Narrow Tracheal diameter Short distance between tracheal rings Cartilage if more flexible Trachea is relatively short Narrow large airways
94 Pediatric Airway
95 Pediatric Airway History acute or gradula onset Fever Drooling Voice changes Difficulty swallowing Cold Symptoms Past Medical History
96 Pediatric Airway Physical Exam Appearance Alertness Muscle tone Ability to cry or speak Work of Breathing
97 Pediatric Airway Circulation Pallor Cyanosis Mottling Cap Refill
98 Pediatric Airway
99 Pediatric Airway Respiratory Status Respiratory Rate Newborn months years years Adolescents 12-18
100 Pediatric Airway Signs of Respiratory Distress Increased Work of Breathing Retractions Nasal Flaring Grunting Head Bobbing
101 Pediatric Airway Sings of Respratory Distress Altered Mental Status Agitation Irritability Lethargy Coma
102 Pediatric Airway Sipgns of Respiratory Distress Colour Cyanosis Pallor Position Sniffing position Tripod position
103 Pediatric Airway Signs of Respiratory Distress Ausculation Snoring Stridour Grunting Wheezing (Rhonchi) Rales(Crackles)
104 Pediatric Airway Practical Points Anatomical differences Appearance is important Signs of Respiratory Distress Increased Work of Breathing Color Position Ausculation
105 Pediatric Airway Upper Airway disease Croup Foreign Body Epiglotitis Bacterial Tracheitis Retropharyngeal Abcess
106 Pediatric Airway Lower Airway Disease Pneumonia Asthma Foreign Body Bronchiolitis
107
108 Pediatric Airway
109 Case 6 6 month old Male assessment He has 48 hours of fever >38.5C. There are no other symptoms and he looks well. The exam is normal. He has a unremarkable birth history and the clinical course to date. After careful history and Physical what what tests would you order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
110 Case 6B A six week old infant female is brought to the ED by her parents. There is a fever of 38.5 C. Delivery was unremarkable. The infant was well until 48 hours ago. There are no other symptoms. After careful history and physical what tests would you order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
111 Case 6C A 24 day old male infant is brought to your ED by parents. He has had 24 hours of fever 38.5 C. The birth history is unremarkable. He looks well. After careful history and Physical. What tests would order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
112 Rochester Criteria VS Philadelphia protocol
113 Both have been studied extensively Enable clinicians to identify young infants who do not need antibiotics or hospitalisation. Widely used in pediatric emergency departments.
114
115 Rochester vs. Philadelphia Main difference: No LP vs. LP Philadelphia specifies > 28 days of age Rochester not specific to > 28 days (but generally not used for under 28 days of age)
116 Questions and Case 6A 6 month old Male assessment He has 48 hours of fever >38.5C. There are no other symptoms and he looks well. The exam is normal. He has a unremarkable birth history and the clinical course to date. After careful history and Physical what what tests would you order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
117 Questions and Answers 6A 6 month old Male assessment He has 48 hours of fever >38.5C. There are no other symptoms and he looks well. The exam is normal. He has a unremarkable birth history and the clincial course to date. After careful history and Physical what what test would you order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
118 Questions and Case 6B A six week old infant female is brought to the ED by her parents. Delivery was unremarkable. The infant was well until 48 hours ago. There are no other symptoms. After careful history and physical what would you order or do.? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
119 Questions and Answers Case 6B A six week old infant female is brought to the ED by her parents. There is a fever of 38.5 C. Delivery was unremarkable. The infant was well until 48 hours ago. There are no other symptoms. After careful history and physical what would you order or do.? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
120 Questions and Case 6C A 24 day old male infant is brought to your ED by parents. He has had 24 hours of fever 38.5 C. The birth history is unremarkable. He looks well. After careful history and Physical. What tests would order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
121 Questions and Answers 6C A 24 day old male infant is brought to your ED by parents. He has had 24 hours of fever 38.5 C. The birth history is unremarkable. He looks well. After careful history and Physical. What tests would order or perform? A. CBC, Blood cultures and urine culture B. Lumbar puncture, CBC, Blood cultures and Urine culture. C. CBC D. Urine Culture
122 Bottom Line Rely on Clinical acumen and Rochester criteria Philadelphia criteria not better and requires a LP (as does Boston Criteria).
123 Case 7 6 year male presents with wheezing and known Asthma. HR 140 BP 90/60 RR48 O2 sat 88% Exam reveal moderate where and intercostal indrawing. How do we assess how sick he is? How do we treat him? How do we decide if he is admitted? Does he need a CXR?
124 Case 7
125 CASE 7 Salbutamol 100Ug via Inhaler and Aerochamber back to back x 3 Ipratropium Bromide 17 ug 5puffs Q15 min x 3 over 1 hour Dexamthasone 0.3 mg/kg po Mg+ if being admitted 25-50mg/ kg over 20minutes maximun 2g.
126 Case 7
127 Case 7 Discharge when wheezing and increased Work of Breathing (WOB) does not recur with no salbutamol for 2 hours. If needing salbutamol less than q2h then admit
128 References Fever Survey highlights Significant Variation in how infants age<60 days are treated and underline the need for guidelines. Hazlett et.al. Acta Pediatrica Evaluation of Fever in Infants and Young Children Hamilton, JH and John, SP. AM Fam Physician 2013;4: Use of Procalcitonin Assay to Predict serious Infection in Young Febrile Infants. Reappraisal of Criteria used to predict serious Bacterial Illness in Infants less than 8 weeks of age. Gara,G et. Al.
129 References TREKK Guidelines Managing The Pediatric Asthma Patient with an acute Asthma exacerbation, Ortiz-Alveraz, O., Mikrogianakis; Canadian Pediatric Society Committee. Pediatric Child Health 2012;17(5):251-5.
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