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Toronto Notes 2019
Common Pediatric ED Presentations
Emergency Medicine ER57
Suicidal Patient
Epidemiology
• attemptedsuicideF>M,completedsuicideM>F
• secondleadingcauseofdeathinpeople<24yr
• riskissignificantlyincreasedinindigenousandLGBTQCanadians,particularlytransindividuals
Management
• ensurepatientsafety:closeobservation,removepotentiallydangerousobjectsfrompersonandroom
• assessthoughts(ideation),means,action(preparatory,practiceattempts),previousattempts,protective
factors
• admitifthereisevidenceofactiveintentandorganizedplan,accesstolethalmeans,psychiatric
disorder, intoxication (suicidal ideation may resolve with few days of abstinence)
• patient may require certification if unwilling to stay voluntarily
• donotstartlong-termmedicationsintheED
• psychiatryorCrisisInterventionTeamconsult
Common Pediatric ED Presentations
See Psychiatry, Common Forms, PS51 for certification (involuntary assessment/ admission)considerations
High Risk Patients
SAD PERSONS
Sex = male
Age >45 yr old Depression
Previous attempts Ethanol use
Rational thinking loss Suicide in family Organized plan
No spouse, no support system Serious illness
Any trauma or suspected trauma patient <1 yr of age with a large, boggy scalp hematoma requires U/S or CT
Modified Glasgow Coma Score
Table 36. Modified GCS
Modified GCS for Infants
Eye Opening
4 – spontaneously 3 – to speech 2–topain
1 – no response
Verbal Response
5 – coos, babbles 4 – irritable cry 3–criestopain 2 – moans to pain 1 – no response
Motor Response
6 – normal, spontaneous movement 5 – withdraws to touch 4–withdrawstopain
3 – decorticate flexion
2 – decerebrate extension 1 – no response
Motor Response
6 – normal, spontaneous movement 5 – localizes to pain
4 – withdraws to pain
3 – decorticate flexion
2 – decerebrate extension 1 – no response
Modified GCS for Children <4 years
Eye Opening
4 – spontaneously 3 – to speech
2 – to pain
1 – no response
Verbal Response
5 – oriented, social, speaks, interacts
4 – confused speech, disoriented, consolable
3 – inappropriate words, not consolable/aware
2 – incomprehensible, agitated, restless, not aware 1 – no response
Respiratory Distress
• seePediatrics,P68
History and Physical Exam
• infantsnotabletofeed,olderchildrennotabletospeakinfullsentences
• anxious,irritable,lethargic–mayindicatehypoxia
• tachypnea>60(>40ifpreschoolage,>30ifschoolage),retractions,trachealtug
■ see Pediatrics, P3 for age specific vital signs • pulsusparadoxus
• wheezing, grunting, vomiting
Table 37. Stridorous Upper Airway Diseases: Diagnosis
Feature
Age Range (yr) Prodrome Temperature Radiography Etiology
Barky Cough Drooling Appear Toxic Intubation/ICU Antibiotics NOTE
Croup
0.5-4
Days
Low grade Steeple sign Parainfluenza Yes
Yes
No
No
No
Oral exam
Bacterial Tracheitis
5-10
Hours to days
High
Exudates in trachea S. aureus/GAS
Yes
No
Yes
Yes
Yes
Oral exam
Epiglottitis1
2-8
Minutes to hours
High
Thumb sign
H. influenzae type b
No
Yes
Yes
Yes
Yes
No oral exam, consult ENT
1Now rare with Hib vaccine in common use