Page 238 - TNFlipTest

ER58 Emergency Medicine
Common Pediatric ED Presentations
Toronto Notes 2019
Rochester Criteria for Febrile Infants Age 28-90 Days Old
• Non-toxic looking
• Previously well (>37 wk gestational age,
home with mother, no hyperbilirubinemia, no prior antibiotics or hospitalizations, no chronic/underlying illness)
• No skin, soft tissue, bone, joint, or ear infection on physical exam
• WBC 5,000-15,000, bands <1,500, urine <10 WBC/HPF, stool <5 WBC/HPF
Management
• croup(usuallylaryngotracheitiscausedbyparainfluenzaviruses)
■ dexamethasone x 1 dose
■ if moderate-severe, add nebulized epinephrine (racemic has limited availability) ■ consider bacterial tracheitis/epiglottitis if unresponsive to croup therapy
■ humidified O2 has no evidence for efficacy
• bacterialtracheitis
■ airway maintenance - usually require intubation, ENT consult, ICU ■ start antibiotics (e.g. cloxacillin), pending C&S
• epiglottitis
■ 4 D’s: drooling, dyspnea, dysphagia, dysphonia + tripod sitting ■ do not examine oropharynx or agitate patient
■ immediate anesthesia, ENT call – intubate
■ then IV fluids, antibiotics, blood cultures
• asthma
■ supplemental O2 if saturation <90% or PaO2 <60%
■ bronchodilator therapy: salbutamol (Ventolin®) 0.15 mg/kg x3 by masks q20min
■ give corticosteroid therapy as soon as possible after arrival (prednisolone 2 mg/kg, dexamethasone
0.6 mg/kg, 2 doses 24 h apart)
■ if severe, add 250-500 μg ipratropium (Atrovent®) to first 3 doses salbutamol if critically ill, not
responding to inhaled bronchodilators or steroids: give IV bolus, then infusion of MgSO4 ■ IV β2-agonists if critically ill and not responding to above
Febrile Infant and Febrile Seizures
FEBRILE INFANT
• forfever>38°Cwithoutobviousfocus ■ <28d
◆ admit
◆ full septic workup (CBC and differential, blood C&S, urine C&S, LP ± stool C&S, CXR if
indicated)
◆ treat empirically with broad spectrum IV antibiotics
■ 28-90 d
◆ as above unless infant meets Rochester criteria, partial septic workup (CBC and differential,
blood C&S, urine C&S, CXR if indicated) ■ >90d
◆ toxic: admit, treat, full septic workup
◆ non-toxic and no focus: investigate as indicated by history and physical
FEBRILE SEIZURES
• seePediatrics,P76
Etiology
• childrenaged6mo-6yrwithfeverorhistoryofrecentfever
• typicalvs.atypicalfebrileseizures
• normalneurologicalexamafterward
• noevidenceofintracranialinfectionorhistoryofpreviousnon-febrileseizures • oftenpositivefamilyhistoryoffebrileseizures
• relativelywell-lookingafterseizure
Investigations and Management
• ifconfirmedfebrileseizure:treatfeverandlookforsourceoffever • ifnotafebrileseizure:treatseizureandlookforsourceofseizure
■ note: may also have fever but may not meet criteria for febrile seizure • ±EEG(especiallyiffirstseizure),headU/S(iffontanelleopen)
Table 38. Typical vs. Atypical Febrile Seizures
Characteristic
Duration
Type of Seizure Frequency
Typical
<15 min Generalized 1 in 24 h
Atypical
>15 min Focal features >1 in 24 h