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Richard J. Scarfone, MD
Associate Professor of Pediatrics
University of Pennsylvania School of Medicine
Medical Director, Emergency Preparedness
The Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania
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Richard J. Scarfone, MD
Associate Editors
Sandip A. Godambe, MD, PhD, MBA
Raymond Pitetti, MD, MPH
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PREFACE
W
e have produced this first edition of The 5-Minute Pedi- ough but very concise, succinct manner so that all key points about
atric Emergency Medicine Consult with the specific goal clinical presentations, differential diagnoses, diagnostic investiga-
of providing a concise, formatted resource for the clinical tions, therapeutic interventions including medications and doses,
management of pediatric emergencies and common pediatric com- and admission or discharge criteria are presented. This text has
plaints encountered in emergency departments and other settings. been authored by selected pediatric emergency physicians from
As academic pediatric emergency physicians, our goal is to apply both emergency and pediatric medicine backgrounds to provide
the best evidence, published clinical practice guidelines, and other true subspecialty expertise.
information to optimize patient care. Numerous constraints may in- The 5-Minute Pediatric Emergency Medicine Consult will be use-
terfere with ones ability to stay appraised of the most current evi- ful to trainees as well as to clinicians far beyond training. Though the
dence and guidelines applicable to pediatric emergency medicine. editors and authors practice pediatric emergency medicine within
We recognize this and present this book as a resource for those the confines of emergency departments in academic medical cen-
who also wish to practice evidence-based medicine but require the ters, we recognize that most pediatric emergencies are not treated
information distilled in a single, easily accessible reference. This in such settings, and many pediatric emergencies are treated out-
5-Minute Pediatric Emergency Medicine Consult is exactly such a side of an emergency department altogether. Thus, we have taken
reference book. Honorifically named for the Fleisher and Ludwig great strides to produce a reference that represents optimal man-
Textbook of Pediatric Emergency Medicine, which is the seminal agement of emergent and urgent pediatric conditions as well as
comprehensive textbook of pediatric emergency medicine, our text common pediatric complaints in all such locations. Clinicians prac-
seeks to provide a rapid reference for use in the clinical workplace ticing in a tertiary care academic medical center with extensive
rather than thorough, extensive coverage of the subject matter. The subspecialty support or those in the community setting in which
5-Minute Pediatric Emergency Medicine Consult is intended to be little or no subspecialty support will find this text to be an invaluable
accurate, pointed, and readily integrated into practice rather than resource.
definitive. We hope this book will serve as a useful and frequently used
Clinicians at all levels of training and all stages of career de- resource to assist in our common goal of providing the best possible
velopment need references to facilitate the provision of optimal pediatric emergency care to our patients.
patient management. Each chapter presents information in a thor-
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FOREWORD
F
ive Minutes What can you do in 5 minutes? Working in the portant overview. At other points, it will be used for a familiar or
pediatric emergency department for more than 35 years has common clinical situation but a 5-minute refresher will provide a re-
often been a humbling experience. Along the way, we have assuring double check to make sure nothing has been overlooked
learned many lessons. One of the most important has been the or forgotten. In either case, that initial orientation and preparation
value of orientation and preparation. We have all provided care for will prove most valuable.
children when they suddenly burst through the doors in the arms We are honored to have our names as part of the title of this
of a police officer or paramedic with major multisystem trauma or book. We view it as a perfect companion to the Textbook of Pediatric
cardiac arrest. We have been in the same critical situation when we Emergency Medicine, 6th Edition where more in-depth information
had just 5 minutes to prepare for the event. As many of the readers can be learned. We thank the editors and authors for allowing us
of this book know, that extra 5 minutes makes a world of difference to share in this work. We see it as yet another important step in
to the outcome and perceived quality of care provided. Even when improving the emergency care to ill and injured children, which has
residents are assigned to the emergency department for a rotation been the foundation of our lifes work.
it is our perception that those who get a brief orientation to the site Five minutes can mean a lot, and 5 minutes of reading one of
perform much better than those who do not. And those who take a the topics that follow will set you on a pathway toward rewarding
minute to prepare before going into a treatment room also evolve clinical care.
to be better physicians.
That brings us to this book, The 5-Minute Pediatric Emergency STEPHEN LUDWIG, MD
Medicine Consult. We know that using this book will provide physi- Philadelphia, Pennsylvania
cians with the orientation and preparation needed to address a wide GARY R. FLEISHER, MD
range of clinical problems. Sometimes it will be a new condition that Boston, Massachusetts
the physician has not faced before, and the topic will give an im- February 2011
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ACKNOWLEDGMENTS
I
thank my wife Miya for her understanding, support, and sacrifice I would like to thank my patients, colleagues, and mentors who have
during the production of this text. taught me so much in my career. Your collective inquisitiveness,
I sincerely thank Lewis Goldfrank and Steve Davidson for giving selflessness, and support have inspired me to become a clinician
me the most formative academic opportunities of my career, and worthy of your trust. I am grateful to the many authors of this book
Lewis Nelson and Bob Hoffman for serving as ideal models of aca- who have worked so hard to create an outstanding resource for
demic emergency physicians and clinician educators. To the many patient care. Thank you to my wife, Karen, for your love and support,
emergency medicine residency classes and notably the chief res- and thank you to my wonderful children Steven and JuliaI love you
idents of Beth Israel Medical Center, I extend thanks for years of and Im proud of the young people that you have become.
rewarding interaction and inspiration to remain in academics. R.J.S.
I acknowledge friends across the globe past and present who
have assisted my endeavors by helping me balance productive work This book is the result of the hard work of countless dedicated
with enjoyable recreation. Lastly, I thank the families and patients authors. It has been a pleasure to work with them and the editorial
to whom Ive provided emergency care for the privilege of treating and publishing team of this book. I want to extend a special thanks to
them. the many residents and fellows past and present whose questions
R.J.H. and pursuit of knowledge have made me a better clinicianeducator.
I would also like to thank my many mentors throughout my training.
With any significant work, there are inevitably numerous individuals Finally, many thanks to my loving family, especially my wife, Libby,
who have contributed to bring this project to fruition. I would like to and three children, Maya, Samir, and Riya, who have made sacrifices,
thank the authors and editors, who have spent enormous amounts yet have been there to support, entertain, and inspire me.
of their own personal time to produce this book. Thanks to the
patients and my colleagues: my co-attendings, the residents and S.A.G.
fellows, and the nurses, who have inspired me to be a better clinician
and teacher. I also want to acknowledge Gary Fleisher and the late I would first like to thank my wife, Leslie, my sons Noah, Ben and
Michael Shannon for their mentorship and guidance. Finally, I deeply Logan, and my daughter Lia, for all of their support and love. Ev-
appreciate my wife Esther, and my parents Jaw and Jean, for their erything I am, I owe to them. I would also like to thank the au-
continual support, patience, and sacrifice. thors that I have worked with, the editorial staff for their support,
V.J.W. and my co-editors who had to put up with me. It has truly been a
pleasure to work on this project, and I have learned a great deal
from all.
R.P.
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CONTRIBUTORS
x r r r Contributors
Contributors r r r xi
xii r r r Contributors
Contributors r r r xiii
xiv r r r Contributors
Contributors r r r xv
Mia L. Karamatsu, MD Abu N.G.A. Khan, MD, MSc Young-Jo Kim, MD, PhD
Clinical Instructor Assistant Clinical Professor Associate Professor of Orthopedic
Department of Emergency Medicine Department of Pediatrics Surgery
Loma Linda University Columbia University College of Physicians Department of Orthopaedic Surgery
Loma Linda University Childrens Hospital and Surgeons Childrens Hospital Boston
Loma Linda, California Attending Physician Boston, Massachusetts
Division of Pediatric Emergency Medicine
Denise G. Karasic, DO Morgan Stanley Children Hospital of Bruce L. Klein, MD
Attending Physician New York Presbyterian Associate Professor
Nemours/A.I. duPont Hospital for Children New York, New York Department of Pediatrics and Emergency
Wilmington, Delaware Medicine
Kajal Khanna, MD, JD George Washington University School of
Harry C. Karydes, DO Fellow Medicine and Health Sciences
Toxicology Fellow Division of Emergency Medicine Section head, Physician Outreach
Department of Emergency Medicine Childrens Hospital Los Angeles Division of Emergency Medicine
Cook County Hospital Los Angeles, California Childrens National Medical Center
Chicago, Illinois Washington, District of Columbia
Anupam Kharbanda, MD, MS
John Kashani, DO Susanne Kost, MD
Assistant Professor
Department of Pediatrics Associate Professor of Pediatrics
Department of Pediatrics
New Jersey Medical School Jefferson Medical College
University of Minnesota
University of Medicine and Dentistry of Philadelphia, Pennsylvania
Research Director
New Jersey Medical Director, Day Medicine and
Division of Pediatric Emergency Medicine
Newark, New Jersey Sedation Service
Amplatz Childrens Hospital
Nemours/A.I.duPont Hospital for Children
Robert M. Kay, MD Minneapolis, Minnesota
Wilmington, Delaware
Associate Professor
Department of Orthopaedic Surgery Hnin Khine, MD Steven Krebs, MD
Keck School of Medicine of the University Associate Professor of Clinical Pediatrics Department of Pediatrics
of Southern California Albert Einstein College of Medicine St. Louis University School of Medicine
Vice Chief Attending Physician Division of Pediatric Emergency Medicine
Childrens Orthopaedic Center Department of Pediatrics Cardinal Glennon Childrens Medical
Childrens Hospital Los Angeles Childrens Hospital of Montefiore Center
Los Angeles, California Bronx, New York St. Louis, Missouri
xvi r r r Contributors
Contributors r r r xvii
xviii r r r Contributors
Contributors r r r xix
xx r r r Contributors
Contributors r r r xxi
xxii r r r Contributors
Contributors r r r xxiii
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CONTENTS
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xxvi r r r Contents
Contents r r r xxvii
xxviii r r r Contents
Contents r r r xxix
xxx r r r Contents
Contents r r r xxxi
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xxxiii
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ABDOMINAL DISTENTION
Besh Barcega
Eugenio Vazquez
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ABDOMINAL DISTENTION
A
Imaging
r A 2- or 3-view abdominal radiograph is the most
DISPOSITION ADDITIONAL READING
Admission Criteria r Long FR, Kramer SS, Markowitz RI, et al.
helpful initial diagnostic study to perform for a r Newborns with fever or infants and children who
patient presenting with abdominal distention. The are ill appearing Radiographic patterns of intestinal malrotation on
findings on the radiograph will aid to determine r Peritoneal signs and those who may also require children. Radiographics. 1996;16:547556.
what additional lab and/or imaging studies will be r Louie JP. Essential diagnosis of abdominal
urgent surgical intervention
needed (2,3). Look at the intraluminal gas pattern, r Poorly controlled pain and/or intractable vomiting emergencies in the first year of life. Emerg Med Clin
presence of free air, calcifications, constipation, and without a specific diagnosis North Am. 2007;25:10091040.
some soft tissue masses: r Intra-abdominal organ trauma r McCollough M, Sharieff G. Abdominal surgical
An intestinal obstruction or a paralytic ileus can r Nephrotic syndrome with hypoalbuminemia emergencies in infants and young children. Emerg
cause distended loops of bowel and air-fluid levels. Med Clin North Am. 2003;21:909935.
Double bubble sign is appearance of a gas-filled refractory to oral corticosteroids r Rao P. Neonatal gastrointestinal imaging. Eur J
stomach and duodenum separated by the pylorus Discharge Criteria Radiol. 2006;60:171186.
and is seen in neonates and infants with duodenal r Patients who are well appearing and have a
atresia or malrotation with volvulus. definitive nonemergent etiology of the abdominal See Also (Topic, Algorithm, Electronic
r Abdominal US is useful for initial evaluation of an distention Media Element)
r Patients who are well appearing and do not have a r Hirschsprung Disease
abdominal mass and can also be used to diagnose
r Nephrotic Syndrome
intussusception. definitive etiology of the abdominal distention but
r Abdominal CT is the most sensitive imaging do have reliable follow-up r Pain, Abdomen
modality for detailed evaluation of intra-abdominal r Patients with abdominal pain and/or vomiting r Peritonitis
solid organ pathology, especially if US findings are whose symptoms are relieved or improved
inconclusive, but it does run the risk of radiation
exposure (3). CODES
r Upper GI series is indicated if malrotation or upper FOLLOW-UP
GI obstruction is suspected. Obtain only if the FOLLOW-UP RECOMMENDATIONS ICD9
patient is clinically stable. r 24-hr follow-up with either the primary care 787.3 Flatulence, eructation, and gas pain
r Air or barium enema is indicated if intussusception
provider or ED if etiology of abdominal distention
is highly suspected. The pediatric surgeon should be has not been determined and symptoms persist
involved due to the risk of bowel perforation. r 2448-hr follow-up with primary care provider if PEARLS AND PITFALLS
etiology has been determined and additional r Necrotizing enterocolitis may occur in term infants
DIFFERENTIAL DIAGNOSIS
r Extra-abdominal pathology such as pulmonary evaluation is needed and should be in the differential diagnosis of any
hyperinflation from bronchiolitis or an asthma r Discharge instructions and medications: newborn with feeding intolerance and abdominal
exacerbation Return if patient develops vomiting, severe distention.
r Unrecognized pregnancy abdominal pain, or fever. r An obstructive bowel process is the most common
If pain is mild, provide an analgesic: cause of acute onset of abdominal distention with
Acetaminophen 1015 mg/kg/dose PO or abdominal pain.
TREATMENT PR q46h r Abdominal masses are usually an incidental finding
PROGNOSIS on abdominal exam. Patients usually present with
INITIAL STABILIZATION/THERAPY abdominal pain only when the mass is causing an
Assess and stabilize airway, breathing, and Dependent on the underlying etiology
obstruction.
circulation. COMPLICATIONS r It is critical to rule out neoplasm in children with
r Bowel obstruction
MEDICATION abdominal swelling.
r Broad-spectrum IV antibiotics if suspicious for r Bowel perforation
peritonitis or sepsis: r Gut necrosis
Gentamicin 2.5 mg/kg/dose PLUS ampicillin/ r Sepsis
sulbactam 50 mg/kg/dose of ampicillin r Death
component OR
Piperacillin/tazobactam 100 mg/kg/dose of
piperacillin component OR REFERENCES
Ampicillin 50 mg/kg/dose PLUS gentamicin
2.5 mg/kg/dose PLUS metronidazole 7.5 mg/kg/ 1. Grant HW, Parker MC, Menzies D, et al. Adhesions
dose after abdominal surgery in children. J Pediatr Surg.
r Analgesic if patient is in pain: 2008;43:152156.
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: 2. Hughes U, Thomas K, Shuckett T, et al. The
Initial morphine dose 0.1 mg/kg IV/SC may be abdominal radiographic series in children with
repeated q1520min until pain is controlled suspected bowel obstructionshould the second
then q2h PRN view be abandoned? Pediatr Radiol. 2002;32:
r Antiemetic if patient has persistent nausea and/or 556560.
vomiting: Ondansetron 0.15 mg/kg/dose IV/PO q6h 3. Lameris W, van Randen A, van Es HW, et al.
PRN Imaging strategies for detection of urgent
r Maintenance IV fluids if patient is found to be conditions in patients with acute abdominal pain:
Diagnostic accuracy study. BMJ. 2009;339:b2431.
dehydrated
SURGERY/OTHER PROCEDURES
r Immediate surgical consultation is required for any
ill-appearing patient with suspected peritonitis from
bowel perforation or malrotation with mid-gut
volvulus.
r Nasogastric tube placement if intractable vomiting
or if a bowel obstruction is suspected
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ABRUPTIO PLACENTA
Shira Yahalom
Imaging
BASICS DIAGNOSIS r US demonstrates abruptio placenta in only 50% of
cases:
DESCRIPTION HISTORY US use to demonstrate hematoma is of limited
r Abruptio placenta refers to separation of the r Triad of severe abdominal/back pain, vaginal
value since most abruptions will not be detected.
placenta from the uterus after 20 wk gestation and bleeding, and fetal distress should alert the clinician US should be used to locate the placenta.
prior to delivery. for the presence of abruptio placenta. r MRI is sensitive in detecting small or posterior
r The severity of separation can range from mild to r Since the bleeding may be concealed, the absence
abruptions.
fatal for both mother and fetus. of vaginal bleeding does not rule out the diagnosis
of abruptio placenta. DIFFERENTIAL DIAGNOSIS
EPIDEMIOLOGY r Abdominal/Back pain may persist between r Placenta previa is associated with painless vaginal
r Abruptio placenta complicates 1% of pregnancies. bleeding.
r 1/3 of all antepartum bleeding is attributed to contractions.
r Decrease in fetal activity as sensed by the mother r Uterine rupture causes severe abdominal pain,
abruptio placenta. r Obtain history regarding cocaine use or recent bleeding, and fetal distress/demise.
r Vasa previa will result in massive fetal blood loss.
RISK FACTORS trauma.
r Maternal HTN r Vaginal or cervical laceration
r Multiple gestation PHYSICAL EXAM r Preterm labor
r Since blood loss may be severe, maternal
r Uterine malformations
tachycardia and hypotension can occur.
r Tobacco or cocaine use r Fundal tenderness may be palpated, and fundal
r Polyhydramnios with sudden uterine decompression
TREATMENT
height may increase due to an expanding
r Previous abruption hematoma. INITIAL STABILIZATION/THERAPY
r Thrombophilias r The amount of vaginal bleeding does not correlate r Obtain large-bore IV access, and start fluid
r Trauma with the degree of abruption: resuscitation with 20 mL/kg crystalloid; repeat as
Avoid pelvic examination until location of the needed.
PATHOPHYSIOLOGY r Supplemental oxygen
r Rupture of blood vessels in the placenta leads to placenta is verified given the differential diagnosis
of placenta previa. r Continuous fetal heart rate and contractions
hematoma formation and placental separation. monitoring
r Placental separation releases prostaglandins, and DIAGNOSTIC TESTS & INTERPRETATION r Close monitoring of the mother for signs of
contractions occur worsening separation and Lab hemodynamic instability
bleeding. r CBC
r Fetal age should be assessed and complications of
r Dissection of blood into the decidua basalis may r Serum electrolytes, LFTs, BUN, and creatinine
prematurity anticipated.
progressively increase the shearing force on r PT/PTT/INR, fibrinogen
placenta. r Blood type and Rh status
ETIOLOGY
Bleeding may result from trauma, defective placental
blood vessels, thrombophilias, drug abuse, or uterine
malformations.
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ABRUPTIO PLACENTA
A
MEDICATION Discharge Criteria See Also (Topic, Algorithm, Electronic
r All patients presenting to the ED with suspected Media Element)
First Line
RhoGAM IM 300 g: abruptio placenta require admission for monitoring. Vaginal Bleeding in Pregnancy
r Given as soon as possible within 72 hr of event for r Transfer to a facility with a neonatal ICU should be
Rh-negative mothers >12 wk gestation considered for stable patients. Transfer should be
Second Line
done after delivery if delivery is required to stabilize CODES
r Typed and crossed-matched packed RBCs or the mother.
r Patients with no evidence of abruption or other
platelets may be indicated. ICD9
significant injury may be discharged after 46 hr of r 641.20 Premature separation of placenta,
r Fresh frozen plasma if disseminated intravascular
normal maternal and fetal monitoring. unspecified as to episode of care
coagulation (DIC) occurs r 641.21 Premature separation of placenta, with
r Tocolytics may be considered with obstetric
FOLLOW-UP delivery
consultation. r 641.23 Premature separation of placenta,
SURGERY/OTHER PROCEDURES FOLLOW-UP RECOMMENDATIONS antepartum
r Obtain immediate obstetric consultation.
Discharge instructions include pelvic rest, no
r Anticipate prematurity of fetus and consult neonatal intercourse, no heavy lifting, and no prolonged
ICU if precipitous delivery of an infant >20 wk standing. PEARLS AND PITFALLS
gestation may occur.
COMPLICATIONS r Patients may not present with the classic triad.
DISPOSITION r Maternal: Hemorrhagic shock, transfusion-related
Consider the diagnosis in all patients presenting
Admission Criteria complications, DIC with preterm labor.
r All patients should be admitted. r Fetal: Complications of prematurity, perfusion r The presenting complaint may only be a decrease in
r Decision to deliver should be made with obstetric compromise, anoxic insult fetal activity per the patient.
consultation and consideration of prematurity risks r Lack of vaginal bleeding does not exclude abruptio
versus fetal and maternal morbidity and mortality. placenta.
r Critical care admission criteria: ADDITIONAL READING r US should not be used to exclude the diagnosis
All hemodynamically unstable patients, either r Abbrescia K, Sheridan B. Complications of second given the low sensitivity of the test. Diagnosis of
before or after delivery, should receive ICU care. and third trimester pregnancies. Emerg Med Clin abruptio placenta remains clinical.
North Am. 2003;21:695710. r Anticipate shock and DIC.
r Ferentz KS, Nesbitt LS. Common problems and r Consult an obstetrician early in the course of
emergencies in the obstetric patient. Prim Care. suspected abruptio placenta.
2006;33(3):727750.
r Francois KE, Foley MR. Antepartum and postpartum
hemorrhage. In Gabbe SG, Niebyl JR, Simpson JL,
et al., eds. Obstetrics: Normal and Problem
Pregnancies. 5th ed. Philadelphia, PA: Churchill
Livingstone Elsevier; 2007.
r Sakornbut E, Leeman L, Fontaine P. Late pregnancy
bleeding. Am Fam Physician. 2007;75(8):
11991206.
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ABSCESS, DENTOALVEOLAR
Kristin S. Stukus
Raymond Pitetti
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ABSCESS, DENTOALVEOLAR
A
Second Line REFERENCE
TREATMENT Clindamycin for penicillin-allergic patients,
1. Graham DB, Webb MD, Seale NS. Pediatric
10 mg/kg/dose PO/IV q6h:
PRE HOSPITAL r Considered second-line parenteral therapy emergency room visits for nontraumatic dental
Assess and stabilize airway, breathing, and r Treatment of choice for penicillin-allergic patients disease. Pediatr Dent. 2000;22:134140.
circulation.
SURGERY/OTHER PROCEDURES
INITIAL STABILIZATION/THERAPY r Incision and drainage of complicated dentoalveolar ADDITIONAL READING
r Assess and stabilize airway, breathing, and
abscesses r Brook I. Microbiology and management of
circulation. r Following resolution of acute infection, pulpectomy
r Antibiotic therapy endodontic infections in children. J Clin Pediatr
is indicated. Dent. 2003;28:1317.
r Pain control r Nerve block: r Delaney JE, Keels MA. Pediatric oral pathology: Soft
r IV hydration, if warranted Block of individual tooth is contraindicated due to tissue and periodontal conditions. Pediatr Clin North
MEDICATION local infection. Am. 2000;47:11251147.
Regional blockage, such as alveolar or maxillary r Krebs KA, Clem DS III. Guidelines for the
First Line dental block, may be performed:
r Oral or parenteral antibiotics: management of patients with periodontal diseases.
Only perform if trained and comfortable in the
Severe infections require parenteral therapy; mild J Periodontol. 2006;77:16071611.
procedure
infections with only moderate swelling without
high fevers may be treated with oral antibiotics. DISPOSITION
Ampicillin/sulbactam 50 mg/kg/dose IV q6h; Admission Criteria CODES
adolescent/adult 12 g IV q6h r Complicated abscess
Penicillin 50 mg/kg PO divided b.i.d.q.i.d. 10 r Inability to handle secretions ICD9
days; adolescent/adult 500 mg PO t.i.d.q.i.d.: r Airway compromise r 522.5 Periapical abscess without sinus
Traditionally was first-line oral or parenteral r Involvement of facial spaces of the head and neck r 522.7 Periapical abscess with sinus
medication used, but due to pathogen r Systemic involvement
resistance, infections requiring parenteral r Failure of outpatient therapy
antibiotics are not treated with penicillin alone. PEARLS AND PITFALLS
Acceptable for traetment of mild oral infections, r Need for IV hydration
but not indicated for moderate to severe r Critical care admission criteria: r Most patients with uncomplicated dentoalveolar
infections requiring parenteral antibiotics due to Airway compromise: Present or pending abscess can be treated as an outpatient.
increased pathogen resistance. Discharge Criteria r Failure to recognize a complicated abscess
r Opioids: r Failure to adequately assess or recognize airway
Uncomplicated dentoalveolar abscess
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: Issues for Referral compromise
Initial morphine dose of 0.1 mg/kg IV/SC may Refer to a maxillofacial or oral surgeon or dentist.
be repeated q1520min until pain is controlled,
then q2h PRN.
Codeine or codeine/acetaminophen dosed as FOLLOW-UP
0.51 mg/kg of codeine component PO q4h PRN
Hydrocodone or hydrocodone/acetaminophen FOLLOW-UP RECOMMENDATIONS
dosed as 0.1 mg/kg of hydrocodone component Discharge instructions and medications:
PO q46h PRN r Follow-up evaluation by a dentist
r NSAIDs: r Complete antibiotic course
Consider NSAID medication in anticipation of Patient Monitoring
prolonged pain and inflammation: Monitor improvement of infection closely.
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
Ketorolac 0.5 mg/kg IV/IM q6h PRN DIET
Naproxen 5 mg/kg PO q8h PRN r As tolerated
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r Soft diet for comfort
r Local anesthetic:
PROGNOSIS
Lidocaine 1% or 2% with or without epinephrine, Uncomplicated dental abscess typically resolves easily
max 5 mg/kg used to infiltrate with proper treatment.
Ropivacaine 1 mg/kg/dose, max 2 mg/kg:
Is optimal isomer of bupivacaine that lacks COMPLICATIONS
r Dentocutaneous fistulas
deadly cardiotoxicity of bupivacaine
Preferred agent due to duration of action and r Acute suppurative osteomyelitis
lack of cardiotoxicity r Cavernous sinus thrombosis
r Suppurative complications:
ALERT Acute suppurative lymphadentis
r Inadvertent IV administration of bupivacaine may
Peritonsillar or pharyngeal abscess
cause immediate cardiac arrest and death. Ludwig angina
Bupivacaine used for nerve block should be placed Maxillary sinusitis
by clinicians with vast experience performing such r Necrotizing fasciitis
a block. Ropivacaine is strongly recommended for
this procedure due to lack of the severe
cardiotoxicity of bupivacaine.
9
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ABSCESS, GLUTEAL
David O. Kessler
ETIOLOGY Imaging
BASICS Subcutaneous abscesses are often polymicrobial, r Bedside US has been used to help distinguish
including common skin flora such as Staphylococcus between cellulitis and abscess when the clinical
DESCRIPTION and Streptococcus (2): exam is inconclusive (3).
r Gluteal abscess is a type of localized infection r Enteric organisms may also be found in abscesses r Bedside US can also be used to help guide a
located beneath the skin: with close proximity to the anus. drainage procedure.
Gluteal describes the location of the abscess r Abscesses are also well visualized with other
being in close proximity to the gluteus muscles. It COMMONLY ASSOCIATED CONDITIONS
r Abscesses are more commonly seen in modalities such as MRI and contrast-enhanced CT
is otherwise similar to simple subcutaneous scans:
abscesses in other locations. immunocompromised patients who are more
However, these imaging tests have been largely
A boil, furuncle, or carbuncle refers to a type of susceptible to infection.
r Comorbid disease should be considered in those replaced by US.
abscess that is associated with a hair follicle and
typically involves the skin. with recurrent or multiple abscesses: Diagnostic Procedures/Other
Folliculitis refers to an infection at a hair follicle HIV, diabetes mellitus, IV drug users Depending on the size, location, and extent of a
that is more superficial with inflammation and pus May also be associated with genetic lesion, needle aspiration or incision and drainage may
localized to the epidermal layer. immunodeficiency syndromes be used.
r A simple gluteal abscess may occur spontaneously DIFFERENTIAL DIAGNOSIS
in a healthy host as a result of localized infection r Hidradenitis suppurativa: Recurrent inflammatory
with common skin flora. DIAGNOSIS disorder affecting the apocrine glands (typically seen
EPIDEMIOLOGY HISTORY in the axilla or buttocks)
r Abscesses or subcutaneous soft tissue infections are r Many abscesses start off as a small pimple or r Pilonidal cyst or abscess
folliculitis that expands over days to weeks. r Necrotizing fasciitis
thought to be common but are poorly reported.
r There is a wide range of presentation and need for r They are usually tender, swollen, red, and warm and r Pyomyositis
intervention; therefore, not all abscesses will present may spontaneously express pus. r Botfly myiasis
for medical care. r Fever may be present. r Osteomyelitis: May also present with drainage to
r Published rates vary between 2.5% and 21.5% in r An abscess may be spontaneous or surface
certain populations and appear to be on the rise (1). chronic/recurrent in nature:
There may be a history of previous abscesses.
RISK FACTORS r History of a cyst at the site of the lesion TREATMENT
r Subcutaneous abscesses may be seen in normal
r History of close contacts with similar lesions
healthy hosts but are more commonly seen in those INITIAL STABILIZATION/THERAPY
r Recent hot tub use r In the initial management of an abscess, warm,
who are immunocompromised, have poor hygiene,
r Comorbidities (Crohn disease, diabetes, etc.) clean compresses (or sitz baths) may be used to help
or have close contact with others who have similar
infections. PHYSICAL EXAM promote spontaneous drainage.
r Outbreaks have occurred in communities that r Abscesses exhibit the signs of an acute infection: r Abscesses are usually extremely painful, so
become colonized with MRSA: Erythema, swelling, warmth, and tenderness. analgesia should be administered early, though full
Athletes (wrestlers) r Induration may be present as a hardened mass of pain relief is often not achieved until pressure is
Military personnel fibrous tissue that is often palpable in an abscess relieved from the wound with a procedure.
IV drug users beneath the skin. MEDICATION
r Simple cysts may be secondarily infected. r Fluctuance may be present as a spongy softness r Recent literature suggests that antibiotics may not
GENERAL PREVENTION indicative of pus or fluid. be necessary in the treatment of gluteal abscess
Good hygiene, antistaphylococcal soap, and proper r There may be overlying cellulitis or central extrusion following successful incision and drainage (4)
care early in the disease course may help prevent of pus. r Incision and drainage is thought to be efficacious
development of larger abscesses. r Regional lymphadenopathy may be associated with regardless of the use of antibiotics
an abscess. r The presence of overlying cellulitis or comorbidities
PATHOPHYSIOLOGY r If an abscess is in close proximity to the anus, a
r Subcutaneous abscesses form when the bodys requires the use of antibiotics, despite the
rectal exam may help to evaluate for rectal performance of incision and drainage
immune system walls off an infection that is often r Debate does exist as to whether incision and
the result of an inoculum of skin flora that enters involvement or communication.
either through a break in the epidermis or a hair drainage alone is enough to treat gluteal abscess.
DIAGNOSTIC TESTS & INTERPRETATION Many practitioners continue to use antibiotics.
follicle.
r A fibrous capsule surrounds a core of liquefied Lab r 1st-generation cephalosporins:
r A simple abscess does not require any lab
necrotic tissue, inflammatory cells, and bacteria in Cefazolin 50100 mg/kg IV divided q8h, max dose
confirmation. Cephalexin 50 mg/kg PO divided t.i.d., max dose
the bodys attempt to expel the foreign material. r Basic labs may be considered with chronic infection
2 g/day
or to evaluate or rule-out comorbid conditions: r MSSA:
Wound cultures, particularly to track rates and Dicloxacillin: <40 kg, 50100 mg/kg/24 hr PO
susceptibilities of MRSA infections or to help guide divided q6h; >40 kg, 250500 mg/dose PO q6h
management in complicated chronic cases (1) (max dose 4 g/24 hr)
Nafcillin: <40 kg, 50200 mg/kg/24 hr PO/IV
divided q6h; >40 kg, 5002,000 mg PO/IV q6h
(max daily dose 12 g).
10
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ABSCESS, GLUTEAL
A
r MRSA: DISPOSITION REFERENCES
Clindamycin: <40 kg, PO 1030 mg/kg/24 hr Admission Criteria
divided q68h, IV 2540 mg/kg/24 hr divided r A simple skin abscess does not typically require 1. Korownyk C, Allan G. Evidence-based approach to
q68h; >40 kg, PO 300 mg/dose q68h, IV admission unless there is a comorbid condition, abscess management. Can Fam Physician. 2007;
1,2001,800 mg/24 hr divided q612h (max daily complication, or a social reason for admission. 53:16801684.
dose 4.8 g/24 hr) r Large abscesses (>5 cm) may be more likely to 2. Stevens DL, Bison AL, Chambers HF, et al. Practice
Trimethoprim/sulfamethizole (dosing based on require inpatient management. guidelines for the diagnosis and management of
trimethoprim): <40 kg, 5 mg/kg/dose PO/IV r A rapidly spreading overlying cellulitis may require skin and soft tissue infections. Clin Infect Dis.
q12h; >40 kg, 160 mg/dose PO/IV q12h admission.
2005;41(10):13731406. [Erratum in Clin Infect
Vancomycin: <40 kg, 10 mg/kg/dose IV q8h (max Dis. 2005;41(12):1830, Clin Infect Dis. 2006;42(8):
1 g/dose); >40 kg, 2 g/24 hr IV divided q612h Issues for Referral 1219.]
(max dose 4 g/24 hr) Subspecialist involvement should be strongly 3. Ramirez-Schrempp D, Dorfman D, Baker W, et al.
Drug of choice, first-line parenteral medication considered for abscesses in children <6 mo of age, Ultrasound soft tissue applications in the pediatric
for MRSA recurrent abscesses, or abscesses also involving emergency department. Pediatr Emer Care.
When antibiotics are used (such as in the case of sensitive locations such as the genitals or perianal 2009;25:4448.
secondary cellulitis), consideration should be area, where concern for a fistula may exist: 4. Hankin A, Everett W. Are antibiotics necessary after
made for whether coverage is warranted for r Depending on the institution, specific referrals may
incision and drainage of a cutaneous abscess? Ann
community- or hospital-acquired MRSA. be handled by pediatric surgery, plastic surgery, or Emerg Med. 2007;50:4951.
gynecology.
SURGERY/OTHER PROCEDURES
r The definitive treatment for a gluteal abscess is
ADDITIONAL READING
incision and drainage of the abscess cavity. FOLLOW-UP
Technique varies widely and is only briefly described Chambers H, Moellering R, Kamitsuka P. Management
here: FOLLOW-UP RECOMMENDATIONS of skin and soft tissue infection. N Engl J Med.
Confirm location for incision and drainage. This r After uncomplicated incision and drainage, patients
2008;359:10631067.
may be done with US, if available, to help identify should follow up within 2448 hr with a provider
fluid pockets and avoid vascular structures. experienced in wound care. See Also (Topic, Algorithm, Electronic
Adequate analgesia is often difficult to achieve, r Warm compresses and/or sitz baths can help provide Media Element)
r Abscess, Perianal
but several strategies may be used. A local field comfort and may promote healing.
r Cellulitis
block (1% or 2% lidocaine with or without
epinephrine depending on the location) provides PROGNOSIS r Pilonidal Cyst
r Most abscesses resolve within 12 wk after incision
injections of anesthetic in a ring around the
indurated space. Injecting into the wound itself is and drainage.
r Recurrence is not uncommon and may be seen in up
typically ineffective because of the acidity of the
to 25% of cases.
CODES
abscess space, and increased pressure from an
injection may worsen pain. COMPLICATIONS ICD9
For superficial abscess, topical anaesthetics such r The most common complications include failure of 682.5 Cellulitis and abscess of buttock
as ethyl chloride spray may help numb the skin the wound to heal and recurrence that often
immediately prior to incision. requires re-exploration or a 2nd incision and
Some patients may require sedation in order to drainage procedure. PEARLS AND PITFALLS
obtain adequate pain control prior to the r Bleeding may also occur but is usually controlled
r Distinguishing between cellulitis and deeper
procedure. spontaneously or with local pressure.
A needle aspiration may be attempted 1st to r Rare complications may be seen with the less infection (eg, abscess) can sometimes be difficult on
confirm the location of the fluid pocket. physical exam alone. Bedside US can be helpful in
frequent causes of an abscess: identifying fluid collections.
Fluctuance typically represents fluid immediately Fistulas can occur in patients with inflammatory
beneath the surface of the skin and may also be r Differentiate between gluteal and rectal abscess. If
bowel disease or if the abscess is in
used to guide the initial incision. in doubt, consult a pediatric surgeon for evaluation.
communication with the bowels.
After topical cleansing with povidone-iodine or an Recurrence is more common in a cyst that has
alcohol solution, incision is made using an become secondarily infected, such as a pilonidal
11-blade scalpel inserted 0.51 cm deep through cyst.
the epidermis and dermal layer and in 1 Severe bleeding can occur if a vessel is lacerated
continuous motion incising 75% of the length during the procedure.
of the wound.
The wound is then explored with a surgical clamp,
and any loculations or fibrous strands should be
broken apart to help release any additional fluid
pockets.
If the wound is deep, a small amount of packing
material may be used to help keep skin layer from
healing prior to granulation of the inside of the
wound.
r Needle aspiration is performed using a small syringe
attached to an 18-gauge needle, withdrawing
slightly on the plunger as the needle is inserted into
the area of greatest fluctuance and aspirating fluid.
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ABSCESS, INTRACRANIAL
Kerry Caperell
Raymond Pitetti
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ABSCESS, INTRACRANIAL
A
MEDICATION SURGERY/OTHER PROCEDURES
r Guided surgical aspiration is indicated to obtain
ADDITIONAL READING
First Line r Frazier J, Ahn E, Jallo GI. Management of brain
r Antimicrobial therapy is the treatment of choice and infected material for cultures to guide definitive
should be broad spectrum until culture results are antimicrobial therapy. abscesses in children. Neurosurg Focus. 2008;
available. r Cultures should be sent for both aerobic and 24(6):E8.
r When the apparent source is otitis media, r Shachor-Meyouhaus Y, Bar-Joseph G, Guilburd JN,
anaerobic pathogens.
mastoiditis, sinusitis, or congenital heart disease, a r Surgical excision is occasionally necessary. et al. Brain abscess in childrenepidemiology,
3rd-generation cephalosporin plus metronidazole is predisposing factors and management in the
DISPOSITION modern medicine era. Acta Paediatr. 2010;99(8):
indicated:
Ceftriaxone or cefuroxime plus metronidazole Admission Criteria 11631167.
r All children with brain abscess should be admitted r Yogev R. Focal suppurative infections of the central
Ceftriaxone 100 mg/kg/dose IV q12h, max single
dose 2 g/24 hr to the hospital. nervous system. In Long S, Pickering L, Prover C,
r Many of these children will warrant admission to a eds. Principles and Practice of Pediatric Infectious
Cefuroxime 50 mg/kg/dose IV q8h, max single
dose 1 g/24 hr pediatric ICU for monitoring, including ICP Disease. 2nd ed. New York, NY: Churchill
Metronidazole 30 mg/kg/day IV q6h, max single monitoring in select cases. Livingstone; 2003:302312.
dose 4 g/24 hr r Yogev R, Maskit B. Management of brain abscesses
Issues for Referral
r When the apparent source includes penetrating r Infectious disease consultation may be useful. in children. Pediatr Infect Dis J. 2004;23:157159.
trauma, ventriculoperitoneal shunt, meningitis, or r Referral to a Critical care specialist is recommended.
See Also (Topic, Algorithm, Electronic
endocarditis, a 3rd-generation cephalosporin plus Media Element)
vancomycin is indicated: r Abscess, Dentoalveolar
Vancomycin 10 mg/kg/dose IV q6h, max FOLLOW-UP r Mastoiditis
individual dose 1 g r Meningitis
r In neonates, ampicillin should be added if Listeria is FOLLOW-UP RECOMMENDATIONS
a possibility: Patient Monitoring
Ampicillin 100 mg/kg/dose IV q6h, max single Most patients will initially require monitoring in the
dose 12 g/24 hr pediatric ICU. CODES
r In immunosuppressed children, coverage for fungal DIET
organisms should be strongly considered. Patients should be NPO given the likelihood for ICD9
procedures requiring sedation/anesthesia. 324.0 Intracranial abscess
Second Line
r Ampicillin/Sulbactam 100 mg/kg/dose IV q6h, max
PROGNOSIS
single dose 12 g ampicillin/24 hr r Even with optimal treatment, mortality from brain PEARLS AND PITFALLS
r Meropenem 40 mg/kg/dose IV q8h, max single dose abscess is as high as 15%.
r A more recent case series had a mortality rate of r Routine lab tests, including CSF, are not generally
6 g/24 hr
r Ciprofloxacin 10 mg/kg/dose IV q12h, max single only 4%. helpful in ruling out brain abscess.
r Factors associated with increased morbidity and r Early imaging is warranted if brain abscess is
dose 1 g/24 hr
r Corticosteroids: mortality include age <1 yr, coma at diagnosis, suspected.
r Empiric antibiotic therapy should cover
Dexamethasone 0.5 mg/kg/dose IV q24h rapidly progressive neurologic deterioration, and
Methylprednisolone 30 mg/kg IV loading dose multiple foci of infection. gram-positive, gram-negative, and anaerobic
followed by 5.4 mg/kg/hr for 23 hr organisms.
COMPLICATIONS r Specific populations may be at risk for unique
This is same dose used in spinal trauma; another
Up to 1/3 of surviving patients will have permanent pathogens, such as Mexican and Central American
dosing regimen may be recommended by the
neurologic disabilities. immigrants with a likelihood for cysticercosis or
neurosurgeon.
Glucocorticoids may lead to an improvement in HIV/immunosuppressed patients at risk for
signs and symptoms secondary to mass effect, but toxoplasmosis, Cryptococcus, and Candida.
they should not be used if a well-defined capsule
is not apparent on imaging.
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14
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15
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ABSCESS, PERIANAL
Antonio Riera
David M. Walker
16
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ABSCESS, PERIANAL
A
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN DISPOSITION REFERENCES
r Stool-bulking agents and stool softeners to prevent Admission Criteria
constipation (post drainage): r Toxic or ill appearing 1. Brook I, Martin W. Aerobic and anaerobic
Polyethylene glycol 3350: 17 g in 8 oz of water r Suspected or confirmed fistula requiring surgical bacteriology of perirectal abscess in children.
qhs; children >6 mos: 0.51.5 g/kg daily intervention Pediatrics. 1980;66:282284.
r Antibioticsuniversal use is debatable. Anaerobic r Suspected child abuse 2. Christison-Lagay E, Hall JF, Wales PW, et al.
and staphylococcal coverage is recommended if ill r Younger age of child Nonoperative management of perianal abscess in
appearing, febrile, or immunocompromised: r Extensive lesions infants is associated with decreased risk for fistula
Oral first line: r Pain not well controlled formation. Pediatrics. 2007;120:e548e552.
Amoxicillin/Clavulanate 20 mg/kg/dose PO 3. Whiteford M, Kilkenny J 3rd, Hyman N, et al.
q12h OR Discharge Criteria Practice parameters for the treatment of perianal
Clindamycin 810 mg/kg/dose PO q8h r Well appearing abscess and fistula-in-ano (revised). Dis Colon
IV first line: r Small, uncomplicated abscess Rectum. 2005;48:13371342.
Ampicillin/Sulbactam 50 mg/kg/dose IV q6h OR r Pain well controlled 4. Quah HM, Tang CL, Eu KW, et al. Meta-analysis of
Clindamycin 1012 mg/kg/dose IV q8h r Adequate wound care plan arranged randomized control trials comparing drainage alone
Suspected MRSA: r Follow-up for wound check in 24 hr vs primary sphincter-cutting procedures for
Trimethoprim/Sulfamethoxazole (TMP/SMX) anorectal abscess-fistula. Int J Colorectal Dis.
5 mg/kg/dose PO q12h based on TMP Issues for Referral 2006;21:602609.
component OR Consider surgical consultation for initial management
Vancomycin 1015 mg/kg/dose IV; determine and/or follow-up.
interval by trough levels ADDITIONAL READING
Penicillin allergic (PO): r Abercrombie JF, George BD. Perianal abscess in
Clindamycin (for MSSA) FOLLOW-UP
TMP/SMX plus metronidazole 10 mg/kg/dose children. Ann R Coll Surg Engl. 1992;74(6):
FOLLOW-UP RECOMMENDATIONS 385386.
PO q8h (for MRSA) r 24-hr follow-up for wound check and repacking of r Ramanujam PS, Prasad ML, Abcarian H, et al.
Penicillin allergic (IV): abscess cavity
Clindamycin (for MSSA) r Frequent daily sitz baths or warm soaks to promote Perianal abscesses and fistulas. A study of 1023
Vancomycin plus metronidazole 10 mg/kg/dose patients. Dis Colon Rectum. 1984;27(9):593597.
further drainage r Stites T, Lund D. Common anorectal problems.
IV q8h (for MRSA) r Consider home nursing services.
Semin Pediatr Surg. 2007;16(1):7178.
SURGERY/OTHER PROCEDURES PROGNOSIS
r Perianal abscess should be treated in a timely r Simple perianal abscesses have excellent outcomes
fashion by incision and drainage (2): after incision and drainage. CODES
Lack of fluctuance should not delay timely r Perianal abscesses with anal fistula have higher
drainage.
r In infants, medical management may be an rates of complications. ICD9
COMPLICATIONS 566 Abscess of anal and rectal regions
acceptable alternative:
In a retrospective study of 140 children <1 yr of r Fistula-in-ano
age for whom abscess size was not reported, r Recurrence
r Stool incontinence (if sphincter-cutting procedure
PEARLS AND PITFALLS
medical management with local hygiene and
systemic antibiotics had equivalent cure rates performed) r Unlike other skin abscesses, cultures grow a mixed
when compared to traditional surgical drainage population of bacteria with a predominance of gut
(3): anaerobic and aerobic species.
Fistula formation was greater in the surgical r Many cases are associated with underlying
drainage group (60%) vs. the medical conditions.
management group (16%). r Incision and drainage remains the treatment of
r Fistulotomy may be performed: choice.
In a meta-analysis of adult patients, surgical r Conservative medical management may be an
drainage with fistulotomy reduced risk of option for children <1 yr of age.
recurrence by 83% but tended to increase rates of
incontinence to flatus and stool (RR 2.46, 95% CI
0.758.06) when compared to surgical drainage
alone (4).
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ABSCESS, PERITONSILLAR
Nikhil B. Shah
18
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ABSCESS, PERITONSILLAR
A
r Potential parenteral regimens include: Admission Criteria REFERENCES
Ampicillin/Sulbactam 200 mg/kg/day divided q6h Critical care admission criteria:
IV OR r Toxicity 1. Ungkanont K, Yellon RF, Weissman JL, et al. Head
Clindamycin 40 mg/kg/day divided q8h IV, which r Potentially life-threatening complications and neck space infections in infants and children.
has the benefit of community-acquired MRSA r Significant airway compromise Otolaryngol Head Neck Surg. 1995;112(3):
coverage 375382.
Vancomycin 4060 mg/kg/day divided q68h IV Discharge Criteria 2. Millar KR, Johnson, DW, Drummond D, et al.
r Patients who are managed as outpatients must be
may be added if no clinical response or in case of Suspected peritonsillar abscess in children. Pediatr
severe infection. observed post-procedure to ensure they can tolerate Emerg Care. 2007;23(7):431438.
r IV antibiotic therapy should be continued until the oral antibiotics, analgesics, and liquids. 3. Szuhay G, Tewfik TL. Peritonsillar abscess or
r Patients who are managed as inpatients may be
patient is afebrile and clinically improved. cellulitis? A clinical comparative paediatric study.
r An oral antibiotic regimen should then be continued discharged home if there is response to treatment as J Otolaryngol. 1998;27(4):206212.
to complete a 14-day course: defined by improvement in pain, fever, and/or 4. Scott PM, Loftus WK, Kew J, et al. Diagnosis of
Amoxicillin/Clavulanate 8090 mg/kg/day divided tonsillar swelling within 24 hr of intervention. peritonsillar infections: A prospective study of
PO b.i.d. OR ultrasound, computerized tomography and clinical
Clindamycin 40 mg/kg/day divided PO q8h diagnosis. J Laryngol Otol. 1999;113(3):229232.
Linezolid may be used when vancomycin has been
FOLLOW-UP
5. Herzon FS, Martin AD. Medical and surgical
added to the parenteral regimen (<12 yr: FOLLOW-UP RECOMMENDATIONS treatment of peritonsillar, retropharyngeal, and
30 mg/kg/day divided PO t.i.d.; 12 yr: r Patients treated as outpatients should have parapharyngeal abscesses. Curr Infect Dis Rep.
20 mg/kg/day divided PO b.i.d). follow-up within 2436 hr, whereas admitted 2006;8(3):196202.
Second Line patients should be seen within several days of
Corticosteroids: discharge.
r Evidence is lacking to support routine use of steroids r Discharge instructions and medications: ADDITIONAL READING
for PTA in children (2). Continue appropriate oral antibiotic regimen. Goldstein NA, Hammerschlag MR. Peritonsillar,
r Some studies demonstrate improvement in pain Analgesics retropharyngeal, and parapharyngeal abscesses. In
scores, symptom severity, and length of stay, while Maintain hydration. Feigin RD, Cherry JD, Demmler-Harrison GJ, et al., eds.
others find no clear difference between treatment Patient Monitoring Textbook of Pediatric Infectious Diseases. 6th ed.
and nontreatment groups. Discharged patients should be instructed that prompt Philadelphia, PA: Saunders; 2009:177.
re-evaluation is necessary for:
SURGERY/OTHER PROCEDURES r Dyspnea
r Drainage in combination with antibiotic therapy and
hydration results in resolution in >90% of cases (5).
r Worsening pain CODES
r Surgical drainage of PTA is performed by one of the r Worsening trismus
following methods: r Enlarging mass ICD9
Needle aspiration r Fever 475 Peritonsillar abscess
Incision and drainage r Neck stiffness
Tonsillectomy r Bleeding (as a complication of drainage procedure)
r Choice of procedure depends upon clinician skill PEARLS AND PITFALLS
level, age and ability of the patient to cooperate, DIET r The diagnosis of PTA is clinical and does not require
cost, and whether the patient has indications for Soft diet and liquids; advance as tolerated lab or imaging tests.
tonsillectomy. PROGNOSIS Classic presentation: Severe sore throat; fever;
r Indications for tonsillectomy include: r PTA usually resolves without sequelae if recognized hot potato voice; drooling; trismus with a
Significant upper airway obstruction either acutely early and treated appropriately. unilaterally enlarged, fluctuant tonsil that pushes
or at baseline (eg, snoring) r Recurrence rate is 1015%. the uvula to the opposite side
Recurrent pharyngitis or PTA r Recurrence rate is higher (40%) in patients with a r Management of PTA includes antibiotic therapy in
Treatment failure with other drainage techniques history of recurrent tonsillitis. combination with a surgical drainage procedure:
r An older, cooperative child or adolescent who is Patients with PTC may be given a trial of
clinically stable without trismus may undergo needle COMPLICATIONS antibiotics alone.
r Airway obstruction
aspiration or incision and drainage with topical r Aspiration pneumonia if the abscess ruptures into
anesthesia or procedural sedation (5).
r If the child is young and unable to cooperate, the the airway
r Sepsis
procedure should be performed in the operating
r Internal jugular vein thrombosis
room.
r Careful attention to maintaining the airway must be r Lemierre syndrome (a potentially fatal condition
given if procedural sedation is undertaken. usually caused by Fusobacterium necrophorum and
r Prompt surgical intervention is indicated in the characterized by thrombophlebitis of head and neck
following circumstances: veins and systemic dissemination of septic emboli)
r Carotid artery rupture
Impending airway compromise (consider exam
under anesthesia) r Carotid artery pseudoaneurysm
Enlarging masses r Mediastinitis
Significant comorbidities (eg, immunodeficiency) r Necrotizing fasciitis
r Sequelae of GAS infection (when GAS is isolated)
DISPOSITION
r Hospitalization may be warranted, particularly in
younger children.
r Older children with uncomplicated PTA who are well
hydrated with adequate pain control may be
managed as outpatients.
19
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ABSCESS, RECTAL
Danniel J. Stites
Todd Mastrovitch
20
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ABSCESS, RECTAL
A
r Intersphincteric abscesses must be drained in the Issues for Referral
r Complex abscesses involving the ischiorectal space,
REFERENCE
operating room.
r Supralevator abscesses should be drained according supralevator abscesses, or abscesses that also 1. Serour F, Gorenstein A. Characteristics of perianal
to the site of origin: involve the contralateral side of the anus (horseshoe abscess and fistula-in-ano in healthy children.
If an ischiorectal abscess, drainage should be abscess) require further workup for the possibility of World J Surg. 2006;30:467472.
performed via the skin through the overlying underlying Crohn disease and often require surgical
buttock. consultation for intraoperative drainage.
Abscesses resulting from the extension of an r Nonhealing or recurrent abscesses and/or fistulas ADDITIONAL READING
intersphincteric abscess or from a pelvic process r Chronic drainage or recurrent abscess may be the r Coates WC. Anorectum. In Marx JA, Hockberger RS,
should be drained through the rectal wall to avoid result of an underlying fistula, requiring further Walls RM, et al., eds. Rosens Emergency Medicine:
extrasphincteric fistula formation. exploration and surgical consultation. Concepts and Clinical Practice. 6th ed. Philadelphia,
MEDICATION PA: Mosby Elsevier; 2006.
r Festen C, van Harten H. Perianal abscess and
First Line
r Antibiotics may not be needed in the otherwise
FOLLOW-UP fistula-in-ano in Infants. J Pediatr Surg. 1998;33:
healthy child. FOLLOW-UP RECOMMENDATIONS 711713.
r Possible indications for antibiotics may include r Discharge instructions and medications: r Klein MD, Thomas RP. Surgical conditions of the
immunocompromised states, valvular heart disease, Maintain the area clean and dry. anus, rectum, and colon. In Kleigman RM, Behrman
diabetes mellitus, underlying Crohn disease, Do not remove abscess packing. RE, Jenson HB, Stanton BF, eds. Nelson Textbook of
extensive cellulites, or other significant Keep abscess covered until wound is re-evaluated Pediatrics. 18th ed. Philadelphia, PA: Saunders
comorbidities: by physician 2 days post drainage. Elsevier; 2007.
Clindamycin 1030 mg/kg/day q8h IV/PO If antibiotics are prescribed, take medication as r Marcus RH, Stine RJ, Cohen MA. Perirectal abscess.
Cefazolin 50100 mg/kg/day qh IV directed. Ann Emerg Med. 1995;25(5):597603.
Trimethoprim/Sulfamethoxazole 10 mg/kg/day Wound check with packing removal or dressing
change within 2 days after drainage. See Also (Topic, Algorithm, Electronic
b.i.d. PO
r Tetanus booster if patient has not received one in Sitz baths (23 times/day) and warm compresses Media Element)
r Abscess, Bartholin Gland
after packing removal until complete abscess
the past 510 yr r Abscess, Gluteal
resolution
Second Line Follow up in 23 wk of drainage for wound
r Analgesics:
evaluation and inspection for possible
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: fistula-in-ano. CODES
Initial morphine dose of 0.1 mg/kg IV/SC may r Activity:
be repeated q1520min until pain is controlled, Patients may perform daily activities without ICD9
then q2h PRN. restriction, understanding that good perianal 566 Abscess of anal and rectal regions
Codeine or codeine/acetaminophen dosed as hygiene can minimize postprocedural
0.51 mg/kg of codeine component PO q4h PRN complications such as reinfection.
Hydrocodone or hydrocodone/acetaminophen PEARLS AND PITFALLS
dosed as 0.1 mg/kg of hydrocodone component Patient Monitoring
r No monitoring is generally required for local r Perianal and ischiorectal abscesses may be drained
PO q46h PRN
r NSAIDs: anesthesia and incision and drainage. in the office or ED with appropriate analgesia and
r Patients with complex disease should undergo local anesthesia.
Consider NSAIDs in anticipation of prolonged pain
and inflammation: further evaluation and possibly testing for associated r Intersphincteric, supralevator, and horseshoe
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN underlying medical problems such as Crohn disease. abscesses generally require surgical consultation
Ketorolac 0.5 mg/kg IV/IM q6h PRN DIET and intraoperative drainage.
Naproxen 5 mg/kg PO q8h PRN r Antibiotics are generally not required and do not
High-fiber diet or fiber supplementation
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN replace incision and drainage as the mainstay of
r Stool-bulking agents and stool softeners to prevent PROGNOSIS treatment.
r Prognosis of perianal abscesses is generally very r Patients should be re-evaluated 23 wk after
constipation (post drainage):
Polyethylene glycol 3350: 17 g in 8 oz of water qhs good when treated appropriately with incision and drainage to ensure abscess resolution and
drainage. evaluation for fistula formation.
DISPOSITION r Incision and drainage in infants works very well but
Admission Criteria in older children may be associated with recurrence
Critical care admission criteria: or fistula formation.
r Signs or symptoms of sepsis
COMPLICATIONS
Discharge Criteria r Patients with rectal abscesses may develop a chronic
r No signs of systemic toxicity fistula, especially if they have a history of Crohn
r Uncomplicated incision and drainage of perianal or disease (1).
ischiorectal abscess r Without appropriate management, up to 85% of
children with perianal abscesses will have recurrent
abscess or fistula formation.
r Fistulas generally do not heal spontaneously and
may require fistulotomy.
21
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ABSCESS, RETROPHARYNGEAL
Nikhil B. Shah
22
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ABSCESS, RETROPHARYNGEAL
A
DISPOSITION REFERENCES
TREATMENT Admission Criteria
r Children with suspected or confirmed RPA should be 1. Philpott CM, Selvadurai D, Banerjee AR. Paediatric
INITIAL STABILIZATION/THERAPY hospitalized and managed in consultation with ENT. retropharyngeal abscess. J Laryngol Otol. 2004;
r Initial therapy depends on the severity of respiratory r Critical care admission criteria: 118:919926.
distress and likelihood of drainable fluid (based on Severe airway compromise 2. Ungkanont K, Yellon RF, Weissman JL, et al. Head
CT findings, clinical features, and clinical course) Toxicity and neck space infections in infants and children.
r Airway management: Development of potentially fatal complications Otolaryngol Head Neck Surg. 1995;112:375382.
If the child has significant stridor or respiratory (eg, sepsis, mediastinitis) 3. Glasier CM, Stark JE, Jacobs RF, et al. CT and
distress, a clinician with advanced airway skills ultrasound imaging of retropharyngeal abscesses in
(eg, ENT, anesthesia) should be present for airway children. AJNR Am J Neuroradiol. 1992;13:
stabilization. FOLLOW-UP 11911195.
Diagnostic workup must be deferred until the 4. Gaglani MJ, Edwards MS. Clinical indicators of
FOLLOW-UP RECOMMENDATIONS childhood retropharyngeal abscess. Am J Emerg
airway is stabilized. r Discharge instructions and medications:
In cases of severe airway compromise, a Med. 1995;13:333336.
Children with RPA should be admitted from the
management protocol similar to that previously 5. Page NC, Bauer EM, Lieu JE. Clinical features and
emergency department.
used for epiglottitis should be considered (ie, r When discharged from the hospital after treatment of retropharyngeal abscess in children.
emergent endoscopic airway exam by ENT with no Otolaryngol Head Neck Surg. 2008;138:300306.
interventions initiated until the child is under appropriate therapy:
anesthesia in the operating room). Follow up within few days of discharge.
r IV fluid resuscitation Patients should be advised to return for ADDITIONAL READING
re-evaluation if the following symptoms
MEDICATION develop: Goldstein NA, Hammerschlag MR. Peritonsillar,
First Line Fever retropharyngeal, and parapharyngeal abscesses. In
r The majority of patients may be managed with early Dyspnea Feigin RD, Cherry JD, Kaplan SL, et al., eds. Textbook
administration of IV antibiotics alone (7590% Worsening/Severe pain of Pediatric Infectious Diseases. 6th ed. Philadelphia,
success rate): Trismus PA: Saunders; 2009:177.
Early institution of antibiotics may prevent Enlarging mass
progression to mature abscess (4). Neck stiffness
r Selection of the antibiotic regimen should be based Patient Monitoring CODES
on regional bacterial sensitivity patterns and include Children with retropharyngeal infections should be
coverage against multiple mixed aerobic and monitored closely for persistence or progression of ICD9
anaerobic pathogens: symptoms and development of complications. 478.24 Retropharyngeal abscess
Ampicillin/Sulbactam 200 mg/kg/day divided q6h
IV OR PROGNOSIS
r RPA seldom leads to long-term sequelae when PEARLS AND PITFALLS
Clindamycin 40 mg/kg/day divided q8h IV:
Added benefit of MRSA coverage detected early and appropriately treated.
r Relapse rate of 15%; may be associated with r Consider the diagnosis of RPA in a child with fever,
r Parenteral treatment should be maintained until the
trauma or anatomic abnormality. stiff neck, and dysphagia.
patient is afebrile and clinical improvement is noted. r When a critical airway is suspected, all interventions
r Oral therapy should then be continued to complete COMPLICATIONS
r Infection may spread from the retropharyngeal should be deferred until the airway is secured.
a 14-day course and includes the following r CT with IV contrast provides an optimal image.
regimens: space to other deep neck spaces, contiguous However, if skilled operators are available,
Amoxicillin/Clavulanate 8090 mg/kg/day divided structures, and the bloodstream. sonography may be used to confirm the diagnosis
q12h OR r Complications are rare but potentially fatal and
and assist in drainage.
Clindamycin 40 mg/kg/day divided q8h include: r Hospitalize all children with RPA in consultation
r Analgesia: Airway obstruction with ENT, with careful attention to maintenance of
Acetaminophen 15 mg/kg/dose PO q46h PRN Sepsis the airway.
Ibuprofen 10 mg/kg/dose PO q6h PRN Aspiration pneumonia (if abscess ruptures into the r Initial therapy depends on severity of respiratory
Morphine 0.1 mg/kg IV/IM/SC q2h PRN airway)
Initial morphine dose 0.1 mg/kg IV/SC may be distress and likelihood of drainable fluid.
Internal jugular vein thrombosis r Initiate empiric antibiotic therapy as soon as
repeated q1520min until pain is controlled Lemierre syndrome: A potentially fatal condition
then q2h PRN usually caused by Fusobacterium necrophorum possible in all patients.
Second Line and characterized by thrombophlebitis of head
In patients not responding to parenteral clindamycin and neck veins and systemic dissemination of
or those with severe disease: septic emboli
r Vancomycin 4060 mg/kg/day divided q68h IV Carotid artery rupture
r Linezolid: Mediastinitis (from extension into chest)
Atlantoaxial dislocation
<12 yr: 30 mg/kg/day divided q8h IV Grisels syndrome
12 yr: 20 mg/kg/day divided q12h IV
Max daily dose 1,200 mg
SURGERY/OTHER PROCEDURES
r Indications for surgical drainage (in combination
with empiric antibiotic therapy) include:
Airway compromise or other life-threatening
complications
Large (>2 cm2 ) hypodense area on CT scan
Failure to respond to IV antibiotic therapy
r Factors associated with drainable fluid at surgery
include duration of symptoms >2 days and
hypodense area >2 cm2 on CT scan (5).
r If surgical drainage is performed, aerobic and
anaerobic specimens for culture should be obtained.
23
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ACETAMINOPHEN POISONING
Stephanie H. Hernandez
r Toxic acetaminophen ingestions are typically initially r In patients with intentional suicidal gestures, 1 in
BASICS silent, and there is no way by physical exam to 500 will fail to disclose an acetaminophen ingestion
determine which patients will have hepatoxicity. that warrants treatment.
DESCRIPTION r Single ingestions of <200 mg/kg are typically
r Acetaminophen is used as an analgesic and RISK FACTORS
considered nontoxic in children. r Increased NAPQI (N-acetyl-p-benzo-quinone)
antipyretic.
r Acetaminophen toxicity is the leading cause of EPIDEMIOLOGY formation:
r Acetaminophen is among the most commonly CYP2E1 induced
hepatoxicity and toxin-induced hepatic failure.
r Acetaminophen is one of the most commonly ingested drugs reported to poison control centers in Decreased hepatic glutathione (GSH) stores
the U.S., with >90,000 cases of exposure reported Poor nutritional status
ingested toxins in the U.S. r Decreased capacity for nontoxic metabolism
r Acetaminophen ingestion may cause a spectrum of in 2008.
r Acetaminophen combination formulations were r Patients who receive antidote treatment more than
illness from minor symptoms and no hepatoxicity to
among the top 5 ingestions reported to poison after 8 hr after acute ingestion
severe hepatoxicity, liver failure, and death. r Chronic supratherapeutic ingestions
r Use of a nomogram to predict the likelihood of centers associated with death in 2008:
Acetaminophen alone is among the top 10.
toxicity and the antidote N-acetylcysteine (NAC), r Acetaminophen poisoning is the leading cause of GENERAL PREVENTION
used to prevent and treat acetaminophen toxicity, r Appropriate parental weight-based dosing in
fulminant hepatic failure in the U.S. and U.K.
play a key role in management of acetaminophen pediatric patients
ingestions. r Recognition of the difference in concentration
between infant and childrens formulation
PATHOPHYSIOLOGY
r Acetaminophen generates the hepatotoxic
500 metabolite NAPQI, which can be converted to less
450 toxic compounds by endogenous glutathione.
400 r Toxicity occurs when excessive NAPQI is produced
350 and glutathione stores are exhausted.
300
ETIOLOGY
250 r Acetaminophen is commonly referred to as Tylenol in
200 (200, 4 Hrs.) the U.S. However, depending on the manufacturer, it
may be recognized by different names worldwide.
If Concentration Values Fall Above Solid
150 Some of these common names include but are not
Line, Hepatoxicity is Likely To Occur
Plasma or Serum Acetaminophen Concentration (mcg/ml)
24
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ACETAMINOPHEN POISONING
A
r Hepatotoxicity occurs most commonly within 24 hr r It is ideal to start NAC within 8 hr of ingestion in
post-ingestion if not treated or if treatment is order to prevent significant hepatoxicity and FOLLOW-UP
initiated >8 hr post-ingestion: mortality.
Clinical findings include jaundice, right upper r NAC IV dosing (21-hr NAC protocol): 150 mg/kg FOLLOW-UP RECOMMENDATIONS
quadrant pain, coagulopathy, and over 60 min, then 50 mg/kg over 4 hr, then Patient Monitoring
encephalopathy. 100 mg/kg over 16 hr: r Psychiatric consultation is required for all intentional
It is usually mixed with 5% dextrose. For patients overdoses.
DIAGNOSTIC TESTS & INTERPRETATION r Patients who recover from hepatotoxicity do not
<40 kg, assure appropriate weight-based
Lab calculation and administration of NAC in IV fluid. require repeat liver function evaluations.
Initial Lab Tests
r Serum acetaminophen concentrations should be See http://www.acetadote.net for a dose
PROGNOSIS
calculator. r If NAC is started within 8 hr from the time of
obtained: Status epilepticus and death have been associated
These must be interpreted according to the ingestion in an acute single ingestion, morbidity and
with medication errors with NAC in pediatric
circumstances of ingestion: Time from ingestion, mortality is very low.
patients. r Chronic overdoses and patients who present late for
coingestants, and LFTs. A loading bolus over 15 min is advocated by
In a single acute ingestion, a serum concentration some, but we advise 60 min due to lower treatment with NAC have increased morbidity and
should be obtained ideally no earlier than 4 hr incidence of severe anaphylactoid reaction with mortality.
post-ingestion, and results should be available no r Poor prognosisthe Kings College criteria:
the longer initial infusion.
later than 8 hr post-ingestion in order to initiate r NAC oral dosing: 140 mg/kg PO loading dose pH <7.3 at 2 days after overdose despite volume
treatment if needed.
followed by 70 mg/kg PO q4h for 72 hr. resuscitation and PT >100, serum creatinine
In single acute ingestions, utilize the r Oral dosing often causes vomiting. >3.3 mmol/L, or severe hepatic encephalopathy
Rumack-Matthew nomogram to determine if r Due to vomiting and length of treatment (72 hr vs. Other criteria predictive of poor prognosis:
treatment with NAC is warranted. Serum lactate >3 mmol/L after fluid resuscitation
In chronic multiple ingestions, call your nearest 21 hr), oral administration is not typically the or phosphate >2.65 on day 2
poison center and/or consult a toxicologist to first-line therapy: IV NAC is preferable.
r Consult your poison control center and/or COMPLICATIONS
determine if treatment is warranted. r Encephalopathy
r LFTs should be routinely obtained if the toxicologist in the setting of multiple or chronic
ingestions in order to decide if NAC is indicated. r Coagulopathy
acetaminophen concentration is in the toxic range or
r An oral NAC regimen should be considered for r Renal failure
in cases of late presentation.
LFTs are usually within normal limits until 24 hr patients with severe and/or active asthma or prior r Fulminant hepatic failure
post-ingestion with the exception of massive severe anaphylactoid reaction to NAC. r Acidosis
overdoses. r Death
Second Line
LFTs may be abnormal with relatively low or r Consider activated charcoal if the risk of aspiration
absent acetaminophen concentrations in chronic is low and the airway is intact:
overdoses. 1 g/kg orally if within 1 hr of ingestion ADDITIONAL READING
r Specific lab tests that indicate poor prognosis
With ingestions of acetaminophen and other r Alander SW, Dowd MD, Bratton SL, et al. Pediatric
include PT >100, creatinine 3.3 mmol/L, lactate substances that may diminish GI motility, such as acetaminophen overdose: Risk factors associated
>3 mmol/L, phosphate >2.6 mmol/L on day 2, pH diphenhydramine or opioids, charcoal may be with hepatocellular injury. Arch Pediatr Adolesc
<7.3. administered even after 1 hr of ingestion.
r Fresh frozen plasma if coagulopathic Med. 2000;154:346.
r Dart RC, Erdman AR, Olson KR, et al.
r Vitamin K if coagulopathic
TREATMENT r Renal replacement therapy for persistent acidosis
Acetaminophen poisoning: An evidence-based
consensus guideline for out-of-hospital
PRE HOSPITAL despite supportive care and/or renal failure management. Clin Toxicol (Phila). 2006;44:1.
General supportive care should be provided. r Mohler CR, Nordt SP, Williams SR, et al. Prospective
SURGERY/OTHER PROCEDURES
INITIAL STABILIZATION/THERAPY Liver transplant may be necessary. evaluation of mild to moderate pediatric
r Maintain vital signs within normal limits; IV fluid acetaminophen exposures. Ann Emerg Med.
DISPOSITION 2000;35:239.
administration is usually indicated.
r Assess the serum acetaminophen concentration at Admission Criteria
r All patients who require treatment with NAC must See Also (Topic, Algorithm, Electronic
least 4 hr post-ingestion. Media Element)
r If the patient has a toxic acetaminophen be admitted.
r Critical care admission criteria: IV NAC administration information (including
concentration as indicated by the Rumack-Matthew weight-based infusion): http://www.acetadote.net
Consider admission to a critical care unit if the
nomogram, administer NAC. In the U.S., toxicity is
patient has the following:
any value above the lower (dashed) line. Altered mental status or encephalopathy
r If the patient reaches 8 hr post-ingestion and the CODES
Metabolic acidosis
serum acetaminophen level is not known, Coagulopathy
immediately administer NAC. Renal failure ICD9
r NAC is most effective when given within 8 hr of
Rising LFTs 965.4 Poisoning by aromatic analgesics, not
ingestion. If a nontoxic serum acetaminophen elsewhere classified
concentration is subsequently noted, the NAC Discharge Criteria
therapy may be discontinued. Treatment with NAC may be terminated and the
patient may be discharged after LFTs are assured to be PEARLS AND PITFALLS
MEDICATION within normal limits and acetaminophen concentration
First Line is less than the limits of detection. r Inappropriate utilization of the Rumack-Matthew
r IV NAC is indicated in a single acute ingestion of nomogram and misinterpretation of acetaminophen
Issues for Referral
acetaminophen when the acetaminophen r Patients with poor prognostic criteria should be concentrations
concentration 4 hr post-ingestion is above the referred for liver transplant: PT >100, creatinine r Premature termination of NAC therapy or failure to
treatment line on the Rumack-Matthew nomogram. 3.3 mmol/L, lactate >3 mmol/L, phosphate continue therapy beyond 21 hr when indicated
r NAC should be started in the setting of suspected >2.65 mmol/L on day 2, pH <7.3. r IV NAC administration should be given carefully;
chronic supratherapeutic acetaminophen dosing r All cases should be reported to the local poison center. dosing errors are common due to the 3 different
with low or nondetectable acetaminophen r Unclear cases or cases of chronic supratherapeutic concentrations of infusion required.
concentration and elevated LFTs. ingestion should be discussed with a poison
specialist and/or toxicologist.
25
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ACNE
Helene Tigchelaar
26
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ACNE
A
r Acne vulgaris (adolescents and young adults): Mild COMPLEMENTARY & ALTERNATIVE ADDITIONAL READING
to moderate acne (starting with 1st 2 and THERAPIES
progressing through therapeutic armamentarium Stress relief measures may be effective. r Cooper AJ. Systematic review of Propionibacterium
until there is improvement): acnes resistance to systemic antibiotics. Med J Aust.
Gentle cleansing with tepid water and mild DISPOSITION 1998;169:259.
cleanser such as a glycolic/salicylic acidbased Admission Criteria r El-Hallak M, Giani T, Yeniay BS, et al. Chronic
cleanser b.i.d. Secondary gram-negative, staphylococcal, or minocycline-induced autoimmunity in children.
Salicylic acid lotion: Thin layer applied to affected streptococcal infections leading to cellulitis or abscess J Pediatr. 2008;153:314319.
area b.i.d. with fever and toxicity r Haider A, Shaw JC. Treatment of acne vulgaris.
Benzoyl peroxide 2.5% daily to b.i.d. as tolerated Issues for Referral JAMA. 2004;292:726.
to entire involved area (not just lesions). r Referral to dermatology for treatment of: r Strauss JS, Krowchuk DP, Leyden JJ, et al.; American
Alternative is salicylic acid: Resistant and severe nodular acne Academy of Dermatology/American Academy of
Benzoyl peroxide bleaches fabrics and hair; in Severe pustular or cystic acne Dermatology Association. Guidelines of care for
dark-skinned patients, it may cause some Isotretinoin therapy acne vulgaris management. J Am Acad Dermatol.
lightening at higher concentrations. r Endocrinology: Rapid onset, atypical age, or 2007;56:651663.
Benzoyl peroxide also may cause excessive persistence
dryness of skin. See Also (Topic, Algorithm, Electronic
May increase concentration of benzoyl peroxide to Media Element)
5% if a lower concentration is tolerated FOLLOW-UP http://www.skincarephysicians.com/acnenet/
Topical antimicrobial (erythromycin or
clindamycin) containing benzoyl peroxide daily FOLLOW-UP RECOMMENDATIONS
Topical retinoid (adapalene or tretinoin) are Discharge instructions and medications: CODES
effective but not typically prescribed from the r Specific primary care or dermatology follow-up in a
emergency department. timely manner will reinforce instructions and ICD9
r Acne vulgaris (moderate to severe) or resistant encourage compliance. 706.1 Other acne
inflammatory acne: r Improvement in lesions with any therapy takes
Add to the above regimen: 48 wk.
Tetracycline 500 mg PO b.i.d. OR r Avoid an excessively complex initial program, PEARLS AND PITFALLS
Doxycycline 100 mg PO b.i.d. especially in boys. r Pearls:
Doxycycline is more effective but can cause r Application of topical medications should be done
photosensitivity or nausea. Time-honored dietary restrictions are not
about 15 min after facial cleansing and drying to
If failure of above, switch to: supported by best evidence.
avoid excessive absorption with increased side r Pitfalls:
Minocycline 50100 mg PO b.i.d. effects.
Minocycline can cause pseudotumor cerebri, r Warn about the possibility of initial worsening of Failing to recognize the profound psychosocial
autoimmune reactions, and blue pigmentation implications of acne for the suffering teen
symptoms, erythema, and scaling with therapy.
of skin and teeth. Missing signs of virilization or atypical
Erythromycin base 3050 mg/kg/day PO divided DIET presentation suggesting an androgen-producing
t.i.d. Dietary restrictions are ineffective. tumor
Trimethoprim (TMP)/Sulfamethoxazole 612 mg Failure to counsel, prevent, and monitor for
PROGNOSIS
TMP/kg/day PO divided b.i.d. pregnancy in females on systemic medications or
With optimal therapy and compliance, acne is a
topical retinoids
Second Line controllable disease.
Use of topical antibiotics not in combination with
The following therapies should be instituted by a COMPLICATIONS benzoyl peroxide can lead to bacterial resistance.
dermatologist: r Acne fulminans:
r Isotretinoin:
Sudden flare in males of severe acne of the chest
Drug is teratogenic. and back with associated fever, myalgia, and
Other possible side effects include headaches, arthralgia
nosebleed, paronychia, depression, elevated liver May occur during early isotretinoin therapy or with
enzymes, and possibly inflammatory bowel testosterone therapy
disease. Treatment includes systemic steroids and oral
r Consider oral contraceptives [norgestimate with antibiotics; after 4 wk, low-dose isotretinoin is
ethinyl estradiol (Ortho Tri-cyclin) or norethindrone used (see Medication section).
acetate with ethinyl estradiol (Estrostep)]. r Gram-negative folliculitis:
r Class B (level II evidence) drugs: Spironolactone, May develop after long-term antibiotic use
antiandrogens, and oral corticosteroids Suspect with flaring and worsening of acne on
Pregnancy Considerations antibiotic therapy
r Oral isotretinoin therapy is highly teratogenic. Use is Treatment with gram-negative antibiotics
r Staphylococcal (MRSA) secondary infections
restricted to prescription by dermatologists under r Excoriated acne: More common in females and
the stringently regulated FDA program iPledge:
Available in unregulated countries consists of compulsive picking at lesions resulting in
r Oral tetracyclines, topical retinoids, and hormonal infection and scarring.
therapy are all contraindicated during pregnancy.
27
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ETIOLOGY
BASICS Hemolysis occurs secondary to either an acquired or DIAGNOSIS
inherited cause:
DESCRIPTION r Acquired: HISTORY
r Hemolysis is the destruction or removal of RBCs r Dyspnea, fatigue, weakness, or angina may occur in
AIHA occurs when the body forms antibodies
before their normal life span of 90120 days. the presence of abrupt hemolysis and severe anemia.
against its own RBCs surface antigens. r Acute onset of pallor may be reported in cases of
r Hemolytic anemia occurs when the rate of hemolysis
Primary AIHA: Autoantibodies are present, but
exceeds the ability of the bone marrow to there is no evidence of systemic disease. It can be brisk hemolysis:
adequately compensate for the loss of RBCs. categorized as warm-reactive AIHA (IgG Slow onset of pallor usually suggests diminished
r This topic focuses on the identification and autoantibodies maximally bind RBCs at 37 C) or RBC production.
r Back pain and dark urine may be reported by
treatment of acute hemolytic anemia. cold-reactive AIHA (autoantibodies preferentially
bind RBCs at 4 C) (2). patients with intravascular hemolysis.
EPIDEMIOLOGY r Jaundice may be present because of an increase in
Cold-reactive AIHA includes cold agglutinin
Incidence disease (IgM autoantibodies) and paroxysmal cold indirect bilirubin.
r The incidence and prevalence of hemolytic anemia r Family history of anemia or autoimmune diseases
hemoglobinuria (IgG autoantibodies).
depends on the etiology. Secondary AIHA: Immune-mediated hemolytic should be illicited.
r Autoimmune-mediated hemolytic anemia (AIHA) is r Family history of splenectomy or cholecystectomy
anemia is only a manifestation of a broader
rare, with an estimated annual incidence of 1 in systemic disorder. Teenagers who present with suggests an inherited hemolytic disorder such as
80,000 persons (1). AIHA are more likely to have an underlying hereditary spherocytosis or pyruvate kinase
RISK FACTORS systemic illness (3). deficiency.
r AIHA is more likely to occur in females. Microangiopathic anemia results from the r Transfusion history should be obtained.
r G6PD deficiency is an X-linked recessive disorder: mechanical destruction of RBCs in circulation r Current and previous medication history should be
Individuals with this disorder are at risk of (eg, disseminated intravascular coagulation [DIC], documented.
developing acute hemolytic anemia when exposed hemolytic uremic syndrome [HUS], thrombotic r Exposure to other agents that may cause abrupt
to certain foods, drugs, and other substances. thrombocytopenia purpura [TTP]). hemolysis in patients with G6PD deficiency (eg,
r Individuals with inherited disorders that cause r Inherited:
naphthalene-containing mothballs, fava beans)
chronic hemolysis during steady-state conditions Enzymopathies (G6PD deficiency, pyruvate kinase should be explored.
(eg, sickle cell anemia [SCA], hereditary deficiency)
Membranopathies (hereditary spherocytosis, PHYSICAL EXAM
spherocytosis) are also at risk of developing acute r Evidence of CHF (tachycardia, gallop rhythm,
hemolytic episodes: hereditary elliptocytosis)
Hemoglobinopathies (thalassemia, SCA) cardiomegaly, and hepatomegaly) may be present.
These acute episodes may be triggered by the r Skin may appear jaundiced or pale:
onset of acute illness or infection. COMMONLY ASSOCIATED CONDITIONS
r Transfusion of incompatible blood products may also r Idiopathic Mucous membranes, conjunctivae, nail beds,
r Malignancy palms, and soles should be closely examined.
trigger an acute hemolytic reaction: r Lymphadenopathy suggests a malignancy.
May occur up to several weeks after the initial r Drugs r Splenomegaly suggests either malignancy or the
transfusion (delayed hemolytic reaction). r Autoimmune disorders
presence of other underlying disorder (eg, hereditary
GENERAL PREVENTION r Infections (viral and bacterial)
spherocytosis, SCA, or systemic lupus erythematosus
r Medications and chemicals that are likely to trigger r Transfusions [SLE]).
hemolysis in patients with G6PD deficiency should r SCA r Leg ulcers may be found in the presence of SCA or
be avoided. r TTP other chronic hemolytic states.
r Patients with chronic hemolytic diseases (eg, SCA, r HUS
hereditary spherocytosis) should be provided DIAGNOSTIC TESTS & INTERPRETATION
r DIC
anticipatory guidance regarding the signs and r Porphyria Lab
symptoms of acute hemolysis and worsening Initial Lab Tests
r Eclampsia r Complete blood and reticulocyte counts should be
anemia.
r Malignant HTN obtained to determine degree of anemia and if bone
PATHOPHYSIOLOGY r Prosthetic valves marrow response is adequate:
There are 2 mechanisms of hemolysis: Peripheral blood smear should be examined.
r Intravascular: Destruction of RBCs in the circulation
Spherocytes and schistocytes are pathognomonic
with release of cell contents into the plasma of hemolysis.
r Extravascular: Removal and destruction of RBCs Platelets and WBCs should also be examined to
with membrane alterations by the macrophages of evaluate for coexisting hematologic or malignant
the spleen and liver disorders.
Thrombocytopenia occurs in SLE and
microangiopathic hemolytic anemia.
r Indirect bilirubin, lactate dehydrogenase (LDH), and
haptoglobin levels should be obtained:
Indirect bilirubin and LDH levels are increased
while haptoglobin levels are usually decreased in
the presence of acute hemolysis.
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DIFFERENTIAL DIAGNOSIS
Extensivesee Etiology.
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DISPOSITION
Admission Criteria
r Critical care admission criteria
r All patients with acute respiratory failure should be
admitted to the intensive care unit
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ADRENAL INSUFFICIENCY
Kevin Ching
r Adrenal medulla:
BASICS Epinephrine and norepinephrinemediated by DIAGNOSIS
sympathetic stimulation
DESCRIPTION HISTORY
r Adrenal insufficiency is characterized by a deficiency ETIOLOGY r Chronic adrenal insufficiency:
r Primary adrenal insufficiency (2):
in the production and availability of adrenocortical Fatigue and weakness
hormones: CAH: Anorexia
21-hydroxylase deficiency: Neonates often Weight loss
In primary adrenal insufficiency, adrenal
dysfunction impairs glucocorticoid and present with salt-wasting CAH (hyponatremia, Nausea and vomiting
mineralocorticoid production. hyperkalemia, acidosis, and hypotension, with Recurrent abdominal pain
In secondary adrenal insufficiency, deficient ambiguous genitalia in females), while Skin pigmentation
corticotropin-releasing hormone (CRH) from the prepubertal children present with virilizing CAH. r Acute adrenal insufficiency (adrenal crisis):
Several other forms of CAH exist, including salt Neonates:
hypothalamus or adrenocorticotropic hormone
(ACTH) from the pituitary impairs adrenal wasting and nonsalt wasting. Lethargy
glucocorticoid production (mineralocorticoid Infection: Vomiting and diarrhea
Tuberculosis (TB), HIV, cryptococcosis, or fungal Weight loss
production is preserved).
r Acute adrenal insufficiency (adrenal crisis) is a infections (histoplasmosis, blastomycosis, or Seizures
coccidiomycosis) Children:
life-threatening emergency involving hypotensive
Autoimmune disease (Addison): Altered mental status
shock that ensues primarily from mineralocorticoid Comorbid autoimmune polyglandular
deficiency: Syncope
syndromes (type 1 diabetes, hypothyroidism, Seizures
Rare in children
etc.) Weakness
Nonspecific presentation often leads to delay in
Adrenal hemorrhage or infarction: Fever
diagnosis and treatment. Waterhouse-Friderichsen syndrome (Neisseria Severe abdominal pain
EPIDEMIOLOGY meningitidis, Streptococcus pneumoniae, Vomiting and diarrhea
Incidence Staphylococcus aureus, Pseudomonas Weight loss
r Incidence of primary adrenal insufficiency is aeruginosa) Skin pigmentation
unknown: Anticoagulant use
Congenital adrenal hyperplasia (CAH), the most Antiphospholipid syndrome PHYSICAL EXAM
r Chronic adrenal insufficiency:
common form of primary adrenal insufficiency, Septic shock:
occurs in 1 of 15,000 births (1). Critically ill patients may develop a relative Often subtle and nonspecific
r Although the incidence of secondary adrenal adrenal insufficiency (3). r Acute adrenal insufficiency (adrenal crisis):
insufficiency is also unknown, iatrogenic Etomidate: Fever
suppression of the hypothalamic-pituitary axis from Sedation agent used in rapid sequence Tachycardia
corticosteroid therapy is more common. induction and procedural sedation Dehydration
Reversible inhibition of cortisol production Hypotension
PATHOPHYSIOLOGY Unclear clinical significance in critically injured Shock
r Adrenal cortex: Altered mental status
trauma patients and critically ill patients with
Aldosteroneprimarily mediated by septic shock (4,5) Coma
renin-angiotensin system: r Secondary adrenal insufficiency:
Also stimulated by hyperkalemia DIAGNOSTIC TESTS & INTERPRETATION
Suppression by exogenous corticosteroid therapy
Aldosterone deficiency leads to hyponatremia, or endogenous steroid production (tumor)
Lab
hyperkalemia, and acidosis. Initial Lab Tests
Hypothalamic-pituitary disease: r Serum chemistries:
Cortisol and androgensmediated by ACTH and Trauma
CRH: Pituitary surgery Hyponatremia, hyperkalemia, metabolic acidosis,
Cortisol, in turn, inhibits both CRH and ACTH. Neoplasm (eg, craniopharyngioma) and hypoglycemia
Glucocorticoid (cortisol) deficiency can lead to r Cortisol level:
Congenital aplasia
hypoglycemia, hypotension, and shock. Obtain early morning sample, if possible.
Upregulation of ACTH increases Under conditions of severe stress, levels
melanocyte-stimulating hormone. <20 g/dL indicate adrenal insufficiency.
Androgen deficiency leads to diminished axillary r Serum ACTH
and pubic hair. r Plasma renin activity
r Serum aldosterone
r Thyroid studies
r CBC
r Blood cultures as indicated
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ADRENAL INSUFFICIENCY
A
Imaging r Administer glucocorticoid: COMPLICATIONS
r Consider abdominal CT scan: Hydrocortisone: r Hypoglycemia
Identify adrenal hemorrhage, calcifications, and If acute adrenal insufficiency suspected, r Hypotension
infiltrative and metastatic diseases. administer stress dose immediately. r Shock
r Consider chest radiograph: Provides both glucocorticoid and r Sepsis
Identify TB, fungal pneumonias mineralocorticoid activity
Infants/toddlers (<3 yr): 25 mg IV/IM
Diagnostic Procedures/Other Children: 50 mg IV/IM
r ECG: REFERENCES
Adolescents (>12 yr): 100 mg IV/IM
Hyperkalemia may manifest as peaked T waves, Follow with 150 mg/day divided q68h 1. Perry R, Kecha O, Paquette J, et al. Primary adrenal
shortened QTc. Maintenance dosing in consultation with an insufficiency in children: Twenty years experience at
r ACTH stimulation test:
endocrinologist the Sainte-Justine Hospital, Montreal. J Clin
Obtain baseline serum cortisol and ACTH levels. Dexamethasone: Endocrinol Metab. 2005;90:32433250.
Administer 250 g IV cosyntropin (synthetic May be administered without interfering with 2. Arlt W, Allolio B. Adrenal insufficiency. Lancet.
ACTH). ACTH stimulation test 2003;361:18811893.
Check serum cortisol levels every 30 min. Negligible mineralocorticoid activity 3. Sarthi M, Lodha R, Vivekanandhan S, et al. Adrenal
Failure of cortisol to rise appropriately indicates 0.030.15 mg/kg/day IV divided q612h status in children with septic shock using low-dose
insufficiency.
Pregnancy Considerations stimulation test. Pediatr Crit Care Med. 2007;8:
DIFFERENTIAL DIAGNOSIS Crosses placenta and suppresses fetal adrenal 2328.
r CAH 4. Cotton BA, Guillamondequi OD, Fleming SB, et al.
r Infectious adrenalitis function:
r Consider fludrocortisone at 0.10.2 mg PO. Increased risk of adrenal insufficiency following
r Autoimmune polyglandular syndrome etomidate exposure in critically injured patients.
r Necessary if dexamethasone is given
r Adrenal hemorrhage Arch Surg. 2008;143:6267.
r Mineralocorticoid dose is NOT weight based.
r Hypopituitarism 5. Jackson WL. Should we use etomidate as an
r Sepsis Second Line induction agent for endotracheal intubation in
r Differential for abdominal pain (eg, acute Vasopressors for refractory hypotension: patients with septic shock? A critical appraisal.
r Dopamine 120 g/kg/min IV Chest. 2005;127:10311038.
appendicitis)
r Epinephrine 0.11 g/kg/min IV
r Norepinephrine 0.11 g/kg/min IV ADDITIONAL READING
TREATMENT
DISPOSITION Oelkers W. Adrenal insufficiency. N Engl J Med.
INITIAL STABILIZATION/THERAPY Admission Criteria 1996;335:12061212.
r Assess and stabilize airway, breathing, and
Critical care admission criteria:
circulation. r Necessary for all presentations of acute adrenal See Also (Topic, Algorithm, Electronic
r Aggressive volume resuscitation: Media Element)
insufficiency (adrenal crisis) Congenital Adrenal Hyperplasia
Bolus of 20 cc/kg of isotonic crystalloid; may
repeat as needed Issues for Referral
r Dextrose: Manage in consultation with an endocrinologist.
0.51 g/kg IV (2 mL/kg of 25% dextrose or CODES
5 mL/kg of 10% dextrose) if hypoglycemic
r Identify precipitant, and consider empiric antibiotics. FOLLOW-UP ICD9
r 255.2 Adrenogenital disorders
MEDICATION FOLLOW-UP RECOMMENDATIONS
r 255.41 Glucocorticoid deficiency
First Line Patient Monitoring
r Correct hyperkalemia: r Monitor and correct hypoglycemia and electrolyte
Calcium: abnormalities.
Calcium gluconate 100 mg/kg/dose IV of 10%
r Ensure appropriate fluid replacement therapy. PEARLS AND PITFALLS
r Monitor and adjust glucocorticoid maintenance r Immediate therapeutic intervention is frequently
solution over 35 min
Calcium chloride 20 mg/kg/dose IV of 10% dosing. necessary prior to diagnostic confirmation.
solution over 5 min (requires central venous r Presentation may be similar in sepsis or
access) disseminated intravascular coagulation.
Insulin and glucose: r Consider in critically ill patients with
Insulin 0.1 units/kg IV over 30 min
pressor-dependent or refractory shock.
Dextrose 0.5 g/kg IV over 30 min r As little as 2 wk of exogenous corticosteroid therapy
Sodium bicarbonate:
12 mEq/kg IV can suppress the hypothalamic-pituitary axis.
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AGITATION
Marsha Ayzen Elkhunovich
Emily L. Willner
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AGITATION
A
DISPOSITION
TREATMENT Admission Criteria FOLLOW-UP
r Significant vital sign abnormalities
PRE HOSPITAL r Respiratory distress FOLLOW-UP RECOMMENDATIONS
Advise EMS personnel to: r Risk of harm to self/others Follow-up recommendations depend on the etiology
r Try to reassure the patient with calm voices and r Inability of caretaker to care for patient of the patients agitated state. Most patients who
present to the emergency department with agitation
decrease stimulation if at all possible. r Impaired neurologic state
r Decrease risk of harm to the patient and others. due to psychiatric or behavioral causes will require
r Need for further diagnostic or therapeutic follow-up with psychiatric or behavioral services.
EMS protocols may include IM sedation with procedures
benzodiazepines. r Critical care admission criteria:
INITIAL STABILIZATION/THERAPY Need for ventilator support because of inability to REFERENCES
r ABCs: Ensure that the patient is adequately control airway or need for significant sedation 1. Lindenmayer JP. The pathophysiology of agitation. J
protecting his or her airway, and stabilize breathing Deteriorating neurologic status Clin Psychiatry. 2000;61(Suppl 14):510.
and circulation abnormalities. Risk of cardiovascular depression or arrhythmia 2. Yildiz A, Sachs S, Turgay A. Pharmacological
r Ensure physical safety of patient, caregiver, and from an ingestion management of agitation in emergency settings.
medical staff. Issues for Referral Emerg Med J. 2003;20(4):339346.
r Verbal reassurance and redirection should be used r If an ingestion is suspected, consultation with a 3. Sorrentino A. Chemical restraints for the agitated,
for all patients. toxicologist or the poison control center is crucial for violent, or psychotic pediatric patient in the
r Chemical restraints can and should be used to identifying optimal treatment. emergency department: Controversies and
protect the patient and health care staff and allow r Consultation with a neurologist is indicated in recommendations. Curr Opin Pediatr. 2004;16(2):
for patient exam and treatment when verbal instances of abnormal neurologic exams and when 201205.
redirection is not adequate. ADEM or encephalitis are suspected. 4. Hilt RJ, Woodward TA. Agitation treatment for
r Consultation with social work services and/or pediatric emergency patients. J Am Acad Child
MEDICATION
r Consider options for chemical restraint as needed. psychiatry is indicated for patients with ingestion, Adolesc Psychiatry. 2008;47(2):132138.
r Benzodiazepines, alone or in combination with overdose, a psychiatric condition, or homicidal or
suicidal ideation for further investigation and
antipsychotics (2): ADDITIONAL READING
potential need for placement in protective care.
Midazolam PO dosing 0.250.5 mg/kg, max
single dose 10 mg, IM/IV dosing 0.1 mg/kg, max COMPLEMENTARY & ALTERNATIVE Dorfman DH. The use of physical and chemical
single dose 6 mg THERAPIES restraints in the pediatric emergency department.
Lorazepam PO/IM/IV 0.05 mg/kg/dose, max single r Physical restraints can be used if alternate measures Pediatr Emerg Care. 2000;16(5):355360.
dose 2 mg are ineffective:
r Atypical antipsychotics: Preferred over classical 4-point physical restraint is optimal.
antipsychotics due to more favorable side effect Subdue the patient with 45 staff members, with CODES
profile one restraining each extremity and one securing
Risperidone (Risperdal): the head. ICD9
PO dosing: 0.25 mg/dose in children 614 yr; It is essential to continually reassess the need for 307.9 Other and unspecified special symptoms or
0.5 mg >14 yr restraints and frequently monitor restrained syndromes, not elsewhere classified
r Classical antipsychotics: Haloperidol IM/IV/PO: patients, as there are risks for further harm with
IM dosing: 612 yr, 13 mg IM/IV; >12 yr, their use.
25 mg IM/IV r Further therapy depends on the etiology of the PEARLS AND PITFALLS
PO dosing: 0.25 mg/dose agitated state.
r Agitated behavior can be caused by a large number
Ziprasidone (Geodon) IM (4): Pregnancy Considerations
IM dosing: Children >12 yr, 1020 mg, dose r Haloperidol (Haldol) is potentially embryotoxic in of organic and psychiatric etiologies, and a detailed
may be repeated q2h (max daily dose 40 mg) history and physical exam is essential to limit the
high doses, so this drug should be avoided in considerations and to direct evaluation and
Olanzapine (Zyprexa) PO/IM (4): pregnancy if possible.
PO dosing: 2.55 mg in children >12 yr treatment.
r There is little literature on the safety of atypical r A developmentally delayed child with agitation
IM dosing: Children >12 yr, 5 mg; consider
using 2.5 mg dose in children <40 kg antipsychotics in those who are pregnant/lactating, needs broad consideration of medical etiologies that
Olanzapine and risperidone are available in oral but no evidence of teratogenicity has been found. may be causing distress prior to diagnosing a
disintergrating wafers that can be administered to primarily behavioral or psychiatric condition.
minimally cooperative patients without the need r All patients with acute agitation should be under
for IM or IV access close supervision. Proper documentation and use of
institution-specific protocol for restraints is
ALERT mandated by the Joint Commission.
r Use with caution when chemically restraining
patients with developmental delay and no prior
psychiatric diagnoses.
r These patients need a thorough medical
evaluation even if agitation improves with
chemical restraint.
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ALTITUDE SICKNESS
David O. Kessler
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ALTITUDE SICKNESS
A
MEDICATION COMPLEMENTARY & ALTERNATIVE REFERENCES
r Oxygen is the primary treatment for altitude THERAPIES
sickness. Supplemental oxygen often dramatically Gingko biloba has been found to be more effective 1. Gallagher SA, Hackett PH. High-altitude illness.
improves symptoms: than placebo for reducing acute mountain sickness in Emerg Med Clin North Am. 2004;22:329355.
Oxygen, including hyperbaric oxygen, is small studies (3). 2. Samuels MP. The effects of flight and altitude. Arch
particularly useful for acute mountain sickness, Dis Child. 2004;89:448455.
high altitude cerebral edema, and high altitude DISPOSITION 3. Barry PW, Pollard AJ. Altitude Illness. BMJ. 2003;
pulmonary edema. Admission Criteria 326(7395):915919.
r Nifedipine 0.250.5 mg/kg/day PO in children r Patients who have altered mental status or
<40 kg, 10 mg PO per day in children >40 kg: neurologic signs should be evaluated for more
Improves overall symptoms; particularly useful in serious etiologies, such as high altitude cerebral CODES
improving pulmonary function in high altitude edema, and admitted for further management.
r Critical care admission criteria:
pulmonary edema ICD9
r Acetazolamide has been used successfully in adults Patients requiring mechanical ventilation 993.2 Other and unspecified effects of high altitude
to help mitigate symptoms of acute mountain Patients with severe symptoms, including
sickness: pulmonary edema, should be admitted to a critical
Acetazolamide 510 mg/kg/day divided t.i.d., or care unit. PEARLS AND PITFALLS
250 mg PO b.i.d. in adults, is typically started Discharge Criteria r Altitude sickness can be prevented by a slow rate of
1 day before ascent and is continued until Patients with acute mountain sickness who return to a
acclimatization is achieved. lower elevation will often return to baseline ascent or by avoiding very high altitudes.
r Children are more susceptible to hypoxemia-related
Acetazolamide is used only to prevent altitude spontaneously and may be safely discharged.
sickness, whereas dexamethasone is used to treat illnesses, such as acute mountain sickness.
r Oxygen is useful for all forms of altitude sickness.
once illness occurs.
Side effects include diuresis, paresthesia, FOLLOW-UP r Though acetazolamide has been traditionally used,
headache, nausea, and vomiting. patients tolerate it less than dexamethasone.
r Dexamethasone: FOLLOW-UP RECOMMENDATIONS
Patients with acute mountain sickness are at risk for
Treatment of altitude sickness: future events and should be counseled regarding
0.51.5 mg/kg IV/IM/SC/PO to a max of 48 mg
prophylaxis and preventative measures.
loading dose followed by 0.5 mg/kg to a max of
4 mg q6h. This is continued for 4872 hr. PROGNOSIS
Should be initiated at 1st suspicion or symptoms r Patients with acute mountain sickness typically
of altitude sickness improve completely without sequelae within several
Prevention of altitude sickness: Lower dosage and days.
frequency: r High altitude pulmonary edema and high altitude
0.05 mg/kg/dose PO q412h. Lesser frequency cerebral edema vary with severity, duration, and
of q12h may be used in children being passively appropriate medical therapy.
taken to altitude who are sedentary, such as
COMPLICATIONS
infants.
In more serious altitude-related illnesses, high altitude
Useful for acute mountain sickness, high altitude
cerebral or pulmonary edema or even death may
pulmonary edema, and high altitude cerebral
occur:
edema r Patients with comorbid pulmonary or cardiac risk
Dexamethasone is typically tolerated much better
than acetazolamide. factors are at greater risk from hypoxemia-related
Dexamethasone is used in both the prevention complications.
and treatment of altitude sickness.
r Ibuprofen 10 mg/kd/dose PO q6h may prevent or
treat headache associated with altitude sickness.
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AMENORRHEA
William I. Krief
Cara Bornstein
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AMENORRHEA
A
Diagnostic Procedures/Other DISPOSITION ADDITIONAL READING
Probing the introitus with a moist cotton-tipped swab Admission Criteria
or soft catheter to verify patency of the hymen and r CNS tumors requiring acute management r Emans SJ. Amenorrhea in the adolescent. In Emans
vagina r Symptomatic eating disorder: SJ, Laufer MR, Goldstein DP, et al., eds. Pediatric
Pathological Findings Bradycardia, orthostatic BP, hypothermia, altered and Adolescent Gynecology. 5th ed. Philadelphia,
Depends on underlying cause mental status, syncope, electrolyte imbalance PA: Lippincott Williams & Wilkins; 2005.
r Master-Hunter T, Heiman D. Amenorrhea:
DIFFERENTIAL DIAGNOSIS Discharge Criteria Evaluation and treatment. Am Fam Physician.
r Hyperprolactinemia-altered metabolism, ectopic All patients who do not meet admission criteria can 2006;73(8):13741382.
production, breast-feeding, hypothyroidism, safely be discharged with appropriate outpatient
medications, pituitary adenoma follow-up. See Also (Topic, Algorithm, Electronic
r Hypergonadotropic hypogonadism (elevated LH and Issues for Referral Media Element)
r Patients should be referred to an endocrinologist Pregnancy
FSH): Gonadal dysgenesis (Turner syndrome),
premature ovarian failure and/or gynecologist for further evaluation.
r Hypogonadotropic hypogonadism (normal or low LH r Patients with an eating disorder require a
and FSH): Eating disorders, constitutional delays of multidisciplinary approach with adolescent CODES
growth or puberty, CNS tumor, chronic illness, medicine, a nutritionist, and a psychologist.
severe depression, cranial radiation, excessive r Counseling is important in adolescents whose ICD9
exercise, Kallmann syndrome, Sheehan syndrome diagnosis will make them unable to conceive. 626.0 Absence of menstruation
r Normogonadotropic: Congenital, hyperandrogenic
anovulation (PCOS, Cushing disease), outflow tract
obstruction (imperforate hymen, transverse vaginal FOLLOW-UP PEARLS AND PITFALLS
septum) FOLLOW-UP RECOMMENDATIONS r If secondary sexual characteristics are present,
r Pregnancy r Discharge instructions and medications: amenorrhea is due to pregnancy until proven
r Thyroid disease Refer for follow-up to a specialist. otherwise.
r Activity: r Important to remember the psychological effects of
Reducing activity if amenorrhea is secondary to impaired body image and self-esteem issues.
TREATMENT excessive exercising
Treatment should be directed toward the underlying DIET
cause of amenorrhea. Increasing caloric intake in patients with an eating
disorder and exercise-induced amenorrhea
MEDICATION
Medical treatment should be initiated following PROGNOSIS
diagnostic workup in the outpatient setting. In most instances, amenorrhea is not life threatening
and patients do well with medical management.
SURGERY/OTHER PROCEDURES
Excision of the hymen for imperforate hymen under COMPLICATIONS
sedation r Wrist and hip fractures when older due to poor bone
mineralization
r Infertility
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ANAL FISSURE
Gregory Garra
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Multiple fissure or nonmidline fissures can be the
result of perianal abscess.
DESCRIPTION HISTORY r Hemorrhoid
r Anal pain during or after defecation accompanied by
An anal fissure is a linear tear or tears in the lining of r Inflammatory bowel disease
lower half of the anal canal. the passage of blood-streaked stools or bright red r HIV
blood per the rectum r Immunosuppression
PATHOPHYSIOLOGY r Pain is typically severe and may last minutes to
r The pathogenesis is poorly understood: r Anal trauma:
hours.
Typically, the anoderm is resistant to abrasions r Infants may present with inconsolable crying. Child sexual abuse
and lacerations. r Children may volitionally withhold stool to prevent
Commonly associated with the passage of hard
stool the pain associated with stool passage. TREATMENT
r History of constipation is elicited in only 25% of PHYSICAL EXAM
cases. However, diarrhea is a predisposing factor in r Linear or pear-shaped split in the lining of the anal INITIAL STABILIZATION/THERAPY
Most anal fissures resolve spontaneously with dietary
47%. canal
r Associated pain may promote stool retention, thus r >90% of anal fissures are identified in the posterior modification and stool softeners.
increasing constipation and establishing a cycle of midline. MEDICATION
worsening pain or chronic fissure. r Spasm of the anal sphincter may obscure First Line
r Most occur in the posterior midline: visualization. r The primary treatment of anal fissures consists of
Rarely in the anterior midline r An anoscope or other clear plastic tubing, such as a anal hygiene, warm water sitz baths to relieve anal
chest tube, may be used to assist in dilating the sphincter spasm, and a stool softener.
ETIOLOGY r Long-term care and resolution may require use of a
r Anal fissures are the result of mechanical disruption anus for improved visualization.
of the anal mucosa or skin external to the anus. stool-softening agent or lubricant, such as
DIAGNOSTIC TESTS & INTERPRETATION polyethylene glycol (eg, Miralax) or mineral oil to
r This is almost exclusively the result of hard stools r Anal fissure is a clinical diagnosis.
r If causes other than constipation or hard stool are a keep the stool soft.
abrading or lacerating the epidermis.
possibility, consider the following: Second Line
COMMONLY ASSOCIATED CONDITIONS Topical anesthetics may be used but are associated
r Anal fissures can be seen in association with CBC
C-reactive protein with delayed healing and skin sensitization.
inflammatory bowel disease, immunosuppression,
and HIV infection. Stool culture, Gram stain, and ova/parasite DISPOSITION
r Anal fissures can result from sexual abuse. evaluation Patients with uncomplicated midline fissures not
Hepatic enzyme testing, total protein, and albumin suggestive of an alternate condition should be
discharged home with appropriate management
advice.
44
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ANAL FISSURE
A
COMPLEMENTARY & ALTERNATIVE ADDITIONAL READING PEARLS AND PITFALLS
THERAPIES
r Ayantunde AA, Debrah SA. Current concepts in anal r Anal fissures in children typically result from hard
Other methods to soften or bulk stool to relieve
constipation include: fissures. World J Surg. 2006;30:22462260. stools. Education about dietary and, if necessary,
r Increasing water intake r Jonas MJ, Scholefield JH. Anal fissure. Gastroenterol medicinal/therapeutic stool softening can prevent
r Use of a high-fiber or high-bran diet Clin North Am. 2001;30:167181. recurrence.
r Consider the possibility of sexual abuse or an
r Psyllium seeds See Also (Topic, Algorithm, Electronic
alternate condition.
Issues for Referral Media Element) r Patients with multiple fissures, fissures not in the
r Children suspected of sexual abuse should be r Gastrointestinal Bleeding: Lower
r Inflammatory Bowel Disease midline, or other tissue abnormalities in the perineal
referred to the child protective services. or anal area should be evaluated for more serious
r Children with suspected inflammatory bowel disease r Rectal Bleeding
disease.
should be referred to gastroenterology for
evaluation.
CODES
FOLLOW-UP
ICD9
FOLLOW-UP RECOMMENDATIONS 565.0 Anal fissure
Discharge instructions and medications:
r All patients should be referred to their primary care
provider for follow-up evaluation if the condition
does not resolve.
DIET
Increased fluids and high-fiber diet
PROGNOSIS
>90% heal spontaneously or with simple measures
within 12 wk.
COMPLICATIONS
Chronic fissure
45
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ANAPHYLAXIS
Christopher G. Strother
46
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ANAPHYLAXIS
A
DISPOSITION COMPLICATIONS
r Respiratory failure
TREATMENT Admission Criteria
r Shock
r Intubated patients
PRE HOSPITAL r Patients in respiratory distress r Multisystem organ failure
r Assess and stabilize airway, breathing, and r Significant generalized reactions and/or persistence r Disseminated intravascular coagulation
circulation. of symptoms
r Administer high-flow oxygen. r Persistent abnormal vital signs
r Obtain IV access and administer IV fluid. r Critical care admission criteria: REFERENCES
r Administer epinephrine, albuterol, and/or
Intubated patients 1. Sampson HA, Munoz-Furlong A, Campbell RL,
diphenhydramine as per local protocol. Persistent hypotension or respiratory distress et al. Second symposium on the definition and
r Cardiac and pulse oximetry monitoring despite adequate therapy requires continuous management of anaphylaxis: Summary
monitoring. reportSecond National Institute of Allergy and
INITIAL STABILIZATION/THERAPY
r Assess and stabilize airway, breathing, and Discharge Criteria Infectious Disease/Food Allergy and Anaphylaxis
circulation. r Patients with complete resolution of symptoms may Network symposium. J Allergy Clin Immunol.
r Consider early intubation if loss of airway access be discharged following a period of observation in 2006;117:391.
from swelling is a possibility. the emergency department (generally 48 hr) 2. Ross MP, Ferguon M, Street D, et al. Analysis of
r Epinephrine is a key part of management. r Patients who receive epinephrine should be food-allergic and anaphylactic events in the
r Volume resuscitation with crystalloids or colloids observed 48 hr for biphasic reactions, which usually National Electronic Injury Surveillance System.
occur within 8 hr but can occur as late as 72 hr. J Allergy Clin Immunol. 2008;121:166.
MEDICATION 3. Moneret-Vautrin DA, Morisset M, Flabbee J, et al.
Issues for Referral
First Line r Patients without previous evaluation by an allergist Epidemiology of life-threatening and lethal
r Epinephrine is the mainstay of treatment: anaphylaxis: A review. Allergy. 2005;60(4):
should be referred as soon as possible for skin
0.01 mg/kg up to 0.5 mg IM/SC q35min: testing. 443451.
Epinephrine IM has the therapeutic advantage r Consultation with an allergist or immunologist can
of SC, and is the preferred route.
May give as an infusion (0.1 g/kg/min up to
be considered for desensitization therapy. ADDITIONAL READING
1 g/kg/min) if needed for persistent hypotension
or severe respiratory symptoms: See Also (Topic, Algorithm, Electronic
IV use is recommended only when absolutely
FOLLOW-UP Media Element)
necessary to maintain BP. Adverse events such FOLLOW-UP RECOMMENDATIONS Rash, Urticaria
as stroke and MI resulting from IV r Discharge instructions and medications:
administration are well reported. Typically, patients are discharged with prescribed
r Albuterol for wheezing: Adjunct to epinephrine for corticosteroid burst dose, diphenhydramine, and CODES
relief of bronchospasm (2.55 mg by nebulizer) an EpiPen.
r IV fluids for hypotension: 20 mL/kg normal saline Follow-up allergy testing should be arranged. ICD9
Consider steroids for up to 72 hr to prevent r 989.5 Toxic effect of venom
per bolus
biphasic reactions. r 995.0 Other anaphylactic shock, not elsewhere
Second Line Consider symptomatic treatment with classified
r Steroids:
diphenhydramine with or without an H2 blocker r 995.60 Anaphylactic shock due to unspecified food
Not helpful in acute management but do help to for up to 72 hr.
prevent progression of symptoms as well as r Activity:
rebound or biphasic symptoms
Methylprednisolone 12 mg/kg q6h, max single
As tolerated PEARLS AND PITFALLS
Avoid activities that might bring a patient into
dose 125 mg IV r IM-administered epinephrine is the mainstay and
contact with potential triggers (ie, bees and bee
Dexamethasone 0.3 mg/kg IV/IM q12h, max drug of choice for treating anaphylaxis.
stings)
single dose 10 mg IV/IM q12h r Up to 20% of patients will not have skin findings.
Prednisone 1 mg/kg/dose PO q12h, max single Patient Monitoring r Diphenhydramine will not treat the cardiovascular
dose 30 mg PO q12h Cardiovascular monitoring is essential in anyone with
r Diphenhydramine: respiratory distress or abnormal vital signs. effects of anaphylaxis.
r Failing to recognize the possibility of a biphasic
Relieves itching and flushing but does NOT DIET reaction and discharging too soon after stabilization
improve cardiovascular or respiratory effects of r Patients should be kept NPO during observation.
can be dangerous (most biphasic reactions occur
anaphylaxis and should not take priority over r Avoid foods allergens. within 8 hr).
epinephrine
12 mg/kg/dose IV/IM/PO q6h, max single dose PROGNOSIS
50 mg IV/IM/PO q6h r Prognosis is generally good if anaphylaxis is
r H2 blockers: recognized and treated early.
Can be used as supplement to diphenhydramine r Development of shock is a poor prognostic indicator.
Ranitidine 1 mg/kg/dose q6h, max single dose r Delay in the administration of epinephrine has been
50 mg IV q6h associated with poor outcomes.
Famotidine 1 mg/kg/dose q12h, max single dose
40 mg IV q12h
r Vasopressors: Can be used for persistent
hypotension despite epinephrine and fluids.
Dopamine, norepinephrine, or phenylephrine can be
used.
47
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ANEMIA
Eyal Ben-Isaac
Vincent J. Wang
48
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ANEMIA
A
Lead (old paint, pica, foreign
medications/foods/pottery) TREATMENT FOLLOW-UP
G6PD deficiency: May be precipitated by
antimalarials, sulfonamides, nitrofurantoin, PRE HOSPITAL FOLLOW-UP RECOMMENDATIONS
naphthalene (moth balls), fava beans r Assess and stabilize airway, breathing, and Discharge instructions and medications:
r Family history of anemia, splenectomy, gallstones circulation. r Return for increased pallor, fatigue, or blood loss
r Assessment for trauma: r Iron supplementation (see Medication)
PHYSICAL EXAM r Timing of follow-up CBC depending on etiology and
r Vital signs (including orthostatics): Tachycardia, IV fluid resuscitation if tachycardic or hypotensive
hypotension, tachypnea Supplemental oxygen usually appropriate severity
r Pallor, heart murmur, hepatosplenomegaly INITIAL STABILIZATION/THERAPY DIET
r Lymphadenopathy: Neoplastic process r Assess and stabilize airway, breathing, and Iron deficiency: Increase dietary iron such as red meat,
r Glossitis: B deficiency circulation. beans, green leafy vegetables, blackstrap molasses,
12
r Dactylitis: SCD r Exclude traumatic etiologies. enriched breakfast cereals, and some sea foods.
r Purpura: Infections, DIC r Evaluate nature of anemia, estimate of blood loss,
PROGNOSIS
r Petechiae: HUS, DIC, pancytopenia and presence of other illnesses. r The prognosis generally is good but overall depends
r Signs of extramedullary hematopoiesis (eg, frontal r Supplemental oxygen usually is appropriate.
on underlying cause and severity.
r Transfusion criteria: Severe hypoxemia, significant r Iron-deficiency anemia resolves with treatment.
bossing)
r Syndromic features: Limb anomalies in Fanconi, ongoing losses, significant tachycardia, and/or
hypotension: COMPLICATIONS
Diamond-Blackfan Chronic anemia can lead to cardiac problems
10 cc/kg packed RBCs over 34 hr (faster if active
DIAGNOSTIC TESTS & INTERPRETATION hemorrhage) (arrhythmia, high output failure) and poor growth.
Lab 1 cc/kg per Hgb level over 34 hr if severely
Initial Lab Tests anemic or any signs/suspicion of CHF on history or
r CBC with differential and smear: exam
ADDITIONAL READING
Mentzer index (MCV/RBC) may suggest iron Use caution if suspecting a hemolytic process. r Aslan D, Altay. Incidence of high erythrocyte count
deficiency (ratio >13) vs. thalassemia (<13). Discuss with the hematologist first if suspecting in infants and young children with iron deficiency
Clues on the smear: an oncologic process. anemia: Re-evaluation of an old parameter.
Acanthocytes: Vitamin E deficiency, liver disease r See Aplastic Anemia topic for aplastic crises and J Pediatr Hematol Oncol. 2003;25(4):303306.
Bizarre shapes: RBC membrane defects, Sickle Cell Disease and Acute Hemolytic Anemia r Cohen AR. Hematologic emergencies. In Fleisher
thalassemia syndromes topics for specifics on these diseases. GR, Ludwig S, eds. Textbook of Pediatric Emergency
Blister or bite cells: G6PD deficiency
MEDICATION Medicine. 6th ed. Baltimore, MD: Lippincott
Helmet cells (fragmented cells): r Oral iron supplementation for deficiency: Williams & Wilkins; 2010.
Microangiopathic anemia r Glader B. The anemias. In Kliegman RM, Behrman
Rouleaux: Inflammation or immune hemolytic Prophylaxis: 12 mg of elemental iron/kg/day
Mild to moderate anemia: 3 mg of elemental RE, Jenson HB, et al., eds. Nelson Textbook of
anemia
Stomatocytes: Liver disease, stomatocytosis iron/kg/day Pediatrics. 18th ed. Philadelphia, PA: Saunders;
Target cells: Iron deficiency, hemoglobinopathy, Severe anemia: 46 mg of elemental iron/kg/day. 2007:20032006.
liver disease Parenteral iron may be indicated for specific
Tear drop cells: Bone marrow failure, burns etiologies: Iron deficiency with inflammatory
Basophilic stippling: Lead toxicity, thalassemia bowel disease and dialysis and oncology patients. CODES
r Reticulocyte count Consultation with the hematologist is
r Consider type and cross-matching blood recommended before such administration. ICD9
r Autoimmune causes: See specific topics. r 280.9 Iron deficiency anemia, unspecified
r Consider heme testing the stool r 283.0 Autoimmune hemolytic anemias
r Other tests depending on initial labs and possible DISPOSITION r 285.9 Anemia, unspecified
etiologies: Admission Criteria
Coombs/Direct antibody test r Admit for anemia requiring inpatient evaluation or
Iron studies (iron, ferritin, total iron-binding for severe symptomatic anemia.
capacity, % saturation) r Critical care admission criteria: PEARLS AND PITFALLS
Hemoglobin electrophoresis Unstable vital signs despite resuscitation r In the immediate newborn period, consider
DIC panel Ongoing blood loss with unstable vital signs hemorrhagic and isoimmune causes, congenital
Tumor lysis labs Discharge Criteria infections, sepsis, and disorders of RBCs.
Diagnostic Procedures/Other r Stable vital signs r Iron deficiency is the most common childhood
Bone marrow aspirate or biopsy may be indicated to r Asymptomatic anemia.
evaluate for an infiltrative process and/or marrow r Able to tolerate oral therapy if needed r CBC and smear typically allow definitive diagnosis
arrest: r Close follow-up is assured of the etiology of anemia.
r Persistent severe normocytic anemia (evaluate for
TEC, Diamond-Blackfan)
Issues for Referral
r Macrocytic anemia without obvious etiology Hematology referral for:
r Aplastic anemia and disorders of RBCs, including
(evaluate for myeloproliferative syndromes,
Diamond-Blackfan) autoimmune hemolytic anemia, heredity
r Blasts on smear (evaluate for leukemia) spherocytosis, hemoglobinopathies, thalassemia,
r Pancytopenias and G6PD deficiency
r CBC suggestive of leukocyte disorders and/or
DIFFERENTIAL DIAGNOSIS thrombocytopenia
See Etiology section. r Evidence of bone marrow failure
49
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ANGIOEDEMA
Rahul Kaila
Nirupama Kannikeswaran
50
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ANGIOEDEMA
A
Diagnostic Procedures/Other r Hereditary angioedema: During an acute attack, REFERENCES
Radioallergosorbent testing (RAST) if food allergy is patients should be treated with fresh frozen plasma
suspected in an outpatient setting (FFP) or C1 inhibitor concentrate: 1. Krishnamurthy A, Naguwa SM, Gershwin ME.
Plasma: 2 units of FFP given IV, may be repeated Pediatric angioedema. Clinic Rev Allergy Immunol.
DIFFERENTIAL DIAGNOSIS 2008;34:250259.
in 2 hr
Myxedema, facial cellulitis, superior vena cava 2. Ferdman RM. Urticaria and angioedema. Clin
Kallikrein inhibitor (Ecallantide):
syndrome, dermatomyositis, facial lymphedema, 30 mg IM given in 3 different injection sites, Pediatr Emerg Med. 2007;8(2):7280.
allergic contact dermatitis, and idiopathic edema
usually both arms and 1 thigh 3. Frigas E, Nzeako UC. Angioedema: Pathogenesis,
Only approved in patients >16 yr differential diagnosis, and treatment. Clin Rev
TREATMENT C1 inhibitor concentrates 1020 U/kg Allergy Immunol. 2002;23:217231.
(alternatively: <50 kg, 500 U; 50100 kg, 4. Soccorsa S, Casali A, Bolondi L. Sonographic
PRE HOSPITAL 1000 U; >100 kg, 1500 U) (4) findings in abdominal hereditary angioedema.
r Assess and stabilize airway, breathing, and J Clin Ultrasound. 1999;27:537540.
DISPOSITION
circulation. 5. Farkas H, Varga L, Szeplaki G, et al. Management
r In children with angioedema of the larynx, Admission Criteria
r Patients with no systemic symptoms and localized of hereditary angioedema in pediatric patients.
administration of epinephrine IM is of utmost angioedema without progression of symptoms may Pediatrics. 2007;120:e713e722.
importance. be discharged home.
r Discontinue exposure to any triggering agent. r Patients with systemic symptoms, diffuse
ADDITIONAL READING
INITIAL STABILIZATION/THERAPY angioedema, and/or progression of symptoms
r Assess and stabilize airway, breathing, and should be admitted to the hospital for close See Also (Topic, Algorithm, Electronic
circulation. monitoring and follow up. Media Element)
r Epinephrine is the drug of choice for patients with r Critical care admission criteria: r Anaphylaxis
anaphylaxis or angioedema with upper airway Patients with laryngeal edema or impending r Asthma
involvement. airway compromise r Atopic Dermatitis
Patients with signs and symptoms of anaphlyaxis r Rash, Urticaria
MEDICATION
r Medication will depend on whether or not the Discharge Criteria
r Patients with no sign of airway compromise can be
patient has hereditary angioedema.
r For hereditary angioedema, standard therapies of managed on an outpatient basis. CODES
r Patients should be discharged home on a short
epinephrine, steroids, and antihistamines are
ineffective and not recommended. course of antihistamines and oral steroids. ICD9
r See treatment of hereditary angioedema below. r 277.6 Other deficiencies of circulating enzymes
r Epinephrine is the drug of choice for patients with r 995.1 Angioneurotic edema, not elsewhere
FOLLOW-UP
anaphylaxis or angioedema with upper airway classified
involvement: FOLLOW-UP RECOMMENDATIONS
r Discharge instructions and medications
Dose = 1:1,000 concentration: 0.01 mg/kg IM,
max single dose 0.5 mg All patients should be discharged with an PEARLS AND PITFALLS
Dose can be repeated in 515 min intervals as epinephrine autoinjector: r Pearls:
needed. Patients with a weight <30 kg require an
r Antihistamines: EpiPen Jr. Early recognition of laryngeal edema to prevent
Avoid medications, food, physical agents and impending airway obstruction
Typically, both an H1 blocker and H2 blocker are Early administration of epinephrine in
used. allergens that cause angioedema.
r For hereditary angioedema: life-threatening angioedema
H1 blockers: Patients with hereditary angioedema require
Diphenhydramine 1 mg/kg IM/IV/PO q6h, max Follow up with an experienced allergist.
Register at the hereditary angioedema different therapy than anaphylaxis, including
50 mg plasma, Ecallantide, or C1 inhibitor concentrate.
Hydroxyzine 0.51 mg/kg IM/IV/PO q6h, max international database at www.haeregister.org.
Discharge patients with a prescription for an
50 mg DIET EpiPen.
H2 blockers: Avoid triggers (food products) that cause r Pitfalls:
Theoretically may be beneficial and are angioedema. Missing hoarseness as a sign of impending airway
commonly used
Famotidine 0.5 mg/kg IV, max single dose 40 mg PROGNOSIS obstruction
Ranitidine 24 mg IV, max single dose 100 mg Hereditary angioedema is incurable, but acute attacks Failure to recognize the potentially progressive
r Steroids: can be treated, and prophylaxis is available. nature of angioedema
For hereditary angioedema, epinephrine, steroids,
Indicated if airway involvement or extensive and antihistamines are not useful.
cutaneous involvement Administering epinephrine solution of 1:10,000
Dexamethasone 0.2 mg/kg IV/IM/PO (max single instead of 1:1,000
dose 10 mg) may be repeated q612h if
necessary.
Methylprednisolone 12 mg/kg IV q6h
Prednisone 2 mg/kg PO (max single 60 mg)
loading dose can be used, followed by 1
mg/kg/dose b.i.d. for 5 days (max 60 mg/day)
51
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ANKLE SPRAIN
Megan E. Lavoie
Marc Gorelick
Grade II (moderate)partial ligament tear: r Inversion stress test (for integrity of CFL):
BASICS Moderate pain Hold foot in neutral, stabilize tibia/fibula above
Swelling with possible ecchymosis ankle joint, invert ankle with other hand to assess
DESCRIPTION Pain with weight bearing or ambulation talar tilt and inversion of midfoot. Compare
r Ankle injury is a musculoskeletal injury where Some joint instability on testing relative to uninjured side.
ligaments of ankle are injured due to stretching or Grade III (severe)complete ligament tear or r Squeeze test (assessing for syndesmosis injury):
tearing, typically from inversion injury. rupture: Compress the tibia and fibula at the level of the
r The major concern is differentiating sprain from Severe pain or occasionally painless midcalf. The test is positive if there is pain distally
fracture. Significant swelling (>4 cm about fibula) over tibia and fibula with calf squeezing.
Unable to bear weight or ambulate r External rotation test (assessing for syndesmosis
EPIDEMIOLOGY Mechanically unstable ankle on testing
r The ankle is the most commonly injured joint among injury):
athletes (1): ETIOLOGY Stabilize leg proximal to ankle joint, grasp plantar
3040% of all athletic injuries Trauma to ankle, typically by inversion or eversion aspect of foot, and rotate it externally. The test is
r Most frequently seen musculoskeletal injury in the positive if there is pain with external rotation.
COMMONLY ASSOCIATED CONDITIONS
emergency department or primary care setting: Fracture DIAGNOSTIC TESTS & INTERPRETATION
75% of all ankle injuries are sprains.. Imaging
85% of sprains are inversion injuries. r If there is concern for fracture, obtain ankle x-rays.
r Incidence is equal in males and females. DIAGNOSIS r Ottawa ankle rules (2,3):
RISK FACTORS HISTORY Obtain AP, lateral, and mortise x-rays of ankle if
Previous ankle sprain or injury r Mechanism of injury patient presents within 10 days of injury with any
r Activity at time of injury of the following:
PATHOPHYSIOLOGY r Previous injury to ankle Bony tenderness in posterior aspect of distal 6
r The ankle is a hinge joint composed of the tibia,
r Location, duration, and quality of pain cm of malleolus of tibia or fibula
fibula, and talus, which in turn are stabilized by Unable to walk for 4 steps immediately after
ligaments medially and laterally: r Bearing weight or ambulatory after injury
injury or in emergency department
Lateral ligaments: Anterior talofibular ligament r Presence of swelling or bruising
If there is bony tenderness over the navicular bone
(ATFL), calcaneofibular ligament (CFL), posterior r Pop or snap in ankle at time of injury or base of the 5th metatarsal, obtain foot x-rays.
talofibular ligament (PTFL): Ottawa ankle rules were not developed for use in
The ATFL is the most commonly injured. PHYSICAL EXAM
r Inspect for swelling, bruising, and deformity. children; if there is concern for fracture involving
The PTFL is the strongest of the lateral ligaments the growth plate, obtain x-rays.
and is rarely injured with inversion injury. Compare with contralateral ankle. r If the sprain is symptomatic >6 wk, or if there is
r Assess passive and active range of motion.
Medial support is from the deltoid complex: crepitus, catching, or locking of the joint, obtain CT
Medial ligament sprain with eversion injury, r Palpate for tenderness along entire length of fibula,
or MRI.
which is commonly associated with lateral tibia, and base of 5th metatarsal.
malleolus fracture r Palpate for tenderness along ligaments. DIFFERENTIAL DIAGNOSIS
r Several types of ligamentous injuries: r Anterior drawer test (for integrity of ATFL): r Fracture of lateral, medial, or posterior malleolus
r Fracture of proximal fibula:
Grade I (mild)ligament stretch: Hold ankle in slight plantar flexion, grasping heel
Mild pain with one hand, holding tibia/fibula above joint Maisonneuve fracture involves a syndesmosis
Minimal if any swelling line, trying to pull foot forward with anterior force injury to the interosseus membrane, which results
Can bear weight or ambulate with minimal pain on heel. Compare laxity relative to uninjured side. in a proximal fibular fracture.
No joint instability on testing
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ANKLE SPRAIN
A
r Fracture of lateral process of talus r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN REFERENCES
r Fracture of anterior process of calcaneus r Opioids:
r Fracture of base of 5th metatarsal Morphine 0.1 mg/kg IV/IM/SC q2h PRN: 1. DiGiovanni BF, Partal G, Baumhauer JF. Acute ankle
r Navicular or midtarsal fracture Initial morphine dose of 0.1 mg/kg IV/SC may injury and chronic instability in the athlete. Clin
r Salter I distal fibula fracture be repeated q1520min until pain is controlled, Sports Med. 2004;23:119.
r Hindfoot sprain then q2h PRN. 2. Steill, IG, McKnight, RD, Greenberg GH, et al.
r Tear of peroneal brevis or longus tendon Codeine or codeine/acetaminophen dosed as Decisions rules for use of radiography in acute
0.51 mg/kg of codeine component PO q4h PRN ankle injuries: Refinement and prospective
r Superficial peroneal nerve injury
Hydrocodone or hydrocodone/acetaminophen validation. JAMA. 1993;269:11271132.
r Osteochondral talar dome injury
dosed as 0.1 mg/kg of hydrocodone component 3. Gravel J, Hedrei P, Grimard G, et al. Prospective
r Syndesmosis (high) sprain PO q46h PRN validation and head-to-head comparison of 3 ankle
r Ankle impingement syndrome rules in a pediatric population. Ann Emerg Med.
SURGERY/OTHER PROCEDURES 2009;54:534540.
Surgery is not needed in the acute setting but may
4. Chorley JN. Ankle sprain discharge instructions
TREATMENT ultimately be indicated by the consulting orthopedic
from the emergency department. Pediatr Emerg
surgeons for grade III sprains.
Care. 2005;21(8):498501.
PRE HOSPITAL Issues for Referral
r Rest, ice, compression, and elevation of affected r Follow up with primary physician, sports medicine,
extremity (RICE) or orthopedics if pain is not improving in 47 days. ADDITIONAL READING
r Avoid weight bearing if painful. r Refer to orthopedics from the emergency
r Pain control department if: Wolfe MH, Uhl TL, Mattacola CG, et al. Management
Fracture or dislocation of ankle sprains. Am Fam Physician. 2001;63(1):
INITIAL STABILIZATION/THERAPY Neurovascular compromise 93104.
r RICE
r Adequate pain control Tendon rupture or subluxation See Also (Topic, Algorithm, Electronic
Wound penetrating joint space Media Element)
r Crutches during initial period, with weight bearing
Locking of joint r Fracture, Foot
as tolerating Syndesmosis sprain r Trauma, Foot/Toe
r Plastic ankle-foot orthotic, walking boot, or Symptoms out of proportion to degree of trauma
posterior splint if severe sprain; air or gel-filled ankle
brace if mild or moderate sprain
r Early mobilization and range-of-motion exercises FOLLOW-UP CODES
r Return to athletics only when jogging is pain free
FOLLOW-UP RECOMMENDATIONS ICD9
and the affected ankle has full range of motion. r Discharge instructions and medications: r 845.00 Unspecified site of ankle sprain
MEDICATION RICE r 845.01 Deltoid (ligament), ankle sprain
r NSAIDs: Analgesic medication r 845.02 Calcaneofibular (ligament) ankle sprain
Consider NSAID medication in anticipation of r Activity:
prolonged pain and inflammation: Weight bearing when pain free
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN No return to athletics until pain free PEARLS AND PITFALLS
Naproxen 5 mg/kg PO q8h PRN
PROGNOSIS r If growth plates are open, the clinician must
Some clinicians prefer to avoid NSAIDs due to Most patients will be back to playing sports by 6 wk,
theoretical concern over influence of callus but up to 50% will have symptomatic complaints for consider a possible Salter-Harris type I fracture.
formation if fracture is present. r Premature return to activity can cause chronic ankle
up to a year after injury (4).
instability and pain. Patients should be counseled
not to return to activity until their injured ankle has
full range of motion and can tolerate weight bearing
without pain.
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ANTICHOLINERGIC POISONING
David H. Jang
Lewis S. Nelson
56
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ANTICHOLINERGIC POISONING
A
When administered, the patient should be on a ADDITIONAL READING
TREATMENT cardiopulmonary monitor, with atropine at the
r Howland MA. Antidotes in depth: Physostigmine. In
bedside to give for immediate.
INITIAL STABILIZATION/THERAPY Should not be used in patients with suspected Goldfrank LR, Flomenbaum NE, Lewin NA, et al.,
r Assess and stabilize airway, breathing, and TCA overdose eds. Goldfranks Toxicologic Emergencies. 8th ed.
circulation. Relative contraindications include reactive airway Stamford, CT: Appleton & Lange; 2006.
r Maintaining vital signs within acceptable limits and disease, atrioventricular block, and intraventricular r Koppel C, Ibe K, Tenczer J. Clinical symptomatology
controlling patient agitation are commonly required. conduction delays. of diphenhydramine overdose: An evaluation of 136
r Patients who are hyperthermic may require cooling Adverse reactions often include increased cases in 1982 to 1985. J Toxicol Clin Toxicol.
and sedation with a benzodiazepine. cholinergic symptoms, such as bradycardia, 1987;25:5370.
r Use of antipsychotics, such as haloperidol, is bronchorrhea, vomiting, and diaphoresis: r Burns MJ, Linden CH, Graudins A, et al. A
Monitoring for bradycardia and airway comparison of physostigmine and benzodiazepines
relatively contraindicated, as these medications may
secretions is especially important. for the treatment of anticholinergic poisoning. Ann
increase risk of cardiac dysrhythmia, lower seizure
Physostigmine when compared to Emerg Med. 2000;35:374381.
threshold, impair heat dissipation, and also have
benzodiazepines showed shorter time to recovery
anticholinergic effects. See Also (Topic, Algorithm, Electronic
from agitation, but length of stay was unchanged.
MEDICATION As a pure antidote, physostigmine is superior to Media Element)
r Activated charcoal: benzodiazepines, but clinician comfort and Sympathomimetic Toxicity
1 g/kg may be administered in cooperative familiarity should determine whether
patients to bind drug in the GI tract. physostigmine or benzodiazepines are used for
Typically, charcoal is used only if ingestion treating anticholinergic symptoms. CODES
occurred <1 hr previously, but anticholinergic
DISPOSITION
medications slowing GI motility and charcoal may ICD9
be administered later than 1 hr after ingestion. Admission Criteria 971.1 Poisoning by parasympatholytics
r Benzodiazepines: r Unstable vital signs, abnormal mental status, patient
(anticholinergics and antimuscarinics) and
Used to control agitation and delirium being a danger to self or others, end-organ toxicity spasmolytics
r If antidotal physostigmine or benzodiazepines are
Extremely favorable safety profile and clinician
familiarity usually indicate benzodiazepines as a needed to reverse anticholinergic symptoms,
first-line medication admission should be strongly considered. PEARLS AND PITFALLS
r Critical care admission criteria:
Diazepam: r Anticholinergic syndrome can be clinically diagnosed
0.1 mg/kg IV, max single dose 10 mg q520min Unstable vital signs, seizures, end-organ toxicity
with a good physical exam and history.
titrated to effect Discharge Criteria r It is important to be wary of medications that are
First line for agitation; faster and more Any patient with vital signs within normal limits, anticholinergic and also have other associated
predictable as a sedative normal mental status, and no evidence of end-organ toxicity, such as TCAs.
Lorazepam in doses of 0.05 mg/kg IV q15min damage may be discharged from the emergency r Use of benzodiazepines or physostigmine to control
titrated to effect is the preferred treatment for department.
seizures. agitation or other neurologic symptoms assists in
r Physostigmine: Issues for Referral management.
r Refer patients with intent of self harm to psychiatry. r Physostigmine is the preferred antidote because it
Dose 0.02 mg/kg, max single dose 0.5 mg in r Refer patients with substance abuse for drug
children <10 yr of age, 12 mg total dose in results in normalization of mental status and
counseling. reversal of other anticholinergic symptoms.
adults, given IV over 5 min
r Although benzodiazepines only result in sedation
Physostigmine is a cholinergic antidote used to
reverse central anticholinergic effects: FOLLOW-UP and do not improve other anticholinergic symptoms,
As such, physostigmine is the preferred clinician familiarity with benzodiazepines and their
medication since it normalizes anticholinergic PROGNOSIS excellent safety profile may warrant use.
symptoms and benzodiazepines only provide Patients who are anticholinergic typically do well with
sedation. good supportive care, with special attention to other
Physostigmine may allow restoration of normal medication effects such as sodium channel blockade.
mental status and avert the need for additional COMPLICATIONS
evaluation such as lumbar puncture or head CT. Complications of anticholinergic toxicity often can
Indications for physostigmine include the presence include seizures and injury to self.
of anticholinergic toxicity without any evidence of
QRS or QTc prolongation.
Half-life is approximately 15 min, but duration of
action may be over an hour. Redosing may be
required as indicated.
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ANTICOAGULANT POISONING
Beth Y. Ginsburg
58
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ANTICOAGULANT POISONING
A
r Elevated PTT is indicative of coagulopathy secondary r In cases of life-threatening hemorrhage secondary
DIAGNOSIS to heparin toxicity. LMWHs do not have an effect on to warfarin or superwarfarins, coagulopathy should
the PTT, and this test cannot be used to monitor for be reversed with a transfusion of fresh frozen
HISTORY LMWH toxicity. plasma (FFP), prothrombin complex concentrate, or
r In absence of a history of exposure, complaints of r Hemoglobin and hematocrit should be monitored in recombinant factor VIIa.
bleeding and/or bruising in conjunction with cases of bleeding. r Exchange transfusion may be used in neonates
abnormal laboratory values may be suggestive of an r Platelets should be monitored for development of following a heparin overdose.
exposure to an anticoagulant. r Oral activated charcoal (1 g/kg) may be administered
r Children with exposure to rodenticide HIT or HITTS.
r Urine and stool may be checked for occult blood. to patients with a recent (1 hr) potentially significant
anticoagulants typically have an exposure history of ingestion of oral anticoagulant as long as there are
possible ingestion of a small quantity of rodenticide. ALERT no contraindications such as altered mental status.
r In children, lab error resulting from inadequately
PHYSICAL EXAM MEDICATION
The physical exam should focus on uncovering filled blood vials to assay coagulation times r Vitamin K in the form of vitamin K (phytonadione)
1
evidence of coagulopathy and bleeding: commonly results from underfilling these tubes. is used to reverse coagulopathy in the setting of oral
r Vital sign abnormalities may include tachycardia and r When filling vacuum tubes, allow the tube to
anticoagulant toxicity.
hypotension depending on the degree of blood loss. aspirate precisely the quantity of blood taken by Vitamin K3 (menadione) is not appropriate for
r Evaluation of the mouth may reveal gingival its vacuum. use; only vitamin K1 (phytonadione) is used.
bleeding. r Even a slightly decreased amount may errantly It should be administered in any case of serious
r Rectal exam may uncover bright red blood or result in falsely prolonged coagulation times due bleeding regardless of the degree of elevation of
melena. Stool may be tested for occult blood. to inappropriate anticoagulant/blood ratio in the the PT or INR.
r A urine sample may reveal gross hematuria and may tube. r Chronic warfarin exposure:
be tested for microscopic hematuria. For patients with an elevated INR who require
r Dermatologic examination may reveal bruising. Imaging chronic anticoagulation, the use of vitamin K and
r Neuroimaging should be performed if there is
r Altered mental status, seizures, or any other transfusion depends on the degree of elevation of
concern for an intracranial hemorrhage. INR and whether or not there is bleeding:
neurologic deficits should elicit concern for r Imaging with CT and/or US may be used for
intracerebral hemorrhage. INR <5.0; no significant bleeding: Lower the
diagnosing hemorrhage into other tissues or warfarin dose, or omit next dose, of warfarin;
DIAGNOSTIC TESTS & INTERPRETATION compartments. monitor INR frequently; resume anticoagulation
Lab when INR reaches therapeutic range.
r Prolongation of the PT and elevation of the INR are INR 5.09.0; no significant bleeding: Omit
indicative of coagulopathy secondary to warfarin or TREATMENT next 12 doses of warfarin; monitor INR
a superwarfarin: frequently; resume anticoagulation when INR
Onset of PT prolongation and INR elevation is
INITIAL STABILIZATION/THERAPY
r Assess and stabilize airway, breathing, and reaches therapeutic range. May administer
between 12 and 24 hr post ingestion. vitamin K 12.5 mg PO, especially if patient is
circulation.
It is not routinely necessary to obtain a PT or INR r Blood transfusion should be initiated in patients at increased risk for bleeding.
prior to this time frame. INR 9.0; no significant bleeding: Hold
If there is a concern for chronic or repeated with significant blood loss who are, or are expected warfarin; administer vitamin K1 2.55.0 mg PO;
exposures to a superwarfarin rodenticide to become, hemodynamically unstable: monitor INR frequently; administer additional
For the purpose of obtaining the baseline, PT and Packed RBCs are useful in replacing lost blood but vitamin K1 as needed; resume anticoagulation
INR are not required. cannot easily or fully correct coagulopathy. when INR reaches therapeutic range.
Serious or life-threatening bleeding and
elevated INR: Hold warfarin; administer vitamin
K1 10-mg slow IV infusion; supplement with
FFP, prothrombin complex concentrate, or
recombinant factor VIIa; administer additional
vitamin K1 as needed q12h.
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ANTICOAGULANT POISONING
r Warfarin (not superwarfarin) exposure: Following r Superwarfarin exposure: After exposure, PT and INR r Blood products:
exposure in asymptomatic patients not requiring should be monitored at 24 and 48 hr post exposure: Vitamin K1 will not begin to affect clotting for 6 hr.
anticoagulation, PT and INR should be monitored at Patients who develop coagulopathy will require Patients with active hemorrhage will require FFP or
24 and 48 hr post ingestion: high doses of vitamin K several times a day for whole blood. Recombinant factor VII (NovoSeven)
Vitamin K1 0.6 mg/kg/dose PO b.i.d.q.i.d, weeks to months. may be used as an alternative to FFP:
typically 510 mg PO b.i.d.q.i.d. 3 days in Vitamin K1 : Starting dose is typically 2550 mg FFP 1525 mL/kg IV; adult dose 24 units IV.
children; max single dose 1050 mg PO PO b.i.d.q.i.d. in adolescents/adults and Based on serial PR/INR, repeated doses may be
b.i.d.q.i.d. 3 days in adolescents 0.6 mg/kg/dose PO b.i.d.q.i.d. in children taken necessary.
Given if coagulation results reveal prolongation for an initial 4-wk period. NovoSeven 35120 g/kg IV
secondary to anticoagulant effects INR should be monitored frequently and the dose r Heparin has a relatively short duration of action.
3 days of therapy is dosing for warfarin titrated up or down according to the INR. Following an overdose, observation alone may be
(medicinal). Upon completion of treatment with vitamin K, INR sufficient if significant bleeding has not occurred:
r Vitamin K may be administered prophylactically should continue to be monitored frequently for Heparin infusion should be held. It may be
1
(without serial measurements of PT and INR) for several days to determine if it is safe to resumed when serial PTT levels reach the
3 days. Treatment for this time period will likely discontinue vitamin K1 therapy. therapeutic range.
cover the expected duration of action of r Parenteral vitamin K : r Protamine:
1
warfarin: Given SC or IV for severe warfarin or Used to reverse coagulopathy due to heparin
This is not recommended following large superwarfarin toxicity toxicity. It has a greater affinity for heparin than
ingestions since the duration of anticoagulation is Children 15 mg IV/SC, adults 1025 mg IV/SC; antithrombin III, thereby causing dissociation of
unpredictable. max volume 5 mL/50 mg per dose at SQ injection the heparin-antithrombin III complex
Treatment for prolonged coagulation due to a site 1 mg of protamine neutralizes 100 U of heparin.
rodenticide such as brodifacoum or difenacoum, IV: Given rarely due to risk of anaphylactoid The dose of protamine given should not exceed
etc., is a min of 4 wk and longer in some cases. reaction. Children dosed as 0.6 mg/kg/dose; max the amount of heparin expected to be found
r Vitamin K should not be given prophylactically single dose 1025 mg in older intravascularly at the time of protamine infusion.
1
following suspected ingestion of a superwarfarin. children/adolescents. Infuse at a rate of 1 mg/min Excess protamine administration may result in
r The duration of action is expected to be several or 5% of total dose/min, whichever is slower. paradoxical anticoagulation.
weeks to months. The administration of vitamin K Slow infusion immediately if there are The dose needed should be calculated from the
for several days will merely delay the onset of an INR anaphylactoid symptoms. dose of heparin administered and assuming a
abnormality and coagulopathy in cases in which a SC administration is reserved for cases in which heparin half-life of 6090 min:
significant amount of superwarfarin was ingested: oral administration is unlikely to be effective, such If 3060 min after heparin injection, give
In addition, most exposures to superwarfarins do as significant GI hemorrhage. 0.5 mg of protamine per 100 U of heparin
not result in anticoagulation since the amount IM administration should always be avoided in initially given.
ingested, if any, is not enough to cause toxicity. In patients with coagulopathy due to risk of If 2 hr after heparin injection, give 0.25 mg of
these cases, PT and INR will remain within normal developing hematomas. protamine per 100 U of heparin initially given.
range and treatment with vitamin K is not needed. IV administration is associated with a risk of
anaphylactoid reaction and even death. Slow IV
infusion of vitamin K1 should be limited to cases
of life-threatening bleeding.
60
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ANTICOAGULANT POISONING
A
Protamine use should be limited to cases of Issues for Referral r Howland MA. Antidotes in depth: Vitamin K . In
1
life-threatening hemorrhage. Patients who present following an intentional Flomenbaum NE, Goldfrank LR, Hoffman RS, et al.,
Protamine is associated with significant adverse overdose require a psychiatric evaluation. eds. Goldfranks Toxicologic Emergencies. 8th ed.
effects, including anaphylactic and anaphylactoid New York, NY: McGraw-Hill; 2006.
reactions, bradycardia, acute lung injury, and r Su M, Hoffman RS. Anticoagulants. In Flomenbaum
thrombocytopenia. FOLLOW-UP NE, Goldfrank LR, Hoffman RS, et al., eds.
Diabetic patients receiving protamine-containing PROGNOSIS Goldfranks Toxicologic Emergencies. 8th ed. New
insulin (NPH) are at increased risk of having an r There is potential for significant morbidity due to York, NY: McGraw-Hill; 2006.
adverse reaction. hemorrhage, particularly in cases of large intentional
Protamine is not recommended for use in cases of overdoses of superwarfarins.
bleeding secondary to LMWHs. r Due to its short duration of action, development of CODES
DISPOSITION significant morbidity secondary to heparin overdose
Admission Criteria is rare. ICD9
r Patients requiring ongoing care for hemorrhage or 964.2 Poisoning by anticoagulants
COMPLICATIONS
at risk for significant hemorrhage, including patients r Hemorrhage, particularly intracranial hemorrhage
with intentional ingestions of superwarfarins
r Critical care admission criteria: with permanent neurologic injury PEARLS AND PITFALLS
r Death
Unstable vital signs, life-threatening hemorrhage r Superwarfarin rodenticide exposure is the most
(eg, intracranial hemorrhage) common anticoagulant issue in pediatric patients.
Discharge Criteria ADDITIONAL READING r Usually, this is a single small exposure with low
r Patients usually may be safely discharged if they likelihood to result in anticoagulation. Due to length
r Ansell J, Hirsh J, Hylek E, et al. Pharmacology and
have a reliable history of an unintentional overdose, of anticoagulation (weeks to months) and potential
management of the vitamin K antagonists. Chest. for fatality, evaluation of PT/INR at 2448 hr is
are asymptomatic, and are not considered to be at
2008;133:160S198S. recommended.
risk for hemorrhage. r Bronstein AC, Spyker DA, Cantilena JR, et al. 2007
r For children with unintentional exposures to r Do not initially give prophylactically vitamin K , as
1
Annual Report of the American Association of this may mask prolonged coagulation that will occur
rodenticides, the chance of toxicity is small, but it
Poison Control Centers National Poison Data and be present for months.
is recommended that they follow up for repeat
PT/INR:
System (NPDS): 25th Annual Report. Clin Toxicol. r Only vitamin K (phytonadione), not vitamin, K is
1 3
2008;46:9271057.
These patients may complete their 24- and 48-hr r Howland MA. Antidotes in depth: Protamine. In useful.
PT and INR testing as outpatients. r Failure to thoroughly fill Vacutainer tubes sent for
Flomenbaum NE, Goldfrank LR, Hoffman RS, et al.,
coagulation profile is a common lab error.
eds. Goldfranks Toxicologic Emergencies. 8th ed. r Failure to aggressively reverse anticoagulated
New York, NY: McGraw-Hill; 2006.
patients with significant active bleeding may result
in severe morbidity and mortality.
r Protamine has anticoagulant properties itself.
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ANTICONVULSANT POISONING
Beth Y. Ginsburg
62
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ANTICONVULSANT POISONING
A
r Ophthalmologic findings often include nystagmus. SURGERY/OTHER PROCEDURES
r Cardiac dysrhythmias may occur with TREATMENT Hemodialysis/hemoperfusion:
carbamazepine toxicity or IV phenytoin toxicity. r Valproic acid; hemodialysis/hemoperfusion; for rapid
r Nausea and vomiting are associated with phenytoin, INITIAL STABILIZATION/THERAPY clinical deterioration, hepatic dysfunction, continued
carbamazepine, gabapentin, valproic acid, and r Assess and stabilize airway, breathing, and drug absorption, and/or serum valproic acid
lamotrigine toxicity. circulation. concentration >1,000 mg/L
r Dermatologic findings include cutaneous bullae in r Assess bedside fingerstick blood glucose r Indications for phenobarbital toxicity are persistent
the setting of phenobarbital toxicity. Local skin concentration for altered mental status. severe hypotension.
irritation may develop in cases of IV phenytoin r Discontinue further dosing of anticonvulsant.
r GI decontamination: DISPOSITION
extravasation. Rash occurs with anticonvulsant
hypersensitivity syndrome. Activated charcoal may be considered in recent
Admission Criteria
r Neurologic findings are common. Ataxia, usually r Abnormal vital signs, metabolic derangements,
(<1 hr) ingestions.
with accompanying nystagmus, is typical with neurologic symptoms, or end-organ dysfunction
Multiple-dose activated charcoal may be r Ataxia resulting from phenytoin or carbamazepine
phenytoin, carbamazepine, and phenobarbital. considered for phenytoin, phenobarbital,
Altered mental status, confusion, lethargy, coma, carbamazepine, and valproic acid toxicity. toxicity. If only ataxia, cardiac monitoring is not
slurred speech, myoclonus, posturing, ataxia, r Phenytoin: required.
r Admission for extended-release valproic acid. Peak
incoordination, and seizures may also result from Cardiac dysrhythmias and hypotension from IV
anticonvulsants generally. phenytoin toxicity usually resolve within an hour. concentrations may take 24 hr to occur.
r Critical care admission criteria:
DIAGNOSTIC TESTS & INTERPRETATION Hypotension generally responds to an IV fluid. The
phenytoin infusion should be stopped for a few Cardiac dysrhythmia, unstable vital signs
Lab minutes and may be restarted at half the initial
Initial Lab Tests Discharge Criteria
r Assess bedside fingerstick blood glucose in all rate. Asymptomatic after a period of observation or if signs
Use of multiple-dose activated charcoal 1 mg/kg and symptoms of toxicity resolve
patients with altered mental status. orally q24h may be indicated.
r CBC is generally recommended. r Phenobarbital:
r Serum electrolytes are genally recommended. FOLLOW-UP
In toxicity, alkalinization with a sodium
r Serum drug concentration for phenytoin,
bicarbonate infusion is an effective means of
phenobarbital, carbamazepine, orvalproic acid: PROGNOSIS
elimination of phenobarbital. r Significant toxicity associated with anticonvulsant
An elevated serum drug concentration may help Multiple-dose activated charcoal is more effective
confirm toxicity and in some cases may help guide exposure is rare.
and safer (recommended). r Potential for significant morbidity and mortality with
management. Use of multiple-dose activated charcoal 1 mg/kg
Serial drug concentrations should be obtained in orally q24h may be indicated. severe toxicity exists.
cases of overdose of phenytoin and r Carbamazepine:
carbamazepine since there may be prolonged or Assess for cardiac dysrhythmia, which may require
delayed absorption. ADDITIONAL READING
treatment with sodium bicarbonate.
Serial drug concentrations also should be Use of multiple-dose activated charcoal 1 mg/kg r Craig S. Phenytoin poisoning. Neurocrit Care.
obtained in cases of overdose of extended-release orally q24h may be indicated. 2005;3:161170.
preparations of valproic acid. r Valproic acid: Use of L-carnitine, possible r Doyon S. Anticonvulsants. In Flomenbaum NE,
r Carbamazepine: Assay serum electrolytes.
hemodialysis or hemoperfusion Goldfrank LR, Hoffman RS, et al., eds. Goldfranks
r Valproic acid:
Toxicologic Emergencies. 8th ed. New York, NY:
Specific lab assays are indicated. In addition to MEDICATION
r Activated charcoal: McGraw-Hill; 2006.
CBC and serum electrolytes, assay LFTs r Lheureux PER, Hantson P. Carnitine in the treatment
andammonia concentration, lipase, and venous 1 mg/kg PO, may be repeated q24h if multidose
activated charcoal is needed. of valproic acid-induced toxicity. Clin Toxicol.
blood gas. 2009;47:101111.
r Lamotrigine: LFTs and serum creatine Do not give multiple doses of charcoal with
r Spiller HA. Management of carbamazepine
phosphokinase sorbitol; severe abdominal bloating and pain may
r Topiramate: Electrolytes, serum bicarbonate, and occur overdose. Pediatr Emerg Care. 2001;17:452456.
Multidose charcoal; useful for phenytoin,
blood gas analysis should be obtained in cases of
phenobarbital, carbamazepine, and possibly
topiramate toxicity. CODES
valproic acid
Diagnostic Procedures/Other r Sodium bicarbonate:
r ECGs in cases of carbamazepine toxicity may
If cardiotoxicity is due to carbamazepine, sodium ICD9
demonstrate QRS widening, QT prolongation, bicarbonate bolus and infusion should be 966.3 Poisoning by other and unspecified
atrioventricular block, and ventricular dysrhythmias. administered for widening of the QRS interval anticonvulsants
r Lamotrigine toxicity may also be associated with >100 msec.
QRS widening. If wide QRS >100 msec, give 1 mEq/kg IV push,
DIFFERENTIAL DIAGNOSIS then repeat ECG 10 min later to assess response. PEARLS AND PITFALLS
r Hypoglycemia If QRS narrowing resulted, bicarbonate infusion of r Common presenting problems are ataxia and
r Sedative-hypnotic intoxication 2 ampules of sodium bicarbonate in 1 L of D5W
nystagmus as well as impaired consciousness or
r Ethanol intoxication may be infused.
r L-carnitine: neurologic function.
r Acute cerebellar ataxia r Newer anticonvulsants have unique toxicities that
r Vertigo The loading dose is 100 mg/kg IV (max single
may require specific treatment.
dose 6 g) over 30 min, followed by 15 mg/kg IV r Multiple-dose activated charcoal may be useful for
r Encephalopathy of other etiology
over 1030 min q4h until clinical improvement is
evident. phenytoin, phenobarbital, carbamazepine, and
Oral dosing of 100 mg/kg/day (up to 3 g/day) possibly valproic acid.
r Phenobarbital coma can mimic brain death.
divided q6h may be given following an acute
overdose without hepatotoxicity or symptomatic
hyperammonemia.
Should be administered in cases of
hyperammonemia or hepatotoxicity.
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APHTHOUS STOMATITIS
Helene Tigchelaar
PATHOPHYSIOLOGY
BASICS r Conflicting theories increasingly support immune DIAGNOSIS
dysregulation.
DESCRIPTION r Cells in an area of diminished mucosal barrier may HISTORY
r Aphthous stomatitis (canker sores) are: r History of lesions:
become the targets of a cell-mediated immune
Recurrent reaction: Prodrome of tingling or burning at site
Painful Targeted by lymphocytes and Langerhans cells Erythematous papule forms
Solitary or occasionally multiple r Antibody formation and complement fixation Develops into a painful ulcer
Limited to the nonkeratinized mucous membranes Length of healing stage depends on severity
induced by L-forms of streptococci may play a role in r Age at onset of lesions
of the mouth (ventral tongue, buccal mucosa, pathophysiology.
labial mucosa, floor of the mouth) r Apparent provocative and relieving factors including
Yellow or gray, shallow, round or oval ulcers, ETIOLOGY emotional stressors and menstrual cycle
r Current evidence suggests a genetic and r Frequency of episodes
sharply demarcated, with an erythematous border
r Discussed are minor recurrent aphthous stomatitis immunologic predisposition. r Impact on quality of life
r Most cases are idiopathic: r Known underlying health conditions
(RAS), major RAS (10%), and herpetiform aphthous
ulceration: No proven viral associations r Associated symptoms: Fever, malaise, genital ulcers,
Minor aphthous stomatitis: COMMONLY ASSOCIATED CONDITIONS ocular and musculoskeletal involvement
Lesions are <1 cm in diameter. r Behcet disease:
Lesions heal in 1 wk without scarring. Vasculitis:
PHYSICAL EXAM
Usually starts in adolescence and improves with r Vital signs
Diagnostic criteria include a min of 3 oral
age r Toxicity
outbreaks per year plus 2 additional extraoral
Major aphthous stomatitis is more severe r Hydration and nutrition
areas of involvement.
(<10%): Findings may not be present simultaneously but r Location, size, number and appearance of lesions:
Ulcers are larger, deeper, more frequent, and may be elicited by history. Minor RAS: Lesions limited to the floor of mouth,
associated with severe pain. Oral and genital lesions similar to all 3 types of tongue, soft palate, and buccal and labial mucosa
Lesions can last weeks to months. RAS r Submental adenopathy is common.
Lesions scar. Cutaneous lesions r Facial edema:
Presents at puberty and does not remit Uveitis, retinal vasculitis, optic neuritis, and Seen with major RAS
Herpetiform ulceration: vascular occlusion may lead to blindness. r Findings outside the oral mucosa suggest the
More frequent in females Arthralgia
Clusters of small lesions (up to 100) throughout possibility of other associated diseases.
Progressive neurologic involvement in 20% of
the mouth patients DIAGNOSTIC TESTS & INTERPRETATION
Herpesvirus is not isolated from these lesions, r Inflammatory bowel disease (IBD): Lab
and there is no initial vesicle. Crohn disease can involve any portion of the GI May occasionally be indicated to look for etiology for
Onset in adulthood RAS:
tract, including the mouth.
EPIDEMIOLOGY r HIV and AIDS: r CBC with differential to rule out cyclic neutropenia
Gingival involvement is a differentiating feature. r Consider serum ferritin, folate, and B vitamin levels
Incidence
r Lifetime risk of a single episode up to 50% May have severe debilitating RAS r Biopsy for recalcitrant atypical lesions
r 20% of the population has RAS: r Periodic fever with aphthous stomatitis, pharyngitis, r Tzanck smear to rule out herpes simplex
Female preponderance and adenitis (PFAPA syndrome):
Pathological Findings
Onset 25 yr with slight male predominance r Biopsy rarely is required and is not diagnostic:
RISK FACTORS Cyclic event of 36-wk intervals with fever lasting
r Genetics: 3040% of patients with RAS have a May be required if suspicion of granulomatous
5 days
family history of aphthous ulcers: infection or inflammatory disease
Otherwise healthy child r Lesions have an ulcer base covered by a
Multiple gene inheritance pattern, penetrance Dramatic defervescence and symptomatic relief
affected by multiple factors with 1 dose of prednisone fibrinopurulent pseudomembrane:
r Dental appliances (braces) can cause mouth trauma, Lymphocytosis and mononuclear cells at the
Mouth lesions are small and few and involve the
increasing the frequency of ulcers lips and buccal mucosa margins of the lesion
r See Commonly Associated Conditions. Superficial tissue necrosis
Pharyngitis and cervical adenopathy
Syndrome generally resolves within 5 yr Neutrophils and debris cover the area of necrosis.
GENERAL PREVENTION r Celiac disease: Dilated blood vessels
r Prevention of mouth trauma:
Dental wax on braces Adherence to a glutenfree diet may promote DIFFERENTIAL DIAGNOSIS
resolution. r Geographic tongue:
Avoid toothbrush abrasions.
r Cyclic neutropenia Migratory glossitis in a maplike pattern
Avoid abrasive foods and citrus fruits.
Avoid chemical irritants, including toothpaste r Iron and possibly zinc deficiency Rarely painful
r Trauma:
containing sodium lauryl sulfate.
r Decreasing physical and emotional stress and Burns from hot foods or caustics
improving rest may decrease the frequency of Biting or sucking injuries to the buccal mucosa
episodes. and palate
r Consider treating deficiencies in iron, zinc, folate,
and B vitamins.
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APHTHOUS STOMATITIS
A
r Herpes simplex gingivostomatitis: COMPLEMENTARY & ALTERNATIVE COMPLICATIONS
Fever (primary herpes infection) THERAPIES Major RAS and associated conditions:
Initial lesions are vesicular. r Topical and systemic tetracycline is a traditional r Scarring
Lesions may be extraoral. therapy with questionable efficacy. r Dehydration and weight loss secondary to decreased
Lesions occur on keratinized mucosa such as the r No support for use of antivirals
oral intake
hard palate and gingiva in addition to distribution r Levamisole, colchicine, gamma globulin, dapsone, r Chronic pain with decreased quality of life
of aphthous ulcers. estrogen replacement, empirical zinc replacement,
r Herpangina (coxsackie A virus):
and monoamine oxidase inhibitors are all therapies
Fever with limited data to support their use. ADDITIONAL READING
Multiple lesions r Vitamin B : Empirical or with documented
12 r Eisenberg E. Diagnosis and treatment of recurrent
Initially vesicular and then ulcerative with an deficiency
erythematous base, limited to the posterior r Licorice root extract (eg, paste or CankerMelts discs, aphthous stomatitis. Oral Maxillofac Surg Clin North
pharynx, uvula, and soft palate Am. 2003;15:111122.
r Hand-foot-and-mouth disease (HFMD; coxsackie A OTC patches) may heal or reduce extension of r Holbrook WP, Kristmundsdottir T, Loftsson T.
existing lesions.
16): r Barrier-protective gels like cyanoacrylate (Orabase Aqueous hydrocortisone mouthwash solution:
Fever Clinical evaluation. Acta Odontol Scand. 1998;
Sooth-N-Seal) protect ulcers from acidic foods and
Vesicles that progress to ulcers on an 56(3):157160.
trauma. r Natah SS, Konttinen YT, Enattah NS, et al. Recurrent
erythematous base limited to the anterior buccal r Debacterol, a topic sulfuric acid/phenolic solution
mucosa, tongue, and hard palate aphthous ulcers today: A review of the growing
(cauterizing agent) that is not FDA approved
Papules and vesicles on hands, feet, knees, r Thalidomide: knowledge. Int J Oral Maxillofac Surg. 2004;33:
elbows, and buttocks 221234.
Other enteroviruses can cause both herpangina Inhibits the production of cytokines r Patel N, Sciubba J. Oral lesions in young children.
and HFMD Found to be effective in numerous studies of HIV
Pediatr Clin North Am. 2003;50(2):469486.
r Oral lichen planus: with severe RAS as well as Behcet disease and
major RAS See Also (Topic, Algorithm, Electronic
White patches on buccal mucosa, plaque on tip of
Teratogenic: Media Element)
the tongue, erosions of gingiva May only be prescribed under FDA-mandated r Hand-Foot-and-Mouth Disease
May be associated with cutaneous or genital r Herpes Simplex
System for Thalidomide Education and
involvement r Inflammatory Bowel Disease
Prescribing Safety (STEPS)
Oral lesions are rare in children.
Additional side effects of rash and somnolence r Oral Lesions
SURGERY/OTHER PROCEDURES r Stomatitis
TREATMENT Silver nitrate cautery improves pain but not healing
time.
MEDICATION CODES
First Line DISPOSITION
r Antimicrobial mouth rinses r The vast majority of patients with RAS can be
r Topical anesthetics: managed as outpatients. ICD9
r Severe outbreaks of major RAS and associated 528.2 Oral aphthae
Topical benzocaine available in gel, liquid
(Anbesol or Orajel), or adhesive disc (Orajel conditions may rarely require hospitalization for IV
protective discs) 4 times a day hydration and parenteral analgesia. PEARLS AND PITFALLS
r Topical steroids:
Discharge Criteria r Pearls:
For symptomatic relief of severe or recurrent Ability to remain hydrated and nourished
outbreaks Recent alternative therapies provide the potential
Topical triamcinolone acetonide or hydrocortisone
Issues for Referral for control of RAS symptoms.
r Severe RAS requires referral to a dermatologist or r Pitfalls:
hemisuccinate cream or ointment applied
oral maxillofacial surgeon. Failure to obtain an adequate history and perform
sparingly b.i.d. r Suspicion for Behcet disease or HIV disease may
Steroid rinses can be used for posterior lesions, an adequate physical exam to identify associated
prednisolone 1 mg/kg/day swish and spit 2 times require referral to an immunologist. conditions such as Behcet disease and
r Suspicion for IBD may require referral to a
a day predisposing conditions such as AIDS and IBD
May predispose to candidal overgrowth gastroenterologist. Failure to recognize the impact on quality of life
r Menthol: for patients with major RAS
Short-acting local anesthetic: FOLLOW-UP
Lozenges
Over-the-counter Canker Cover is menthol in an FOLLOW-UP RECOMMENDATIONS
adhesive disc. Patient Monitoring
Second Line Pregnancy monitoring for females on systemic
r Intra- and perilesional glucocorticoids for deep or medications
prolonged major lesions as a single intramucosal DIET
injection Avoid acidic, spicy, salty, or abrasive foods.
r Oral steroids:
Prednisone 1 mg/kg/day tapered over 2 wk PROGNOSIS
r Episodes of minor RAS become less frequent as the
May also use rinse and swallow prednisolone
1 mg/kg/day b.i.d. for combined topical and patient ages.
systemic treatment r Major RAS and herpetiform RAS are chronic health
problems that may be controllable with appropriate
medications but do not remit.
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APLASTIC ANEMIA
Dana Aronson Schinasi
Imaging
BASICS DIAGNOSIS No imaging is needed to establish the diagnosis of
aplastic anemia.
DESCRIPTION HISTORY
r Aplastic anemia is characterized by pancytopenia r Clinical presentation is variable and is based on the Diagnostic Procedures/Other
degree of pancytopenia, and specific cell lines that Bone marrow aspiration and biopsy:
and a hypocellular bone marrow. r Staging is based on exam of peripheral blood and
r May be inherited (congenital) or acquired: are depleted:
>80% of cases are acquired. Progressive anemia: Suggested by history of marrow and has implications for treatment and
fatigue, pallor, dyspnea, headache outcome.
EPIDEMIOLOGY Neutropenia: Suggested by history of fever, Pathological Findings
Incidence mucosal ulcerations, recurrent bacterial infections Bone marrow aspiration and biopsy:
r Incidence is 2 per million people per year in the Thrombocytopenia: Suggested by easy bruising, r Hypocellular marrow with fatty replacement
U.S. (1). petechiae, jaundice, mucous membrane bleeding r Absence of abnormal infiltrates or fibrosis
r Incidence is triphasic, with peaks at (2): r Recent infection, medication use, radiation
25 yr of age, due to inherited causes treatment or exposure DIFFERENTIAL DIAGNOSIS
2025 yr r History of failure to thrive, short stature, and nail, r Acute lymphoblastic leukemia
>60 yr skin, or hair anomalies may point to an underlying r Acute myelogenous leukemia
inherited syndrome. r Bone marrow infiltration
RISK FACTORS r Family history of anemia
r No age, sex, or racial predominance r Chemotherapy effects
r Risk for acquired aplastic anemia is higher in the r Human herpesvirus 6
PHYSICAL EXAM
setting of: r Pallor is usually the first sign of aplastic anemia: r Megaloblastic anemia
Viral infection (Epstein-Barr virus, parvovirus B19, May be accompanied on skin exam by bruising, r Multiple myeloma
hepatitis, HIV) petechiae, purpura r Myelodysplastic syndrome
Drugs (NSAIDs, chloramphenicol, sulfonamides, r Findings on cardiovascular exam range from r Non-Hodgkin lymphoma
carbamazepine, cimetidine, nifedipine) tachycardia and systolic flow murmur to overt signs r Osteopetrosis
Toxins (nitrous oxide, radiation, benzene) of heart failure such as weak pulses, prolonged r Splenic sequestration
Autoimmune disease (systemic lupus capillary refill, pulmonary congestion, and
erythematosus) hepatomegaly.
Pregnancy r Jaundice and tender hepatomegaly may be seen in TREATMENT
Graft vs. host disease (GVHD) some patients.
GENERAL PREVENTION r Splenomegaly may be present. PRE HOSPITAL
r Specific findings of certain inherited syndromes (5): r Assess and stabilize airway, breathing, and
Avoidance of risk factors, if known
Fanconi anemia: Microcephaly, strabismus, short circulation.
PATHOPHYSIOLOGY r Stop exposure to possible offending agent, if known.
r Mostly unknown, although immune dysfunction has stature, mental retardation, hyperpigmentation,
been implicated in the pathogenesis (3) hypopigmentation, thumb anomalies, skeletal INITIAL STABILIZATION/THERAPY
r Involves loss of, or injury to, pluripotent anomalies r Support hemodynamics:
Shwachman-Diamond syndrome: Eczema, skeletal Crystalloid IV fluids are the initial fluids of choice
hematopoietic stem cells (4):
anomalies to support circulation.
In absence of infiltrative bone marrow process
Dyskeratosis congenita: Oral leukoplakia, Since aplastic anemia is usually of gradual onset,
ETIOLOGY dysmorphic nails, dental anomalies, exudative most patients are well compensated and can
r Inherited (congenital): retinopathy tolerate moderate levels of anemia.
See Commonly Associated Conditions. Amegakaryocytic thrombocytopenia: Absent radii Blood and platelet transfusions: Goal is relief of
Familial aplastic anemia Diamond-Blackfan syndrome: Cleft palate, symptoms of poor tissue oxygenation or CHF, not
r Acquired: micrognathia, thumb anomalies restoration of normal hemoglobin levels.
Idiopathic: No clear etiology is identified in the DIAGNOSTIC TESTS & INTERPRETATION Exposure to HLA may adversely affect future
majority of children with acquired aplastic anemia. engraftment of transplanted bone marrow;
Lab
Following orthotopic liver transplantation therefore, transfusions should be used judiciously.
Initial Lab Tests
COMMONLY ASSOCIATED CONDITIONS r CBC: Irradiated, cytomegalovirus-negative blood
r Fanconi anemia Anemia: Usually normocytic, may be macrocytic products should be used to minimize
r Shwachman-Diamond syndrome Neutropenia, with toxic granulation alloimmunization
r Spontaneous bleeding may occur with platelet
r Dyskeratosis congenita Absence of blast cells
r Amegakaryocytic thrombocytopenia Thrombocytopenia counts <10,000/L; consider transfusion at these
Normal morphology on peripheral smear; no levels.
(thrombocytopenia-absent radius syndrome)
r Diamond-Blackfan syndrome suggestion of leukemia
r Cartilage-hair hypoplasia Reticulocyte count <1%
r Coombs test, lactate dehydrogenase, renal and
r Pearson syndrome
r Dubowitz syndrome hepatic function tests may be useful in evaluating
r Paroxysmal nocturnal hemoglobinuria the etiology
r Serologic viral testing for Epstein-Barr virus,
parvovirus, hepatitis, and HIV, as indicated
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APLASTIC ANEMIA
A
MEDICATION REFERENCES
First Line FOLLOW-UP
Broad-spectrum antibiotics to cover potentially 1. Young NS, Kaufman DW. The epidemiology of
life-threatening infections in the setting of fever with FOLLOW-UP RECOMMENDATIONS acquired aplastic anemia. Haematologica.
r Discharge instructions and medications: 2008;93(4):489.
neutropenia:
r Vancomycin 10 mg/kg/dose IV q6h Patients should return to the emergency 2. Shimamura A, Guinan EA. Acquired aplastic
r Ceftriaxone 5075 mg/kg/dose IV q24h department if they develop fever, prolonged anemia. In Nathan DG, Orkin SH, eds. Hematology
bleeding, or signs of heart failure. of Infancy and Childhood. Philadelphia, PA: WB
r No role for prophylactic antibiotics with neutropenia
Medications vary based on severity and should be Saunders; 2003:256.
in the absence of fever prescribed in conjunction with a pediatric 3. Nakao S. Immune mechanism of aplastic anemia.
Second Line hematologist. Int J Hematol. 1997;66(2):127134.
r Immunosuppressive therapy (when no HLA-matched r Activity:
4. Young NS, Maciejewski J. The pathophysiology of
sibling is available): Patients with splenomegaly or thrombocytopenia acquired aplastic anemia. N Engl J Med.
Antithymocyte globulin 40 mg/kg/day for 4 days should avoid contact sports. 1997;336:1365.
Cyclosporine 12 mg/kg/day IV starting on day 5 Dental work should be postponed until the patient 5. Shimamura A. Clinical approach to marrow failure.
for 36 mo is no longer neutropenic. Hematology. 2009;329337.
Prednisone 40 mg/m2 /day (max single dose Patient Monitoring 6. Fuhrer M, Rampf U, Baumann I, et al.
60 mg/day) PO for 2 wk r Blood counts should be monitored on a regular Immunosuppressive therapy for aplastic anemia in
Recombinant human granulocyte basis. children: A more severe disease predicts better
colony-stimulating factor 5 g/kg/day SC for r Patients should be monitored for adverse effects of survival. Blood. 2005;106:2102.
28 days
r HLA-matched unrelated donor hematopoietic cell immunosuppressive therapies. 7. Davies JK, Guinan EC. An update on the
DIET management of severe idiopathic aplastic anaemia
transplantation
r Avoid potential causative agents. in children. Br J Haematol. 2007;136:549.
SURGERY/OTHER PROCEDURES r Neutropenic patients should avoid raw meats, dairy
A central venous catheter is required for the
products, and certain fruits and vegetables. ADDITIONAL READING
administration of immunosuppressive therapy and r Salt restriction is recommended while on
hematopoietic cell transplantation.
cyclosporine or steroid therapy. See Also (Topic, Algorithm, Electronic
DISPOSITION Media Element)
PROGNOSIS r Acute Hemolytic Anemia
Admission Criteria Depends on severity of pancytopenia (7):
Critical care admission criteria: r Anemia
r The spontaneous recovery rate is not well
r Hemodynamic instability, persistent or uncontrolled r Leukemia
established (1). r Lymphoma
bleeding, septic shock r Estimated 5-yr survival rate for patients receiving an
r All patients with neutropenia and fever require
HLA-matched sibling donor hematopoietic stem cell
admission for broad-spectrum antibiotics, while transplant is >90% (6).
awaiting culture and sensitivity results. r Estimated 5-yr survival rate for patients receiving CODES
r All patients with a new diagnosis require admission
immunosuppression is 75% (1).
for further diagnostic testing and for initiation of ICD9
therapy. COMPLICATIONS r 284.01 Constitutional red blood cell aplasia
r Complications of aplastic anemia include infections r 284.89 Other specified aplastic anemias
Discharge Criteria
r Patients should not be discharged from the and bleeding. r 284.9 Aplastic anemia, unspecified
r Complications related to immunosuppressive
emergency department without consultation with a
pediatric hematologist. therapies and conditioning regimens for stem cell
r Patients deemed eligible for discharge by a pediatric transplantation include GVHD and graft failure. PEARLS AND PITFALLS
hematologist must have normal vital signs, be r In contrast to those with leukemia, children with
afebrile, and be without signs of CHF or bleeding.
aplastic anemia should have WBCs of normal
Issues for Referral morphology on the peripheral smear.
Diagnostic and management decisions should r Patients with fever and neutropenia require
always be made in consultation with a pediatric broad-spectrum antibiotics and admission.
hematologist.
COMPLEMENTARY & ALTERNATIVE
THERAPIES
HLA-matched sibling donor hematopoietic cell
transplantation is the treatment of choice for children
with severe or very severe disease (6):
r Survival rates are better than using
immunosuppression alone.
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APNEA
Robin L. Altman
Ilene A. Claudius
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APNEA
A
Discharge Criteria 6. Abu-Shaweesh J, Martin R. Neonatal apnea:
r Well appearing
TREATMENT r Normal physical exam
Whats new? Pediatr Pulmonol. 2008;43:
937944.
PRE HOSPITAL r Single episode of apnea without high-risk features 7. Zuckerbraun NS, Zomorrodi A, Pitetti RD.
Assess and stabilize airway, breathing, and r >4348 wk postconceptual age Occurrence of serious bacterial infection in infants
circulation. r Abuse is not suspected. aged 60 days or younger with an apparent
INITIAL STABILIZATION/THERAPY r Follow-up is ensured. life-threatening event. Pediatr Emerg Care.
r Assess and stabilize airway, breathing, and r Family is comfortable with discharge. 2009;25(1):1925.
circulation. 8. Altman RL, Li KI, Brand DA. Infections and
r For recurring apneas or an ill-appearing patient, Issues for Referral apparent life-threatening events. Clin Pediatr.
r Patients diagnosed with or suspected to have
2008;47(4):372378.
rapid stabilization and initial therapies focus on seizures should be referred to neurology. 9. Brand DA, Altman RL, Purtill K, et al. Yield of
airway control, respiratory support as needed, and r Patients with GERD should be referred to their
consideration of sepsis or other life-threatening diagnostic testing in infants who had an apparent
primary care provider or gastroenterology. life-threatening event. Pediatrics. 2005;
conditions such as head injury. r Patients with recurrent apneas or apnea of
r For the child with recurrent apneas, consider a 115(4):885893.
prematurity should be referred to pulmonology. 10. Pittetti RD, Whitman A, Zaylor D. Accidental and
targeted workup of the potential underlying cause.
nonaccidental poisonings as a cause of apparent
MEDICATION life-threatening events in infants. Pediatrics.
First Line
FOLLOW-UP 2008;122:e359e362.
r Oxygen may be needed with significant apnea
FOLLOW-UP RECOMMENDATIONS
and/or cyanosis. r Discharge instructions and medications are guided
r If a cause is identified or suspected, targeted therapy by the cause and use of xanthine therapy.
ADDITIONAL READING
should be initiated (eg, anticonvulsant for suspected r No activity restrictions r Hall KL, Zalman B. Evaluation and management of
seizure or bronchodilator for bronchoconstriction). r Parents should be taught infant CPR apparent life-threatening events in children. Am
r Further therapy should be determined based on the
Patient Monitoring Fam Physician. 2005;71(12):23012308.
suspected etiology. r Close primary care provider follow-up is required. r Kiechl-Kohlendorfer U, Hof D, Peglow UP, et al.
Second Line r Consider consultation by pulmonology for home Epidemiology of apparent life threatening events.
r For apnea of prematurity, methylxanthines and Arch Dis Child. 2005;90:297300.
monitoring of preterm infants with extreme apnea, r Southall DP, Plunkett CB, Banks MW, et al. Covert
CPAP are the mainstays of therapy: infants with anatomic abnormalities susceptible to
Aminophylline: airway compromise, infants with neurologic or video recordings of life-threatening child abuse:
Loading dose: 5 mg/kg PO/IV Lessons for child protection. Pediatrics. 1997;
metabolic disorders affecting respiratory control,
Maintenance dose: 12 mg/kg/dose q68h 100(5):735760.
and infants with chronic lung disease (1).
Caffeine:
Loading dose: 10 mg/kg PO/IV PROGNOSIS See Also (Topic, Algorithm, Electronic
Maintenance dose: 510 mg/kg PO/IV per day r Apnea of prematurity typically resolves by 43 wk Media Element)
Theophylline: postconceptual age. Obstructive Sleep Apnea
Loading dose: 5 mg/kg PO r Risk of SIDS after an uncomplicated ALTE is 03%.
Maintenance dose: 36 mg/kg/day PO divided Children with recurrent ALTEs or those requiring
q68h significant resuscitation may have an increased risk CODES
r Further therapy should be determined based on the of future SIDS. This data can be applied to apnea as
suspected etiology. well. ICD9
r 770.81 Primary apnea of newborn
DISPOSITION r 770.82 Other apnea of newborn
Admission Criteria REFERENCES
r Floor admission:
Ill appearance 1. Committee on Fetus and Newborn. American
Academy of Pediatrics. Apnea, sudden infant PEARLS AND PITFALLS
Condition (eg, sepsis) requiring admission
Age <4348 wk postconceptual age death syndrome, and home monitoring. r A good history is key to determining the cause.
Consider admission for high-risk apneic event (eg, Pediatrics. 2003;111(4):914917. r Consider occult child abuse.
multiple apneas, bradycardia, significant and 2. Finer N, Higgins R, Kattwinkel J, et al. Summary r It is essential to address parental concerns. If apneic
prolonged change in tone and color) proceedings from the apnea-of-prematurity
events are recurrent, ensure that parents have been
Respiratory acidosis group. Pediatrics. 2006;117(3):S47S51.
trained in infant CPR.
Risk for child abuse 3. Nimavet D, Sherman M, Santin R, et al. Apnea of
Physical exam findings, lab testing, or medical or prematurity. eMedicine. Available at http://
family history that is concerning enough to the emedicine.medscape.com/article/974971-
health care provider to necessitate admission overview. Accessed September 13, 2010.
Marked obstructive apnea with associated hypoxia 4. DeWolfe CD. Apparent life-threatening event: A
or hypercarbia review. Pediatr Clin North Am. 2005;52(4):
Physician or parental concern regarding severity of 11271146.
event, degree of resuscitation needed, medical 5. Davis N, Bossung-Sweeney L, Peterson DR.
history Epidemiological comparisons of sudden death
Apnea of prematurity requiring initiation of syndrome with infant apnoea. Aust Paediatr J.
methylxanthines 1986;22(Suppl 1):2932.
r Critical care admission criteria:
Need for intubation or recurrent apneic episodes
that might portend the need for intubation
Identification of underlying disease requiring
critical care monitoring
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ETIOLOGY
BASICS An underlying diagnosis is identified in only 50% of DIAGNOSIS
cases (50% are idiopathic):
DESCRIPTION r GI: HISTORY
r According to the NIH, an infant apparent Detailed accounts from witnesses (caretaker) and
Gastroesophageal reflux
life-threatening event (ALTE) is an unexpected, emergency prehospital personnel may provide
Intussusception
frightening episode that is characterized by some important insight on nature of event:
Volvulus r Condition:
combination of (1): Swallowing incoordination
Apnea (central, obstructive, or mixed) r Neurologic: Awake, asleep, crying, position (prone vs. supine)
Color change (cyanosis, pallor, redness, or r Activity during event:
Seizure
plethora) CNS hemorrhage Coughing, feeding, vomiting, gagging
Marked change in muscle tone (limpness or r Respiratory effort:
Hydrocephalus
rigidity) Chiari malformation Fast, slow, shallow, stridor, gasping, choking, none
Choking or gagging Central hypoventilation syndrome r Color:
Fear (in some cases) that the infant has died Vasovagal syncope Red, blue, purple, pale
r An ALTE may prompt the caregiver to stimulate or r Respiratory: r Tone and movement:
resuscitate the infant before recovery. Laryngotracheomalacia Limp, rigid, convulsions
EPIDEMIOLOGY Vocal cord dysfunction r Duration:
Incidence Vascular ring Time to recovery (eg, normal respiratory pattern or
Unknown, though estimates range from 0.56% Obstructive sleep apnea tone)
(2): Foreign body aspiration r Interventions (and duration):
r Most occur in infants <1 yr of age, peaking at 1 wk Congenital airway anomalies None, gentle or vigorous stimulation, artificial
Stimulation of laryngeal chemoreceptors respirations, CPR
to 2 mo of age (3).
Breath-holding spell r Recent illnesses
RISK FACTORS r Cardiac: r Past medical history:
r Prematurity
Congenital heart disease (eg, ductal-dependent Prenatal care
r Infection with respiratory syncytial virus (RSV) lesion) Prematurity
r Male gender Dysrhythmia (eg, long QT, Wolff-Parkinson-White Developmental history
r Prone sleeping position syndrome) Feeding history
r Feeding difficulties Cardiomyopathy Sleep habits
r History of apnea, cyanosis, or pallor Myocarditis Prior events
r Metabolic/Endocrine: r Family/Social history:
PATHOPHYSIOLOGY Inborn error of metabolism Siblings with sudden infant death syndrome (SIDS)
r The pathophysiology of ALTE in infants is unclear.
Endocrine disorder Dysrhythmias
r Apnea (1): r Infection:
Medications in home
Cessation of respiratory airflow for any reason: Sepsis or meningitis Smoking, alcohol, or substance abuse
In central apnea, respiratory pauses may be RSV
caused by CNS immaturity, seizures, or tumors. Pertussis PHYSICAL EXAM
In obstructive apnea, breathing may be r Infants may appear well without any signs or
Croup
obstructed by a laryngeal web, vascular ring, Pneumonia symptoms of pathology:
tracheoesophageal fistula, or foreign body. r Child abuse: In 1 study, 83% of infants evaluated by
In pathologic apnea, there is a respiratory pause paramedics had unremarkable physical exams
Physical abuse
>20 sec accompanied by bradycardia, cyanosis, Munchausen by proxy (eg, suffocation, intentional
after an ALTE (4).
pallor, hypotonia, or other signs of compromise. poisoning, head trauma)
In apnea of infancy, there is an unexplained r Normal:
respiratory pause >20 sec, or <20 sec when Respiratory pauses
accompanied by bradycardia, cyanosis, pallor, Periodic breathing
hypotonia, or other signs of compromise.
Periodic breathing is a normal respiratory pattern
involving 3 brief pauses interrupted by <20 sec
of normal respirations in between (no bradycardia,
cyanosis, or hypotonia).
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APPENDICITIS
Lindsey Tilt
Anupam Kharbanda
Progression to suppurative appendicitis occurs Rovsing sign: Pushing on the abdomen in the left
BASICS when bacteria and inflammation spread lower quadrant elicits pain in the RLQ
transmurally to the serosa of the appendix and Obturator sign: Pain on passive internal rotation
DESCRIPTION inflammatory exudate irritates neighboring of the flexed right thigh
r Appendicitis is an inflammation of the appendix, a tissues. This surrounding tissue is innervated by Psoas sign: Pain on passive extension of the right
blind-ending structure that arises from the cecum. the T12 and L1 spinal nerves, which causes thigh with the patient lying on the left side
r Occurs in 1 in 15 individuals (7%) somatic pain that the patient localizes in the right Since these maneuvers can be painful to an
r Males > females (3:2) lower quadrant (RLQ). already uncomfortable child, less forceful
r Familial predisposition Ultimately, gangrenous appendicitis may occur, alternatives include asking the child to walk or
r Seasonal peak: Spring and fall which involves necrosis of the appendiceal wall hop and whether that causes pain.
r Diet may influence frequency of appendicitis: and can rapidly progress to perforation if r A pelvic exam should be considered in teenage
untreated. female patients due to the overlap in presentation of
Countries with high-fiber diets have a lower
incidence of appendicitis as compared to those ETIOLOGY many gynecologic processes.
with lower-fiber diets (1). r Luminal obstruction: Lymphoid follicle hyperplasia, DIAGNOSTIC TESTS & INTERPRETATION
r Mortality is low (<1%), but morbidity is high and fecalith, foreign bodies, parasites Lab
mostly associated with perforation. r Direct invasion:
Initial Lab Tests
r Perforation occurs in 1530% of patients but is not Enteric infection leads to ulceration of the mucosa. r WBC: The likelihood of appendicitis is greatly
evenly distributed through age groups: Superinfection leads to inflammation and necrosis. decreased if the WBC is <10,000/L (2).
Greatest in children <4 yr; this is thought to be, in The most common bacteria responsible are r C-reactive protein (CRP): Combining use of WBC
part, due to patients inability to communicate Escherichia coli, Bacteroides fragilis, and and CRP increases sensitivity of laboratory
their symptoms. Peptostreptococcus and Pseudomonas species. evaluation of possible appendicitis.
Perforation usually occurs within 3648 hr of r Urinalysis:
onset of symptoms. May be useful in differentiating appendicitis from
Prevalence of perforation with symptoms >36 hr DIAGNOSIS
a urinary tract infection
is as high as 65% (2). HISTORY Sterile pyuria may occur with appendicitis due to
EPIDEMIOLOGY r Classic presentation: the proximity of the inflamed appendix to the
Incidence Abdominal pain: bladder. Bacteria and nitrates should be absent in
r 12 in 10,000 children per year <4 yr of age Vague, periumbilical pain develops first. the urine.
r 25 in 10,000 children per year in 1017 yr olds (1) Colicky r Urine pregnancy test: Useful in ruling out pregnancy
r Most common in the 2nd decade of life (2) Unrelated to activity or position as a cause as well as recognition in the event a CT
Nausea and/or anorexia: scan is considered
GENERAL PREVENTION Follows the abdominal pain r Serum chemistry: If local practice involves
In any child having abdominal surgery, elective Food refusal is a useful surrogate in children. documentation of renal function prior to use of IV
appendectomy should be considered to obviate the Migration of pain to the RLQ: contrast with CT scan, obtaining these lab values
future risk of appendicitis. Occurs 612 hr following onset of pain early may decrease time to CT imaging.
Pain is exacerbated by movement.
PATHOPHYSIOLOGY Imaging
r The 2 leading hypotheses are: Vomiting: r X-rays are not routinely useful in the diagnosis of
Often occurs as the infection progresses
Luminal obstruction: Nausea/Vomiting is present in more than half of appendicitis, but recognition of a fecalith or free air
Obstruction trapping mucus in the appendix, under the diaphragm may quickly provide radiologic
patients with appendicitis.
leading to elevated intraluminal pressure Classically follows the onset of pain evidence necessary for the decision to undergo
Increased pressure leading to impaired surgery.
Fever: r US:
perfusion and venous drainage and thus Common but nonspecific finding in children
ischemia of the appendix Findings of appendicitis include a nonperistalsing,
Bacteria entering the compromised tissue, presenting with appendicitis
r <50% of pediatric patients will present with the noncompressible, blind-ending tubular structure
leading to inflammatory infiltrate and eventually >6 mm in diameter
necrosis classic presentation. Women and toddlers are most
Strengths:
Direct invasion: likely to have atypical presentations (1), including Low cost, no radiation, and requires little
Direct bacterial invasion of the ulcerated diffuse abdominal pain, vomiting, or fever.
preparation time
mucosa of the appendix after enteric infections PHYSICAL EXAM Provides dynamic images
May explain why appendicitis is more common r Observe the patient. Especially useful in females, where acute
in the spring and fall, when enteric infections r Begin with a component of the physical exam that is gynecologic disease can often be confused with
are at a peak (1,3) not painful (cardiac/pulmonary). appendicitis
r Appendicitis and perforation represent a continuum r Assess for difficulty with walking, jumping, or Limitations:
of disease. positioning. Operator dependent, low negative predictive
r Patient signs and symptoms correlate with degree r Auscultate bowel sounds, which may be normal, value
and timing of inflammation: hyperactive, or hypoactive depending on stage of
Initially, isolated inflammation within the appendix disease.
causes edema and inflammatory infiltration of the r Palpate at McBurney point: 1/3 the distance from
appendiceal wall. Early distention of the appendix the right anterior superior iliac spine to the umbilicus
triggers visceral pain, which is transmitted r Assess for specific signs for appendicitis:
primarily through sympathetic fibers traveling to
Rebound tenderness: Pain that is elicited on
the spinal cord along T10, so pain is appreciated
release of pressure after deep palpation of the
as periumbilical and vague.
abdomen
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APPENDICITIS
A
r CT scan: r Complicated/Advanced appendicitis: PROGNOSIS
Findings of appendicitis include a fluid-filled Select antibiotics that cover Gram-negative rods Patients do well after an appendectomy, with most
tubular structure >6 mm in diameter with and anerobes. Length of treatment is often children going home in 2448 hr. In comparison, in
periappendiceal inflammation. influenced by normalization of inflammatory cases of complicated appendicitis, one case study
Choice of contrast: markers and temperature (typically 1 wk). reported a mean hospital length of stay of 61/2
Rectal contrast alone is sufficient for the Piperacillin/Tazobactam: days (7).
diagnosis of appendicitis (4) but is difficult to >9 mo of age, <40 kg: 300 mg piperacillin
COMPLICATIONS
administer in young children. component/kg/day in divided doses q8h r Abscess, phlegmon, diffuse peritonitis, cellulitis,
Recent literature suggests that CT with IV >40 kg: 3 g piperacillin/0.375 g tazobactam
small bowel obstruction, ileus, wound infections,
contrast alone is useful and sufficient (5). q6h
fistulas, sepsis, death
Strengths: Second Line r Complications are more common in perforated
Not operator dependent r 2nd-generation cephalosporin:
No decrease in quality of image with obesity appendicitis.
Cefoxitin 100 mg/kg/day divided q6h, max single r Decreased fertility in females with appendicitis is
Provides a better view of the extent of disease,
dose 12 g/day recognized.
which can guide drainage of fluid collections or Cefotetan 4080 mg/kg/day divided q12h, max
alternative diagnoses single dose 6 g/day
Limitations: Radiation exposure, contrast r If penicillin allergic: Gentamicin (22.5 mg/kg/dose
exposure, higher cost
REFERENCES
r A negative or equivocal result on US should be q8h or 5 mg/kg/dose per day) and metronidazole
(30 mg/kg/day in divided doses q6h, max single 1. Rothrock SG, Pagane J. Acute appendicitis in
followed with the more sensitive CT scan to reliably dose 4 g/day) children: Emergency department diagnosis and
exclude appendicitis or to identify those patients management. Ann Emerg Med. 2000;36:3951.
with appendicitis missed by US (4). SURGERY/OTHER PROCEDURES 2. Bundy DG. Does this child have appendicitis?
r Acute appendicitis:
DIFFERENTIAL DIAGNOSIS JAMA. 2007;298(4):438451.
r General: Surgical treatment is indicated for acute
3. Carr NJ. The pathology of acute appendicitis. Ann
appendicitis.
Gastroenteritis, mesenteric adenitis, constipation, Diagn Pathol. 2000;4(1):4658.
Surgical timing: The choice of when to go to the
acute pancreatitis, peptic ulcer, Henoch-Schonlein operating room is variable among individual 4. Garcia Pena BM, Mandl KD, Kraus SJ, et al.
purpura, cholecystitis, inflammatory bowel surgeons/institutions. Debate exists over the risks Ultrasound and limited computed tomography in
disease, septic arthritis of delaying surgery in patients who are candidates the diagnosis and management of appendicitis in
Meckel diverticulitis, volvulus, referred pain from for appendectomy (eg, delays >8 hr). children. JAMA. 1999;282:10411046.
pneumonia/pleuritis r Complicated/Advanced appendicitis (appendicitis 5. Kharbanda AB, Taylor GA, Bachur RG. Suspected
r Genitourinary: appendicitis in children: Rectal and intravenous
with gangrene or perforation of the appendix):
Pregnancy/Ectopic pregnancy, pelvic inflammatory Acute presentation of advanced appendicitis contrast-enhanced versus intravenous contrast-
disease, ovarian torsion, follicular rupture, (ie, perforation with signs and symptoms <96 hr, enhanced CT. Radiology. 2007;243(2):520526.
endometriosis without a well-organized abscess on CT) and 6. Green R, Bulloch B, Kabani A, et al. Early analgesia
Urinary tract infection, nephrolithiasis patients who remain unstable despite for children with acute abdominal pain. Pediatrics.
Testicular torsion, orchitis, hernia resuscitation will go to the operating room for an 2005;166:978983.
appendectomy. 7. St Peter SD, Tsao K, Spilde TL, et al. Single daily
Patients with stable perforations such as with a dosing ceftriaxone and metronidazole vs standard
TREATMENT triple antibiotic regimen for perforated appendicitis
well-formed abscess or phlegmons may be
INITIAL STABILIZATION/THERAPY observed initially on antibiotics. in children: A prospective randomized trial.
r NPO, provide IV fluids, correct any electrolyte Some surgeons elect for 1014 days of outpatient J Pediatr Surg. 2008;43:981.
abnormalities antibiotics followed by an interval appendectomy
r NG tube if there is concern for obstruction or ileus in 68 wk.
Interval appendectomy is an increasingly common CODES
MEDICATION practice despite the lack of randomized clinical
First Line trials comparing this with standard appendectomy. ICD9
r Early analgesia is recommended. There is no r 540.0 Acute appendicitis with generalized peritonitis
DISPOSITION r 540.1 Acute appendicitis with peritoneal abscess
increase in missed appendicitis or in negative
All patients with acute appendicitis should be
appendectomies after analgesia (6):
admitted from the emergency department. r 541 Appendicitis, unqualified
Morphine 0.1 mg/kg IV/IM/SC q2h PRN
Initial morphine dose 0.1 mg/kg IV/SC may be
repeated q1520min until pain is controlled FOLLOW-UP PEARLS AND PITFALLS
then q2h PRN
r For acute appendicitis, antibiotics are usually given FOLLOW-UP RECOMMENDATIONS r Failure to diagnose appendicitis is one of the most
preoperatively to decrease the risk of abscess Postoperatively, patients should return if they develop common causes for malpractice lawsuits in pediatric
formation and wound infection: any symptoms of an abdominal abscess, such as emergency medicine.
Ampicillin/Sulbactam 100200 mg abdominal pain, vomiting, or fever. r Younger children, particularly of toddler age, are at
ampicillin/kg/day divided q6h to a max of 12 g increased risk for perforated appendicitis, probably
q6h due to inability to communicate pain sensation.
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ARTHRITIS, RHEUMATOID
Helene Tigchelaar
Usha Sethuraman
74
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ARTHRITIS, RHEUMATOID
A
r Rheumatic fever DISPOSITION r Pericarditis:
r Other immune-mediated diseases: Admission Criteria Presenting symptom or accompany systemic JIA
Henoch-Schonlein purpura, SLE, Kawasaki r Pericarditis/Symptomatic pericardial effusion Subclinical pericardial effusion or pericarditis
disease, polyarteritis r MAS or toxic appearing Chest pain, tachycardia, dyspnea, cardiomegaly,
Drug reaction, serum sickness friction rubs
r Hematologic/Oncologic: Issues for Referral CXR, ECG, echo
r Rheumatology referral for suspected JIA
Leukemia, lymphoma, neuroblastoma, bone Treatment:
r Ophthalmology for suspicion of uveitis ABCs
tumor, hemoglobinopathies, and hemophilia r Hematology/Oncology referral for suspected
r IBD Systemic steroids
malignancy Quality-of-life issues include depression, lower
r Orthopedic/Infectious disease for septic joint rate of marriage, increased unemployment as
TREATMENT COMPLEMENTARY & ALTERNATIVE
patients enter adulthood, and limited
socialization.
MEDICATION THERAPIES
r Physical and occupational therapy, splinting
First Line r Emotional support with counseling or therapy
NSAIDs: ADDITIONAL READING
r Inhibit COX-1 and COX-2 in the inflammatory r Borchers AT, Selmi C, Cheema G, et al. Juvenile
response
r For mild cases, response in 6 wk
FOLLOW-UP idiopathic arthritis. Autoimmun Rev. 2006;5:
279298.
r 50% respond to the 1st NSAID FOLLOW-UP RECOMMENDATIONS r DeWitt EM, Sherry DD, Cron RQ. Pediatric
r Another 50% respond to a 2nd NSAID Patient Monitoring rheumatology for the adult rheumatologist: Therapy
r Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r Patients on MTX and biologic agents require close
and dosing for pediatric rheumatic disorders. J Clin
r Ketorolac 0.5 mg/kg IV/IM q6h PRN monitoring of CBC and LFTs. Rheumatol. 2005;11(1):2133.
r Naproxen 5 mg/kg PO q8h PRN r Patients on etanercept require monitoring for r Giannini EH, Ilowite NT, Lovell DJ, et al. Long-term
neurologic complications including neuropathy. safety and effectiveness of etanercept in children
Second Line r All patients with JIA require monitoring for
r Disease-modifying antirheumatic drugs with selected categories of juvenile idiopathic
ophthalmic complications. arthritis. Arthritis Rheum. 2009;60(9):27942804.
r Required in 2/3 of persistent joint disease
r Goldmuntz EA, White PH. Juvenile idiopathic
r Retards progression of disease: PROGNOSIS
r Mortality reported is 0.291.1%. arthritis. A review for the pediatrician. Pediatr Rev.
Methotrexate (MTX) 515 mg/m2 once weekly r 60% of deaths are due to systemic type. 2006;27:2432.
PO, IM or SC: r Ravelli A, Martini A. Juvenile idiopathic arthritis.
Used for systemic/polyarticular forms r Spontaneous remission varies by subtype:
Requires folic acid supplementation Systemic onset: Lancet. 2007;369:767778.
Requires lab monitoring 50% remit in 1 yr, 25% joint destruction
Improvement after 612 wk Oligoarticular: Best prognosis of all:
Combination therapy with leflunomide has 3550% remission rates CODES
better outcome when monotherapy fails. Chronic uveitis has high morbidity; extended
Sulfasalazine, hydroxychloroquine type has worse prognosis. ICD9
r Biologic agent: Tumor necrosis factor (TNF) receptor RF-positive polyarticular disease has a 6% 10-yr r 714.30 Chronic or unspecified polyarticular juvenile
antagonists: remission rate: rheumatoid arthritis
Generally chronic and progressive r 714.31 Acute polyarticular juvenile rheumatoid
Rapid improvement in MTX resistance cases
Etanercept 0.4 mg/kg SC biweekly or 0.8 mg/kg Psoriatic arthritis is chronic and destructive. arthritis
r Biologic agents are continuing to improve functional r 714.32 Pauciarticular juvenile rheumatoid arthritis
SC once weekly
Other TNF-alpha antagonists used are infliximab outcome.
and adalimumab. r Predictors of progressive disability: Female sex,
r Oral or IV steroids 0.52.0 mg/kg/day PO: early-onset symmetric disease, hip involvement, PEARLS AND PITFALLS
Systemic JIA, rarely used for other subtypes positive RF, and prolonged elevation of ESR
r Pearls:
Not for long-term therapy COMPLICATIONS
r Uveitis (may be presenting complaint): Increased use of disease-modifying antirheumatic
Early use of MTX to allow weaning of steroids
r Corticosteroid joint injection: drugs and biologic agents is dramatically
Common in pauciarticular with positive ANA improving outcome.
Most commonly used in pauciarticular Red eye, tearing, pain, decreased vision r Pitfalls:
Prevents use of systemic drugs Permanent damage may have occurred.
r All patients with JIA require emergent Severe pain, refusal to bear weight, or a red hot
Triamcinolone hexacetonide
r Treatment of uveitis: severely painful joint suggests infection or
ophthalmology exam for eye complaints: malignancy rather than JIA.
Frequent eye exams Regular slit lamp exam on a set schedule: Normal laboratory studies including negative ANA
Topical corticosteroids and mydriatics Frequency based on duration, age at onset, and and acute phase reactants do not rule out JIA.
Systemic steroids and sub-Tenon injections ANA status of disease Patients on immunosuppressive therapy may not
r Macrophage activation syndrome (58%):
SURGERY/OTHER PROCEDURES demonstrate normal serologic or clinical response
r Release of joint contractures Systemic onset highest risk to infection.
r Joint replacement Fever, hepatosplenomegaly, anemia, Failure to entertain the diagnosis of uveitis in any
r Autologous stem cell transplants lymphadenopathy, thrombocytopenia and child with a red, painful, or tearing eye
leukopenia, neurologic abnormalities
May follow infection or due to drugs (MTX,
sulfasalazine, NSAIDs)
Treatment:
High-dose IV corticosteroids
Cyclosporin
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ARTHRITIS, SEPTIC
Rebecca L. Vieira
Nikhil B. Shah
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ARTHRITIS, SEPTIC
A
Diagnostic Procedures/Other r Ciprofloxacin 10 mg/kg/dose q12h up to max COMPLICATIONS
r Arthrocentesis is necessary 400 mg IV q12h r Osteomyelitis
r Orthopedic consultation if uncomfortable or For use if suspected GC arthritis, only appropriate r Bacteremia or sepsis
inexperience performing arthrocentesis in areas without GC quinolone resistance r 1040% will have the following:
r Oxacillin 50 mg/kg/dose IV q68h up to max Decreased joint function(restriction, increased
DIFFERENTIAL DIAGNOSIS
r Fracture, sprain, soft tissue traumatic injury 1 g/dose IV q6h laxity
r Nafcillin 25 mg/kg/dose IV q46h up to max 2 g IV Limb length discrepancy
r Other orthopedic conditions (eg, slipped capital
q46h Avascular necrosis
femoral epiphysis, Legg-Calve-Perthes disease) r Clindamycin 10 mg/kg/dose IV q8h
r Oncologic processes (eg, leukemia, osteosarcoma, Enlargement of the femoral head (in septic
r Vancomycin 10 mg/kg/dose IV q12h up to max arthritis of the hip)
osteoid osteoma)
r Aseptic arthritis single dose 1 g IV q12h
r Sexually active adolescents: Anti-staph and strep
r Reactive arthritis REFERENCES
r Lyme disease agent plus coverage for N. gonorrhoeae
r Cellulitis (3rd-generation cephalosporin or quinolone if in 1. Riise OR, Handeland KS, Cvancarova M, et al.
nonquinolone-resistant geographic area) Incidence and characteristics of arthritis in
r Osteomyelitis
SURGERY/OTHER PROCEDURES Norwegian children: A population-based study.
r Transient synovitis
Septic hip usually mandates surgical irrigation: Pediatrics. 2008;121(2):e299306.
r Arthroscopy and needle aspiration may be 2. Yagupsky P, Bar-Ziv Y, Howard CB, et al.
Epidemiology, etiology, and clinical features of
TREATMENT considered in certain circumstances, but this
septic arthritis in children younger than 24 months.
decision is made by orthopedic surgeon.
MEDICATION Arch Pediatr Adolesc Med. 1995;149(5):53740.
DISPOSITION 3. Sauer ST, Farrell E, Gellar E, et al. Septic arthritis in
First Line
r Analgesics, antipyretics, and antibiotics are the Admission Criteria a patient with juvenile rheumatoid arthritis. Clin
r All patients are admitted Orthop Relat Res. 2004;(418):21921.
mainstay pharmacologic agents. r If findings are equivocal, arthrocentesis or
r Opioids 4. Mathews CJ, Coakley G. Septic arthritis: Current
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: orthopedic consultation cannot occur in ED, admit diagnostic and therapeutic algorithm. Curr Opin
Initial morphine dose 0.1 mg/kg IV/SC may be patient for inpatient therapy and observation. Rheumatol. 2008;20:457.
repeated q1520min until pain is controlled Discharge Criteria 5. Luhmann JD, Luhmann SJ. Etiology of septic
then q2h PRN r Well-appearing arthritis in children: An update for the 1990s.
Codeine codeine/acetaminophen dosed as r No fever, normal WBC, normal ESR and CRP, able to Pediatr Emerg Care. 1999;15:40.
0.51 mg/kg of codeine component PO q4h PRN bear weight (if lower limb joint)
Hydrocodone or hydrocodone/acetaminophen r Synovial fluid analysis with WBC <50,000 cells/
dosed as 0.1 mg/kg of hydrocodone component microL and negative Gram stain in well-appearing CODES
PO q46 h PRN child with good follow-up
r NSAIDs ICD9
Issues for Referral r 711.40 Arthropathy, site unspecified, associated
Consider NSAID medication in anticipation of r Refer to orthopedic surgeon
prolonged pain and inflammation r Refer to infectious disease specialist for unusual with other bacterial diseases
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN. r 711.45 Arthropathy involving pelvic region and
Ketorolac 0.5 mg/kg IV/IM q6h PRN pathogens or therapy failure
thigh associated with other bacterial diseases
Naproxen 5 mg/kg PO q8h PRN r 711.46 Arthropathy involving lower leg associated
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN
r Septic arthritis is a surgical emergency that requires
FOLLOW-UP with other bacterial diseases
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ASCARIS LUMBRICOIDES
Ami P. Shah
Raymond Pitetti
r They further mature in the lungs for 1014 days. PHYSICAL EXAM
BASICS r Larvae then penetrate the alveolar walls and enter r Most patients are asymptomatic.
the tracheobronchial tree. From this site, they are r The patient may be malnourished.
DESCRIPTION coughed up, swallowed, and reach the small r Nonspecific GI symptoms, including abdominal pain
r Ascaris lumbricoides is the largest small intestinal r Heavy worm load may present as intestinal
intestine:
parasite, growing up to 40 cm. Loffler syndrome: Acute transient pneumonitis obstruction.
r It is a roundworm (nematode) that is the most may occur during the larval migratory phase, r May present with signs of biliary obstruction and
common cause of helminth infections in humans. presenting with fever, cough, and marked peritonitis, including:
EPIDEMIOLOGY eosinophilia. Abdominal distention
r >1 billion people are infected with this worm r In the small intestine, they mature into adult worms,
Decreased bowel sounds
annually. where they then reside. Scleral icterus
r Most common in tropical and subtropical areas r Adult female worms lay 200,000 eggs per day. Jaundice
r Uncommon in the U.S., found predominantly in rural r Eggs are passed in the feces. They need to incubate Pallor
southeastern parts of the U.S. for 23 wk in the soil to become infectious.
DIAGNOSTIC TESTS & INTERPRETATION
r Global distribution ETIOLOGY Lab
r 1/41/3 of the worlds population is infected with A. lumbricoides, or roundworm: A small intestinal r Stool for ova and parasites:
this worm. parasite Infection is confirmed by identification of eggs in
r School-aged children have highest incidence. the stool sample.
COMMONLY ASSOCIATED CONDITIONS r Peripheral blood can be tested to look for
RISK FACTORS Malnutrition
r Poor hygiene and sanitation eosinophilia in severe cases or suspected case of
r Unwashed vegetables and fruits Loffler syndrome.
r Children playing in soil
DIAGNOSIS Imaging
r Not routinely required
HISTORY
GENERAL PREVENTION r Patients may present with nonspecific GI and r X-ray, US, and CT scan of the abdomen may be
r Routine sanitary hygiene, especially good hand
pulmonary symptoms, such as: required based on the clinical presentation.
washing
r Washing vegetables and fruits well, especially if Nausea
DIFFERENTIAL DIAGNOSIS
Vomiting r Acute appendicitis
grown in soil that uses human feces as a fertilizer Abdominal pain r Cholangitis
PATHOPHYSIOLOGY Diarrhea r Hepatitis
r Infection starts with ingestion of fertilized eggs. Cough
r Pancreatitis
Unfertilized eggs are not infective: Nasal congestion
r Patients may cough up round white strings or r Other helminth or tropical parasitic infections, such
Ingestion of eggs is typically from unwashed fruits
or vegetables that contain eggs. noodlelike material. as strongyloides and hookworm
Children may become infected directly from their r Travel to tropical areas or living on a farm are crucial
hands when playing in soil or sand containing the components of the history.
parasite.
r The larvae then hatch in the small intestine, from
where they enter the portal circulation and reach the
lungs via systemic circulation.
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ASCARIS LUMBRICOIDES
A
SURGERY/OTHER PROCEDURES COMPLICATIONS
r May be required to relieve obstruction caused by a r Loffler syndrome
TREATMENT r Small bowel obstruction
heavy worm load
INITIAL STABILIZATION/THERAPY r Endoscopic retrograde cholangiopancreatography r Small bowel perforation and peritonitis
r Assess and stabilize airway, breathing, and may help relieve biliary obstruction. r Biliary tract obstruction
circulation.
r Symptomatic care unless signs of intestinal DISPOSITION
obstruction are present
Admission Criteria ADDITIONAL READING
r Secondary intestinal obstruction, peritonitis, bowel
r Emergent surgical consultation if intestinal
perforation, or biliary tract obstruction American Academy of Pediatrics. Ascaris lumbricoides
obstruction r Critical care admission criteria: infections. In Pickering LK, Baker CJ, Kimberlin DW,
MEDICATION If unstable vital signs, particularly due to et al., eds. Red Book: 2009 Report of the Committee
First Line pulmonary compromise on Infectious Diseases. 28th ed. Elk Grove Village, IL:
r Treatment should be instituted for all cases, both Author; 2009:221222.
Discharge Criteria
asymptomatic. Appropriate antihelminth therapy has been initiated See Also (Topic, Algorithm, Electronic
r Benzimidazoles (albendazole and mebendazole) are
Issues for Referral Media Element)
wormicidals. These agents act by blocking the Infectious disease referral may be required in the U.S. http://www.dpd.cdc.gov/dpdx/html/Ascariasis.htm
energy/adenosine triphosphate production of the since the infection is infrequent.
worms, leading to their death:
Albendazole: <2 yr of age, 200 mg PO as a single CODES
dose; >2 yr of age, 400 mg PO as a single dose FOLLOW-UP
Mebendazole: >2 yr of age 100 mg PO b.i.d.
3 days: FOLLOW-UP RECOMMENDATIONS ICD9
Used in children >2 yr Discharge instructions and medications: 127.0 Ascariasis
r Ivermectin 150200 g/kg PO once, max single r Emphasize personal hygiene and hand washing.
dose 400 mg: r Although not necessary, it is recommended to
PEARLS AND PITFALLS
Used in children >15 kg repeat the stool sample for ova and parasites
Do not use during lactation. 23 wk after antihelminth therapy. r Pearls:
A 2nd course of antihelminth therapy may be Though rarely encountered in the U.S., Ascaris
ALERT necessary if the sample is positive. should be considered in any child with suggestive
For all medications above, safety not established in signs or symptoms.
Patient Monitoring
children <2 yr of age. r Inspect stools every day for worm passage. Antihelminth therapy is generally effective and
Pregnancy Considerations r If coughing, inspect the sputum for worms. safe.
r Pitfalls:
Safety not established in pregnant patients.
PROGNOSIS Delay in diagnosis can lead to serious
Second Line Unless there are rare complications such as bowel complications, including intestinal obstruction,
For cases of partial or complete intestinal and biliary obstruction or Loffler syndrome, the prognosis with peritonitis, bowel perforation, or biliary tract
tract obstruction: treatment is excellent. obstruction.
r Piperazine is a helminth paralytic. It causes flaccid
paralysis of the worms and thus facilitates their
passage from the small intestine (75 mg/kg PO per
day 2 days).
r Pyrantel pamoate is a neuromuscular depolarizing
agent that can be used alternatively (11 mg/kg/dose
PO as a single dose).
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ASCITES
Nirupama Kannikeswaran
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ASCITES
A
r US-guided paracentesis is preferred to reduce the SURGERY/OTHER PROCEDURES DIET
incidence of complications. r Large-volume paracentesis with albumin infusion: r Salt-restricted diet
r Removal of >100 mL/kg of ascitic fluid is considered For diuretic resistant ascites, tense ascites, or those r Maintain calorie intake at goal.
large-volume paracentesis, and albumin with respiratory distress secondary to ascites r Protein intake (1 g/kg/day) unless patient is severely
replacement in addition to IV fluid replacement r Definitive therapy may involve: catabolic
typically accompanies such paracentesis. Transjugular intrahepatic portasystemic shunts
(TIPS) and peritoneovenous shunts for refractory PROGNOSIS
DIFFERENTIAL DIAGNOSIS Variable depending on the cause and extent of
r Obesity ascites
Liver transplantation underlying disease
r Abdominal masses (eg, neuroblastoma,
DISPOSITION COMPLICATIONS
hepatoblastoma, Wilms tumor) r Respiratory distress
r Pregnancy Admission Criteria
r Ascites resistant to oral diuretic therapy r SBP
r Urine and fecal retention
r If SBP is suspected r Complications of portal HTN: Variceal hemorrhage,
r Critical care admission criteria: hepatorenal syndrome, liver failure
TREATMENT Ascites causing significant respiratory distress
PRE HOSPITAL Complications of underlying disease: Liver failure, REFERENCES
variceal hemorrhage, hepatic encephalopathy
Assess and stabilize airway, breathing, and circulation.
Discharge Criteria 1. Moore KP, Wong F, Gines P, et al. The
INITIAL STABILIZATION/THERAPY r Uncomplicated, small-volume ascites management of ascites in cirrhosis: Report on the
r Assess and stabilize airway, breathing, and consensus conference of the International Ascites
r Stable vital signs
circulation. r No airway or hemodynamic compromise Club. Hepatology. 2003;38:258266.
r Ascites with respiratory compromise should be 2. Peter L, Dadhich SK, Yachha SK. Clinical and
treated with paracentesis. Issues for Referral laboratory differentiation of cirrhosis and
r Dietary sodium restriction to 12 mEq/kg/day: r All patients with ascites require referral to a extrahepatic portal venous obstruction in children.
Effective in reducing the dose of diuretics and subspecialist for determination of the extent of J Gastroenterol Hepatol. 2003;18:185189.
leads to shorter hospital stay; effective only if underlying disease and its management. 3. Runyon BA, Montano AA, Akriviadis EA, et al. The
urinary sodium >15 mEq/24 hr r Referral to dietician to set caloric goal and serum-ascites albumin gradient is superior to the
r Water restriction is not recommended unless there sodium-restricted diet exudates-transudate concept in the differential
is associated hyponatremia (serum sodium diagnosis of ascites. Ann Intern Med. 1992;117:
<130 mmol/L). FOLLOW-UP 215220.
MEDICATION
r Diuretics are used to produce a negative fluid FOLLOW-UP RECOMMENDATIONS
r Discharge instructions and medications: CODES
balance of 10 mL/kg/day. Spironolactone and
furosemide are preferred diuretics. Steady gradual Sodium restricted diet:
12 mEq/kg/day for infants and children ICD9
loss is preferred. Oral diuretics are preferred
12 g/day (4488 mEq of sodium per day) in 789.59 Other ascites
compared to IV diuretics:
Spironolactone 1.53.3 mg/kg/day PO/IV in adolescents
r Consider combination oral diuretic therapy:
divided doses b.i.d.q.i.d. PEARLS AND PITFALLS
Furosemide 0.51 mg/kg/dose PO/IV q8h PRN Single morning dose of spironolactone
r For suspected or culture proven SBP: (0.33 mg/kg) along with furosemide (0.5 mg/kg) r Paracentesis is the gold standard to detect the
Cefotaxime 50 mg/kg/dose IV q8h, max single in the ratio of 5:2 underlying cause of ascites.
r Follow up with an appropriate specialist based on r Urgent paracentesis is indicated in patients with
dose 2 g/day
Ceftriaxone 50 mg/kg IV per day the etiology of ascites. ascites and fever or those with acute
r To prevent SBP: r Activity:
decompensation or significant respiratory distress
Penicillin 50 mg/kg/day PO divided b.i.d.q.i.d. Bed rest is not recommended in children with secondary to ascites.
may be used to prevent SBP in patients with uncomplicated ascites. r Prompt initiation of broad-spectrum antibiotic
ascites. This practice is losing prevalence due to Patient Monitoring therapy is indicated if SBP is suspected.
poor penicillin sensitivity of streptococcal bacteria. r Strict intake and output
r Weight
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ASTHMA
Catherine H. Chung
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ASTHMA
A
r Ketamine 0.252 mg/kg IV/IM loading dose: PROGNOSIS
r Improvement of an asthma exacerbation can be
TREATMENT May be followed with infusion
Ketamine may be used in an attempt to avert expected in 2448 hr.
PRE HOSPITAL intubation or as sedation prior to endotracheal r Long-term control of asthma symptoms can be
r Assess and stabilize airway, breathing, and intubation. expected in 24 wk.
circulation. r Noninvasive positive pressure ventilation: r 50% of children with asthma will be asymptomatic
r Administer supplemental oxygen. BiPAP/CPAP: as adults.
r Administer bronchodilators as appropriate protocol. Use in an attempt to avert endotracheal intubation
COMPLICATIONS
MEDICATION DISPOSITION r Cardiorespiratory arrest
Admission Criteria r Pneumothorax
First Line
r Mild to moderate exacerbations: Critical care admission criteria: r Pneumomediastinum
Oxygen to achieve oxygen saturation >90% r Altered mental status, need for ventilation support r Pneumonia
Inhaled beta2 -agonist, with or without (BiPAP/CPAP, mechanical ventilation), need for r Cardiac dysrhythmias
ipratropium, up to 3 treatments in 1st hr adrenergic infusion, need for very frequent (eg,
Inhaled beta2 -agonist may be either albuterol or q60min nebulization, significant respiratory acidosis,
levalbuterol: severe hypoxia, hypercarbia, respiratory failure, ADDITIONAL READING
Albuterol 0.15 mg/kg/dose by intermittent or complications (pneumothorax, dysrhythmias), or r Camargo CA Jr, Spooner CH, Rowe BH. Continuous
continuous nebulization (0.5 mg/kg/hr) comorbidities (pneumonia, cystic fibrosis)
Continuous nebulization has similar efficacy and r Admit less severely ill patients to the general versus intermittent beta-agonists in the treatment of
side effects as intermittent dosing. inpatient unit. acute asthma. Cochrane Database Syst Rev.
Levalbuterol (0.075 mg/kg) by intermittent 2003:cd001115.
Discharge Criteria r Craven D, Kercsmar CM, Myers TR, et al.
or continuous nebulization r Good clinical response to treatment that is sustained
Ipratropium bromide (0.250.5 mg), up to Ipratropium bromide plus nebulized albuterol for the
60 min after last treatment treatment of hospitalized children with acute
3 treatments in 1st hr, given concurrently with r Peak flowmeter >80% predicated
inhaled beta2 -agonist asthma. J Pediatr. 2001;138:51.
r Caregiver and patient competence in proper use of r Kulick R, Ruddy R. Allergic emergencies. In Fleisher
Systemic corticosteroids if no immediate
improvement or prolonged symptoms prior to inhaler G, Ludwig S, eds. Textbook of Pediatric Emergency
r Reliable caregivers to provide continual observation Medicine. 4th ed. Philadelphia, PA: Lippincott
arrival:
Prednisone or prednisolone 12 mg/kg PO, max and management of medication Williams & Wilkins; 2000;9991016.
single dose 60 mg r National Asthma Education and Prevention
Issues for Referral
Methylprednisolone 2 mg/kg Refer to an allergist or pulmonologist if: Program. Expert Panel Report 3: Guidelines for the
Dexamethasone 0.6 mg/kg IV/IM/PO, max r Atypical symptoms or questionable diagnosis Diagnosis and Management of Asthma. NIH-NHLBI
single dose 12 mg r Comorbid conditions (sinusitis, nasal polyps, severe publication. Washington, DC: U.S. Government
Single-dose dexamethasone equivalent to burst Printing Office. October 2007.
rhinitis, vocal cord dysfunction)
dose of prednisone; may be used without r Specialized treatment for immunotherapy See Also (Topic, Algorithm, Electronic
subsequent steroid treatment
r Severe exacerbations: r Poor control of asthma symptoms Media Element)
r Patient requires additional education and guidance r Bronchiolitis
As outlined for mild to moderate exacerbations, r Wheezing
plus consider: on complications of therapy, medication adherence,
Nonrebreathing mask to deliver supplemental or allergen avoidance
oxygen r Life-threatening asthma exacerbation
Epinephrine 1:1000, 0.01 cc/kg/dose (max r >2 oral corticosteroid courses per year CODES
single dose 0.5 cc) SC or IM
Indicated for those with very tight wheezing with ICD9
impaired delivery of inhaled beta-agonists. FOLLOW-UP r 493.00 Extrinsic asthma, unspecified
IV magnesium sulfate 5075 mg/kg over 20 min, r 493.02 Extrinsic asthma, with (acute) exacerbation
r Discharge instructions and medications:
max single dose 2.5 g r 493.81 Exercise induced bronchospasm
Terbutaline 10 g/kg SC/IV bolus: Provide an asthma action plan detailing when and
May follow with infusion of 0.4 g/kg/min; how to escalate therapy.
increase by increments of 0.30.5 g/kg/min Patients with persistent asthma should be started
on a daily inhaled corticosteroid. PEARLS AND PITFALLS
q30min as needed for respiratory distress r Activity: r Albuterol and levalbuterol, at equipotent doses,
Second Line Avoid exercise or pollen if these are triggers. have similar efficacy and safety profiles.
Adjunctive therapies, with largely unproven benefit, Patient monitoring r In severe asthma with very poor aeration, wheezing
may be considered for severely ill children who are Use peak flowmeter to monitor lung function.
unresponsive to more conventional treatment: may not be heard.
Provide asthma action plan to clarify medication r Ketamine is the sedative of choice for endotracheal
r Heliox (mixture of oxygen and helium) to reduce plan and warning signs. intubation due to bronchodilatory properties.
turbulent airflow and resistance
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ASYSTOLE
Mioara D. Manole
Robert W. Hickey
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ASYSTOLE
A
MEDICATION REFERENCES
TREATMENT Administration routes:
r IV or IO is preferable. 1. Topjian AA, Berg RA, Nadkarni VM. Pediatric
PRE HOSPITAL r Absorption of medication through a tracheal tube is cardiopulmonary resuscitation: Advances in
r Activate EMS (5). science, techniques, and outcomes. Pediatrics.
uncertain.
r Get automated defibrillation (automatic external r Epinephrine: 2008;122:10861098.
defibrillator) (5). 0.01 mg/kg of 1:10 000 for the 1st and 2. Moler FW, Meert K, Donaldson AE, et al.
r Start CPR (5). subsequent doses IV or IO: In-hospital versus out-of-hospital pediatric cardiac
r Airway management (5): Higher doses (IV or IO) are no longer arrest: A multicenter cohort study. Crit Care Med.
Short transport time: Bag-mask ventilation recommended and may be harmful. 2009;37:22592267.
Long transport time: Placement of advanced If administered via tracheal tube, use a dose of 3. Atkins DL, Everson-Stewart S, Sears GK, et al.
airway depends on the level of training, 0.1 mg/kg to compensate for lower absorption. Epidemiology and outcomes from out-of-hospital
experience, and availability of end-tidal CO2 r Magnesium sulfate for hypomagnesemia or torsades cardiac arrest in children: The Resuscitation
detector. de pointes: Outcomes Consortium EpistryCardiac Arrest.
If airway is obstructed, reposition (jaw thrust, 2550 mg/kg, max 2 g IV or IO Circulation. 2009;119:14841491.
head tilt chin lift) and look for foreign body in the r Dextrose if glucose is <50 mg/dL: 4. Reis AG, Nadkarni V, Perondi MB, et al. A
oropharynx. 0.25 g/kg rapid IV infusion (2.5 cc/kg D10) prospective investigation into the epidemiology of
in-hospital pediatric cardiopulmonary resuscitation
INITIAL STABILIZATION/THERAPY SURGERY/OTHER PROCEDURES using the international Utstein reporting style.
r Airway and breathing (5):
Extracorporeal membrane oxygenation (ECMO): Pediatrics. 2002;109:200209.
Tracheal intubation r Consider ECMO-CPR (E-CPR) for selected patients in 5. The International Liaison Committee on
Use capnography or an end-tidal CO2 detector. which ROSC cannot be achieved (eg, in-hospital CA, Resuscitation (ILCOR) consensus on science with
Resuscitation with 100% O2 . witnessed arrests with bystander CPR and short treatment recommendations for pediatric and
After ROSC: Titration of FiO2 to ensure adequate transport time, in select patients with reversible neonatal patients: Pediatric basic and advanced life
oxygenation while avoiding hyperoxia pathologic processes).
r Compression technique: Push hard, push fast, support. Pediatrics. 2006;117:e955e977.
r Consider ECMO for patients with hemodynamic
minimize interruptions (5): instability after ROSC.
Push hard: 1/3 of the depth of the chest
Infant: Chest compressions with 2 thumbs DISPOSITION CODES
encircling hands technique (2 rescuers), or Admission Criteria
2-finger technique (1 rescuer) Critical care admission criteria: ICD9
Children: 1- or 2-hand technique r All patients who have sustained CA 427.5 Cardiac arrest
r Compression/Ventilation ratio (5):
Lay rescuers 30:2 for single responder PEARLS AND PITFALLS
Health care providers 15:2 FOLLOW-UP
After advanced airway is placed (eg, endotracheal r Pearls:
tube, laryngeal mask airway, Combitube, etc.), FOLLOW-UP RECOMMENDATIONS ECMO-CPR should be considered for selected
ventilations are given without interrupting chest PROGNOSIS patients.
r Survival is lower for the following categories:
compressions at a rate of 810/min (compressions Check for potential causes of CA (6Hs, 5Ts).
give at 100/min). Infants r Pitfalls:
r Treatment algorithm (5): Congenital abnormalities (cardiac, chromosomal
Inadvertent hyperventilation during CPR is
CPR abnormalities)
common and harmful.
Epinephrine every 35 min Chronic conditions (malignancy, transplant,
Check pulse and cardiac rhythm every 2 min. pulmonary, renal)
r Survival is higher for the following categories:
Rotate compressors every 2 min.
Check for potential causes (6Hs and 5Ts). Bystander CPR was administered.
r Postresuscitation care (5): ROSC was obtained in the field or before arrival to
Ventilation: the hospital.
Target normocapnia: Hospitals staffed with pediatric physicians
Hyperventilation can cause hypocapnia and In-hospital CA vs. out-of-hospital CA (2)
cerebral vasoconstriction, causing secondary Children compared with adolescents
r Survival to hospital discharge for all cases of
brain insult.
Hyperventilate only for impending herniation. pediatric CA:
Temperature: Out-of-hospital CA: 12%
Avoid hyperthermia. In-hospital CA: 27%
Therapeutic hypothermia may be beneficial for r Good neurologic outcome in children who gain
neurologic outcome. ROSC (2):
Consider inducing therapeutic hypothermia for Out-of-hospital CA: 24%
1224 hr for comatose patients. In-hospital CA: 47%
Hemodynamic support: COMPLICATIONS
Vasoactive drugs to improve hemodynamics and r Hypoxic-ischemic encephalopathy
maintain normotension: Epinephrine, r Seizures
norepinephrine, dopamine r Death
Glucose control:
Avoid hyperglycemia or hypoglycemia.
Glucose-containing fluids are not recommended
during resuscitation unless hypoglycemia is
present.
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ATAXIA
Steven Krebs
Faye Doerhoff
ETIOLOGY
BASICS r Acute ataxia: DIAGNOSIS
Acute cerebellar ataxia:
DESCRIPTION Historically, primary varicella was the most HISTORY
r Ataxia is a disturbance in making coordinated r Duration/progression of symptoms
common etiology of acute cerebellar ataxia,
movements. r Identify any previous similar or related episodes.
preceding as many as 26% of cases (2).
r Ataxias may be generalized, affecting gait or Generally considered postinfectious; commonly r Identify recent illnesses (weeks to months).
affecting extremities alone. occurs 2 wk following viral illness r Associated vertigo or otalgia
r Acquired ataxia is commonly differentiated into Infectious/Immune-mediated conditions for which r Recent head or neck trauma
acute, recurrent, or chronic: directed therapy may be required: r Recent immunizations
Acute ataxia in children is uncommon, and Brainstem encephalitis; pneumococcal or r Constitutional symptoms
life-threatening causes of pure ataxia are rare: meningococcal meningitis; herpes simplex virus r Access or exposure (witnessed or suspected) to
The most common cause is acute cerebellar (HSV)-1; acute demyelinating encephalomyelitis
medication, alcohol, or household chemicals
ataxia (40% of all cases) (1). (ADEM); mycoplasma pneumonia; legionella; r Changes in gait, speech, general coordination
Most common in younger children (24 yr of malaria; MS; systemic infections such as r Changes in cognitive function (in conjunction with
age) but may affect older children typhoid, scarlet fever, diptheria, leptospirosis,
70% have a history of antecedent infection and coxiella (Q fever) motor findings may suggest toxic/acquired
13 wk prior to ataxia. Infectious/Immune-mediated conditions for which pathology)
r Changes in personality or behavior
Toxic exposures account for 30% of acute supportive care is primary treatment:
Direct infection by echovirus, coxsackie B; post- r Recurrent or persistent headache, vomiting, and/or
cases.
Most commonly, it is a poisoning in children or parainfectious cerebellitis by Epstein-Barr diplopia suggest intracranial mass lesion and
6 yr of age. virus, hepatitis A, influenza A and B, coxsackie possible elevated ICP
2nd peak in adolescence, associated with A, parvovirus B19, measles, mumps, enterovirus r Delay or loss of developmental milestones in infants
intentional ingestion or drug abuse Toxic exposure/ingestion: Alcohol, ethylene glycol, and toddlers
Chronic ataxias can be further classified as anticonvulsants, dextromethorphan, r Repeated bronchopulmonary infections
progressive or nonprogressive: antihistamines, risperidone, phenothiazines (ataxia-telangiectasia)
Episodic and chronically progressive ataxias are Mass lesions: Tumor, vascular malformation, r Family history of ataxia (episodic ataxia)
uncommon and usually are caused by inherited abscess (cerebellar, cerebral, epidural)
metabolic or genetic disorders. Head or neck trauma: Cerebellar PHYSICAL EXAM
r Signs of increased ICP must be evaluated: Bulging
contusion/hemorrhage, posterior fossa
RISK FACTORS hematoma, postconcussion syndrome, fontanelle in infants, papilledema, Cushing triad
Access or exposure to toxic substances that may cause vertebrobasilar dissection (bradycardia, HTN, abnormal or irregular
ataxia Vertigo or vestibular pathology respirations)
Postictal r Meningismus including nuchal rigidity, Brudzinski
GENERAL PREVENTION
Poison prevention education is the most effective way Stroke and Kernig signs
Paraneoplastic syndrome: Opsoclonus-myoclonus r Neurologic exam may be difficult depending on
to prevent toxic exposures:
r Emphasize childproof containers and safe storage of syndrome (neuroblastoma) age/cooperation of the child: Include general
prescription medications so that they are Sensory ataxia: Guillian-Barre syndrome (GBS), consciousness, cranial nerve function, strength,
inaccessible to children. Miller-Fisher syndrome (MFS) tone, deep tendon reflexes (hyper- or areflexia),
Other: Nonconvulsive seizures/epilepsy, central proprioception, noting symmetry with all:
PATHOPHYSIOLOGY pontine myelinolysis, conversion disorder, paretic Patients with chronic lesions usually have normal
r Complex movements and activities are coordinated tone and reflexes.
ataxia of upper or lower motor neurons
by the cerebellum: r Recurrent ataxia: In infants, check for decreased truncal and/or
The cerebellum lies in the posterior cranial fossa Recurrence of acute cerebellar ataxia extremity tone, areflexia, decreased deep tendon
beneath the tentorium. Migraine or equivalents: Basilar migraine, benign reflexes
Lesions in the cerebellum, its afferent, and/or paroxysmal positional vertigo (BPPV) r Detailed cerebellar examination: Difficult to
efferent pathways can cause ataxia: Metabolic disorders: Mitochondrial disorders, urea impossible in younger children:
Midline lesions affect truncal gait with swaying cycle defects, amino/organic acidopathies, Observe posture and gait for wide base,
during walking, sitting or standing, or Hartnup disease staggering, zig-zag course, short unequal steps,
head/neck bobbing (titubations) Genetic: Episodic ataxia types 14 inability to sit/stand unsupported
Unilateral hemisphere lesions cause movement r Chronic ataxia: Swaying provoked with eye closure (Romberg
disturbance in the ipsilateral side Progressive ataxia: sign) may or may not be present depending on the
Acute cerebellar ataxia usually results from Brain tumor: Astrocytoma, pontine glioma, site of the lesion (lower vermis lesions cause
postinfectious cerebellar demyelination. medulloblastoma, ependymoma postural tremor not enhanced with eye closure)
r Hydrocephalus and increased intracranial pressure
Genetic: Friedrich ataxia, ataxia telangiectasia, Limb ataxia more marked in:
(ICP) from space-occupying lesions (posterior fossa spinocerebellar degeneration, Refsum disease Upper than lower extremities
tumors, cerebellar hemorrhage) may cause ataxia. Metabolic: Abetalipoproteinemia, liposomal Complex than simple movements
r Pathology of the inner ear or proprioceptive sensory Fast then slow movements (finger-to-nose,
storage disease, mitochondrial defects
dysfunction may also cause ataxia. Nonprogressive ataxia: heel-to-shin, rapid alternating movements)
Head trauma, cerebral palsy, kernicterus Distal movements are typically more affected than
Congenital malformations: Arnold-Chiari, proximal movements.
cerebellar agenesis/hypoplasia, Dandy-Walker Oculomotor signs such as rebound nystagmus,
opsoclonus
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ATAXIA
A
DIAGNOSTIC TESTS & INTERPRETATION Acyclovir IV q8h: 20 mg/kg <12 yr old; 10 mg/kg PROGNOSIS
12 yr old r Outcome is largely determined by etiology.
Lab
r Bedside serum glucose testing If immunocompromised, cover for Listeria r Acute cerebellar ataxia has an excellent prognosis,
r Lumbar puncture (LP) if febrile, toxic appearing, or monocytogenes with most patients recovering completely without
meningitic: Ampicillin 50 mg/kg IV q6h plus aminoglycoside intervention within 2 wk to 3 mo.
r Consider mannitol or hypertonic saline for increased r With or without specific treatment, >90% of GBS
CSF studies including culture with Gram stain,
protein, glucose, cell count, and viral studies: HSV, ICP: and MFS patients recover fully within 612 mo.
enterovirus, etc. Neurosurgery consultation is necessary for any
patient with evidence of increased ICP. COMPLICATIONS
Obtain opening pressures when possible.
Tumors, stroke, traumatic brain injury, and brainstem
CSF examination is routinely normal in Second Line encephalitis are commonly complicated by significant
postinfectious acute cerebellar ataxia. r GBS and MFS may be treated with intravenous
r Urine/serum toxicology screens: neurologic sequelae.
immunoglobulin (IVIG) and/or plasmaphoresis.
Drug level should be obtained where a specific r ADEM/inflammatory conditions may be treated with
intoxicant is identified. methylprednisolone or IVIG (specialty consultation REFERENCES
r Urinary catecholamine metabolites for suspicion of recommended). 1. Gierhon-Korthals MA, Westberry KR, Emmanuel PJ.
neuroblastoma
r Serologic evaluation for suspected inborn error of DISPOSITION Acute childhood ataxia: 10-year experience. J Child
Admission Criteria Neurol. 1994;9(4):381384.
metabolism includes CBC, transaminases, ammonia, r Inpatient admission criteria: 2. Connolly AM, Dodson WE, Prensky AL, et al.
lactate, pyruvate, and ketone levels.
Any acute ataxia without established etiology Course and outcome of acute cerebellar ataxia.
Imaging Concern for active infectious etiology requiring IV Ann Neurol. 1994;35(6):673679.
r Urgent head/brain imaging (usually CT) in any
antibiotic/antiviral treatment
patient with acute presentation of unknown Suspicion of GBS/MFS
etiology, focal neurologic deficits, altered Known or suspected ingestion of toxic substance ADDITIONAL READING
consciousness, recent head trauma, signs of requiring prolonged monitoring for clearance r Friday JH. Ataxia. In Fleischer GR, Ludwig S,
increased ICP, or persistent ataxia for >1 wk: r Critical care admission criteria:
Any patient having LP performed should first have Henretig FM, et al., eds. Textbook of Pediatric
Cases requiring advanced airway support Emergency Medicine. 6th ed. Philadelphia, PA:
head imaging to rule out obstruction or cerebellar Evidence of increased ICP, for neurosurgical
herniation. Lippincott Williams & Wilkins; 2010.
intervention, or for monitoring of treatment r Johnston MV. Movement disorders. In Kleigman RM,
MRI can detect inflammation/encephalitis, and is
better at posterior fossa imaging but is slower Discharge Criteria Behrman RE, Jenson HB, et al., eds. Nelson
r Well-appearing patients with acute cerebellar ataxia Textbook of Pediatrics. 8th ed. Philadelphia, PA:
than CT; need for stat MRI may be discussed with
neurologist and/or radiologist. r Toxic substance ingestions with short half-life and Saunders; 2007.
r If nuchal rigidity or pain or headache, consider return to baseline function r Ryan MM, Engle EC. Acute ataxia in childhood.
urgent CT or MRI; cerebellar herniation may cause Issues for Referral J Child Neurol. 2003;18(5):308316.
these symptoms. r Consider emergency department or inpatient
Diagnostic Procedures/Other neurology consultation especially when no clear
Further diagnostic testing may be indicated after etiology is readily identified. CODES
consultation with neurology: r Consider infectious disease consultation for
r EEG in patients with altered consciousness and inpatients with suspected infectious etiology. ICD9
r Local or regional poison control center and/or r 334.3 Other cerebellar ataxia
fluctuating clinical signs r 781.2 Abnormality of gait
r Electromyography in patients with sensory ataxia toxicology consultation for management
recommendations of known or suspected ingestion r 781.3 Lack of coordination
may help diagnose or confirm GBS or MFS.
r Inpatient cardiology evaluation if suspicion or
DIFFERENTIAL DIAGNOSIS diagnosis of Friedrich ataxia
See Etiology. r Inpatient genetics evaluation if suspicion of inborn PEARLS AND PITFALLS
error of metabolism r Failure to recognize signs of increased ICP may
TREATMENT result in worse neurologic outcomes or delay of
FOLLOW-UP lifesaving intervention.
PRE HOSPITAL r Acute cerebellar ataxia generally has no other
In the setting of recent trauma, cervical spine FOLLOW-UP RECOMMENDATIONS symptoms outside of incoordination, unsteady gait,
stabilization and evaluation of ABCs r Discharge instructions and medications:
or tremorany other findings require investigation
Supportive care and reassurance are the of alternate etiologies.
INITIAL STABILIZATION/THERAPY
r Prompt evaluation of ABCs mainstays in the majority of cases. r MFS is characterized by triad of ataxia, areflexia,
r Appropriate immobilization in cases of trauma For significant ataxia, head protection may be and opthalmoplegia (usually diplopia).
indicated due to risk of fall.
MEDICATION r Activity:
First Line Strenuous activities such as sports or those
r Suspicion of active infectious etiology (meningitis, requiring complex coordination (eg, bicycling)
encephalitis) warrants coverage with should be avoided until all symptoms resolve.
broad-spectrum antibiotics pending identification of
a causative organism. Consider acyclovir as well:
Ceftriaxone 50 mg/kg IV (max single dose 2 g)
q12h (meningitic dosing)
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ATLANTOAXIAL INSTABILITY
Joni E. Rabiner
Jeffrey R. Avner
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ATLANTOAXIAL INSTABILITY
A
DIFFERENTIAL DIAGNOSIS DISPOSITION ADDITIONAL READING
r Atlantoaxial dislocation
Admission Criteria
r Os odontoideum r Admit patients with suspected AAI. r Avner JR. Evaluation of the cervical spine. In
r Critical care admission criteria: Wolfson AB, Hendey GW, Ling LJ, et al., eds.
Symptoms of spinal cord compression Harwood-Nuss Clinical Practice of Emergency
TREATMENT Medicine. 5th ed. Philadelphia, PA: Lippincott
Discharge Criteria Williams & Wilkins; 2009:11001105.
PRE HOSPITAL Stable cervical spine without neurologic symptoms r Loder RT. The cervical spine. In Morrissy R, Weinstein
Cervical spine immobilization if: Issues for Referral
r Trauma with the presence of neck pain, limitation of S, eds. Lovell and Winters Pediatric Orthopedics.
Consult neurosurgery and/or orthopedic surgery for 6th ed. Philadelphia, PA: Lippincott Williams &
neck movement, neurologic symptoms, distracting symptomatic AAI. Wilkins; 2006:871920.
injury r Rahimi SY, Stevens EA, Yeh DJ, et al. Treatment of
r Known AAI with neurologic symptoms
FOLLOW-UP atlantoaxial instability in pediatric patients.
INITIAL STABILIZATION/THERAPY Neurosurg Focus. 2003;15(6):14.
r Maintain cervical spine stabilization with a hard FOLLOW-UP RECOMMENDATIONS r Shetty A, Kini A, Prabhu J. Odontoid fracture: A
r Discharge instructions and medications: retrospective analysis of 53 cases. Indian J Orthop.
cervical collar until a thorough neurologic exam is
completed and appropriate imaging, if indicated, is Follow-up for repeat imaging as directed 2009;43(4):352360.
obtained and reviewed. Neurologic consultation and close follow-up r Swischuk LE. Emergency Imaging of the Acutely Ill
r Asymptomatic AAI: No treatment should be assured if there is any radiographic or Injured Child. 4th ed. Baltimore, MD: Lippincott
r Symptomatic AAI: Cervical spine stabilization abnormality or if there is high suspicion of injury Williams & Wilkins; 2000.
maintaining the spine in a neutral position (eg, persistent neck pain, neurologic symptoms)
regardless of radiographic results. See Also (Topic, Algorithm, Electronic
r Rotary subluxation: Most resolve spontaneously;
r Activity: Media Element)
antibiotics to treat associated infections as r Fracture, Cervical spine
needed: Activity recommendations are made on an r Spinal Cord Compression
<1 wk of symptoms: Soft collar, rest for a week, individual basis.
r Trauma, Neck
physical therapy In general, avoid contact sports or sports with
>1 wk of symptoms: Halo traction high risk of neck flexion in patients with:
Postsurgical stabilization
MEDICATION Down syndrome with ADI >5 mm CODES
First Line High-risk sports include gymnastics, diving,
Consider NSAIDs to reduce inflammation in rotary pentathlon, butterfly stroke, high jump, and soccer. ICD9
subluxation: Patient Monitoring 718.88 Other joint derangement, not elsewhere
r Ibuprofen 10 mg/kg/dose PO/IV q6h PRN, max dose Observe for neurologic symptoms. classified, involving other specified sites
800 mg PO, 2.4 g/24 hr
r Ketorolac 0.5 mg/kg IV/IM q6h PRN, max dose PROGNOSIS
30 mg/dose, 120 mg/24 hr
Depends on cause of AAI and neurologic PEARLS AND PITFALLS
r Naproxen 5 mg/kg PO q8h PRN, max dose involvement: r Pearls:
r Good prognosis for those with symptomatic AAI
500 mg/dose, 1,250 mg/24 hr Down syndrome is an important associated
treated with surgery
Second Line condition that increases the risk of AAI and
r Methylprednisolone 30 mg/kg IV over 15 min COMPLICATIONS resultant spinal cord compression.
r Subluxation Any patient with an increased predental space on
followed by an infusion of 5.4 mg/kg over the next
r Spinal cord compression with excessive range of lateral cervical spine x-ray should have additional
23 hr:
Indicated for neoplastic or inflammatory etiology motion in AAI radiographic imaging (CT or MRI) to delineate the
of spinal cord compression presence and/or extent of injury, regardless of the
Dosage derived from adult guidelines due to lack presence or absence of neurologic symptoms.
of high-level evidence in pediatrics REFERENCES Persistent torticollis, neck pain, or limitation of
Steroids are no longer routinely used for spinal neck movement (especially if associated with
1. American Academy of Pediatrics Committee on trauma or a recent head/neck infection) may be a
cord trauma, as current data has led to its Sports Medicine and Fitness. Atlantoaxial instability
withdrawal from Advanced Trauma Life Support sign of atlantoaxial rotary subluxation.
in Down syndrome: Subject review. Pediatrics. r Pitfalls:
(ATLS) guidelines. 1995;96:151154.
r Dexamethasone may be used for spinal cord Forcing the neck into a neutral position during
2. Willis BPD, Dormans JP. Nontraumatic upper clinical evaluation if there is resistance to
compression: cervical spine instability in children. J Am Acad
Numerous dosing regimens exist, with no very movement, increased pain, or torticollis
Orthop Surg. 2006;14:233245. Inaccurate measurement of the predental space
definitive benefit of a specific regimen. Refer to
the consulting neurologist and/or neurosurgeon on a lateral cervical spine x-ray
for dosing recommendations. Attempting and/or forcing flexion and extension
views of the cervical spine if there are neurologic
SURGERY/OTHER PROCEDURES symptoms
Posterior C1-2 fusion for unstable displacement,
neurologic involvement, or transverse ligament
injuries, as they are unlikely to heal
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ATOPIC DERMATITIS
Desiree M. Seeyave
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ATOPIC DERMATITIS
A
r Mid-potency steroids: Second Line PROGNOSIS
Betamethasone valerate (Valisone) 0.1% Prednisone 12 mg/kg PO divided per dayb.i.d.: r Up to 50% of patients outgrow atopic dermatitis
cream/ointment b.i.d. r A short course may be given in disease that is after 5 yr of age.
Fluticasone (Cutivate) 0.05% cream/ointment difficult to control or hospitalized patients. r Can be a lifelong condition; tends to improve with
b.i.d. r Never use in any case of eczema herpeticum. age
Mometasone (Elocon) 0.1%
cream/ointment/lotion b.i.d. DISPOSITION COMPLICATIONS
r Hyper- or hypopigmentation of affected areas
Prednicarbate (Dermatop) 0.1% b.i.d. Admission Criteria r Sepsis from bacterial or viral superinfection
Triamcinolone acetonide (Aristocort) 0.1% r Ill appearing
r Extensive skin involvement with weeping, secondary r Localized abscess formation
cream/ointment b.i.d.
r Low-potency steroids: r Flexion contractures in severe cases
bacterial or viral superinfection
Hydrocortisone 12.5% cream/ointment/lotion r Dehydration from excessive loss of fluids from the r Overuse of potent topical steroids can result in
b.i.d.t.i.d. skin hypopigmentation, telangiectasias, atrophy, striae,
Desonide (DesOwen) 0.05% cream b.i.d. r Disseminated eczema herpeticum for IV antivirals and systemic absorption leading to
Fluocinolone acetonide (Synalar) 0.01% cream, hypothalamic-pituitary axis suppression and growth
apply sparingly b.i.d. Discharge Criteria retardation.
r Well appearing
r Low-cost generic steroids:
r Mild-moderate involvement of skin
Betamethasone dipropionate 0.05% r Reliable follow-up
ointment/cream REFERENCES
Mometasone 0.1% cream/ointment/lotion Issues for Referral 1. Paller A, Eichenfield LF, Leung DY, et al. A 12-week
Triamcinolone acetonide 0.1% ointment/cream Refer to dermatologist in severe cases, unresponsive study of tacrolimus ointment for the treatment of
Fluocinolone acetonide 0.01% to topical steroids, extensive lichenification, eczema atopic dermatitis in pediatric patients. J Am Acad
Hydrocortisone 1% cream/ointment/lotion herpeticum Dermatol. 2001;44(1 Suppl):S47S57.
r Bland emollients (eg, Aquaphor, Vaseline), apply
COMPLEMENTARY & ALTERNATIVE 2. Hoare C, Li Wan Po A, Williams H. Systematic
liberally several times a day review of treatments for atopic eczema. Health
r Antihistamines to control itching: THERAPIES
r Phototherapy with ultraviolet B for extensive and Technol Assess. 2000;4(37):1191.
Diphenhydramine 1.25 mg/kg/dose q6h PO/IM/IV 3. Isolauri E, Arvola T, Tas YS, et al. Probiotics in the
resistant disease (2)
(max 300 mg/day) r Probiotic-supplemented formula: Bifidobacterium management of atopic eczema. Clin Exp Allergy.
Hydroxyzine 2 mg/kg/day divided q68h PO; 2000;30(11):16041610.
0.51 mg/kg/dose q46h IM PRN lactis Bb-12 and Lactobacillus strain GG decrease
r Calcineurin phosphatase inhibitors: severity of atopic dermatitis in babies being weaned
off breast milk (3).
Suppresses T-cell function r Trim nails to prevent scratching. CODES
Safe and effective in children >2 yr of age with r Protective clothing while sleeping.
severe atopic dermatitis (1)
r Cold compresses q.i.d. for acute flares with oozing, ICD9
Tacrolimus 0.03% or 0.1% cream or pimecrolimus r 690.12 Seborrheic infantile dermatitis
1% cream: Apply a thin layer to the skin b.i.d. and crusting, and superinfection
r 691.8 Other atopic dermatitis and related conditions
continue for 1 wk after skin clearance.
r Antivirals for eczema herpeticum: r 705.81 Dyshidrosis
Acyclovir 15 mg/kg/day IV divided q8h or 1,200
FOLLOW-UP
mg/day PO (max 80 mg/kg/day) divided q68h FOLLOW-UP RECOMMENDATIONS
710 days Discharge instructions and medications:
PEARLS AND PITFALLS
Valacyclovir 20 mg/kg PO t.i.d. for 5 days (max r Frequent application of emollients for skin r Good skin care and lubrication are essential for
3 g/day) in children >2 yr r Limit length, frequency, and temperature of bathing. control of disease.
r Topical steroids for active lesions: Mild, mid-, high r Topical steroid overuse can lead to chronic skin
ALERT
r Use of corticosteroids on the face may produce potency changes and adrenal suppression.
r Primary care provider follow-up in 12 wk, sooner if r Eczema herpeticum and severe disease can lead to
permanent change in cosmetic appearance. Limit
corticosteroid use on the face to <35 days of culture of lesions was performed severe fluid loss from lack of a protective skin barrier.
r Return for pain or swelling, increasing discharge,
continuous use.
r Calcineurin phosphate inhibitors should not be fever, worsening of skin condition
used with occlusive dressings, and sun exposure DIET
should be avoided. Side effects include burning, Avoid known food allergies; in severe disease, avoid
pruritus, flulike symptoms, allergic reaction, common food allergens (eg, milk protein, peanuts,
erythema, and headache. eggs).
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93
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BACTEREMIA
Joni E. Rabiner
Jeffrey R. Avner
describe bacteremia in a well-appearing, previously common), Hib (if incomplete immunization) 15 hr (5)
healthy child (usually 336 mo of age) without a Bacteremia/Osteomyelitis: S. aureus, Salmonella Time to positive culture for contaminants:
source of infection on history or physical exam. r Bacteremia in children who are Mean 31 hr (5)
immunosuppressed: Contaminants: Slow growth, gram-positive
EPIDEMIOLOGY
S. aureus, Staphylococcus epidermidis (associated rods, coagulase-negative gram-positive cocci
Incidence with cellulitis, abrasion, indwelling catheters) C-reactive protein and ESR are nonspecific
r The incidence of bacteremia varies with a variety of
Streptococcus viridans (associated with mucosal inflammatory markers.
factors including: tenderness, mouth sores)
Exposure to a particular organism (ie, local Imaging
Gram-negative organisms (E. coli, Klebsiella, Consider CXR for occult pneumonia.
epidemiology) Pseudomonas)
The host immune status (eg, HIV, sickle cell S. pneumoniae Diagnostic Procedures/Other
disease, cancer) Salmonella Consider procedures related to complications of
Clinical appearance (well vs. ill) bacteremia:
Risk factors (eg, dental work, indwelling catheters) COMMONLY ASSOCIATED CONDITIONS r Bladder catheterization to evaluate for urinary tract
r Declining incidence of occult bacteremia: Complications include focal infections, meningitis, infection (UTI)
Routine Haemophilus influenzae type b (Hib) and sepsis, septic shock, pneumonia, and septic arthritis. r Lumbar puncture to evaluate for meningitis
heptavalent pneumococcal conjugate (PCV7) r Joint aspiration to evaluate for septic arthritis
vaccines have significantly decreased the
prevalence of occult bacteremia from 35% to DIAGNOSIS DIFFERENTIAL DIAGNOSIS
0.250.7% in vaccinated, nontoxic febrile r Viral illness
HISTORY r UTI
children (13). r Fever:
The risk of bacteremia in incompletely vaccinated r Occult pneumonia
>38 C (100.4 F) for infants <3 mo of age or
febrile children is likely <35% due to herd children with immunodeficiency r Sepsis
immunity. >39 C (102.2 F) for children 336 mo of age r Contaminated blood culture (false positive)
For vaccinated febrile children, the risk of serious who are well appearing and at risk for occult
complications is <0.05% (4). bacteremia
r The rate of contaminant isolation from blood r Risk factors: Chronic underlying illness, TREATMENT
cultures is 1.8% (2): immunodeficiency, recent antibiotic use
For example, with a bacteremia rate of 0.25%, r Immunization status INITIAL STABILIZATION/THERAPY
there would be 7 contaminated blood culture r Assess and manage ABCs per Pediatric Advanced
results for every 1 true positive blood culture (3). PHYSICAL EXAM Life Support (PALS) protocol.
r Vital signs r Patients with organisms other than S. pneumoniae
RISK FACTORS r General appearance:
r Chronic underlying medical conditions (such as S. aureus, N. meningitidis, H. influenzae)
r Immunodeficiency: HIV, chemotherapy Well appearing in occult bacteremia typically require hospital admission and parenteral
r Incomplete immunization: <6 mo of age or Ill appearance suggests a serious bacterial illness antibiotic therapy.
associated with the bacteremia. r If penicillin-susceptible bacterial growth, clinical
incomplete primary series of 3 vaccinations for both r Complete physical exam looking for source of signs and symptoms in the child guide
Hib and PCV7, although there may be effect with as infection: management:
few as 1 dose of vaccine (1) Petechiae, especially below the nipple line,
r Recent or current antibiotic use These patients may be appropriate candidates for
suggest the diagnosis of meningococcemia. outpatient therapy with amoxicillin, particularly if
GENERAL PREVENTION pathogen is S. pneumoniae.
DIAGNOSTIC TESTS & INTERPRETATION r Suspected occult bacteremia:
Routine vaccination with Hib, PCV7, and
Lab
meningococcal conjugate vaccine as per the Advisory Completely immunized child, no severe illness
Initial Lab Tests
Committee on Immunization Practices (ACIP) r If bacteremia is known from a prior blood culture other than fever, normal vital signs: No empiric
antibiotics are required.
PATHOPHYSIOLOGY result:
r Bacteria enter bloodstream: Repeat blood culture
Directly (eg, dental work, laceration, catheter Additional lab tests vary depending on:
placement) Age of the patient
Indirectly through disruption of normal mucosal Specific bacteria identified
barriers, usually following viral infection or other Host risk factors
focal infection: Appearance of the patient
Often associated with nasopharyngeal Persistence of fever
colonization or exposure (eg, meningococcemia, Other symptoms (nuchal rigidity, joint swelling,
invasive pneumococcal disease) respiratory distress, etc.)
r Bacteria in bloodstream are either cleared
spontaneously or cause focal infection or septicemia
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BACTEREMIA
r For incompletely immunized children with elevated Issues for Referral ADDITIONAL READING
WBC >15,000/mm3 : Any child with persistent or recurrent bacteremia
Consider ceftriaxone. should be referred to, or have consultation with, an r Avner JR. Acute fever. Pediatr Rev.
r For immunocompromised patients or patients with infectious disease specialist. 2009;30(1):513.
r Baraff LJ. Management of infants and children with
B
systemic symptoms, particularly unstable vital
signs: fever without source. Pediatr Ann.
Consider ceftriaxone and vancomycin.
FOLLOW-UP 2008;37(10):673679.
r In specific circumstances, such as leukopenic FOLLOW-UP RECOMMENDATIONS See Also (Topic, Algorithm, Electronic
oncology patients, additional antibiotic coverage for Discharge instructions and medications: Media Element)
Pseudomonas may be indicated. r If the child is treated with antibiotics, follow-up r Fever in Children Older than 3 Months
r Known bacteremia from a prior blood culture r Fever in Infants 03 Months of Age
within 24 hr.
result: r If the child is not treated with antibiotics, follow-up r Meningococcemia
If bacteremia is thought to represent a true for persistent fever in 48 hr. r Sepsis
pathogen (ie, not a contaminant), antibiotic r If the child looks sicker, or if new signs or symptoms
administration should be determined on the basis develop, the patient should follow-up sooner.
of known or epidemiologically determined
bacterial sensitivities. Patient Monitoring CODES
Clinical symptoms:
MEDICATION r Fever ICD9
First Line r Appearance r 771.83 Bacteremia of newborn
r Ceftriaxone 50100 mg/kg/day IV/IM divided r 790.7 Bacteremia
q1224h PROGNOSIS
Vancomycin 4060 mg/kg/day divided q6h r Depends on age, severity, etiology, past medical
May be added based on local susceptibility history, and immunization status
patterns of S. pneumoniae and severity of illness if r For occult bacteremia, spontaneous resolution of PEARLS AND PITFALLS
present, and immune status of patient bacteremia occurs in >90% without antibiotic r Pearls:
r Amoxicillin 80 mg/kg PO divided b.i.d.t.i.d.: treatment. Occult (unsuspected) bacteremia occurs in
Used for patient with penicillin-sensitive well-appearing febrile children.
COMPLICATIONS
pathogens, particularly S. pneumoniae As the incidence of occult bacteremia has declined
r Antipyretics as needed: Pneumonia, septic arthritis, osteomyelitis, meningitis,
sepsis, septic shock, death below 0.5% (with universal PCV7 and Hib
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN vaccination), routine CBC and blood culture
Acetaminophen 15 mg/kg/dose PO/PR q4h PRN management strategies for febrile young children
Second Line REFERENCES should be abandoned.
r Pitfalls:
Clindamycin 10 mg/kg IV/PO q8h: 1. Carstairs KL, Tanen DA, Johnson AS, et al.
r May be appropriate as parenteral or oral therapy in Not assuring appropriate follow-up for a child
Pneumococcal bacteremia in febrile infants with suspected or documented bacteremia within
penicillin-allergic patients presenting to the emergency department before 2448 hr
DISPOSITION and after the introduction of the heptavalent
penumococcal vaccine. Ann Emerg Med.
Admission Criteria 2007;49:772777.
r Neonates <28 days
r Outpatient follow-up cannot be assured 2. Herz AM, Greenhow TL, Alcantara J, et al.
r Dehydration, lethargy, ill appearance Changing epidemiology of outpatient bacteremia in
3- to 36-month-old children after the introduction
r Immunocompromised patient with known or
of the heptavalent-conjugated pneumococcal
suspected bacteremia vaccine. Pediatr Infect Dis J. 2006;25:293300.
r Bacteremia with persistent fever
3. Wilkinson M, Bulloch B, Smith M. Prevalence of
r Critical care admission criteria: occult bacteremia in children aged 3 to 36 months
Sepsis presenting to the emergency department with fever
Meningitis with neurologic symptoms in the postpneumococcal conjugate vaccine era.
Discharge Criteria Acad Emerg Med. 2009;16:220225.
Children with occult bacteremia who return for 4. Meltzer AJ, Powell K, Avner JR., AJ, et al. Fever in
follow-up due to a positive blood culture for S. infants and children. Consensus in Pediatrics.
pneumoniae can be discharged home if the child 2005;1(7):119.
remains afebrile, well appearing, and has no evidence 5. Avner JR, Baker MD. Occult bacteremia in the
of serious bacterial infection (eg, meningitis): post-pneumococcal conjugate vaccine era: Does
r Patients with organisms other than S. pneumoniae the blood culture stop here? Acad Emerg Med.
(such as S. aureus, N. meningitidis, H. influenzae) 2009;16:258260.
typically require hospital admission and parenteral
antibiotic therapy.
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BALANITIS/BALANOPOSTHITIS
Kerry Caperell
Raymond Pitetti
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BALANITIS/BALANOPOSTHITIS
r Most irritant and bacterial cases can be treated with See Also (Topic, Algorithm, Electronic
topical mupirocin b.i.d. for 1 wk FOLLOW-UP Media Element)
r If group A streptococcus is suspected, amoxicillin r Epididymitis/Orchitis
b.i.d. for 10 days is necessary.
r Cases due to STIs are treated in the same manner as
FOLLOW-UP RECOMMENDATIONS
Discharge instructions and medications:
r Scrotal Pain
r Testicular Torsion
B
r Sitz baths 3 times daily until signs of inflammation r Urinary Tract Infection
the respective STI.
r Fungal infection can be treated with topical nystatin disappear
r Good hygiene
q.i.d. for 1 wk.
r Only use gentle force to retract the foreskin.
Second Line r Antibiotics as indicated
CODES
For group A streptococcal infections, any of the
r Follow up with the primary care physician as needed.
regimens for strep pharyngitis is adequate. ICD9
PROGNOSIS 607.1 Balanoposthitis
SURGERY/OTHER PROCEDURES r Most patients have an uneventful course.
r Forced retraction of the foreskin to release pus
followed by cleaning with chlorhexidine or Betadine r Up to 10% of patients will have a recurrence.
PEARLS AND PITFALLS
may be performed: COMPLICATIONS
This procedure is typically very painful and may be r Most cases resolve with only local care and
Balanitis xerotica obliterans, a chronic inflammatory
preceded with topical anesthetic such as EMLA or disease, is a separate entity that should be considered antibiotics.
another analgesic. r If there is significant swelling between the foreskin
in cases of balanitis that are refractory to conventional
If this is performed, instruct the parent to continue treatment (3). and glans, forced retraction of the foreskin to
retracting the foreskin multiple times daily to release pus may be highly beneficial.
ensure it remains retractible. r Balanitis suspected of being secondary to sexually
r A dorsal slit through the phimotic area performed REFERENCES transmitted pathogens should raise the possibility of
emergently if bladder drainage by catheterization or sexual abuse.
suprapubic aspiration is necessary but cannot be 1. Fergusson DM, Hons BA, Lawton JM, et al.
carried out. This procedure would usually be Neonatal circumcision and penile problems: An
performed by a urologist. 8-year longitudinal study. Pediatrics. 1988;81:
537541.
DISPOSITION 2. Kiss A, Kiraly L, Kutasy B, et al. High incidence of
Admission Criteria balanitis xerotica obliterans in boys with phimosis:
Patients with urinary obstruction requiring Prospective 10-year study. Pediatr Dermatol.
catheterization or surgery should be admitted. 2005;22:305308.
Discharge Criteria 3. Schwartz RH, Rushton HG. Acute balanoposthitis in
Uncomplicated cases can be discharged from the young boys. Pediatr Infect Dis J. 1996;15:176177.
emergency department.
Issues for Referral ADDITIONAL READING
r Patients with urinary retention who cannot be
catheterized should be seen by a urologist r Edwards SK. European guideline for the
emergently. management of balanoposthitis. Int J STD AIDS.
r Those who have urinary retention, phimosis, or 2001;12(Suppl 3):68.
disease that is refractory to treatment should be r Link R. Cutaneous diseases of the external genitalia.
seen by a urologist. In Wein AJ, Kavoussi LR, Novick AC, et al., eds.
r Suspicion of a sexually transmitted etiology in a Campbell-Walsh Urology. 9th ed. Philadelphia, PA:
young child should be further investigated for the Saunders; 2007.
possibility of sexual abuse.
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BAROTRAUMA, SINUS
Curt Stankovic
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BAROTRAUMA, SINUS
MEDICATION Issues for Referral 3. Weissman B, Green RS, Roberts PT. Frontal sinus
r Otorhinolaryngologist referral may be necessary for barotrauma. Laryngoscope. 1972;82(12):
First Line
r Nasal decongestants: severe or persistent symptoms. 21602168.
r Otorhinolaryngology or neurosurgery referral may be
Oxymetazoline 0.05%, 2 sprays in each nostril
necessary if the sphenoid sinus is involved and does
4. Setliff RC 3rd. Minimally invasive sinus surgery: The
rationale and the technique. Otolaryngol Clin North
B
b.i.d. for 35 days (1)
Phenylephrine not respond to first-line treatment. Am. 1996;29(1):115124.
r Analgesics (NSAIDs) at age-appropriate doses r Dental referral may be necessary if barodontalgia is
r Opioids: present. Barodontalgia may result in referred pain to
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: face. ADDITIONAL READING
Initial morphine dose of 0.1 mg/kg IV/SC may r Brubakk AO, Neuman TS. Bennett and Elliotts
be repeated q1520min until pain is controlled, FOLLOW-UP Physiology and Medicine of Diving. 5th rev ed.
then q2h PRN. United States: Saunders Ltd.; 2003:800.
Codeine or codeine/acetaminophen dosed as FOLLOW-UP RECOMMENDATIONS r Hanna HH, Tarington CT. Otolaryngology in
0.51 mg/kg of codeine component PO q4h PRN r Discharge instructions and medications:
aerospace medicine. In DeHart RL, ed.
Hydrocodone or hydrocodone/acetaminophen Nasal decongestants and oral analgesics Fundamentals of Aerospace Medicine. Philadelphia,
dosed as 0.1 mg/kg of hydrocodone component Oral antibiotics if fluid is seen in the sinus cavity PA: Lippincott Williams & Wilkins; 1985:520530.
PO q46h PRN r Activity:
r NSAIDs: Avoid activities that may result in barotrauma See Also (Topic, Algorithm, Electronic
Consider NSAID medication in anticipation of until fully recovered. Media Element)
r Barotrauma, Ear
prolonged pain and inflammation. If undergoing endoscopic sinus surgery, the
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r Sinusitis
patient may return to full activity in 13 wk.
Ketorolac 0.5 mg/kg IV/IM q6h PRN
Naproxen 5 mg/kg PO q8h PRN PROGNOSIS
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN Generally considered good. Patients typically respond CODES
r Aspirin should be avoided due to the potential for to first-line medications:
r Recurrent barosinusitis may be secondary to
hematoma formation. ICD9
r If bleeding or sinus effusion is present, antibiotics anatomic pathology. These patients are more likely 993.1 Barotrauma, sinus
to need surgical drainage of the affected sinus.
are indicated (1): r Patients with uncontrolled or chronic sinusitis as
Amoxicillin 4080 mg/kg/day PO divided
b.i.d.t.i.d., max daily dose 2 g well as seasonal allergies may find more difficulty PEARLS AND PITFALLS
Clindamycin 30 mg/kg PO divided t.i.d., max daily returning to normal activities. r Treat patients who have blood or fluid in the sinus
dose 1.8 g COMPLICATIONS cavity with antibiotics to prevent infectious
Trimethoprim/Sulfamethoxazole (TMP/SMZ) r Rarely, a sinus may rupture and result in
complications.
10 mg/kg/day PO divided b.i.d., max single dose pneumocephalus causing vertigo, vomiting, r Refer patients with severe or unresponsive
320 mg TMP/1,600 mg SMZ headache, and pain. symptoms to otorhinolaryngology.
r Other complications include orbital cellulitis, r Recognize life-threatening complications of
Second Line
Pseudoephedrine 1 mg/kg/dose PO given b.i.d.q.i.d.; abscess, and hematoma formation. barotrauma.
adult dose 60120 mg PO (1)
SURGERY/OTHER PROCEDURES
r Surgery is used to restore sinus ventilation.
REFERENCES
r May be necessary if traditional medications fail and 1. Hamilton-Farrell M, Bhattacharyya A. Barotrauma.
symptoms persist Injury. 2004;25(4):359370.
r Endoscopic sinus surgery has improved efficacy 2. Baughman SM, Brennan J. Barotrauma secondary
when compared to conventional surgical options (4) to inflammatory maxillary sinus polyp: A case
report. Aviat Space Environ Med. 2002;73(11):
DISPOSITION 11271131.
Admission Criteria
Uncontrollable pain
Discharge Criteria
Ability to manage pain with oral analgesics or
opioids
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BETA-BLOCKER POISONING
Amit K. Gupta
Mark Su
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BETA-BLOCKER POISONING
r Lorazepam 0.05 mg/kg IV, max dose 2 mg: r IV fat emulsion therapy (Intralipid 20% 1 mL/kg) has
ADDITIONAL READING
First-line agent for seizures been shown in animal models and case reports to
r Sodium bicarbonate (12 mEq/kg) IV bolus for signs be beneficial in lipid-soluble drug overdoses r Brubacker J. Beta-adrenergic antagonists. In
of sodium channel blockade on ECG followed by IV (propranolol).
r The proposed mechanism of action is the lipid
Goldfrank LR, Flomenbaum NE, Lewin NA, et al.,
eds. Goldfranks Toxicologic Emergencies. 8th ed.
B
infusion of 3 ampules of sodium bicarbonate in 1 L
of D5W at twice maintenance. Carefully monitor sink theory, where drugs may become trapped in Stamford, CT: Appleton & Lange; 2006:924941.
serum pH. an expanded plasma lipid compartment. Another r Kerns W 2nd, Schroeder D, Williams C, et al. Insulin
Second Line proposed theory is that the emulsion acts as improves survival in a canine model of acute
r A variety of inotropes are available if above additional fuel source for the heart due to the beta-blocker toxicity. Ann Emerg Med. 1997;29:748.
energy from fatty acids. r Love JN, Howell JM, Litovitz TL, et al. Acute beta
treatments fail.
r Norepinephrine infusion (0.12 g/kg/min) IV and SURGERY/OTHER PROCEDURES blocker overdose: Factors associated with the
titrate to maintain adequate cardiac output: r Extracorporeal membrane oxygenation has also development of cardiovascular morbidity. J Toxicol
Directly stimulates alpha- and beta1 -adrenergic been attempted in patients who have hypotension Clin Toxicol. 2000;38:275.
r Taboulet P, Cariou A, Berdeaux A, et al.
receptors, thus increasing inotropic and refractory to all pharmacologic therapies.
vasopressor effects r Intra-aortic balloon counterpulsation is another Pathophysiology and management of self-poisoning
r Epinephrine infusion (0.1 g/kg/min) IV and titrate invasive supportive option in refractory cases and with beta-blockers. J Toxicol Clin Toxicol. 1993;31:
to maintain adequate cardiac output: has been used successfully to improve cardiac 531.
Directly stimulates alpha- and beta-adrenergic output and BP. See Also (Topic, Algorithm, Electronic
receptors Media Element)
r Dopamine 520 g/kg/min IV and titrate to DISPOSITION r Calcium Channel Blocker Poisoning
maintain adequate cardiac output:
Admission Criteria r Digoxin Poisoning
r All patients with exposure to sustained-preparation
Indirectly stimulates alpha- and beta1 -adrenergic r Shock, Cardiogenic
dopaminergic receptors to produce ionotropic, beta-blockers should be admitted to a monitored
chronotropic, renal/splanchnic vasodilatory (at low setting due to the potential of delayed toxicity.
r Admit all symptomatic patients.
doses), and vasopressor (at high doses) effects CODES
r Amrinone 50 g/kg IV loading dose with r Critical care admission criteria:
maintenance infusion of 0.50 g/kg/min IV and Patients with signs of hemodynamic instability
should be admitted to an ICU setting. ICD9
titrate to desired effect: r 971.3 Poisoning by sympatholytics (antiadrenergics)
Inhibits myocardial phosphodiesterase, leading to Discharge Criteria r 972.0 Poisoning by cardiac rhythm regulators
increased cAMP levels May discharge if the patient remains asymptomatic
r High-dose insulin/glucose infusion: after observation for 6 hr for immediate-release
Insulin (1 unit/kg bolus followed by 1 unit/kg/hr) preparations
Glucose must be coadministered, initially 1 g/kg
PEARLS AND PITFALLS
bolus followed by infusion of 0.5 g/kg/hr. r Hypotension and bradycardia can occur as
Frequent blood glucose monitoring, initially FOLLOW-UP consequences of beta-blocker overdose.
q1015min for the 1st few hours, is necessary. FOLLOW-UP RECOMMENDATIONS r Glucagon is the first-line agent for beta-blocker
This therapy has been shown to be effective in r Discharge instructions and medications: toxicity.
case reports and in animal models. Follow up with the primary pediatrician. r Admission and observation are indicated for any
The theorized mechanism is via positive inotropic Return to the emergency department for change sustained-release beta-blocker ingestion.
effects of insulin and cardiac utilization of glucose in behavior, alteration in mental status, or if ill r Certain beta-blockers such as propranolol and
as an energy source. appearing.
Frequent monitoring of serum glucose and acebutolol may cause myocyte sodium channel
r Activity: blockade leading to QRS prolongation.
potassium levels is necessary.
Normal activity after discharge
COMPLEMENTARY & ALTERNATIVE Patient Monitoring
THERAPIES Patients with intentional overdoses should be
r Enhanced elimination with hemodialysis is only
monitored for acts of self-harm.
effective for beta-blockers with low volumes of
distribution and high water solubility (ie, atenolol, PROGNOSIS
naldol, and sotalol). The prognosis is generally good for isolated
r Cardiac pacing may be effective in increasing the beta-blocker overdose.
rate of myocardial contractions, but electrical COMPLICATIONS
capture is not always successful and BP is not r Cardiovascular collapse
always restored. r Shock
r Death
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DIFFERENTIAL DIAGNOSIS
r Sepsis
DISPOSITION ADDITIONAL READING
Admission Criteria r Lee CK, Jonas MM. Pediatric hepatobiliary disease.
r Inborn errors of metabolism r Patients with complications related to biliary tract
r CF
r Hypothyroidism
disease such as ascending bacterial cholangitis Curr Opin Gastroenterol. 2007;23:306309.
r McEvoy CF, Suchy FJ. Biliary tract disease in B
require admission for treatment.
r Alpha-1 antitrypsin deficiency r Critical care admission criteria: children. Pediatr Clin North Am. 1996;43:7598.
r Progressive familial intrahepatic cholestasis Intensive supportive care may be required for See Also (Topic, Algorithm, Electronic
r Ascariasis infants with conjugated hyperbilirubinemia. Media Element)
r Infectious hepatitis r Jaundice, Conjugated
Discharge Criteria
Patients who are stable with LFTs and electrolytes r Jaundice, Unconjugated
within acceptable limits and a known diagnosis may
TREATMENT be discharged to the care of their appropriate
subspecialist. CODES
INITIAL STABILIZATION/THERAPY Issues for Referral
The treatment of acute gallbladder hydrops is These patients should be managed in conjunction with ICD9
supportive and typically subsides spontaneously. a pediatric gastroenterologist or hepatologist and r 576.9 Unspecified disorder of biliary tract
MEDICATION surgeon. r 751.61 Biliary atresia, congenital
Broad-spectrum antibiotics should be administered in r 751.69 Other congenital anomalies of gallbladder,
cases of suspected acute cholangitis: bile ducts, and liver
r Beta-lactam/beta-lactamase inhibitor monotherapy: FOLLOW-UP
Ampicillin-sulbactam (3 g q6h) OR FOLLOW-UP RECOMMENDATIONS
Piperacillin/Tazobactam (3.375 g q6h) OR Discharge instructions and medications: PEARLS AND PITFALLS
Ticarcillin/Clavulanate (3.1 g q4h) r Close follow-up with the appropriate subspecialists r The possibility of hepatobiliary disease must be
r Metronidazole (500 mg IV q8h) PLUS ceftriaxone
is critical. considered in any neonate with jaundice beyond
(100 mg/kg IV q24h)
r Monotherapy with a carbapenem: PROGNOSIS 2 wk of age.
r Untreated biliary atresia has an extremely poor r Evaluation for cholestatic jaundice may be delayed
Imipenem (500 mg q6h) OR
Meropenem(1 g q8h) OR prognosis. to 3 wk of age in breast-fed infants if the exam is
r The most important predictor for success in a patient normal.
Ertapenem (1 g daily) r Biliary atresia be differentiated from other causes of
r Metronidazole (10 mg/kg/dose IV q8h) PLUS a with biliary atresia is early operative therapy (before
fluoroquinolone (ciprofloxacin 15 mg/kg IV q12h) or 60 days of age). neonatal cholestasis because early intervention is
r The course of PSC is variable but typically associated with more favorable outcome.
levofloxacin 10 mg/kg/dose q24h) r An elevated conjugated bilirubin level should
progressive.
SURGERY/OTHER PROCEDURES prompt a structured and rapid evaluation of biliary
r Diversion of bile flow, usually by Kasai procedure COMPLICATIONS
r Choledochal cysts and biliary atresia can be tract disorders.
(hepatoportoenterostomy) is essential for survival in
biliary atresia. complicated by ascending cholangitis, hepatic
r Surgical excision of choledochal cysts provides cirrhosis, and portal HTN.
r Choledochal cysts are associated with an increased
excellent long-term results.
r Liver transplantation is frequently required for incidence of biliary carcinoma.
r Caroli disease is a risk factor for malignancy and
patients with end-stage liver disease resulting from
biliary atresia or PSC. recurrent cholangitis.
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BIPOLAR DISORDER/MANIA
Todd A. Mastrovitch
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BIPOLAR DISORDER/MANIA
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BITE, ANIMAL
Michael L. Epter
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BITE, ANIMAL
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BITE, HUMAN
Michael L. Epter
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BITE, HUMAN
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BLEPHARITIS
Ruby F. Rivera
r Isotretinoin use can cause blepharitis and corneal DIAGNOSTIC TESTS & INTERPRETATION
BASICS irritation. Lab
r Lab testing is not always indicated.
DESCRIPTION COMMONLY ASSOCIATED CONDITIONS r Culture of the eyelid margins should be obtained in
r Blepharitis is an inflammation of the eyelid often r Seborrheic dermatitis
r Atopic dermatitis patients with recurrent anterior blepharitis and
associated with conjunctivitis and keratitis.
r Blepharitis is usually chronic, intermittent, and r Meibomian gland dysfunction usually associated those not responding to therapy.
bilateral. with rosacea and seborrhea Diagnostic Procedures/Other
r Blepharitis is classified by anatomic location (1): Microscopic exam of epilated eyelash to reveal
Demodex mite
Anterior blepharitis: DIAGNOSIS
Affects the base of the eyelashes and eyelash DIFFERENTIAL DIAGNOSIS
follicles HISTORY r Conjunctivitis
Usually caused by Staphylococcus species and r Burning, itching, eye discharge, contact lens r Discoid lupus erythematosus
seborrhea discomfort, photophobia, loss of eyelashes r Lacrimal duct obstruction
Posterior blepharitis: r Eyelashes sticking together in the morning usually
Affects the meibomian glands and gland orifices common in staphylococcal blepharitis
Usually caused by meibomian gland dysfunction r Recent exposure to an infected person TREATMENT
EPIDEMIOLOGY (eg, pediculosis palpebrarum) r Eyelid hygiene is the mainstay of treatment.
r Epidemiologic data on the incidence and prevalence r Current and previous use of systemic or topical
medications (eg, isotretinoin) Warm compress 12 times daily followed by eyelid
of blepharitis is lacking. massage
r Common but underdiagnosed in children (2,3) PHYSICAL EXAM r Cleaning the eyelid margin with a cotton ball soaked
r Staphylococcal blepharitis is characterized by:
PATHOPHYSIOLOGY in diluted baby shampoo
The pathophysiology of blepharitis is complex and Scaling, crusting, and erythema of the eyelid
margin MEDICATION
results from interaction of various factors including lid
margin secretion, lid margin organisms, and a Loss of eyelashes and corneal involvement may First Line
occur. Bacitracin or erythromycin ophthalmic ointment:
dysfunctional tear film (4). r Seborrheic blepharitis is characterized by: r Apply 1/ 1/ -inch ribbon 12 times daily for 1 wk
4 2
ETIOLOGY Greasy scaling of the eyelid margin r Duration should be guided by severity of symptoms
r Bacterial:
There is often seborrhea of the scalp and and response to therapy.
Staphylococcus aureus eyebrows.
Staphylococcus epidermidis r Meibomian gland dysfunction is characterized by: Second Line
r Selenium sulfide/tar shampoo, as seborrheic
Propionibacterium acnes Frothy discharge
r Parasitic: blepharitis is often associated with seborrheic
Prominent blood vessels dermatitis of the scalp and eyebrows
Demodex folliculorum Thickening of the eyelid margin r Topical corticosteroids may be helpful in those with
Pediculosis palpebrarum caused by Pediculosis Expression of meibomian secretions
humanus corporis or capitis severe inflammation:
Demodex infestation of the facial skin has been Hydrocortisone ophthalmic cream (1%) applied
implicated in rosacea and blepharitis (4). b.i.d. to affected area
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BLEPHARITIS
r Patients unresponsive to eyelid hygiene and topical 3. Hammersmith KH, Cohen EJ, Blake TD, et al.
antibiotics can be given oral antibiotics: FOLLOW-UP Blepharoconjunctivitis in children. Arch
Tetracycline: >8 yr of age, 2550 mg/kg/day Ophthalmol. 2005;123:16671670.
divided q6h; adult dose, 12 g PO divided
b.i.d.q.i.d.
FOLLOW-UP RECOMMENDATIONS
Discharge instructions and medications:
4. Jackson WB. Blepharitis: Current strategies for B
diagnosis and management. Can J Ophthalmol.
Doxycycline: >8 yr of age, 24 mg/kg/day divided r Warm compresses applied 12 times daily followed 2008;43:170179.
b.i.d.; adult dose 100 mg PO b.i.d. by eyelid massage
Erythromycin ethylsuccinate: 3050 mg/kg/day r Cleaning the eyelid margin with a cotton ball soaked See Also (Topic, Algorithm, Electronic
divided q8h Media Element)
in diluted baby shampoo r Chalazion
Azithromycin: 10 mg/kg PO on day 1, then r Bacitracin or erythromycin ophthalmic ointment:
r Conjunctivitis
5 mg/kg PO days 25; adult dose, 500 mg PO day 1/ 1/ -inch ribbon 12 times daily for 2 wk.
1, then 250 mg PO days 25
4 2 r Eye, Red
Duration of therapy should be guided by severity of r Hordeolum
DISPOSITION symptoms and response to therapy.
r Artificial tears applied twice daily for dry eyes
Admission Criteria
Admission is generally not required. Rarely, in cases of Patient Monitoring CODES
visual loss, intractable pain, corneal loss, or unclear Close follow-up and monitoring with the patients
diagnosis, admission may be indicated. primary care physician to ensure resolution ICD9
Discharge Criteria PROGNOSIS r 373.00 Blepharitis, unspecified
Patients with blepharitis should almost universally be r Blepharitis is usually a chronic, intermittent r 373.01 Ulcerative blepharitis
discharged. condition. r 373.02 Squamous blepharitis
Issues for Referral r Patients should be advised that symptoms may
r Patients with blepharitis with the following
improve with treatment but that there will be
symptoms should be emergently referred to an recurrences. PEARLS AND PITFALLS
ophthalmologist: r Patients should continue eyelid hygiene even after
Visual loss r Blepharitis is usually a chronic condition caused by
symptoms improve.
Moderate to severe pain inflammation due to bacterial infection, parasitic
r Patients with blepharitis with the following COMPLICATIONS infection, seborrheic dermatitis, or chemical
r Hordeolum
symptoms may be referred to an ophthalmologist for irritation.
r Chalazion r Blepharitis may result from pediculosis pubis.
follow-up within 12 days:
Chronic or severe redness r Dry eyes secondary to aqueous tear deficiency Pediculosis pubis is an STI; if present in a young
Unresponsiveness to therapy patient, the possibility of sexual abuse must be
Corneal involvement considered.
REFERENCES
1. American Academy of Ophthalmology, Ophthalmic
News and Education Network. Blepharitis:
Preferred Practice Pattern Guideline, 2003.
2. Viswalingam M, Rauz S, Morlet N, et al.
Blepharoconjunctivitis in children: Diagnosis and
treatment. Br J Ophthalmol. 2005;89:400403.
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BLINDNESS
Desiree M. Seeyave
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BLINDNESS
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BOTULISM
Adhi Sharma
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BOTULISM
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BRADYCARDIA
Adam Vella
Karen Goodman
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BRADYCARDIA
Diagnostic Procedures/Other
r The single most important test is a 12-lead ECG,
DISPOSITION ADDITIONAL READING
Admission Criteria r Brady WJ Jr, Harrigan RA. Evaluation and
which may reveal conduction abnormalities such as r Stable, symptomatic patients may be admitted to
sinus bradycardia and 1st-, 2nd-, and 3rd-degree AV
block (complete heart block).
inpatient units that are capable of cardiac management of bradyarrhythmias in the emergency
department. Emerg Med Clin North Am. 1998;16(2):
B
monitoring or Holter devices.
r Other testing may be helpful, as indicated: r Critical care admission criteria: 361388.
r Doniger S, Sharieff G. Pediatric dysrhythmias.
24-hr ambulatory (Holter) monitoring may have A patient who remains unstable requires
greater yield if the initial ECG is normal and the admission to the ICU for further monitoring and Pediatr Clin North Am. 2006;53:85105.
index of suspicion is high for arrhythmias. r Gewitz MH, Woolf P. Cardiac emergencies. In
intervention.
Exercise testing and ambulatory monitoring may A patient who has converted from an unstable Fleisher GR, Ludwig S, Henretig FM, et al., eds.
diagnose chonotropic abnormalities. rhythm should be admitted to the ICU for Textbook of Pediatric Emergency Medicine. 6th ed.
Tilt table testing, or evaluation of orthostatic BP, monitoring. Philadelphia, PA: Lippincott Williams & Wilkins;
may help define indeterminate cases of vasovagal 2010.
bradycardia. Discharge Criteria r Goldberger AL. Clinical Electrocardiology: A
r Asymptomatic and chronic bradycardia may be
Invasive electrophysiologic testing may be helpful Simplified Approach. 7th ed. Philadelphia, PA:
in the unusual circumstances in which the managed on an outpatient basis in stable patients.
r If a reversible cause of the patients bradycardia is Mosby; 2006.
mechanism of the bradycardia remains uncertain, r Magrum JM, DiMarco JP. The evaluation and
attempts to monitor the heart rate have been recognized and treatment or management is under
management of bradycardia. N Engl J Med.
unsuccessful, or symptoms suggest a potentially way, the patient may be discharged to follow up
2000;342(10):703709.
life-threatening arrhythmia. with the primary care provider (PCP) or cardiologist. r McGregor T, Parkar M, Rao S. Evaluation and
DIFFERENTIAL DIAGNOSIS Issues for Referral management of common childhood poisonings. Am
r Unstable patients who require transcutaneous or
See Etiology for further details. Fam Physician. 2009;79(5):397403.
transvenous pacing or other more advanced modes r Mehta AV, Chidambaram B, Garrett A. Familial
of treating symptomatic bradycardia should have symptomatic sinus bradycardia: Autosomal
TREATMENT cardiology involved as soon as possible.
r Patients with a history of cardiac disease and
dominant inheritance. Pediatr Cardiol. 1995;16:231.
r Park M, George R. Pediatric Cardiology for
PRE HOSPITAL cardiac surgery may benefit from involvement of Practitioners. 5th ed. Philadelphia, PA: Mosby; 2008.
r Assess and address the ABCs, and follow the cardiology to further clarify potential causes of their r Tintinalli JE, Gabor D, Stapczynski JS, et al., eds.
Pediatric Advanced Life Support (PALS) or Advanced arrhythmia and ways to manage them. Tintinallis Emergency Medicine: Comprehensive
Cardiac Life Support (ACLS) protocol. r Asymptomatic or stable patients with cardiac
r Administer oxygen via face mask if symptomatic Study Guide. 6th ed. Columbus, OH: McGraw-Hill;
etiologies for their symptoms should have scheduled 2003.
from bradycardia. follow-up with cardiology. r Vetter VL, ed. Pediatric Cardiology. The Requisites in
INITIAL STABILIZATION/THERAPY Pediatrics. Philadelphia, PA: Mosby Elselvier; 2006.
r Stabilize the airway and provide oxygen.
r Chest compressions are indicated for patients with
FOLLOW-UP
bradycardia and hemodynamic compromise. FOLLOW-UP RECOMMENDATIONS
r Discharge instructions and medications:
CODES
r Among symptomatic patients with bradycardia, the
cause of the bradycardia must be ascertained in Patients should follow up with their PCP or ICD9
order to potentially reverse these factors, especially cardiologist as recommended. r 426.10 Atrioventricular block, unspecified
with regard to extrinsic factors. Depending on the need for a further workup, r 427.89 Other specified cardiac dysrhythmias
r Volume expansion with IV fluids patients may be instructed to schedule r 746.86 Congenital heart block
appointments for Holter monitoring, repeat ECGs,
MEDICATION or blood work.
First Line r Activity:
r Epinephrine 0.01 mg/kg (1:10,000) IV/IO with a Activity that may have precipitated an event of
PEARLS AND PITFALLS
max single dose of 1 mg: bradycardia should be avoided until a thorough r Hypoxia is a common cause of bradycardia. If
May repeat the dose q35min to a max dose of evaluation and clearance have been made. present, hypoxia should be corrected before
10 mg Patient Monitoring progressing to use of medications.
r Atropine 0.02 mg/kg IV/IO (min dose of 0.1 mg): r Bradycardia is an arrhythmia in which symptoms
Depending on the need for a further workup, patients
May repeat dose once during the resuscitation may be instructed to obtain Holter monitoring or may range from asymptomatic to life threatening.
Second Line repeat ECGs. r The etiology of the abnormal rhythm may aid in the
r Epinephrine infusions may be started at management and treatment of the bradycardia.
PROGNOSIS r Treatment protocols are aimed at stabilizing the
0.11 g/kg/min, particularly if a response to single Depending on the etiology and severity of the
doses of epinephrine is noted but the patient has bradycardia, the prognosis may range from an patient, searching for the etiology, and treating the
failed to achieve hemodynamic stability. asymptomatic and resolvable arrhythmia to a severely underlying pathology.
r Isoproterenol infusion may be started at
symptomatic bradycardia that can result in cardiac
0.052 g/kg/min as a second-line agent when arrest and sudden death.
epinephrine has failed.
r Specific antidotal therapy may be indicated for COMPLICATIONS
cardiovascular medication toxicity. (Refer to Symptomatic bradycardia may lead to cardiovascular
Beta-Blocker Poisoning, Calcium Channel Blocker collapse and death.
Poisoning, and Digoxin Poisoning topics.)
SURGERY/OTHER PROCEDURES
r Follow current PALS protocol with regard to chest
compression and endotracheal intubation.
r Consider cardiac pacing, especially if a conduction
defect is suggested.
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DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Abscess
r Lymphadenopathy
DESCRIPTION HISTORY r Lymphadenitis
r A branchial cleft cyst is a lateral neck mass or sinus r May present as an asymptomatic neck mass or as an
r Parotitis
tract that arises when a branchial arch fails to close acute infection, with a painful, red, acutely r Vascular malformation
(most commonly the 2nd arch) following the 4th or enlarging mass.
r Up to 40% initially present during upper respiratory r Scrofula
5th wk of gestation (13). r Ectopic thyroid
r They may occur anywhere along the anterior border tract infections (because of lymphatic tissue that is
present within the cyst): r Neoplasm (eg, rhabdomyosarcoma)
of the sternocleidomastoid muscle or the
Occasionally noted at birth when a pit or sinus is r Neurofibroma
mandibular ramus.
seen on the neck r Lipoma
EPIDEMIOLOGY r Torticollis with sternocleidomastoid muscle knot
r Most common congenital anomaly of the lateral PHYSICAL EXAM
r Mobile, nontender, fluctuant mass located along the may be incorrectly presumed to be a tumor.
neck r Thyroglossal duct cysts (midline)
r Comprise about 30% of congenital neck masses anterior border of the sternocleidomastoid muscle
r Equal incidence among males and females r When infected: r Cystic hygromas
Erythema overlying the cyst
GENERAL PREVENTION Tenderness to palpation
Prevention of branchial cleft cyst complications is best May be draining if a sinus is present TREATMENT
accomplished by early diagnosis and excision.
DIAGNOSTIC TESTS & INTERPRETATION Ideally, cysts or sinuses are noted prior to infection
PATHOPHYSIOLOGY Lab and referred to an otolaryngologist or pediatric
r Branchial cleft anomalies are lined with various
Inflammatory markers are nonspecific for infected surgeon for surgical excision.
types of epithelium and will rarely develop into branchial cleft cysts:
squamous cell carcinoma in adults (13). r Elevation of WBC count or C-reactive protein are INITIAL STABILIZATION/THERAPY
r Cysts have no external opening. If infected, the cysts must be treated with antibiotics
r Sinuses may open to the exterior neck. typical with infected cysts. prior to surgical intervention, as operating on infected
r Fistulas open into the pharynx (or both the neck and Imaging lesions results in a significantly higher risk of
r CT neck, with contrast, is the diagnostic study of recurrence and complications.
pharynx).
r Approximately 2/3 of cysts have associated sinuses choice. MEDICATION
r Sonography or MRI may also be used.
or fistulas. First Line
r Up to 10% of patients have bilateral branchial Diagnostic Procedures/Other r Antibiotics:
anomalies, which is more commonly associated with Fine-needle aspiration should NOT be performed, as it Antimicrobial agents that treat both typical oral
craniofacial syndromes. may make resection more difficult and may lead to flora and gram-negative bacteria:
infectious complications. Ampicillin/Sulbactam 50 mg/kg/dose IV q6h
ETIOLOGY Amoxicillin/Clavulanate 45 mg/kg/day PO b.i.d.
Result from failure of obliteration of branchial clefts Pathological Findings
r Analgesics:
(primitive gills) during embryologic development Excised lesions consist of epithelium and may also
include lymphoid, salivary, or sebaceous tissue. Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
COMMONLY ASSOCIATED CONDITIONS Acetaminophen 15 mg/kg/dose PO/PR q4h PRN
Branchio-oto-renal syndrome is an autosomal Codeine/Acetaminophen dosed as 0.51 mg/kg of
dominant disorder consisting of branchial arch codeine component PO q4h PRN
anomalies (usually bilateral), profound deafness, and Hydrocodone or hydrocodone/acetaminophen
varying degrees of renal anomalies. dosed as 0.1 mg/kg of hydrocodone component
PO q46h PRN
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BREAST LESIONS
Alyssa Abo
Atima Chumpa Delaney
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BREAST LESIONS
q12h
>7 postnatal days and weight >2,000 g:
7.5 mg/kg/day IV divided q8h
Cefotaxime:
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BRONCHIOLITIS
Suzanne Schuh
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Asthma/Recurrent virus-induced wheezing
r Possible mechanisms with later viral-induced
DESCRIPTION HISTORY wheeze: Subnormal lung function prior to
r Bronchiolitis is a lower respiratory tract infection r Upper respiratory prodrome of coryza, cough, and
bronchiolitis, genetic factors, bronchiolitis-induced
with airway inflammation and bronchoconstriction. fever lung changes
r It is characterized by upper respiratory prodrome r Fever usually <39 C r Pertussis: Usually no respiratory distress between
followed by wheezing/crepitations. r Decreased fluid intake
coughs, no wheezing
r Bronchiolitis may include tachypnea, hypoxemia, r Increased work of breathing, usually 1st episode r Bacterial pneumonia: Focal wheezing, often toxic
and respiratory distress. r Sleep disruption
appearance, isolated consolidation without airway
EPIDEMIOLOGY PHYSICAL EXAM disease on radiograph
r Vital signs, including respiratory rate, temperature, r Foreign body: Typically sudden onset, afebrile
Incidence r CHF: Chronic feeding problems, failure to thrive
r The most common lower respiratory tract infection and pulse oximetry:
Mild hypoxemia common r Congenital abnormalities: Protracted clinical course,
in the 1st yr of life with a rate of 1020 episodes per
100 children No evidence that mild hypoxemia predicts recurrent pneumonias
r Responsible for 16% of all hospital admissions in progress of disease
r Respiratory distress with chest retractions, tracheal
the 1st yr of life (1,2)
tug, nasal flare/grunting (severe disease) TREATMENT
Prevalence r Tachypnea, tachycardia
Accounts for up to 60% of all lower respiratory tract r Lethargy (hypoxemia or severe disease) PRE HOSPITAL
illness during the 1st yr of life and for up to 32% of r Cardiorespiratory and oxygenation monitoring is
r Frank dehydration uncommon
hospitalizations for lower respiratory tract infection in essential.
this age group r Wheezing; may be absent in mild or severe disease r Young infants have limited respiratory reserve and
r Crepitations
RISK FACTORS may decompensate suddenly.
r Risk factors for bronchiolitis: DIAGNOSTIC TESTS & INTERPRETATION INITIAL STABILIZATION/THERAPY
Exposure to tobacco smoke, lack of breastfeeding Lab r Assess and stabilize airway, breathing, and
r Predictors of need for airway intervention/ICU care: Initial Lab Tests circulation.
Age <7 wk r Most cases need no investigations (3). r Bag-mask ventilation with apnea
Weight <4 kg r Most blood assays are not useful. r Intubation if persistent apnea, impending respiratory
Respiratory rate >80/min r Blood gas analysis may be useful in severe disease failure
Heart rate >180 bpm to detect respiratory failure. r Supplemental oxygen if oxygen saturation <90% (3)
Prematurity r Virologic testing (ELISA, fluorescent antibody r IV hydration if dehydrated or severe respiratory
Comorbidity: Cardiac/Pulmonary disease, testing, PCR, culture) in critically ill, neonates, distress
immunodeficiency, neuromuscular disease comorbidities, atypical presentation
r Not necessary for diagnosis but may be used for MEDICATION
GENERAL PREVENTION
r Palivizumab prophylaxis: cohorting during hospital admission First Line
r Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
Indicated at 32 wk gestation if 6 mo old at r Consider urinalysis and urine culture in febrile
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN
start of respiratory syncytial virus (RSV) season children <3 mo of age.
and 28 wk gestation if 12 mo old at start RSV r Consider sepsis workup in febrile bronchiolitis in r Most patients require no pharmacotherapy beyond
season (3) those <28 days of age if respiratory status permits: antipyretics.
r Hand washing to limit viral transmission r Bronchodilators (albuterol, epinephrine): Not
Bacterial coinfections are rare (5).
routinely indicated; do not change hospitalization
PATHOPHYSIOLOGY Imaging rates or clinical course (7):
Viral-induced necrosis of small airway epithelium, r Chest radiographs:
Therapeutic trial of albuterol 2.5 mg via nebulizer
acute neutrophilic inflammation and edema, profuse Not indicated in typical presentation (6) or 500 g via metered-dose inhaler/spacer an
mucus and bronchospasm May demonstrate airway disease, atelectasis, option:
hyperinflation Continue only if major decrease in work of
ETIOLOGY
r RSV in 8590% The minority have airway and airspace disease breathing
r Human meta pneumovirus, coinfections with RSV Pneumonia is viral. Response usually mild and transient
r Consider chest radiograph when:
common (4) Should not be routinely used (3)
r Parainfluenza Need to exclude another diagnosis
r Influenza Chronic course with lack of resolution over 3 wk
Critically ill with impending respiratory failure
r Adenovirus
Atypical presentation in toxic or deteriorating child
COMMONLY ASSOCIATED CONDITIONS
Otitis media
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BRONCHIOLITIS
r Epinephrine: PROGNOSIS
r Generally excellent
ADDITIONAL READING
Has a theoretical advantage over albuterol due to
its alpha effects r 20% still symptomatic at 3 wk r Hartling L, Wiebe N, Russell K, et al. Epinephrine for
Does not decrease hospitalization on its own (8)
Very temporary benefit
r Severe bronchiolitis with need for airway support bronchiolitis. Cochrane Database Syst Rev. 2004;
(1):cd003123.
B
rare (2%):
r Bronchodilators not effective after discharge r Levine DA, Platt SL, Dayan PS, et al. Risk of serious
Patients at risk if very young or premature, if there
is marked tachycardia/tachypnea (above), and if bacterial infection in young febrile infants with
Second Line
r Corticosteroids: Controversial; of questionable there are comorbidities. respiratory syncytial virus infections. Pediatrics.
2004;113:17281734.
benefit (810): COMPLICATIONS r Mallory MD, Shay DK, Garrett J, et al. Bronchiolitis
Not recommended by most widely accepted r Otitis media
practice guideline (3) r Dehydration (poor feeding common but frank management preferences and the influence of pulse
r Antibiotics: oximetry and respiratory rate on the decision to
dehydration rare) admit. Pediatrics. 2003;111(1):e45e51. Available
Not indicated r Pneumonia
at http://www.pediatrics.org/cgi/content/full/111/1/
Consider if associated bacterial disease (otitis r Apnea e45.
media), toxic appearance, sepsis syndrome r Respiratory failure
See Also (Topic, Algorithm, Electronic
DISPOSITION
Media Element)
Admission Criteria r Bacterial Pneumonia
r Hospitalize if: REFERENCES r Pneumonia, Aspiration
Hypoxemia <90% on room air 1. Stang P, Brandenburg N, Carter B. The economic r Respiratory Distress
Home oxygen is an option in otherwise healthy
burden of respiratory syncytial virus-associated r Wheezing
infants with mild bronchiolitis and room air bronchiolitis hospitalizations. Arch Pediatr
saturations in the upper 80s. Adolesc Med. 2001;155(1):9596.
Dehydration with inability to maintain hydration
2. Shay DK, Holman RC, Newman RD, et al. CODES
Major comorbidity
Bronchiolitis-associated hospitalizations among
Need to rule out alternative diagnosis
US children, 19801996. JAMA. 1999;282(15):
Severe increase in the work of breathing ICD9
14401446. r 466.11 Acute bronchiolitis due to respiratory
Strongly consider in infants with high-risk criteria:
Weight <4 kg, age <7 wk, respiratory rate 3. American Academy of Pediatrics Subcommittee on
syncytial virus (rsv)
>80/min, heart rate >180 bpm Diagnosis and Management of Bronchiolitis. r 466.19 Acute bronciolitis due to other infectious
Significant social concerns Diagnosis and management of bronchiolitis.
Pediatrics. 2006;118:17741793. organisms
r Critical care admission criteria:
Recurrent apneas 4. Smyth RL, Openshaw PJM. Bronchiolitis. Lancet.
2006;368:312322.
Concern regarding impending respiratory failure, PEARLS AND PITFALLS
increasing oxygen requirements 5. Greenes DS, Harper MB. Low risk of bacteremia in
febrile children with recognizable viral syndromes. r Pay close attention to vital signs.
Discharge Criteria Pediatr Infect Dis J. 1999;18:258261. r Very young infants and patients with comorbidities
r Mild respiratory distress:
6. Schuh S, Lalani A, Allen U, et al. Evaluation of the or highly abnormal vital signs have the greatest risk
Consider for moderate respiratory distress if the
utility of radiography in acute bronchiolitis. of decompensation.
patient is meeting other discharge criteria. r The majority of infants with bronchiolitis require no
r Acceptable oxygen saturation in room air 90% J Pediatr. 2007;150:429433.
r Well hydrated 7. Kellner JD, Ohlsson A, Gadomski AM, et al. investigations and no pharmacotherapy,
Bronchodilators for bronchiolitis. Cochrane
r Follow-up available
Database Syst Rev. 2000;(2):cd001266.
8. Plint AC, Johnson DW, Patel H, et al. Epinephrine
FOLLOW-UP and dexamethasone in children with bronchiolitis.
N Engl J Med. 2009;360:20792089.
FOLLOW-UP RECOMMENDATIONS 9. Schuh S, Coates AL, Binnie R, et al. Efficacy of oral
Discharge instructions and medications: dexamethasone in outpatients with acute
r Close, frequent follow-up and reassurance are often bronchiolitis. J Pediatr. 2002;140:2732.
helpful. 10. Corneli HM, Zorc JJ, Mahajan P, et al. A
r Warn parents that symptoms may persist for 23 wk. multicenter, randomized, controlled trial of
r Frequent small feeds usually are required. dexamethasone for bronchiolitis. N Engl J Med.
r Nasal suctioning may be helpful. 2007;257:331339. [Erratum, N Engl J Med.
r Instruct parents that pharmacotherapy after 2008;359:1972.]
discharge generally is not beneficial.
r Bronchodilators after discharge do not change the
subsequent clinical course.
r Daily oral corticosteroids such as prednisolone
1 mg/kg after a trial of dexamethasone 1.0 mg/kg
and 2 treatments of epinephrine 1:1,000 3 mL by
nebulization 30 min apart in the emergency
department may be considered:
Not routinely recommended (3)
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BURN, CHEMICAL
Mark X. Cicero
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BURN, CHEMICAL
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BURN, THERMAL
Nikhil B. Shah
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BURN, THERMAL
MEDICATION Discharge Criteria 3. Nagel TR, Schunk JE. Using the hand to estimate
r Pain control is essential. r No airway compromise the surface area of a burn in children. Pediatr
r Opioid analgesia is often required: r Burns <10% TBSA Emerg Care. 1997;13(4):254255.
Morphine 0.1 mg/kg IV/IM/SC q2h PRN:
Initial morphine dose of 0.1 mg/kg IV/SC may
r Tolerating adequate fluids by mouth
r No suspicion for inflicted burn injury
4. Sargent RL. Management of blisters in the
partial-thickness burn: An integrative research
B
be repeated q1520min until pain is controlled, r Family must have the resources to support an review. J Burn Care Res. 2006;27(1):6681.
then q2h PRN. outpatient care plan that includes the following: 5. Passaretti D, Billmire DA. Management of pediatric
Hydrocodone or hydrocodone/acetaminophen Teaching proper wound care and dressing burns. J Craniofac Surg. 2003;14(5):713718.
dosed as 0.1 mg/kg of hydrocodone component techniques to the patient and family 6. Sheridan RL. Burns. Crit Care Med. 2002;
PO q46h PRN Pain control 30(11 Suppl):S500S514.
Codeine 0.51 mg/kg/dose PO q46h Clearly defined early return conditions (eg, signs
r NSAIDs:
of infection)
Consider NSAID medication in anticipation of Immediate and long-term follow-up with scar ADDITIONAL READING
prolonged pain and inflammation: management r Kassira W, Namias N. Outpatient management of
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
Ketorolac 0.5 mg/kg IV/IM q6h PRN Issues for Referral pediatric burns. J Craniofac Surg. 2008;19(4):
Naproxen 5 mg/kg PO q8h PRN Follow-up is essential to a successful outcome: 10071009.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r Re-evaluate every 12 wk for wound healing and r Reed JL, Pomerantz WJ. Emergency management of
r Tetanus prophylaxis as indicated: infection until epithelization occurs, then every 6 wk pediatric burns. Pediatr Emerg Care. 2005;21(2):
thereafter for scarring. 118129.
Tetanus toxoid 0.5 mL IM r Long-term rehabilitation, including physical and
r Superficial burns are managed with moisturizers and
over-the-counter analgesics: occupational therapy
r Pressure therapy (application of pressure garments), CODES
Silver sulfadiazine: Apply b.i.d. to the burn area
until healed; should not be used on the face. massage, and/or splints may be needed to treat
Neosporin cream: Apply q.i.d. to burn area until wound contracture sites as the scar matures. ICD9
r Requires a multidisciplinary approach r 949.0 Burn of unspecified site, unspecified degree
healed. r 949.1 Erythema due to burn (first degree),
SURGERY/OTHER PROCEDURES unspecified site
r Partial- and full-thickness burn wound FOLLOW-UP r 949.2 Blisters with epidermal loss due to burn
management: (second degree), unspecified site
Clean burns with mild soap and water. FOLLOW-UP RECOMMENDATIONS
Debride devitalized tissue. Discharge instructions and medications:
Leave blisters intact unless large, painful, or if r Maintain proper wound care, and change the
PEARLS AND PITFALLS
rupture is imminent (4). dressing twice a day.
Apply a topical antibiotic, such as 1% silver r Pain control with over-the-counter or narcotic r Most burns are small and can be managed as an
sulfadiazine (avoid in sulfa allergy and neonates); analgesics as indicated outpatient.
mafenide to cartilaginous areas; or bacitracin to r Major burns require aggressive attention to airway
Patient Monitoring
the face. management, adequate fluid resuscitation, and
Monitor for infection, hypertrophic scar formation, and
Synthetic occlusive dressings (eg, Acticoat) are an wound care.
development of contractures. r Long-term follow-up and rehabilitation are essential
alternative to topical antimicrobials for burns
<2% TBSA and <24 hr old PROGNOSIS to a successful outcome.
Cover with a sterile nonadherent dressing, then Mortality from burn injury is related to young age,
wrap with gauze or a woven gauze bandage roll. burn extent, and the presence of inhalational injury.
r Emergent escharotomy may be indicated to relieve
COMPLICATIONS
restriction of the chest wall or to reduce r Delayed respiratory failure (inhalation injury)
compartment pressure in an extremity. r Wound infection
DISPOSITION r Sepsis
The majority of burns are small and may be managed r Hypertrophic scar formation
in the outpatient setting (ie, partial thickness <10% r Contractures
TBSA or full thickness <2%) (5).
Admission Criteria
r Criteria for transfer to a burn center (6): REFERENCES
Partial-thickness burns >20% TBSA at any age or
1. CDC, National Center for Injury Prevention and
>10% TBSA in those <10 yr of age
Control, WISQUARS. 10 leading causes of
Full-thickness burns >5% TBSA
unintentional injury deaths, United States. Available
Any significant burn to the face, hands, major
at http://webappa.cdc.gov/cgi-bin/broker.exe.
joints, genitalia, or perineum
Accessed November 25, 2009.
Inhalation, chemical, or electrical injury
Significant associated injuries 2. Drago DA. Kitchen scalds and thermal burns in
r Patients with significant burns not fulfilling the children five years and younger. Pediatrics.
2005;115(1):1016.
above criteria should be admitted to the hospital for
observation, IV fluids, and pain control.
r Critical care admission criteria:
Unstable vital signs; need for mechanical
ventilation
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CAFFEINE/THEOPHYLLINE POISONING
David H. Jang
Lewis S. Nelson
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CAFFEINE/THEOPHYLLINE POISONING
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CANDIDIASIS
Desiree M. Seeyave
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CANDIDIASIS
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r CO causes a leftward shift of the oxyhemoglobin r Neurologic symptoms can include agitation, seizure,
BASICS dissociation curve, which decreases off-loading of confusion, and coma.
oxygen from Hb. r Dermatologic:
DESCRIPTION r A series of immune-mediated damage in the CNS as Burns may be present on skin as well as in nares.
r Smoke inhalation is a major cause of death from
well as oxidative damage can lead to lipid Skin findings can include cherry-red colorations as
fires. Significant fire exposures can also lead to peroxidation. a result of CN exposure and lack of oxygen
carbon monoxide (CO) and cyanide (CN) poisoning, r CN is an inhibitor of multiple enzymes, including extraction across capillary bed.
which causes cellular hypoxia. cytochrome oxidase. This leads to cellular hypoxia
r CO is leading cause of mortality from poisoning in DIAGNOSTIC TESTS & INTERPRETATION
with an elevated lactate and often has multiorgan
the U.S. effects.
Lab
r There is substantial morbidity in CO poisoning r CN is also a very potent neurotoxin that affects Initial Lab Tests
r CO testing should occur with patients who present
survivors by delayed neurologic sequelae (DNS). areas of the brain with high metabolic activity, such
r Combustion of organic nitrogen-containing products as the basal ganglia and cerebellum.
with CO-related complaints such as headache or
flulike symptoms.
like plastics, polyurethanes, wool, silk, nylon, and r The carboxyhemoglobin (COHb) level is important to
synthetic rubber can produce CN. ETIOLOGY
r Smoke from closed-space fires obtain with smoke inhalation:
EPIDEMIOLOGY r Exhaust from furnaces, combustion engines such as Normal levels range between 0 and 5% with
r CO is the leading cause of poisoning death in
generators, automobiles, furnaces neonates; patients with hemolytic anemia may
children and adults in the U.S. have higher levels.
r There are >1.5 million fire incidents in the U.S. with COMMONLY ASSOCIATED CONDITIONS Levels >5% are considered abnormal, levels
r Burns:
>3,000 fire deaths per year. >25% are considered very elevated, and levels
r There are >2,000 nonfire CO deaths yearly in the Airway
>45% are extremely elevated:
Lung injury Heavy smokers can have levels as high as 10%.
U.S.
r CO poisoning contributes to >5,000 smoke Skin High levels may confirm CO exposure but do not
r Smoke inhalation
inhalation deaths per year. correlate with clinical symptoms or outcome.
r After Hurricane Katrina in Louisiana and Hurricane It is important to consider testing cohabitants of
Ike in Texas, it was recognized that a significant DIAGNOSIS the patient for CO exposure.
r Blood gas analysis, lactate and methemoglobin
number of pediatric exposures to CO result with use
of gasoline-powered generators during electrical HISTORY concentrations:
r The primary complaint from smoke inhalation is
outages. Metabolic acidemia is indicative of CN toxicity.
r A significant number of closed-space or indoor fires respiratory, ranging from cough to respiratory r Lactate can be elevated in the setting of hypoxia,
result in CN exposure due to combustion of certain distress and coma. serious CO poisoning, and CN toxicity. Rapidly
r Early symptoms of CO exposure are often
materials in fires. obtain a lactate level:
r The majority of CO and CN exposure is nonspecific and can mimic a viral syndrome, Lactate elevation is extremely sensitive and
unintentional. Either can occur in suicidal attempts especially during winter months when an indoor usually is specific for CN exposure in the setting of
but this is far less common. heater may be in use. closed-space fires.
r A headache that is described as diffuse and aching Levels >10 mmol/L suggest CN poisoning and
RISK FACTORS is the most common complaint. should trigger CN antidote use.
r Vehicular, such as riding in the back of a pickup truck r Heavy CO poisoning can manifest as syncope, coma, CN concentrations can be obtained but often are
r Use of propane-powered equipment (ie, ice rink not readily available to be meaningful. Blood CN
or seizure.
resurfacers or forklifts in enclosed spaces) r Children often manifest atypical symptoms of CO concentration >1.0 ug/mL is considered toxic.
r Gas furnaces during the winter months r Troponin can be elevated due to diffuse myocardial
poisoning, presenting with vomiting or an isolated
r Smoke inhalation seizure. damage.
r Use of combustion engines in a location without r Patients with long-term exposure to low levels of CO r Elevations of creatine phosphokinase (CPK) are
proper ventilation, such as using a often will complain of a persistent headache and typically mild, but rhabdomyolysis may occur, so
gasoline-powered generator indoors or leaving an nonspecific cognitive problems such as memory loss. assay CPK as indicated.
automobile running inside a closed garage r Patients with smoke inhalation and severe metabolic
Imaging
GENERAL PREVENTION acidosis should also be evaluated for possible CN r Chest radiograph should be obtained in most cases
r Use smoke and CO detectors, especially during the toxicity. of smoke inhalation, which can show interstitial
r The persistent or delayed effects of CO poisoning can changes and diffuse alveolar involvement.
winter, and learn to recognize symptoms of CO
poisoning (ie, flulike symptoms). include apraxia and agnosias, dementia, amnestic r A noncontrast head CT should be obtained in
r Use of an indoor detector that senses both smoke syndromes, parkinsonism, and cortical blindness. unresponsive patients or those with focal neurologic
and CO is recommended. PHYSICAL EXAM deficits.
r Assess vital signs and pulse oximetry. Diagnostic Procedures/Other
PATHOPHYSIOLOGY r Tachycardia and hypotension are common in
r Toxic combustion products from fires include ECG should be obtained to evaluate for dysrhythmias
chemical asphyxiants (CO and CN), simple toxicity. Tachypnea and hyperpnea may also occur. and ischemia with severe exposure.
asphyxiants (such as carbon dioxide), and irritants. r Respiratory:
Pathological Findings
r CO is a by-product of hemoglobin (Hb) degradation. Head and neck findings include burns, soot in Autopsies from severe CO poisoning can show
r CO binds with Hb with 200 times greater affinity nares, copious oral secretions, and oropharyngeal necrosis of the cerebellum, globus pallidus, and
than oxygen, which renders it incapable of edema. hippocampus.
delivering oxygen. CO also binds with cytochrome May also exhibit drooling, stridor, and inability to
oxidase and inhibits cellular respiration. handle secretions
Pulmonary symptoms include rhonchi, crackles,
and wheezing.
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CARDIOGENIC SHOCK
Marsha Ayzen Elkhunovich
Vincent J. Wang
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CARDIOGENIC SHOCK
r Coagulation studies and platelets to check for r Improve contractility: Issues for Referral
evidence of disseminated intravascular coagulation Correct hypoglycemia with a dextrose bolus. Consultation from the emergency department as
(DIC) Replace electrolytes as needed (specifically, necessary:
r Hemoglobin level to determine if blood should be calcium and potassium) to maximize myocardial r Cardiology for most cardiogenic shock cases
given to maximize oxygenation function. r Toxicology for ingestions or drug overdoses
r Type and cross match in case of need for blood Correct acidosis with sodium bicarbonate or r Metabolism if known metabolic disease
product transfusion tromethamine (THAM). r Trauma surgery if traumatic etiology
Inotropic agents if needed
Imaging r Decrease afterload:
r Chest radiograph to evaluate for cardiomegaly,
Administer vasodilators, avoiding hypotension. FOLLOW-UP
C
pulmonary edema, pneumothorax
r Focused abdominal sonograph for trauma (FAST)
ALERT PROGNOSIS
exam if trauma or for evaluation of pericardial r In infants in whom heart disease is suspected, r Depends on the extent of tissue damage and the
effusion or pneumothorax avoid administration of 100% oxygen during the timing of intervention
r Echo to evaluate for obstructive lesions, shortening r Some patients may require extracorporeal
resuscitation, as it can induce closure of the
fraction, and volume status if suspecting structural patent ductus arteriosus in neonates and cause membrane oxygenation or a left ventricular assist
or functional heart disease overcirculation in the lungs of older infants. device and may need cardiac transplantation in the
Diagnostic Procedures/Other r Use only enough supplemental oxygen delivery to future.
ECG to look for evidence of dysrhythmias, ST changes, achieve adequate oxygenation (3). See the Patent COMPLICATIONS
and low voltages Ductus Arteriosus and Ductal Dependent Cardiac If there is prolonged tissue hypoperfusion and hypoxia,
DIFFERENTIAL DIAGNOSIS Emergencies topics. end-organ damage, such as to the kidney, liver, lung,
r Hypovolemic shock and/or brain, may occur.
r Distributive (septic) shock MEDICATION
r Anaphylaxis First Line
r Inborn error of metabolism r Inotropic agents to increase cardiac output: REFERENCES
Dobutamine 1. De-Wahl Granelli A, Wennergren M, Sandberg K,
Dopamine et al. Impact of pulse oximetry screening on the
TREATMENT Epinephrine detection of duct dependent congenital heart
Isoproterenol (if heart rate is low) disease: A Swedish prospective screening study in
PRE HOSPITAL r Antidysrhythmic agents for dysrhythmias: 39,821 newborns. BMJ. 2009;338:a3037.
r Assess and continuously reassess ABCs.
r Ensure airway patency, and administer supplemental Lidocaine 2. Lees MH, King DH. Cardiogenic shock in the
Digoxin neonate. Pediatr Rev. 1988;9(8):258266.
oxygen as necessary. Adenosine
r Bag-mask ventilation and sometimes endotracheal 3. Steinhorn RH. Evaluation and management of the
Esmolol cyanotic neonate. Clin Pediatr Emerg Med. 2008;
intubation may be necessary. Amiodarone 9(3):169175.
r Obtain access with an IV or intraosseous line.
r Administer fluid boluses with guidance from the Second Line
r Corticosteroids: First line if suspecting adrenal
base station.
r Administer CPR if necessary.
insufficiency CODES
r Nitric oxide if pulmonary HTN
r Capillary glucose assessment and glucose r Amrinone or milrinone should be used to decrease ICD9
supplementation as necessary afterload in appropriate patients who have 785.51 Cardiogenic shock
structural heart disease and/or poor contractility if
ALERT
the patients have an adequate BP.
In patients with cardiogenic shock, endotracheal PEARLS AND PITFALLS
intubation may lead to complete cardiovascular SURGERY/OTHER PROCEDURES
r Pericardiocentesis may be necessary in cardiac r Pearls:
collapse. Intubate only if necessary, and be prepared
to administer CPR if needed. tamponade. Initial treatment of shock should generally be the
r Thoracentesis if large pulmonary effusions are same regardless of etiology.
INITIAL STABILIZATION/THERAPY present or to resolve a pneumothorax or hemothorax It is more important initially to start treatment and
r ABCs: See Pediatric Advanced Life Support (PALS) or decrease further tissue injury than to determine
DISPOSITION the exact etiology.
Advanced Cardiac Life Support (ACLS) protocols for Admission Criteria r Pitfalls:
initial stabilization steps. The goal of initial r Any patient who presents to the emergency
treatment is to restore tissue perfusion both directly Performing invasive procedures on patients with
department in cardiogenic shock warrants cardiogenic shock (eg, intubation, line placement)
and by correcting the underlying etiology. admission.
r General: r Telemetry monitoring is necessary for any patient
may bring about complete cardiovascular collapse.
Provide optimal ventilation and oxygenation. Not being prepared to administer CPR
with a recent history of cardiogenic shock.
Connect the defibrillator, and administer CPR if r Critical care admission criteria:
needed.
Need for ventilatory support
Obtain venous access, preferably peripheral and
Need for inotropic support
central venous.
Prostaglandin E2 infusion in an infant
Obtain arterial access for more accurate
High risk for cardiovascular collapse/dysrhythmia
continuous BP measurements.
r Improve preload:
Begin fluid resuscitation (cautiously if there is
known heart disease or evidence of CHF).
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CARDIOMYOPATHY
Heather R. Saavedra
Marc Gorelick
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CARDIOMYOPATHY
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DISPOSITION REFERENCES
TREATMENT Admission Criteria
r Immunocompromised children usually need to be 1. Jackson L, Perkins B, Wender JD. Cat scratch
MEDICATION hospitalized for observation and therapy. disease in the United States: An analysis of three
First Line r Children with bacillary peliosis, bacillary national databases. Am J Public Health. 1993;83:
r In uncomplicated cases in immunocompetent hosts, angiomatosis, or complicated or disseminated
17071711.
cat scratch disease is a self-limited illness requiring disease often need to be hospitalized and receive 2. English R. Cat-scratch disease. Pediatr Rev. 2006;
only supportive care. parenteral antibiotics. 27:123128.
In uncomplicated cases, there is controversy over
the utility of treatment with azithromycin (3).
Discharge Criteria
r Most immunocompetent patients with suspected cat
3. Massei F, Gori L, Macchia P, et al. The expanded
spectrum of bartonellosis in children. Infect Dis Clin
C
r Azithromycin: North Am. 2005;19:691711.
scratch disease can be safely discharged.
Dose 10 mg/kg/dose on day 1 followed by r Patients with disseminated disease and
5 mg/kg/dose on days 25; adult dose 500 mg
day 1 followed by 250 mg PO days 25
immunocompromised patients should be admitted ADDITIONAL READING
for antibiotic therapy.
Patients with more disseminated disease may Schutze G, Jacobs R. Bartonella species (cat-scratch
benefit from treatment with azithromycin. disease). In Long S, ed. Principles and Practice of
r Immunocompromised patients always require FOLLOW-UP Pediatric Infectious Diseases. 3rd ed. Philadelphia, PA:
antimicrobial therapy. Churchill-Livingstone; 2008:851854.
r In the immunocompromised child, erythromycin, FOLLOW-UP RECOMMENDATIONS
Discharge instructions and medications: See Also (Topic, Algorithm, Electronic
rifampin, doxycycline, or gentamicin should be used
alone or in combination. r Patients should be followed closely by their primary Media Element)
r Analgesics are indicated for pain due to care provider. Fever of Unknown Origin
lymphadenopathy. r Many clinicians elect to treat with a 5-day course of
r NSAIDs: azithromycin.
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
CODES
PROGNOSIS
Ketorolac 0.5 mg/kg IV/IM q6h PRN r Uncomplicated cases gradually resolve over several
Naproxen 5 mg/kg PO q8h PRN ICD9
months without treatment.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r Even in immunocompromised hosts, the prognosis is 078.3 Cat-scratch disease
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ETIOLOGY
BASICS r Midline lumbar disc herniation DIAGNOSIS
r Meningitis
DESCRIPTION r Space-occupying lesions in the spinal cord: HISTORY
r Cauda equina syndrome is a rare condition that r Pain in the lumbar region
Epidural hematoma r Pain that radiates down both legs in the sciatic
results from the compression of the nerve roots of Abscess
the spinal cord distal to L1. Tumor distribution
The cauda equina, or horsetail, represents the r Ankylosing spondylitis r Numbness or weakness in both legs that is often
lower end of the spinal cord and contains the r Paget disease progressive
nerve roots from L1L5 and S1S5. r Urinary retention
r Inferior vena cava thrombosis
r Compression of these nerve roots manifests as one r Rectal sphincter dysfunction
r Lymphoma
or more of the following: r Altered urinary sensation
r Sarcoidosis
Weakness of the lower extremities r Altered perineal sensation
r Trauma (blunt or penetrating):
Saddle anesthesia r Urinary frequency
Bowel or bladder dysfunction Can rarely be related to spinal anesthesia or r Urinary incontinence
Sexual dysfunction lumbar puncture
r Sexual dysfunction
EPIDEMIOLOGY COMMONLY ASSOCIATED CONDITIONS
r Uncommon with unclear incidence r Meningomyelocele PHYSICAL EXAM
r Usually reported as a case report r Lumbar vertebral subluxation r Sensory deficit in a saddle distribution
r Neoplasia in the lumbosacral area: r Sensory deficit in the perineal area
RISK FACTORS r Often asymmetric flaccid paralysis of the lower
r History of cancer Can be primary or metastatic
Often Ewings sarcoma or neuroblastoma extremities
r History of low back trauma r Decreased rectal sphincter tone
r Epidural hematoma or abscess
PATHOPHYSIOLOGY r Positive straight leg raise test
r Compression of some or all of the nerve roots from r Reflex abnormalities: Loss or diminution
L1S5 by any lesion (see below)
r These nerve roots are particularly susceptible to DIAGNOSTIC TESTS & INTERPRETATION
injury since they have a poorly developed Imaging
r MRI is the preferred imaging modality.
epineurium. r If concerned, MRI should be performed emergently.
r CT scan is inferior for diagnosing cauda equina
syndrome:
However, it is the modality of choice if fracture is a
concern.
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CAUSTIC EXPOSURE
Kristopher Hunt
Robert J. Hoffman
ETIOLOGY r Ingested:
BASICS The following routes of exposure: Typical findings include burns to the lips and
r Inhalational oropharynx.
DESCRIPTION r Dermal Patients may exhibit dribble marksburns to
r Caustic exposures cause histologic damage on
r Ocular the chin or chest from dribbled or spilled caustic
contact with tissue. r Oral liquid.
r The most familiar types are acids and alkali: Dysphonia, aphonia, and stridor are ominous signs
r GI
Others are desiccants, vesicants, and protoplasmic of airway injury and should trigger immediate
poisons. action to stabilize and secure the airway.
r Caustics are often found in cleaning products. DIAGNOSIS Ominous signs include evidence of viscous
r Acids include hydrochloric acid, sulfuric acid, and perforation, hemodynamic instability, peritoneal
hydrofluoric acid (HF). HISTORY signs, and signs of airway compromise.
r Alkali include ammonia, calcium hydroxide, sodium r Dermal: Except in peritonitis, the abdominal exam
hydroxide, and household bleach. Patients may or may not know of a specific caustic correlates poorly with extent of damage.
r HF poses a specific problem because it is a weak that has been exposed on skin. Suicidal intent in the adolescent may be an
HF exposure will present with a complaint of independent risk factor for severity of injury.
acid, allowing it to remain in an undissociated state
severe pain, discordant with physical exam
and penetrate skin:
findings. Burns with a benign skin appearance
DIAGNOSTIC TESTS & INTERPRETATION
Contact with a body surface area as small as 2% Lab
may be life threatening.
with concentrated HF may be fatal. Initial Lab Tests
Onset of pain is directly related to concentration
EPIDEMIOLOGY of HF: Serum chemistry, a venous or arterial blood gas
Very concentrated HF >4050% causes analysis:
Incidence r Screening acetaminophen and salicylate should be
There are >100,000 reported exposures to caustic immediate symptoms, weak HF <10% solution
agents annually in the U.S.: typically causes symptoms only many hours done if there was intent of self-harm.
r Household bleach is the most common. (614) after exposure. Imaging
r Ocular: r Radiographs of the chest and abdomen may aid in
GENERAL PREVENTION Patients typically have severe pain. demonstrating pneumothorax,
Keep poisons inaccessible to children. Lack of pain may be the result of a severe burn. pneumomediastinum, pleural effusion, or
r Inhalational: intraperitoneal air:
PATHOPHYSIOLOGY
r Acids and alkali exert damage as a result of proton Upper airway irritation, chest pain, or dyspnea Radiographs are not routinely indicated but are
donation or acceptance, respectively. after aerosolized caustic exposure used in symptomatic patients.
r Acids cause coagulation necrosis; the upper layer of r Ingested: r CT of the chest, abdomen, and/or pelvis may
damaged tissue forms a leathery eschar, preventing Suicidal intent, more prevalent in adolescent further delineate injuries; use only in symptomatic
deeper tissue penetration: ingestions, may predict significant injury. patients:
HF is a unique caustic capable of causing severe Patients may complain of a variety of symptoms In the case of an ingested button battery,
systemic toxicity and dysrhythmias due to both following caustic ingestion, and there may be a radiographs of the neck, chest, and abdomen
depletion of calcium and magnesium and great disparity between symptomatology and should be obtained to locate the battery as well as
hyperkalemia. severity of injury. obtain an estimate of size.
Acids may cause damage to other organs. such as Pain complaints may be referred to the
Diagnostic Procedures/Other
the spleen, liver, and biliary tree after being oropharynx, chest, or abdomen. These may r Obtain a 12-lead ECG.
absorbed and distributed systemically. include dysphagia, odynophagia, drooling, r Endoscopy:
r Alkalis cause liquefaction necrosis, which is more abdominal pain, chest pain, or vomiting.
Ominous symptoms: Constitutional symptoms or Gold standard for assessment of GI damage
extensive and severe because saponification and Endoscopy after a caustic ingestion will not result
protein disruption allow the caustic to penetrate systemic complaints such as dizziness, listlessness,
fever, chills, HA, or syncope in damage to the endoscope.
through layers of tissue. Do not delay endoscopy to allow the injury to
r Extent of injury after caustic exposure is mostly Weeks after ingestion, dysphagia and vomiting
may result from stricture formation. develop; delay increases the risk of perforation.
determined by pH, particularly if the substance is No evidence supports the idea that viscous
below pH 2 or >12: PHYSICAL EXAM perforation is more likely with endoscopies
Concentration is also a determinant of injury, with r Dermal: performed for caustic ingestions relative to those
more severe injuries resulting from more Patients will have localized pain and apparent performed for any other reason.
concentrated solutions. burns. The presence of vomiting, drooling, stridor, and
Food in the stomach as well as vomiting may HF exposure may have minimal or no apparent the inability to voluntarily take oral liquids are
diminish the effect of the caustic ingestion. skin lesions: reliable factors in young children to predict
Tissue penetration, duration of contact, and Severe pain out of proportion related to the esophageal or gastric injury:
volume of caustic are other factors of injury. physical exam is very common with HF. Children with none of these signs and
For ocular exposures, alkaline agents have a r Ocular: symptoms can be presumed to not have severe
potential to injure the eye to a greater extent at a Diminished visual acuity and clouding of the GI involvement and do not require endoscopy.
lower concentration largely due to the inability of cornea are poor prognostic signs. Presence of 2 of these findings are indications
tears to buffer alkaline substances. r Inhalational: for endoscopy. These criteria are only applicable to
Patients may present with relative degrees of children and may not be applicable to adolescents.
tachypnea, stridor, dysphonia, aphonia, Other indications include any patient or
bronchospasm, hypoxia, hypercarbia, or circumstance that is considered to be unreliable
respiratory arrest depending on the involved surrounding an ingestion (particularly suicidal
caustic exposure. intent) and any patient with 2nd- or 3rd-degree
orofacial burns.
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CAUSTIC EXPOSURE
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CELIAC DISEASE
Nina Gold
Todd A. Mastrovitch
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CELIAC DISEASE
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CELLULITIS
Louis A. Spina
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CELLULITIS
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CEREBRAL CONTUSIONS
Lynn Babcock Cimpello
r Secondary injury to surrounding brain tissue can DIAGNOSTIC TESTS & INTERPRETATION
BASICS occur from: Lab
Mass effect that decreases cerebral blood flow to r CBC:
DESCRIPTION surrounding tissue and increases in intracranial Anemia (hemoglobin <9 mg/dL) increases the
r Cerebral contusion is bruising of the cerebral pressure (ICP) from cerebral autoregulation likelihood of cerebral injury (5).
parenchyma and consists of brain tissue damage A release of toxic metabolites from a cascade of Thrombocytopenia is a risk factor for progression
and vascular injury: biochemical and physiologic responses of hemorrhage (3,4).
Resultant findings include edema and r There are 3 phases of brain swelling due to r Coagulation studies:
microhemorrhages. contusions (24): Progression of contusion is associated with
Can range from focal to diffuse 1st 24 hr: coagulation abnormalities (INR >1.3) (3).
r About 2% of the population in the U.S. live with Life threatening r Serum glucose:
disabilities from traumatic brain injuries (TBIs) (1). Formation of idiogenic osmoles draws fluid into Admission serum glucose 300 mg/dL is
EPIDEMIOLOGY the core of the contusion. associated with death (6).
Next 2472 hr: r Electrolytes and serum osmolality are useful if
Incidence 30% of hemorrhages will expand during this
r TBIs are the leading cause of death and disability for initiating hyperosmolar therapy.
time frame.
children >1 yr of age (1). Edema expands to adjacent uninjured tissue. Imaging
r About half a million children sustain TBIs per year r Image findings in contusions vary with their stages
Slow, delayed swelling can continue for up to
(1). 10 days after injury. of evolution.
r Cerebral contusions occur in 2030% of children r Head CT is the most common acute imaging
with severe TBI. ETIOLOGY modality:
r Presence of a contusion is a strong predictor of poor Depends on age: Edema appears as hypodense areas.
r <4 yr: Falls, child abuse, and motor vehicle collisions
outcomes in those with TBI. Microhemorrhages appear as hyperdense areas.
r >4 yr: Motor vehicle collisions, sports, and assaults Up to 25% of initial CT findings may be normal
RISK FACTORS
r Male due to partial volume averaging between edema
COMMONLY ASSOCIATED CONDITIONS
r Minority groups r Skull fractures and hemorrhages.
r Lower socioeconomic status r Other intracranial injuries Up to 50% of contusions can progress, thus:
Follow-up CT should be considered if neurologic
r Alcohol use r Child abuse in younger children
deterioration or rises in ICP occur.
r Child abuse r After stabilization, MRI is the criterion standard for
r Coagulation abnormalities increase the risk of defining contusions:
DIAGNOSIS
progression of cerebral contusions. Predicts neurocognitive impairments
HISTORY Can demonstrate hemorrhage earlier than CT
GENERAL PREVENTION r Mechanism with direct blow to head or
r Primary prevention measures, such as wearing DIFFERENTIAL DIAGNOSIS
helmets and seat belts, as well as use of airbags and acceleration/deceleration forces r Other intracranial injuries
r Loss of consciousness, alteration of mental status,
stair gates, can decrease the incidence and severity r Other causes of alteration of mental status such as
of the injury. headache, amnesia, nausea, vomiting, irritability, or
ingestions, infections, or hemorrhage
r Controlling secondary insults from hypoxemia, seizures
r Focal neurologic symptoms related directly to the
hypotension, and intracranial HTN are critical since
these lead to poor outcomes. contused area may be present, such as behavioral TREATMENT
changes with frontal contusions or memory
PATHOPHYSIOLOGY disturbances with temporal contusions. PRE HOSPITAL
r Primary injury of cerebral contusions occurs from r Inconsistent history or mechanism should raise r Assess and stabilize airway, breathing, and
direct trauma when the head is stationary or from suspicions of child abuse. circulation.
acceleration/deceleration forces when the head is in r Cervical spine precautions
motion: PHYSICAL EXAM r Transport to a trauma center with pediatric
r Vital signs
Coup contusions occur directly under the site of
r Glasgow Coma Scale (GCS) expertise, if possible.
impact from the resultant deformation of the skull.
Contrecoup contusions occur on the opposite side r Signs of increasing ICP include: INITIAL STABILIZATION/THERAPY
from the impact site from the deceleration forces. Worsening of mental status r Management depends on severity of injury.
Contusions from acceleration/deceleration forces Bradycardia, irregular respirations, and HTN r Primary goal is to prevent or ameliorate secondary
occur when the brain strikes the bony skull. (Cushing triad) brain injury (7).
r Areas of the brain in close contact with the skull are Changes in pupillary responses starting with r Assess and stabilize airway, breathing, and
most commonly affected: Orbitofrontal cortex, ipsilateral dilation and progressing to ptosis and circulation:
anterior temporal lobe, and posterior portion of the loss of medial gaze Control airway as needed:
superior temporal gyrus area with the adjacent Decorticate or decerebrate posturing Rapid sequence endotracheal intubation if
parietal opercular area. r Signs of head trauma such as scalp laceration, scalp GCS <8, significant hypoxemia, inability to
hematoma, signs of basilar skull fractures (raccoon control airway, or hemodynamic instability exists
eyes or Battle sign), hemotympanum, or CSF Normalize PCO2 (PCO2 of 3538 mm Hg).
rhinorrhea or otorrhea Maintain perfusion:
Establish vascular access.
Administer isotonic solutions to avoid
hypotension (systolic BP <5th percentile for
age).
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CEREBRAL CONTUSIONS
r Maintain cervical spine precautions. r Children with small contusions (<10 mm) and a 5. Kurtz P, Schmidt M, Claassen J, et al. Anemia is
r Maintain euthermia: normal neurologic exam can be admitted to a associated with brain tissue hypoxia and
Hyperthermia is associated with worse outcomes. regular pediatric floor: metabolic crisis after severe brain injury. Crit Care.
r Correct abnormalities in glucose, electrolytes, blood Monitor for neurologic signs of progression 2009;13(Suppl 1):92.
counts, and coagulation studies. r Critical care admission criteria: 6. Cochran A, Scaife ER, Hansen KW, et al.
r Early consultation with neurosurgery Children with moderate/severe contusions Hyperglycemia and outcomes from pediatric
r ICP monitoring is recommended for children with (>10 mm) or alteration of mental status should traumatic brain injury. J Trauma. 2003;55(6):
GCS 8. be admitted to the ICU for monitoring. 10351038.
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CERVICAL LYMPHADENITIS
Marc A. Auerbach
Lawrence Siew
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CERVICAL LYMPHADENITIS
DIFFERENTIAL DIAGNOSIS
r Lymphadenopathy
Second Line
r Amoxicillin/Clavulanate 45 mg/kg/day PO divided
ADDITIONAL READING
r Midline neck lesions: Thyroglossal duct cysts, b.i.d.t.i.d., max dose 2 g/day 1014 days: r Buchino JJ, Jones VF. Fine needle aspiration in the
epidermoid cysts, and lipomas If periodontal disease is present, consider evaluation of children with lymphadenopathy. Arch
r Cystic hygroma, branchial cleft cyst, thyroid tumors, clindamycin or amoxicillin/clavulanate. Pediatr Adolesc Med. 1994;148:13271330.
r Trimethoprim/Sulfamethoxazole (TMP/SMZ) r Hazra R, Robson CD, Perez-Atayde AR, et al.
laryngocele
10 mg/kg/day PO divided q12h, max daily dose Lymphadenitis due to nontuberculous mycobacteria
320 mg TMP/1,600 mg SMZ daily in children: Presentation and response to therapy.
TREATMENT r Azithromycin 10 mg/kg day 1, then 5 mg/kg PO
days 25:
Clin Infect Dis. 1999;28:123129.
r Leung AK, Davies HD. Cervical lymphadenitis: C
INITIAL STABILIZATION/THERAPY Used specifically for catscratch disease Etiology, diagnosis, and management. Curr Infect
r Acute bilateral lymphadenitis is usually due to
Dis Rep. 2009;3:183189.
self-limited viral infections. Observation with no DISPOSITION r Peters TR, Edwards KM. Cervical lymphadenopathy
treatment is usually appropriate. Admission Criteria and adenitis. Pediatr Rev. 2000;12:399405.
r Acute unilateral lymphadenitis: r Failure of outpatient management
In a well-appearing child with a minimally r Pain requires IV medications See Also (Topic, Algorithm, Electronic
enlarged and tender lymph node, measuring initial r Requires IV fluids Media Element)
dimensions and monitoring over time is r For further workup Catscratch Disease
recommended.
For warm and tender lymph nodes, without Discharge Criteria
r Other more serious diagnoses have been ruled out.
evidence of fluctuance, a course of oral antibiotics CODES
r No airway compromise
is recommended.
r Ability to take PO
If ill appearing or abscess is suspected, IV ICD9
antibiotics are indicated. r 017.20 Tuberculosis of peripheral lymph nodes,
Issues for Referral
Nonresponse to antibiotics: Consider ENT and/or unspecified examination
MEDICATION r 289.1 Chronic lymphadenitis
infectious disease consult.
First Line r 289.3 Lymphadenitis, unspecified, except mesenteric
r Empiric oral regimens including amoxicillin,
penicillin, cephalexin, or clindamycin are appropriate FOLLOW-UP
for most infections.
r Infections with severe illness should be treated with FOLLOW-UP RECOMMENDATIONS PEARLS AND PITFALLS
parenteral antibiotics. Discharge instructions and medications: r Cervical lymphadenitis is inflammation of 1
r Duration of treatment is 1014 days. r Take medications as prescribed. Return to primary
cervical lymph nodes.
r Oral therapy: care provider to evaluate for improvement on r Most commonly, acute bilateral lymphadenitis is due
Cephalexin 50 mg/kg/day PO divided b.i.d.q.i.d., antibiotics. to upper respiratory infections.
max dose 2 g/day Patient Monitoring r Unilateral lymphadenitis may require treatment: PO
Amoxicillin 40 mg/kg/day PO divided b.i.d.q.i.d., Monitor clinical response to treatment to note antibiotics in moderate illness and IV antibiotics for
max dose 2 g/day improvement or lack thereof. severe illness.
Penicillin 50 mg/kg/day PO divided b.i.d.q.i.d., r 80% of acute unilateral lymphadenitis is due to
max dose 2 g/day PROGNOSIS
r Cervical lymphadenitis spontaneously regresses in pyogenic infection by group A streptococcus or
Clindamycin 30 mg/kg/day PO divided t.i.d.q.i.d., S. aureus.
most children over the course of several weeks.
max dose 1.8 g/day: r Mycobacterial infections may take a long time to r Suspect NTM or TB with chronic lymphadenopathy.
Optimal for polymicrobial infections, suspected
MRSA resolve.
r Parenteral therapy: COMPLICATIONS
Cefazolin 50100 mg/kg/day IV divided q8h, r Persistent or recurrent lymphadenitis is the most
max dose 6 g/day frequent complication.
Nafcillin or oxacillin 150 mg/kg/day IV divided r Development of a sinus tract or disseminated
q6h, max dose 6 g/day disease associated with mycobacterial disease
r Abscess formation, cellulitis, bacteremia
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CHALAZION
Nicole D. Porti
Karen Franco
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CHALAZION
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CHANCROID
Marcelo Sandoval
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CHANCROID
Patient Monitoring
r 3-day symptomatic improvement and 7-day
ADDITIONAL READING
TREATMENT
subjective appearance improvement are typical of See Also (Topic, Algorithm, Electronic
MEDICATION successful treatment (3,5). Media Element)
r Incision and drainage may need to be done later if r Herpes Simplex
First Line
r Azithromycin 1 g PO 1 dose bubo develops or recurs despite primary ulcer r Sexually Transmitted Infections
r Ceftriaxone 250 mg IM 1 dose healing (2,3,5). r Syphilis
r Single-dose regimens assure compliance but may r Repeat syphilis and HIV testing at 3 mo is
fail in HIV or in uncircumcised patients (15). recommended (2).
CODES
C
Second Line PROGNOSIS
r Ciprofloxacin 500 mg PO b.i.d. 3 days r Generally excellent with improvement by 3 days and
r Erythromycin base 500 mg PO t.i.d. 7 days (15) healing by 714 days (2,3,5) ICD9
r Longer healing times and treatment failures are 099.0 Chancroid
Pregnancy Considerations
r Safety of azithromycin in pregnancy and lactation seen in uncircumcised men, larger ulcers, and
HIV-positive patients (15).
has not been established (2). r Erythromycin regimen for 7 days may be preferred PEARLS AND PITFALLS
r Ciprofloxacin is contraindicated in pregnancy (2).
for HIV patients (2). r Pearls:
r Any treatment failure should also prompt a search HSV and syphilis are the most common source of
SURGERY/OTHER PROCEDURES
r Buboes <5 cm in size usually resolve with for a different or coinfecting STI, drug resistance, anogenital ulcers, followed by chancroid.
treatment. Size >5 cm usually requires drainage (5). noncompliance, and/or HIV-positive status (2). Clinical impression is often unreliable in
r Incision and drainage of buboes is preferred over COMPLICATIONS differentiating syphilis, HSV, and chancroid.
aspiration, as there is less need to repeat the r Scarring (1,3) Emergency department testing with darkfield and
procedure (2,5). r Balanoposthitis (4) Tzanck smears, direct immunofluorescence, and
r Phimosis (4) viral cultures and syphilis serologies should be
DISPOSITION done if available to enhance correct diagnosis and
r Bubo rupture and superinfection (1,4,5)
Admission Criteria treatment.
r Rarely necessary r Phagendic variant with widespread necrosis and Buboes may persist or even grow after ulcer
r Admission is warranted in rare cases of extensive tissue destruction (5) resolution, but this does not necessarily mean
tissue necrosis or severe systemic illness. Refer to r Systemic fever/illness (rare) treatment failure.
complications below. r Fistula formation (4) Buboes often resolve with treatment, but if
>5 cm in size, incision and drainage, rather than
Issues for Referral
r Sexual partners need evaluation and treatment if aspiration, is preferred.
REFERENCES Treatment failure is associated with coinfection
exposed within 10 days of lesion or symptom onset
with another STI or HIV.
(2). 1. Lews DA. Chancroid: Clinical manifestations, r Pitfalls:
r Some states require notification of child protection diagnosis, and management. Sex Transm Inf.
If a purely clinical approach without testing in the
authorities if the patient is below the age of 2003;79:6871.
emergency department is the only practical
consent. Know your local reporting requirements 2. CDC, Workowski KA, Berman SM. Diseases option, failing to ensure that the patient
and call social services as needed. characterized by genital ulcers. Sexually transmitted understands follow-up is crucial due to the
diseases treatment guidelines 2006. MMWR Morb potential for error in diagnosis.
FOLLOW-UP Mortal Wkly Rep. 2006;55(RR-11):1430. Not arranging follow-up syphilis and HIV
3. McKinzie J. Sexually transmitted diseases. Emerg serologies at 3 mo
FOLLOW-UP RECOMMENDATIONS Med Clin North Am. 2001;19(3):723743. Failing to recommend that sexual partners seek
r Follow-up in 37 days with the primary care 4. Frenkl TL. Sexually transmitted infections. Urol Clin evaluation for STI
provider (2). North Am. 2008;35(1):3346.
r Incision and drainage packing removal in 2448 hr 5. Keck J. Ulcerative lesions. Clin Fam Pract. 2005;
if applicable 7(1):1330.
r Discharge instructions and medications: 6. CDC. Sexually Transmitted Diseases Surveillance,
Analgesics as needed 2007. Atlanta, GA: Author; 2006. Available at
Avoid sexual activity until lesions are healed. http://www.cdc.gov/std/stats07/main.htm.
Safe sex education 7. Wising C, Azem J, Zetterberg M, et al. Induction of
apoptosis/necrosis in various human cell lineages
by Haemophilus ducreyi cytolethal distending toxin.
Toxicon. 2005;45(6):767776.
165
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CHICKENPOX/SHINGLES
Keri Cohn
Sarita Chung
166
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CHICKENPOX/SHINGLES
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CHILD ABUSE
Lili Moran
168
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CHILD ABUSE
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CHOLELITHIASIS
Lauren S. Chernick
Anupam Kharbanda
r Cholesterol stones form when there is excess DIAGNOSTIC TESTS & INTERPRETATION
BASICS cholesterol in the bile: Lab
Cholesterol supersaturates the bile and Initial Lab Tests
DESCRIPTION crystallizes. r No lab testing is necessary when stones are
r Gallstones are crystalline structures formed from Stone growth is accentuated in those with confined to the gallbladder (all will be normal).
both normal and abnormal bile components. abnormal/decreased motility of the gallbladder. r The following are reasonable tests to evaluate other
r Symptoms develop when stones migrate out of the r Brown pigment stones, although rare, often develop
causes of abdominal pain:
gallbladder into the biliary canals: in the presence of obstruction and infection. They AST, ALT, direct and indirect bilirubin, and GGT
40% of children with gallstones are often contain bacteria, calcium bilirubinate, (liver involvement)
asymptomatic. cholesterol, and fatty acids. Amylase and lipase (pancreatitis)
Gallstone complications occur when stones: CBC (hemolytic anemia or leukocytosis)
Obstruct the cystic duct (cholecystitis) ETIOLOGY
r Hemolytic disease C-reactive protein (elevated in cholecystitis)
Obstruct the common bile duct (choledolithiasis)
r Prematurity Urine pregnancy and urinalysis
Cause an infection of the common bile duct Leukocytosis suggests cholecystitis.
r Inflammatory bowel disease
(cholangitis) Elevated GGT or direct bilirubin suggests
r Obesity
EPIDEMIOLOGY cholangitis.
r Oral contraceptive use
Prevalence r Pregnancy Imaging
r In children, gallstones are rare (0.10.2%) but are r US is the modality of choice (5):
recently thought to be increasing (1.9%) (1): Strengths:
Most common type of stone in children is black DIAGNOSIS Sensitivity and specificity >95%
pigment stones (2). Visualizes stones as small as 2 mm
Females = males until puberty, when females HISTORY Inexpensive and noninvasive
> males r No single sign or symptom is highly sensitive or Gallbladder distention, wall thickening, or
r In adults, gallstones are common with >20 million specific for cholelithiasis. pericholecystic fluid suggests cholecystitis.
cases/year in the U.S. (3): r Biliary colic results from gallbladder contraction and Weaknesses:
Most common type of stone in adults is presents with the following characteristics: Poor visualization of common bile duct
cholesterol stones. Pain in right upper quadrant (RUQ) and/or r Plain radiographs:
Females > males epigastrium Low sensitivity for stone visualization
r The prevalence of gallstones is higher in children Persistent or episodic pain, but the pain should A poor choice to rule in or out cholelithiasis
with certain chronic diseases like hemolytic anemia: last less than a few hours r CT: Rarely used as the test of choice due to its poor
The prevalence of gallstones in children with sickle Pain that may radiate to right shoulder, back, or visualization of stones:
cell disease (SCD) is double the general flank Strengths:
population. Possible association with nausea, vomiting, or Helps to define gallbladder anatomy and
50% of all children with SCD will develop eating fatty foods adjacent organs
gallstones. r Incidental gallstones can be asymptomatic. Weaknesses:
r Of all ethnic groups in the U.S., Native Americans r Pain lasting longer than 46 hr suggests biliary Associated with a lower sensitivity than US for
have the highest prevalence. obstruction. visualizing stones
r Magnetic resonance cholangiopancreatography
RISK FACTORS PHYSICAL EXAM
r Black pigment stones have been associated with r Asymptomatic or mildly symptomatic gallstones (MRCP) and endoscopic retrograde
cholangiopancreatography (ERCP) help to delineate
hemolytic diseases such as SCD and should accompany normal vital signs.
r Certain components of the physical exam may the anatomy of the extrahepatic and intrahepatic
beta-thalassemia, cystic fibrosis, ileal resection, and
biliary tract and identify the location of stones:
prolonged total parenteral nutrition (4). suggest complications such an obstruction of the
r Cholesterol stones have been associated with MRCP:
biliary tree or biliary infection: Strengths: Useful diagnostic mechanism for
female gender, obesity, pregnancy, rapid weight Tachycardia or fever localizing stones, has a sensitivity between 90
loss, and a family history of gallstones. Bradypnea due to splinting and 96%, and can better visualize the common
RUQ and/or epigastric pain bile duct (6)
PATHOPHYSIOLOGY Jaundice
r Stones form when 1 normal component of bile Weaknesses: Does not provide a method for
A hard, rigid, or distended abdomen stone removal, not available at all institutions,
increases in quantity and supersaturates, thus
Murphy sign: and requires sedation
forming a nidus for stone formation. Worsening pain or inspiration arrest when RUQ
r Stones are typically classified as black pigment, ERCP:
is palpated Strengths: Provides a diagnostic and therapeutic
cholesterol, brown pigment, or mixed. Highly sensitive in adults for cholecystitis
r Black pigment stones form when there is excess mechanism for localizing and removing the
bilirubin in the bile: stone
Weaknesses: Invasive and may offer no
Abnormal production or destruction of RBCs leads
to increased levels of bilirubin. advantage for clearance of the bile duct over
surgical approaches
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CHOLELITHIASIS
DIFFERENTIAL DIAGNOSIS r Patients with a clinical picture suggestive of 4. Wesdorp I, Bosman D, Graaf A, et al. Clinical
r RUQ/Epigastric pain: GERD, gastritis, pancreatitis, cholecystitis should be admitted; the timing of presentations and predisposing factors of
peptic ulcer disease, hepatitis, appendicitis, acute cholecystectomy and/or ERCP is surgeon/GI cholelithiasis and sludge in children. J Pediatr
acalculous cholecystitis, inflammatory bowel specialist dependent but often occurs before Gastroenterol Nutr. 2000;31:411417.
disease, acute gastroenteritis discharge. 5. Bortoff G, Chen MYM, Ott DJ, et al. Gallbladder
r Gallstone complications: Cholecystitis, r Cholecystectomy is not recommended for incidental stones: Imaging and intervention. Radiographics.
choledolithiasis, cholangitis, pancreatitis or asymptomatic gallstones. 2000;20:751766.
DISPOSITION 6. Tipnis NA, Dua KW, Werlin SL. A retrospective
TREATMENT Admission Criteria
assessment of magnetic resonance cholangio-
pancreatography in children. J Pediatr
C
r Patients with unresolved biliary colic or any
Gastroenterol Nutr. 2008;46:5964.
PRE HOSPITAL suspicion of cholecystitis, choledolithiasis,
r Uncomplicated cholelithiasis or biliary colic requires cholangitis, or pancreatitis should be admitted.
no intervention by EMS. r Critical care admission criteria: ADDITIONAL READING
r If the patient has abnormal vital signs, secure IV Patients who are ill with unstable vital signs
r Aufderheide TP, Brady WJ, Tintinalli J. Cholecystitis
access and administer IV fluids. despite fluid resuscitation and antibiotics should
be considered for ICU admission. and biliary colic. In Tintinalli JE, Gabor D,
INITIAL STABILIZATION/THERAPY Stapczynski JS, et al., eds. Tintinallis Emergency
Ill-appearing patients, likely suffering from biliary Discharge Criteria Medicine: Comprehensive Study Guide. 6th ed.
r Patients with incidental gallstones or asymptomatic
stone complications, should be stabilized: Columbus, OH: McGraw-Hill; 2003:7680.
r Assess and support the airway, if necessary. gallstones can be discharged home with primary r Broderick A, Sweeney BT. Gallbladder disease. In
r Assess circulatory needs: care physician follow-up.
r Patients with resolved biliary colic can be discharged Walker WA, Kleinman RE, Sherman PM, et al., eds.
Place 2 large-bore IV catheters. Pediatric Gastrointestinal Disease: Pathophysiology,
Give IV fluids for volume deficiency (20 cc/kg with timely outpatient surgical follow-up (within
Diagnosis, Management. Philadelphia, PA: Mosby;
boluses of normal saline). 1 wk).
2004:15511565.
Provide pain control. r Friedman JR, Kennedy MC. Cholelithiasis. eMedicine
r Assess for signs of peritonitis.
FOLLOW-UP Pediatrics: General Medicine. April 13, 2009.
MEDICATION Available at http://emedicine.medscape.com/article/
FOLLOW-UP RECOMMENDATIONS 927522-overview.
First Line Discharge instructions and medications:
r Analgesics: See Also (Topic, Algorithm, Electronic
r Return to the emergency department if the pain is
Merperidine 1 mg/kg IV q4h, max single dose Media Element)
severe, pain is not resolved with NSAIDs, or jaundice r Hepatitis
100 mg
develops. r Pain, Abdomen
Ketorolac 0.5 mg/kg q8h IV/IM, max single dose
30 mg PROGNOSIS
r Antiemetics for nausea: Ondansetron 0.1 mg/kg IV, r Some gallstones will resolve without any medical
max single dose 4 mg intervention.
r Patients with recurrent biliary colic without
CODES
r Antibiotics if suspicious for acute cholecystitis or
cholangitis, covering Escherichia coli and Klebsiella cholecystecomy have a high likelihood of ICD9
species: experiencing a biliary obstruction. r 574.20 Calculus of gallbladder without mention of
2nd-generation cephalosporin with anaerobic COMPLICATIONS cholecystitis, without mention of obstruction
coverage such as: r Gallbladder perforation r 574.21 Calculus of gallbladder without mention of
Cefoxitin 80160 mg/kg/24 hr divided q46h r Peritonitis cholecystitis, with obstruction
IM/IV OR r Bacterial overgrowth r 575.10 Cholecystitis, unspecified
Cefotetan 4080 mg/kg/24 hr divided q12h
r Choledocholithiasis: Stone obstructing the common
IV/IM
Piperacillin/Tazobactam: Infants <6 mo, biliary duct
150300 (piperacillin component) mg/kg/24 hr IV
r Ascending cholangitis PEARLS AND PITFALLS
divided q68h; infants >6 mo and children, r Pancreatitis r Gallstones are relatively uncommon in children.
300400 mg/kg/24 hr IV divided q68h Children with hemolytic or ileal diseases are more at
Second Line risk.
r Cholesterol stones are more likely to respond to REFERENCES r Diagnostic modality of choice is US.
nonsurgical management than other stones. 1. Kaechele V, Wabitsch M, Thiere D, et al. Prevalence r Patients with asymptomatic gallstones can be
r Bile salt dissolvents such as ursodiol (Actigal) of gallbladder stone disease in obese children and followed as outpatients.
1015 mg/kg/24 hr daily PO: adolescents: Influence of the degree of obesity, sex, r Patients complaining of uncomplicated cholelithiasis
Usually prescribed as outpatient medication and pubertal development. J Pediatr Gastroenterol should not appear ill.
Stone must be noncalcified, small, and with a low Nutr. 2006;42:6670. r Resolved biliary colic can be followed up in the
likelihood of causing complications. 2. Stringer MD, Taylor DR, Soloway RD. Gallstone surgery clinic.
Good for patients when surgery is too high of a composition: Are children different? J Pediatr. r Do not discharge home patients with sustained
risk to perform (eg, cardiac disease) 2003;142(4):435440. biliary colic, possible cholecystitis, choledolithiasis,
May not work and stones can recur (4) 3. Everhart JE, Khare M, Hill M, et al. Prevalence and or cholangitis. Patients should be admitted, given
SURGERY/OTHER PROCEDURES ethnic differences in gallbladder disease in the antibiotics, and have a surgical evaluation.
Laparoscopic cholecystectomy is the treatment of United States. Gastroenterology. 1999;117:
choice for symptomatic cholelithiasis. 632639.
r Patients with mild intermittent biliary colic can be
scheduled for outpatient elective laparoscopic
cholecystectomy.
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CHOLINERGIC POISONING
Robert J. Hoffman
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CHOLINERGIC POISONING
r Atropine:
TREATMENT 0.05 mg/kg IV, max initial dose 2 mg, IV over FOLLOW-UP
5 min
PRE HOSPITAL If still symptomatic 5 min later, double the dose PROGNOSIS
r Assess and stabilize airway, breathing, and r Varies with specific poison and quantity ingested
and administer IV.
Continue dosing q5min, doubling the dose and r With appropriate supportive care and antidote use,
circulation.
r Administer atropine and pralidoxime if indicated by titrating to effect. most patients recover fully.
Use of autoinjector (AtroPen) is acceptable: r Prolonged paralysis or neurologic sequelae are
local protocol.
r If topical exposure, decontaminate as per local 1540 lb (718 kg), 0.5 mg IM
protocol.
4090 lb (1941 kg), 1.0 mg IM
possible.
C
>90 lb and adults (>41 kg), 2.0 mg COMPLICATIONS
r Neurologic sequelae including intermediate
INITIAL STABILIZATION/THERAPY Give initial autoinjector dose:
r Decontamination of any patient exposed to topical If no symptoms discontinue
syndrome or organophosphate-induced delayed
cholinergic agents such as pesticides or nerve gas is If severe symptoms persist, immediately give 2
neuropathy
r End-organ injury due to hypoperfusion
critical. This action must be taken prior to treatment additional doses.
in the emergency department: r Pulmonary insufficiency due to bronchospasm or
End point of treatment is drying of pulmonary
This is a particular instance when airway, secretions/pulmonary edema. pulmonary edema
breathing, circulation is not priority. Even r Shock
Reversal of miosis gives a good approximation for
compromised patients do not receive attention to adequate quantity of atropine administration. r Death
ABCs in the emergency department until they are If wet, treatment is atropine.
decontaminated. r Pralidoxime:
Failure to decontaminate the patient may result in 25 mg/kg, max single dose 1 g, IV over ADDITIONAL READING
ongoing toxicity of the patient and may result in 1530 min, followed by 2550 mg/kg/hr, to max r Eddleston M, Phillips MR. Self poisoning with
staff falling ill due to direct contact or from fumes infusion of 500 mg/hr
emanating from an inadequately decontaminated pesticides. BMJ. 2004;328:42.
600-mg dose autoinjector may be used. r Okudera H, Morita H, Iwashita T, et al. Unexpected
patient. Indicated for fasciculations, weakness, or paralysis
r Assess and stabilize airway, breathing, and nerve gas exposure in the city of Matsumoto: Report
If weak, treatment is pralidoxime. of rescue activity in the first sarin gas terrorism. Am
circulation. r Benzodiazepine for seizure:
r Administer high-flow oxygen. J Emerg Med. 1997;15:527.
r Supportive care by management of respiratory
Diazepam 0.1 mg/kg IV, 0.5 mg/kg PR. When r Schexnayder S, James LP, Kearns GL, et al. The
given IV, may repeat dose q510min PRN. pharmacokinetics of continuous infusion
compromise, bradycardia or dysrhythmia, Lorazepam 0.05 mg/kg IV, may repeat dose
bronchospasm, and severe toxicity pralidoxime in children with organophosphate
q10min PRN. poisoning. J Toxicol Clin Toxicol. 1998;36:549.
MEDICATION Second Line r Schier JG, Hoffman RS. Treatment of sarin exposure.
First Line Albuterol: JAMA. 2004;291:182.
r In addition to doses of atropine and pralidoxime r 0.15 mg/kg nebulized q15min as needed for
below, autoinjectors may be used: wheezing
DuoDote (2.1 mg atropine/600 mg pralidoxime):
DISPOSITION
CODES
1 IM injection initially:
If there are no severe symptoms, give no Admission Criteria
r Any treatment with medication warrants hospital ICD9
additional medication. 971.0 Poisoning by parasympathomimetics
If severe symptoms persist, give 2 additional IM admission for observation and possibly further
(cholinergics)
autoinjection doses. treatment.
r Although initially only adult doses adapted from r Critical care admission criteria:
military antidote kits were available, pediatric kits, Unstable vital signs, seizure, or severe toxicity PEARLS AND PITFALLS
as well as combination atropine/pralidoxime Discharge Criteria r Appropriate decontamination of the patient is
(DuoDote), are available. Asymptomatic for 46 hr without any treatment given
during hospital stay critical to treat the patient and to protect staff in
cases of exposure to pesticides or other
Issues for Referral organophosphate agents.
r Consider toxicology consultation to manage
r Copious quantities of atropine may be needed.
poisoning. r Control of seizures is critical.
r Consult psychiatry if the patient has attempted
r After pesticide poisoning, prolonged treatment for
self-harm.
several days may be required.
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COCAINE POISONING
John Kashani
174
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COCAINE POISONING
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COLITIS
Andrew Heggland
Barbara M. Garcia Pena
176
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COLITIS
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Imaging
r Chest radiographs may show:
Issues for Referral
r Stable patients can be given a referral for outpatient
REFERENCES
Increased reticulation or a honeycombed rheumatology but should have prompt follow-up by 1. DeSilva TN, Kress DW. Management of collagen
appearance in SS a primary care provider and/or subspecialist. vascular diseases in childhood. Dermatol Clin.
Globular enlargement of the cardiac silhouette is r Refer patients to a center with: 1998;16(3):579592.
seen in PAN. Pediatric rheumatology 2. Silverberg NB, Paller AS. Collagen vascular diseases
r Bone scan and MRI with gadolinium may reveal Other subspecialists as needed for anticipated in children. Curr Probl Dermatol. 2000;12(4):
joint findings and may be done in the inpatient or complications of the disease 177182.
outpatient setting. Physical therapy and nutritionists 3. Arthritis Foundation Disease Center database
2009.
C
Diagnostic Procedures/Other COMPLEMENTARY & ALTERNATIVE
ECG is necessary in patients with SS and PAN: 4. Bengtson AA, Rylander L, Hagmar L, et al. Risk
THERAPIES
r Pulmonary HTN may cause ventricular hypertrophy. r Sun avoidance and protection factors for developing systemic lupus
r Cardiac involvement in PAN may show ST r Physical therapy erythematosis: A case control study in southern
r Psychosocial therapy Sweden. Rheumatology. 2002;41:563571.
depression and inverted T waves (6).
r Keep hands warm with polyester, plastic, or 5. Adib N, Hyrich K, Thornton J, et al. Association
DIFFERENTIAL DIAGNOSIS between duration of symptoms and severity of
Malignancy, infection, muscular dystrophies, viral sheepskin gloves during cold exposure for Raynaud diseases at first presentation to paediatric
myositis, school phobias, postinfectious reactive phenomenon (1). rheumatology. Rheumatology. 2008;47(7):
r Biofeedback training may help decrease the
arthritis, traumatic arthritis, torn meniscus, 991995.
hemarthrosis, osteochondritis, Legg-Calve-Perthes, frequency of Raynaud syndrome attacks (2). 6. Callen JP. Collagen vascular diseases. J Am Acad
r Nutritional evaluation and guidance
osteomyelitis, neuropathy, and periodic fever Dermatol. 2004;51(3):427439.
syndromes 7. Fox RJ. Sjogrens syndrome. Lancet. 2005;366:
FOLLOW-UP 321331.
8. Akikusa JD, Schneider EA, Harvey D, et al. Clinical
TREATMENT FOLLOW-UP RECOMMENDATIONS features and outcome of pediatric Wegeners
INITIAL STABILIZATION/THERAPY Discharge instructions and medications: granulomatosis. Arthritis Rheum. 2007;57(5):
r The complexity and the systemic nature of CVD r 12 day follow-up for patient reassessment and to 837844.
should be kept in mind when such patients present make appropriate referrals
to the emergency department. PROGNOSIS ADDITIONAL READING
r If the patient is unstable, support the ABCs. r CVDs have a variable course, and findings at
r An integrated multisystem approach (eg, r Furst DE, Breevald FC, Kalden JR, et al. Updated
presentation are usually not predictive.
rheumatology, immunology, and orthopedics) is r The course of CVD varies from mild disease with few consensus statement on biological agents for the
recommended for patients with CVD. complications to multiorgan disease leading to treatment of rheumatic diseases, 2007. Ann Rheum
death (eg, PAN, SS). Dis. 2007;66(Suppl 3):iii2iii22.
MEDICATION r Wagener JS, Soep JB, Hay TC. Collagen vascular
r Arthralgia and myalgia are generally treated with r Sjogren syndrome develops and progresses slowly
but has an increased risk of lymphoma. disorders. In Taussig LM, Landau LI, eds. Pediatric
salicylates or NSAIDs (2).
r Corticosteroids (oral and/or IV) used early in the r Patients with MCTD have milder symptoms and Respiratory Medicine. 2nd ed. Philadelphia, PA:
Mosby; 2008:693703.
course of these diseases may help attenuate fewer complications than other CVDs.
inflammation (2,6). COMPLICATIONS
r Artificial tears, oral lozenges, and fluids in patients r Raynaud phenomenon can be severe enough to lead
with Sjogren syndrome may be used to limit damage
CODES
to gangrenous changes that can lead to
from decreased secretions (7). autoamputation or osteomyelitis of the digits.
r In PAN, mild to moderate HTN is treated with r Pulmonary HTN and fibrosis is seen in SS with ICD9
r 446.0 Polyarteritis nodosa
diuretics, hydralazine, and beta-blockers. respiratory decompensation. r 446.20 Hypersensitivity angiitis, unspecified
r Cyclophosphamide and methotrexate are needed for r Pulmonary hemorrhage and upper airway r 710.1 Systemic sclerosis
life-threatening illness; cyclosporin can also be used. obstruction is seen in PAN. r 710.9 MCTD
r Cutaneous nodules in PAN may ulcerate and are at
DISPOSITION r 714.0 Rheumatoid disease
Admission Criteria risk of infection.
r Inpatient admission should be considered when r Enlarging granulomas in WG can disrupt local
immediate subspecialty care is needed. anatomy, causing orbital invasion or deafness. PEARLS AND PITFALLS
r Unstable patients (eg, hypertensive encephalopathy r Pericarditis is seen in PAN and SS.
r Blindness is seen in Behcet disease due to posterior r Sjogren syndrome patients have greater problems
or CHF in PAN)
r Critical care admission criteria: uveitis. with corticosteroids, including acceleration of
Unstable patients (eg, severe HTN with r Renal complications may gradually lead to chronic periodontal disease and thrush (7).
renal failure in SS, PAN, and Behcet. r PAN may present with acute scrotal pain and
encephalopathy or CHF in PAN) should be
admitted to the ICU. purpura with dysuria.
r Behcet disease may mimic numerous other
Discharge Criteria
r Well appearing and in no distress conditions seen commonly in the emergency
r Acute symptoms controlled in the emergency department and should be considered when
appropriate.
department r WG may present as an orbital pseudotumor or
r Reliable follow-up
severe sinusitis (8).
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COMPARTMENT SYNDROME
Michael L. Epter
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COMPARTMENT SYNDROME
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CONCUSSION
Emily Schapiro
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CONCUSSION
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DISPOSITION REFERENCE
TREATMENT Admission Criteria
r Any CHD patient with an O requirement over 1. Meckler GD, Lowe CG. To intubate or not to
2
INITIAL STABILIZATION/THERAPY baseline, acute respiratory distress, or worsening intubate? Transporting infants on prostaglandin E1.
r Immediate evaluation and treatment of the ABCs CHF not responsive to emergency department Pediatrics. 2009;123(1):e25e30.
and continuous pulse oximetry are crucial. therapy should be admitted.
Administer oxygen (O2 ) judiciously. r Patients with confirmed or symptomatic respiratory
Establish IV access: >1 site is recommended. syncitial virus should be admitted for observation.
ADDITIONAL READING
r Obtain blood and urine samples. r Critical care admission criteria: r Gewitsz MH, Woof PK. Cardiac emergencies. In
r Small, frequent IV boluses of normal saline or Any patient who is intubated and/or requiring Fleisher GR, Ludwig S, Herentig FM, eds. Textbook of
C
lactated Ringer solution of 10 cc/kg are indicated to vasopressor support should be promptly admitted Pediatric Emergency Medicine. 6th ed. Philadelphia,
treat hypotension. to a pediatric ICU (neonatal, pediatric, or PA: Lippincott Williams & Wilkins; 2010.
r 4 extremity BPs should be measured. cardiothoracic). r Penny DJ, Shekerdemian LS. Management of the
r A full sepsis evaluation should be initiated and The decision to admit should be made in neonate with symptomatic congenital heart disease.
antibiotics empirically started after the appropriate conjunction with a pediatric cardiologist. Arch Dis Child Fetal Neonatal Ed. 2001;84(3):
cultures are obtained in infants <23 mo of age Discharge Criteria F141F145.
who are exhibiting signs and symptoms of sepsis: r Rudolf AM. Congenital Diseases of the Heart:
A patient who has been evaluated by a pediatric
Fever >38.0 C, irritability, respiratory distress, cardiologist and deemed to be stable may be Clinica-Physiological Considerations. 2nd ed.
lethargy. discharged home with outpatient cardiology Armonk, NY: Futura Publishing Company; 2001.
r Caution must be used if a lumbar puncture is follow-up. r Savitsky E, Alejos J, Votey S. Emergency department
indicated, especially in an unstable cyanotic child. Issues for Referral presentations of pediatric congenital heart disease. J
r If a patient requires a higher level of care at a Emerg Med. 2003;24(3):239245.
MEDICATION r Silverbach M, Hannon D. Presentation of congenital
First Line tertiary pediatric center, then arrangements for
transport should be made. heart disease in the neonate and young infant.
In a cyanotic patient who may have ductal-dependent r A specialized pediatric critical care transport team Pediatr Rev. 2007;28:123131.
CHD, a prostaglandin (PGE1 ) infusion should be r Wylie TW, Sharieff GQ. Cardiac disorders in the
initiated. may be necessary to facilitate the transport.
r Infusion rates should be started at 0.050.1 pediatric patient. Emerg Med Rep. 2005;10:112.
g/kg/min with a max rate of 0.4 g/kg/min. FOLLOW-UP
r A common side effect of PGE is apnea; prompt
intubation may be necessary.
1
FOLLOW-UP RECOMMENDATIONS CODES
r Elective intubation of patients on PGE for transport Discharge instructions and medications:
1
may increase the risk of transport complications (1). r Parents should be instructed to look for worsening ICD9
r 745.5 Ostium secundum type atrial septal defect
r Other occurrences associated with PGE include signs and symptoms of the patients CHD.
1
r Discharge medications should be based upon the r 746.9 Unspecified congenital anomaly of heart
hyperthermia, flushing, arrhythmias, hypotension, r 747.0 Patent ductus arteriosus
and seizures. recommendations of the consulting pediatric
Second Line cardiologist.
r A child with CHF may benefit from a dose of r A follow-up appointment with a pediatric
cardiologist should be made. PEARLS AND PITFALLS
furosemide at 0.51 mg/kg.
r If a urine output of 35 cc/kg/hr is not achieved r A combination of cyanosis, murmur, and abnormal
PROGNOSIS
within 12 hr after the 1st dose of furosemide, Prognosis is based on the patients initial acuity, CHD pulses is associated with a PGE1 -sensitive CHD
repeat doses of 1 mg/kg can be given at hourly type, and need for surgical treatment. lesion.
intervals to a max of 35 mg/kg. r Routine intubation of patients on PGE is not
1
r If hypotension persists after IV fluid boluses, COMPLICATIONS necessary.
r Hypoxic brain injury
dopamine should be initiated at 5 g/kg/min and r Administration of high levels of O may worsen a
r FTT 2
titrated up to a max of 20 g/kg/min. r Severe metabolic acidosis patient with cyanotic CHD:
r For further inotropic support, dobutamine can be O2 can act as a pulmonary vasodilator; hence,
r Multiple organ failure
added with an initial rate of 5 g/kg/min with caution is warranted when administering O2 in a
r Cardiopulmonary arrest
titration to a max rate of 20 g/mg/min. suspected CHD patient.
r Caution should be used with higher doses of
dobutamine because of its vasodilator effects that
may lead to precipitous drops in BP, especially in the
hypovolemic CHD patient.
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ETIOLOGY
BASICS r Varies by age of presenting symptoms and DIAGNOSIS
functional classification
DESCRIPTION r 1st day of life: HISTORY
r Presentation is usually related to the increased
CHF is the inability of the heart to provide an Cardiac dysfunction: Hypoglycemia, sepsis,
adequate level of tissue perfusion to meet metabolic hypocalcemia, myocarditis, birth asphyxia metabolic energy requirement in CHF.
requirements. r Changes in infant feeding habits:
Structural: Valvular regurgitation, extracardiac
arteriovenous malformation Increase in feeding time, >3060 min for a bottle
EPIDEMIOLOGY (regardless of amount)
Conductional: Supraventricular tachycardia,
Incidence Caloric intake <75 kcal/kg/day
r 12,000 cases of pediatric heart failure occur in the congenital heart block
Hematologic: Hyperviscosity states (eg, Increased work of breathing
U.S. each year (1): Early fatigue, agitation, or irritability
polycythemia), anemia
61% of cases were associated with congenital r 1st wk of life: Diaphoresis, especially with feeds
heart disease (CHD) or cardiac surgery. r Prolonged general fatigue and malaise
82% of cases occur in infants. Structural: Persistent pulmonary HTN of the
r Weight loss, anorexia, or nausea
r For primary cardiomyopathies in structurally normal newborn, aortic coarctation, critical aortic stenosis
(AS), hypoplastic left heart syndrome (HLHS), r Decreased exercise tolerance or activity
hearts, the incidence is 0.87 per 100,000 infants (2). r Tachypnea, orthopnea, or paroxysmal nocturnal
critical pulmonary stenosis (PS), interrupted aortic
RISK FACTORS arch (IAA), transposition of the great arteries orthopnea
r CHD, especially conditions with left-to-right (TGA), obstructed total anomalous venous return r Chronic cough
shunting or left-sided obstruction (TAPVR), pulmonary atresia, patent ductus r Frequent lower respiratory tract infections
r Dilated or hypertrophic cardiomyopathy arteriosus (PDA) r Above symptoms associated with excessive salt or
r Previous cardiac surgery Metabolic: Adrenal insufficiency, hyperthyroidism fluid intake
r Metabolic or renal disorders Renal: Systemic HTN, renal failure
Cardiac dysfunction and conductional PHYSICAL EXAM
PATHOPHYSIOLOGY abnormalities r Sinus tachycardia
r CHF physiology is due to volume overload, pressure r 1st 2 mo of life: r Systemic hypotension
overload, inadequate inotropic state, alteration in Structural: Ventricular septal defect (VSD), r Murmurs may be present depending on location and
chronotropic state, or a combination. atrioventricular canal, single ventricle, atrial septal size of defect or lesion (see Heart Murmur topic).
r Cardiac output (CO) equals heart rate (HR) r Increased precordial activity in shunt lesions
defect, PDA, nonobstructed TAPVR, truncus
multiplied by stroke volume (SV): arteriosus, AS, IAA, anomalous coronary artery, r S3 or ventricular gallop
HR is controlled by neurologic and intrinsic cardiac HLHS r S4 or atrial kick due to ventricular hypertrophy
conduction input. Myocardial: Cardiomyopathy, myocarditis, Pompe r Cool or mottled extremities
SV depends on cardiac muscle contractility, disease r Decreased peripheral pulses or capillary refill
preload, and afterload. Pulmonary: Pulmonary HTN, central
r Preload is the volume that must be ejected from the r Pulsus paradoxus
hypoventilation syndromes, upper airway
r Jugular venous distension
left ventricle (LV) at the end of diastole, which obstruction (eg, tracheomalacia),
depends on venous return. A larger filling volume bronchopulmonary dysplasia r Tachypnea
causes increased contractility via the Frank-Starling Other: Hypothyroidism, renal and metabolic r Cyanosis, central or peripheral
mechanism. causes as above r Persistent hacking cough
r Afterload is the pressure required to eject preload r Childhood and beyond: r Grunting, retractions, or nasal flaring
volume from the LV, typically measured as systolic Acquired causes: Sepsis, infective endocarditis, r Wheezing, and less commonly rales
aortic pressure. rheumatic heart disease, cocaine toxicity r Hepatomegaly or liver tenderness
r Clinical manifestations of CHF are primarily caused Genetic: Noonan syndrome, Marfan syndrome, r Jaundice in infants
by alterations in fluid retention and adrenergic Hurler syndrome, Duchenne muscular dystrophy, r Peripheral edema or ascites in older children
activity: Friedreich ataxia
Inadequate systemic perfusion results in fluid Unrepaired CHD: Valvular insufficiency, DIAGNOSTIC TESTS & INTERPRETATION
retention via the kidneys and renin-angiotensin Eisenmenger syndrome, Ebstein anomaly, severe Lab
system. PS r Diagnosis is primarily clinical, but certain lab assays
After initial brief improvement in preload, dilated Repaired CHD: Fontan procedure may cause may be useful.
cardiomyopathy occurs and increases ventricular protein-losing enteropathy and CHF. r Glucose and ionized calcium levels should be
wall stress, pressure, and myocardial oxygen Failure of surgical palliation: Large systemic to measured and monitored.
demand. pulmonary artery shunt, pulmonary atresia with r Hyponatremia, hypochloremia, or anemia may be
Compensatory cardiac hypertrophy then reduces large VSD, prosthetic valve failure, ventricular present during volume overload.
contractility and thus CO. failure following TGA arterial switch operation, r Blood gas measurement may demonstrate metabolic
r Increased -adrenergic tone augments HR and reopened VSD, aortic insufficiency following
acidosis and hypoxemia.
contractility but causes many of the typical signs and valvotomy or truncus arteriosus repair, mitral r Elevated troponin or creatine phosphokinase levels
symptoms of CHF due to an increased sympathetic insufficiency after endocardial cushion repair,
myocardial ischemia following operative arrest, PS may be seen in myocardial inflammation or ischemia.
state. r The role of brain natriuretic peptide (BNP) levels is
or outflow tract obstruction, pulmonary
insufficiency unclear in children:
Collagen vascular disease: Systemic lupus Elevation may aid in distinguishing respiratory
erythematosus, juvenile idiopathic arthritis distress as cardiac or respiratory.
Other: Kawasaki disease, neuromuscular BNP >300 pg/mL is strongly correlated with poor
weakness, hypo/hyperthyroidism, renal disease, outcome (3).
end-stage cystic fibrosis, systemic HTN
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CONJUNCTIVAL INJURY
Donald T. Ellis, II
Sandip A. Godambe
Pathological Findings
BASICS DIAGNOSIS r Pronounced conjunctival chemosis
r Epithelial loss
DESCRIPTION HISTORY r Corneal edema and opacification
r The conjunctival membranes represent the thin, r Most cases are readily identifiable from the history;
translucent covering of the white sclera of the globe however, burns from UV light may present with DIFFERENTIAL DIAGNOSIS
severe pain hours after the event. r Corneal abrasion
(bulbar conjunctiva) and the inside of the eyelids
(palpebral conjunctiva). r Pain r Infectious conjunctivitis
r The most common conjunctival injuries include r Photophobia r Allergic conjunctivitis
direct trauma and burns from chemical irritants or r Foreign body sensation r Foreign body
radiant energy, as with ultraviolet (UV) light. r Conjunctival redness and tearing r Glaucoma
r Scleritis/Episcleritis (such as in systemic lupus
EPIDEMIOLOGY PHYSICAL EXAM
Incidence r Epiphora erythematosus, Wegener granulomatosis,
r The annual incidence of all forms of eye injury has r Chemosis rheumatoid arthritis, and inflammatory bowel
been reported at 1% (1). r Hyperemia disease)
r Conjunctival and corneal abrasions comprised r Corneal clouding
16.5% of the ocular injuries in the same study (1). r Scleral pallor TREATMENT
RISK FACTORS r Teardrop pupil (as seen with ruptured globe)
As with trauma in general, conjunctival injury is more r Foreign body (Eyelid eversion is critical when PRE HOSPITAL
r Trauma: An eye shield (not eye patch) should be
common in males than females. evaluating for potential presence of foreign bodies.)
r UV keratitis may present with punctuate lesions over placed if there is concern for a ruptured globe or if
GENERAL PREVENTION accommodation is painful.
r Eye protection is critical to reducing the risk of any the corneal surface (seen on fluorescein staining) (3). r Thermal: Copious irrigation and rapid cooling of the
eye injury. ALERT ocular structures
r It has been postulated that 90% of eye injuries are r Chemical (alkali, acid): Copious irrigation with
Strong acids may be associated with pale
preventable. conjunctiva and corneal clouding, which may be buffered solution (such as Diphoterine or lactated
PATHOPHYSIOLOGY followed by desquamation. The absence of Ringer):
r Traumatic injury occurs from direct trauma from an hyperemia may then obscure the degree of tissue However, if none is available, use any sterile,
object or foreign body. injury. nontoxic solution (such as normal saline).
r Alkaline substances induce liquefactive necrosis, Tap water is a preferable alternative to delayed
which can allow the chemical to reach into the irrigation and may be utilized immediately
DIAGNOSTIC TESTS & INTERPRETATION
deeper tissues in the anterior chamber (2). following the injury:
Lab However, hypotonic solutions are associated
r Acids are typically responsible for superficial injury,
Initial Lab Tests with a risk of increasing the depth of
as they cause coagulation of the tissues, which Other lab testing is usually not indicated in penetration.
prevents them from reaching deeper layers in the conjunctival injury.
eye (2): INITIAL STABILIZATION/THERAPY
Substances with a pH of 2.5 cause penetrating Imaging r All conjunctival injuries:
injury similar to that seen with alkalis. Imaging is generally not helpful unless orbital or other Administer topical anesthetic drops to provide
Hydrofluoric acid, in particular, has been known to facial fractures are suspected. comfort and to facilitate examination (once
cause deep, alkalilike eye injuries. Diagnostic Procedures/Other ruptured globe has been ruled out).
r Fluorescein staining is strongly encouraged when r Chemical burns:
ETIOLOGY
r Trauma: the differential diagnosis includes entities such as Irrigate (see above) until pH has normalized for 30
corneal abrasion, retained foreign body, herpetic min. Normal pH should be 6.57.5.
Play or sports activity
keratitis, and UV burns. Irrigation using a Morgan lens is recommended to
Motor vehicle accidents r pH testing may be used in chemical burns, but
Foreign body (dirt, sand, glass, etc.) achieve adequate reaching of areas under the
Self-inflicted (rubbing eye, scratching eye) irrigation should never be delayed. eyelids.
r Alkali: Oven cleaners, fireworks, dishwashing r pH testing of the lacrimal fluid should be 6.57.5. Never attempt to neutralize alkali burns with
Wait several minutes after discontinuing irrigation of acidic solutions and vice versa.
detergent
r Acid: Battery acid, bathroom cleaners, rust-removal the eye before testing to obtain an accurate result. Do not remove contact lenses during irrigation, as
r Visual acuity should also be determined at baseline, these may serve as physical barriers to block
agents, automotive wheel cleaners deeper penetration of the corrosive substance.
r UV: Welding light, tanning beds, outdoor activities but as with pH testing, it should not delay irrigation.
r Must consider performing slit lamp exam with Remove after completion of irrigation.
at increased elevation Evert the lids to ensure that no foreign material
r Thermal: Fire, steam, hot liquids fluorescein staining and measurement of intraocular
pressure remains.
r Thermal burns:
COMMONLY ASSOCIATED CONDITIONS
r Conjunctival injury may also be associated with As with chemical burns, irrigate liberally (see
corneal abrasion, hyphema, open globe injury, above) and remove any foreign matter.
facial/airway burns, and facial injury, including Remove contact lenses.
fractures. May need to remove eschar from eyelids
r See respective topics on Fracture, Orbital; Corneal Ensure that any perioral or airway burns are
Abrasion; Hyphema; Foreign Body, Cornea; and addressed.
Burn, Chemical.
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CONJUNCTIVAL INJURY
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CONJUNCTIVITIS
Audrey H. Le
Sandip A. Godambe
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CONJUNCTIVITIS
r Simple bacterial conjunctivitis can be treated with DISPOSITION 3. AAP Subcommittee on Management of Acute Otitis
topical antibiotics (2): Admission Criteria Media. Diagnosis and management of acute otitis
First line: r Consider sepsis evaluation and/or hospitalization of media. Pediatrics. 2004;113:14511465.
Trimethoprim/Polymixin B (Polytrim) 12 gtt neonates with gonococcal, chlamydial, or HSV 4. CDC. Sexually transmitted diseases treatment
q.i.d. for 1 wk: Broad spectrum, inexpensive, infections. guidelines. 2006. Morb Mortal Wkly Rep.
minimal side effects r Consider admission for any patient with gonococcal 2006;55(RR-11):3849.
Aminoglycosides (gentamicin, tobramycin, conjunctivitis. 5. Wilhelmus K. Therapeutic interventions for herpes
erythromycin) 0.5-inch ribbon q.i.d. for 1 wk. simplex virus epithelial keratitis. Cochrane
Discharge Criteria
The 1st 2 have good gram-negative coverage
but are ineffective for Chlamydia. Erythromycin
r Simple bacterial infections in immunocompetent Database Syst Rev. 2008;(1):cd002898.
6. Patel PB, Diaz MC, Bennett JE, et al. Clinical
C
has good activity against Chlamydia but poor children may be managed on an outpatient basis
with appropriate treatment. features of bacterial conjunctivitis in children. Acad
activity against gram-negative organisms and
r Close follow-up with an ophthalmologist for HSV Emerg Med. 2007;14:15.
Staphylococcus species.
Sodium sulfacetamide 10% (Bleph-10) 13 gtt infection
q23h while awake for 1 wk: Good coverage of Issues for Referral ADDITIONAL READING
gram-positive organisms but may cause r Epidemic keratoconjunctivitis requires follow-up
r Bielory L, Friedlaender MH. Allergic conjunctivitis.
significant local irritation within 7 days with an ophthalmologist since keratitis
Second line: is a potential complication. Immunol Allergy Clin North Am. 2008;28:4358.
Fluoroquinolones (ciprofloxacin 0.3%, r Patients with viral infections who do not show r Ehlers JE, Shah CP. The Wills Eye Manual. 5th ed.
ofloxacin) 12 gtt q.i.d. for 1 wk: Broad improvement within 710 days should be referred Philadelphia, PA: Lippincott Williams & Wilkins;
spectrum but more expensive to an ophthalmologist. 2008.
4th-generation fluoroquinolones (gatifloxacin r Mahmood AR, Narang AT. Diagnosis and
0.3% 12 gtt q2h (max 8 times per day) while management of the acute red eye. Emerg Med Clin
awake for 2 days, then q.i.d. for 5 days; FOLLOW-UP North Am. 2008;26:3555.
moxifloxacin 0.5% 1 gtt t.i.d. for r Prentiss KA, Dorfman DH. Pediatric ophthalmology
1 wk): Broad spectrum with increased efficacy FOLLOW-UP RECOMMENDATIONS in the emergency department. Emerg Med Clin
against gram-positive organisms; expensive Discharge instructions: North Am. 2008;26:181198.
r Conjunctivitis-otitis syndrome is most often r Allergic conjunctivitis should have follow-up within r Robinett DA, Kahn JH. The physical examination of
attributable to nontypeable H. influenzae, and may weeks depending on the response to treatment. the eye. Emerg Med Clin North Am. 2008;26:116.
be treated with antibiotics alone (3): r Simple bacterial conjunctivitis should follow up r Wagner RS, Aquino M. Pediatric ocular
Amoxicillin/Clavulanate: High dose (dosed as within 34 days if symptoms do not improve. inflammation. Immunol Allergy Clin North Am.
amoxicillin) 8090 mg/kg/day PO divided b.i.d. or r Patients with HSV, chlamydia, or gonococcal
2008;28:169188.
t.i.d. infection should follow up within 2 days.
Cefdinir 14 mg/kg/day given once daily or divided r Hand washing and other hygiene is critical to
b.i.d., max 600 mg/day prevent spread of infection. CODES
Cefpodixime 10 mg/kg/day divided b.i.d., max
800 mg/day PROGNOSIS
r Gonococcal conjunctivitis is treated with a single Most cases of conjunctivitis resolve without ICD9
complications. r 077.3 Other adenoviral conjunctivitis
dose of parenteral ceftriaxone (2550 mg/kg, max r 372.14 Other chronic allergic conjunctivitis
125 mg) and saline eye lavage (4). COMPLICATIONS r 372.30 Conjunctivitis, unspecified
r Chlamydial infection can be treated with: r Corneal ulcers
Erythromycin ophthalmic ointment and oral r Scarring
erythromycin 50 mg/kg/day divided q.i.d. for r Keratitis
14 days in neonates: PEARLS AND PITFALLS
A 2nd course is occasionally required. r Treating HSV conjunctivitis with steroids can cause
Adolescents and adults may be treated with REFERENCES uncontrolled viral proliferation and increase the risk
topical antibiotics for conjunctivitis, along with of secondary infection.
systemic antibiotics (eg, azithromycin 1 g PO, 1. Owen CG, Shah A, Henshaw K, et al. Topical r Patients with allergic conjunctivitis treated with
erythromycin base 500 mg q.i.d. for 7 days, or treatment for seasonal allergic conjunctivitis:
Systemic review and meta-analysis of efficacy and topical steroids require close supervision, and
doxycycline 100 mg b.i.d. for 7 days) for genital
effectiveness. Br J Gen Prac. 2004;54(503): treatment should be limited to 2 wk to decrease the
disease (4).
r Most cases of viral conjunctivitis can be treated with 451456. risk for complications.
r Gonococcal and chlamydial infections should be
supportive care including cold compresses and 2. Sheikh A, Hurwitz B. Antibiotic versus placebo for
acute bacterial conjunctivitis. Cochrane Database considered in every neonate presenting with eye
artificial tears.
r Treatment of HSV includes cool compresses and Syst Rev. 2007;(4):cd001211. discharge.
r Patients should discontinue use of contact lenses
topical antiviral medications (eg, trifluridine 1%
while being treated for any conjunctivitis.
drops, vidarabine ointment). Severe cases may
require oral antiviral medications and/or topical
cycloplegic medications (5), given in cooperation
with an ophthalmologist.
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CONJUNCTIVITIS, NEONATAL
Emily Schapiro
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CONJUNCTIVITIS, NEONATAL
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CONSTIPATION
Besh Barcega
Mary Jane Piroutek
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CONSTIPATION
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CONTACT DERMATITIS
Solomon Behar
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CONTACT DERMATITIS
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CONVERSION DISORDER
Allison A. Keller
D. Richard Martini
Charles W. Pruitt
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CONVERSION DISORDER
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CORNEAL ABRASION
Nicole D. Porti
Karen Franco
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CORNEAL ABRASION
DIFFERENTIAL DIAGNOSIS
r Corneal ulceration
Second Line
r Topical antibiotics:
REFERENCES
r Conjunctivitis Sulfacetamide 10% solution: 12 gtt q2h 1. Edwards RS. Ophthalmic emergencies in a district
r Keratitis Polymyxin/Trimethoprim solution: 12 gtt q2h general hospital casualty department. Br J
r Corneal perforation Ciprofloxacin solution: 12 gtt q2h Ophthalmol. 1987;71:938942.
r Ruptured globe r Ibuprofen 10 mg/kg/dose PO q6h 2. Nelson LB, Wilson TW, Jeffers JB. Eye injuries in
r Recurrent corneal erosion r Acetaminophen/Oxycodone 0.1 mg/kg/dose q6h childhood: Demography, etiology, and prevention.
r Corneal foreign body Pediatrics. 1989;84:438441.
SURGERY/OTHER PROCEDURES
r Chemical burn r None 3. Peyman GA, Rahimy MH, Fernandes ML. Effects of
morphine on corneal sensitivity and epithelial
C
r Iritis r Treating simple corneal abrasions by patching does
wound healing: Implications for topical ophthalmic
not improve healing or reduce pain (4). analgesia. Br J Ophthalmol. 1994;78(2):138141.
TREATMENT DISPOSITION 4. Turner A, Rabiu M. Patching for corneal abrasion.
Corneal abrasions are managed on an outpatient Cochrane Database Syst Rev. 2006;(2):cd004764.
INITIAL STABILIZATION/THERAPY basis.
r Cover the globe with a protective shield if
penetrating trauma is suspected. ADDITIONAL READING
r Apply a topical anesthetic for patient comfort and to FOLLOW-UP
See Also (Topic, Algorithm, Electronic
facilitate the exam. FOLLOW-UP RECOMMENDATIONS Media Element)
Discharge instructions: r Conjunctivitis
MEDICATION
r Instruct the patient to use antibiotics as prescribed r Foreign Body, Cornea
First Line
r Topical antibiotics are the mainstay of treatment. or until asymptomatic (may be shorter duration than
Ointment is better than drops since it acts as a 35 days).
r Repeat eye exam in 24 hr. CODES
lubricant and is administered less often. Duration of
treatment is typically 35 days: r If symptoms persist >4 hr, re-exam by an
Bacitracin ointment 0.5 ribbon to lower eyelid ophthalmologist is warranted. ICD9
q48h r Advise eye rest. Significant eye movement may 918.1 Superficial injury of cornea
Erythromycin ointment: 0.5 ribbon to the lower interfere with healing.
eyelid q48h Patient Monitoring
Sulfacetamide ointment: 0.5 ribbon to the lower Follow up for fluorescein testing in 2448 hr to ensure
PEARLS AND PITFALLS
eyelid q48h healing. May be done by optometry, ophthalmology, a r A patient with eye pain, FB sensation, and tearing
r Topical NSAIDs have been found to be useful in
primary care provider, or the emergency department with preceding trauma or FB likely has a corneal
reducing pain:
PROGNOSIS abrasion or more significant injury.
Ketorolac tromethamine 0.5%: 1 gtt q.i.d. for up r Rule out penetrating trauma 1st:
to 2 wk Healing within 2448 hr is to be expected. The
r Topical anesthetics: prognosis is excellent in most cases. Emergent referral to ophthalmology is warranted
if penetrating trauma exists.
Use a minimal amount in the emergency COMPLICATIONS r Topical antibiotics are the treatment of choice, with
department, and do not let the patient take drops r Deeper abrasions involving the visual axis may heal
home. These agents can compromise wound resolution of abrasion expected in 12 days.
with a scar, leading to loss of visual acuity. r Follow-up for fluorescein testing in 2448 hr should
healing (3) and blunt normal corneal reflex and r Allergic conjunctivitis secondary to ophthalmic
sensation. be ensured to assess for healing.
medications
Tetracaine 0.5% ophthalmic solution: r Recurrent corneal erosions may occur in area of
Apply 12 gtt x 1; may repeat once
healed abrasion if reinjured.
Proparacaine 0.5% ophthalmic solution:
Apply 12 gtt x 1; may repeat up to 57 times
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COSTOCHONDRITIS
Abu N.G.A. Khan
Faiz Ahmad
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Tietze syndrome is similar to costochondritis, except
for the presence of significant swelling, frequently at
DESCRIPTION HISTORY the right sternoclavicular or costochondral junction.
r Costochondritis is an inflammatory process of the The onset of costochondritis is often insidious. Chest It is usually due to minor trauma and responds to
costochondral or costosternal joints that causes wall pain with a history of repeated minor trauma or NSAIDs.
localized pain and tenderness. unaccustomed activity (eg, painting, moving furniture) r Muscle strain is common, especially if there is a
r It is a benign cause of chest pain and is an is common. Pain may be described as follows: history of sports participation or exertion, although
important consideration in the differential diagnosis r Sharp, nagging, aching, or pressurelike
quite often there is no known precipitating event.
of chest pain: r Affects the anterior chest wall Blunt trauma may cause recurrent pain long after
Although the term costochondritis often is used r Usually unilateral (left side more frequent than the the event. Chronic or paroxysmal coughing can
interchangeably with fibrositis and Tietze right side) cause muscle strain or even rib fractures.
syndrome, these are distinct diagnoses. r Usually localized but may extend or radiate r Precordial catch, or Texidor twinge, is a
EPIDEMIOLOGY extensively relatively frequent cause of sharp pain of short
r Exacerbated by trunk movement, deep inspiration, duration in healthy teenagers and young adults. It is
Incidence
and/or exertion often related to exercise and is characterized by a
The exact prevalence of a musculoskeletal etiology for
r Lessens with decreased movement, quiet breathing, brief, sharp, shooting pain that pinpoints to the left
chest pain is not known, although overall prevalence
or change of position substernal border or apex. The onset is sudden, with
of a musculoskeletal etiology for chest pain was
1030%. r May be severe a momentary hesitation on inspiration, then shallow
r May wax and wane breathing resumes until the pain subsides, usually
RISK FACTORS within a minute. The pain may recur frequently or
r Girls are affected more often than boys. PHYSICAL EXAM remain absent for months.
r Peak age for chest pain in children is 1214 yr of r Pain with palpation of affected costochondral joints r Chest wall pain from herpes zoster follows a
age. is a consistent finding in costochondritis. dermatomal pattern and may precede the rash by
r Typically, the 2nd to 5th costochondral junctions are 12 days. This is rare in adolescents and children.
GENERAL PREVENTION r Bornholm disease: Also known as epidemic
involved; in 90% of patients, >1 junction is
Modify improper posture or ergonomics at home,
involved. pleurodynia or Devils grip. Its usually caused by
school, or the workplace. r Surprisingly, patients may not be aware of the chest some strains of coxsackievirus or echovirus and is
PATHOPHYSIOLOGY wall tenderness until exam. due to inflammation of pleural lining or intercostal
r Costochondritis is an inflammatory process of the r The diagnosis should be reconsidered in the absence muscles. Pain is spasmodic, lasting 1530 min.
costochondral or costosternal joints. of local tenderness to palpation: Symptoms may last from 26 days. Complications
r The 2nd to 5th costochondral junctions most Tietze syndrome is characterized by are rare but may include orchitis, pericarditis,
commonly are involved. nonsuppurative edema. myocarditis, and aseptic meningitis. Treatment is
r >1 site is affected in 90% of cases. Costochondritis has no palpable edema. pain control with NSAIDs.
r Other diagnoses:
ETIOLOGY DIAGNOSTIC TESTS & INTERPRETATION
r The etiology of costochondritis is not well defined. Cardiovascular: Myocardial ischemia, pericarditis,
Lab supraventricular tachycardia
r Costochondritis is often preceded by an upper No specific diagnostic studies exist for costochondritis. Pulmonary: Asthma/Bronchospasm, pneumonia,
respiratory infection or exercise. The clinical scenario and the most likely differential pneumothorax, pneumomediastinum
r Repetitive minor trauma has been proposed as the diagnoses should guide which laboratory tests are to GI: Reflux, esophagitis
most likely cause. be obtained: Rheumatoligic: Fibromyalgia, rheumatoid arthritis
r Bacterial or fungal infections of these joints occur r An ECG may be helpful to rule out cardiac pathology. Oncologic: Leukemia, sarcoma, etc.
uncommonly, usually in patients who are IV drug Miscellaneous: Psychogenic chest pain (stress,
Imaging
users or those who have had thoracic surgery. r Chest radiograph is not routinely warranted but is anxiety), breast development (both sexes)
r Costochondritis, among others, is a common
sometimes obtained to rule out differential
noncardiac cause of chest pain in athletes. diagnoses for chest pain.
r Some case reports exist where bone (gallium) scans
have been used to confirm the clinical diagnosis.
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COSTOCHONDRITIS
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COUGH
Eileen Murtagh Kurowski
Lynn Babcock Cimpello
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COUGH
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CROUP
Mary Jane Piroutek
Lilit Minasyan
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CROUP
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CRYING/COLIC
Seth L. Brindis
Marianne Gausche-Hill
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CRYING/COLIC
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CRYPTORCHIDISM
Marie Waterhouse
Deborah R. Liu
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CRYPTORCHIDISM
REFERENCES
TREATMENT FOLLOW-UP
1. Berkowitz G, Lapinski RH, Dolgin SE, et al.
Most pediatric urologists consider surgery to be FOLLOW-UP RECOMMENDATIONS Prevalence and natural history of cryptorchidism.
r Follow up with a pediatric urologist or surgeon. Pediatrics. 1993;92:4449.
first-line treatment for simple cryptorchidism. r No limitations on physical activity 2. Pettersson A, Richiardi L, Nordenskjold A, et al.
MEDICATION Age at surgery for undescended testis and risk of
Human chorionic gonadotropin or Patient Monitoring
Encourage routine self-exams by the patient or testicular cancer. N Engl J Med.
gonadotropin-releasing hormone therapies:
r Overall success rates are extremely variable primary caretaker for testicular malignancy. 2007;356:18351841.
3. Tasian GE, Hittelman AB, Kim GE, et al. Age at
C
(675%) but comparable for the 2 hormones. PROGNOSIS orchiopexy and testis palpability predict germ cell
r Higher success rates in older patients (>5 yr), r Dependent on multiple factors, including location of
and Leydig cell loss: Clinical predictors of adverse
bilateral UDT, and retractile testis testis, uni- or bilateral, and age at discovery histological features of cryptorchidism. J Urol.
r Adverse effects include impaired spermatogenesis r Correction before 2 yr of age may lower future
2009;182:704709.
and/or precocious puberty. infertility risks. 4. Yeung CK, Tam YH, Chan YL, et al. A new
r Correction before puberty lowers future malignancy
management algorithm for impalpable
SURGERY/OTHER PROCEDURES risk.
r Laparoscopic or open orchiopexy to secure the testis undescended testis with gadolinium enhanced
COMPLICATIONS magnetic resonance angiography. J Urol.
in the scrotum
r Orchiopexy: Recommended age of operation at r Testicular malignancy: 1999;162:9981002.
It is unclear whether lack of descent itself 5. Lee P, OLeary LA, Songer NJ, et al. Paternity after
312 mo:
increases the malignancy risk or underlying unilateral cryptorchidism: A controlled study.
Orchiopexy allows better routine self-exams for
intrinsic pathology is responsible for both. Pediatrics. 1996;98:676679.
malignancy monitoring.
The surgical plan must balance the anesthesia risk Relative risk of malignancy is 2.758 (if
against the potential malignancy risk. uncorrected) (2):
r Orchiectomy for selected patients, particularly those Falls to 23 if surgically corrected before ADDITIONAL READING
with atrophic or hypertrophic testis, in which the puberty (2) r Bonney T, Hutson J, Southwell B, et al. Update on
malignancy risk is higher Higher risk if bilateral UDT, abdominal location, congenital versus acquired undescended testes:
r The decision to observe, remove, or repair a UDT in abnormal karyotype, or coexistent endocrinopathy Incidence, diagnosis, and management. ANZ J Surg.
Seminoma is the most common (70% of 2008;78:10101013.
the postpubertal male is complex, since the
malignancy and fertility benefit from surgery may be
malignancies in uncorrected patients, 30% in r Esposito C, Caldamone AA, Settimi A, et al.
corrected patients) malignancy. Management of boys with nonpalpable
limited.
Embryonal carcinoma, teratocarcinoma, and undescended testis. Nat Clin Pract Urol.
DISPOSITION choriocarcinoma are also seen. 2008;5:252260.
Admission Criteria r Infertility: r Schneck FX, Bellinger MF. Abnormalities of the
r Cryptorchidism not associated with underlying Germ cell development in UDT begins to testes and scrotum and their surgical management.
medical conditions rarely requires admission to the deteriorate after 1 yr of age. In Wein AJ, Kavoussi LR, Novick AC, et al., eds.
hospital. Infertility risk increases with age. Campbell-Walsh Urology. 9th ed. Philadelphia, PA:
r Cryptorchidism as a sign of an undiagnosed medical Early surgical correction (between 3 and 12 mo of Saunders; 2007.
condition (eg, congenital adrenal hyperplasia or age) is important. r Virtanen HE, Toppari J. Epidemiology and
prune-belly syndrome) may require admission for There is a lack of paternity in 10% of formerly
pathogenesis of cryptorchidism. Human Reprod
further evaluation. cryptorchid males compared to 5% of controls (5).
r Surgical complications include postoperative edema, Update. 2008;14:4958.
Discharge Criteria r Wood HM, Elder JS. Cryptorchidism and testicular
Patients not experiencing pain, in whom torsion is not inflammation, and tension of the spermatic cord:
cancer: Separating fact from fiction. J Urol.
suspected, can generally be discharged with These can lead to ischemic injury and testicular
2009;181:452461.
appropriate follow-up. atrophy.
r Testicular torsion is rare in cryptorchid patients but
Issues for Referral
should be suspected in any male with acute
All patients with a testis located outside of normal
abdominal pain and an empty ipsilateral
CODES
anatomic position should be referred to a pediatric
hemiscrotum:
urologist or surgeon upon diagnosis. ICD9
If suspicious for torsion, obtain an immediate US
and/or urological or surgical consultation. 752.51 Undescended testis
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CUSHING SYNDROME
Todd P. Chang
Imaging
BASICS DIAGNOSIS r Imaging is typically not done emergently.
r On plain films, bone age is typically delayed.
DESCRIPTION HISTORY r CT or MRI of the abdomen can locate and
r Cushing syndrome (CS) is a constellation of signs r Inquire about medication use.
r Weight gain and growth failure can occur insidiously differentiate an adrenocortical tumor or adrenal
and symptoms from excessive glucocorticoids, with hyperplasia.
typical cushingoid features, cardiovascular, over time and are more prevalent in infants and r MRI of the sella turcica can confirm a pituitary
hematologic, and endocrine effects. younger children.
r Cushingoid features include: r Facial and body fat changes adenoma, though only half of microadenomas are
r Disproportionate skin pigmentation, increased visible by MRI (3).
Facial fat deposition (moon facies)
Posterior neck fat deposition (buffalo hump) sweating, or acne Diagnostic Procedures/Other
r Headache, depression, emotional lability, or r ECG to evaluate for myocardial ischemia chest pain
Abdominal striae (stretch marks)
Truncal obesity with thin extremities psychosis or if other suggestive symptoms exist
r Cushing disease refers to CS caused by a pituitary r Muscle pain, frequent fractures r An endocrinologist can confirm CS through a 24-hr
adenoma that produces excess adrenocorticotropin r Hirsutism, amenorrhea, virilization, and other urine cortisol screen, serial circadian cortisol levels,
hormone (ACTH), which is the most common cause and/or dexamethasone suppression testing.
pubertal disturbances may have occurred.
of CS in children 5 yr. DIFFERENTIAL DIAGNOSIS
PHYSICAL EXAM r Obesity
EPIDEMIOLOGY r Elevated body mass index and poor growth: Children
r DM
Incidence with CS are shorter than regular obese children (2). r Hypothyroidism
r Pediatric CS is significantly more rare than r HTN
r Cushingoid features are almost always present in r Polycystic ovarian syndrome
adult-onset CS.
r Occurs in females more often than males
older children.
r Adrenocortical tumors account for most cases of CS r Skin findings include acanthosis nigrans, generalized
in children <7 yr.
TREATMENT
hyperpigmentation, hyperhidrosis, and striae:
r Incidence has been reported to be 15% in patients Cafe-au-lait spots with distinct, jagged edges PRE HOSPITAL
of all ages with diabetes mellitus (DM) or HTN (1). coast of Maine are found with Assess the patient, and support airway, breathing, and
RISK FACTORS McCune-Albright syndrome circulation until hospital arrival.
r Focal neurologic signs are rare but can suggest
Chronic oral or IV glucocorticoid use for other INITIAL STABILIZATION/THERAPY
underlying inflammatory conditions ischemia or infarct: r Check for signs of acute addisonian crisis if a patient
Papilledema may be present with associated
PATHOPHYSIOLOGY is under stress (infection, trauma, etc.).
pseudotumor cerebri. r In a patient with CS who appears ill or toxic:
r Excess hypercortisolemia causes characteristic r Evidence of inappropriate androgen activity, such as
changes to adipose tissue, hair follicles, and skin. Crystalloid or colloid IV resuscitation as needed to
hirsutism, acne, body odor, and virilization may be
r Hypercortisolemia can come from abnormalities in maintain perfusion
seen in prepubertal children.
any portion of the hypothalamus-pituitary-adrenal Broad-spectrum antibiotic therapy
axis or from a purely exogenous source. DIAGNOSTIC TESTS & INTERPRETATION Vasopressors as necessary
Lab MEDICATION
ETIOLOGY Initial Lab Tests
r Causes of CS are divided into ACTH dependent or r Lab tests are needed if the patient appears ill or First Line
ACTH independent: r Hydrocortisone for addisonian crisis: 12 mg/kg IV
r ACTH dependent: toxic.
r With suspected sepsis, shock, or addisonian crisis: bolus, then 100 mg/m2 /day divided or as an
Pituitary adenoma (Cushing disease) infusion. See Adrenal Insufficiency topic.
CBC may show lymphopenia despite elevated r Broad-spectrum antibiotic therapy:
Ectopic ACTH-producing tumor WBCs.
r ACTH independent: Ceftriaxone 50 mg/kg IV q12h, adult max single
Chemistries may show hypernatremia and
Exogenous glucocorticoid use or abuse is the most dose 2,000 mg OR
hypokalemia from mineralocorticoid effects.
common cause of pediatric CS. Meropenem 20 mg/kg IV q8h, adult max single
Blood culture
Adrenal adenoma or carcinoma: dose 1,000 mg OR
Free cortisol level will be low or undetectable in
Beckwith-Weidemann syndrome Piperacillin/Tazobactam 100 mg/kg IV q8h, adult
crisis.
Primary adrenocortical hyperplasia: r Recommended nonemergent labs for CS include a max single dose 3,000 mg
Carney complex Consider adding vancomycin 10 mg/kg IV q6h
workup for pituitary involvement:
Multiple endocrine neoplasia type 1 (adult max single dose 1,000 mg) if MRSA or if
Free T4
Primary pigmented adrenocortical disease, also local antibiotic resistance of Streptococcus
Thyroid-stimulating hormone pneumoniae warrants.
known as micronodular adrenal disease Prolactin
McCune-Albright syndrome
Luteinizing hormone
Macronodular adrenal hyperplasia
Follicle-stimulating hormone
Free testosterone
Androstenedione
Dehydroepiandrosterone sulfate (DHEA-S)
Beta-hCG
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CUSHING SYNDROME
Second Line
r Antihypertensive agents for uncontrolled
ADDITIONAL READING
FOLLOW-UP
hypertension (see Hypertension topic): Nicardipine Chan LF, et al. Pediatric Cushings syndrome: Clinical
(5 mg/kg/min IV, then titrated 13 mg/kg/min) has FOLLOW-UP RECOMMENDATIONS features, diagnosis, and treatment. Arq Bras
minimal risk of hypotension. Discharge instructions and medications: Endocrinol Metabol. 2007;51(8):12611271.
r Medications to lower serum cortisol levels such as r Taper steroids as soon as possible.
bromocriptine or ketoconazole should be
PROGNOSIS CODES
administered only under the guidance of a pediatric
Untreated CS can lead to DM, HTN, dyslipidemia, and
endocrinologist.
hypercoagulability in adults (4).
ICD9
C
SURGERY/OTHER PROCEDURES COMPLICATIONS
r Transphenoidal resection for pituitary adenoma 255.0 Cushings syndrome
r Acute addisonian crisis
r Adrenalectomy(-ies) for adrenal causes
r Obesity
r Radiation may be useful for certain neoplasms. PEARLS AND PITFALLS
r Growth arrest
DISPOSITION r Pubertal arrest r Consider corticosteroid use or abuseeither
Admission Criteria r Osteoporosis
intentional or unintentional
r Admission should be considered in children with r MI r Consider a relative acute addisonian crisis in a
symptomatic HTN, toxic or septic appearance, or r Cerebrovascular ischemia patient who appears cushingoid
high suspicion of neoplasm. r Sepsis and septic shock r CS in infancy is almost always associated with
r Critical care admission criteria: r Pathologic and stress fractures McCune-Albright syndrome.
Septic shock requiring significant fluid r DM and hyperosmolar coma r Obesity with growth failure warrants endocrinologic
resuscitation (>60 mL/kg), pressors, or positive evaluation.
pressure ventilation
Discharge Criteria REFERENCES
r No evidence of acute addisonian crisis
r No symptomatic HTN 1. Baid SK, Rubino D, Sinaii N, et al. Specificity of
screening tests for Cushings syndrome in an
Issues for Referral overweight and obese population. J Clin Endocrin
r Because pediatric CS differs in etiology and workup Metab. 2009;94(10):38573864.
from adult CS, a pediatric endocrinologist is 2. Greening JE, Storr HL, McKenzie SA, et al. Linear
preferred to an adult endocrinologist. growth and body mass index in pediatric patients
r Most lab testing for CS takes a significant time to with Cushings disease or simple obesity. J
process; it may be beneficial to patient care to begin Endocrinol Invest. 2006;29(10):885887.
the lab workup in the emergency department for the 3. Magiakou MA, Mastorakos G, Oldfield EH, et al.
endocrinologist follow-up. Cushings syndrome in children and adolescents.
Presentation, diagnosis, and therapy. N Engl J Med.
1994;331(10):629636.
4. Boscaro M, Arnaldi G. Approach to the patient with
possible Cushings syndrome. J Clin Endocrinol
Metab. 2009;94:31213131.
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ADDITIONAL READING
TREATMENT FOLLOW-UP r American Academy of Pediatrics. Red Book: 2006
PROGNOSIS Report of the Committee on Infectious Diseases.
The condition is benign and self-limited but can cause
The prognosis is excellent. Hookworm-related CLM is 27th ed. Elk Grove Village, IL: Author; 2006:272.
severe pruritus. The intense pruritis and risk for r Juzych LA, Douglass MC. Cutaneous larva migrans.
infection often mandate treatment. a self-limiting disease. Human beings are accidental
hosts, with the larva dying and the lesions resolving eMedicine Dermatology. 2008. Available at
MEDICATION within 48 wk. Rarely, the disease can last for years. http://emedicine.medscape.com/article/998709-
First Line overview.
r The drug of choice is ivermectin. A single dose COMPLICATIONS
r Secondary infections
C
(200 g per kg of body weight) kills the migrating r Allergic reactions
larva effectively and relieves itching quickly (24). r Erythema multiforme CODES
r Cure rates after a single dosage range from
77100%. ICD9
r Contraindicated in children who weigh <15 kg (or 126.9 Ancylostomiasis and necatoriasis, unspecified
REFERENCES
<5 yr of age) and in pregnant and breast-feeding
women 1. Heukelbach J, Feldmeier H. Epidemiological and
r Off-label use in children has been shown to be safe. clinical characteristics of hookworm-related PEARLS AND PITFALLS
cutaeous larva migrans. Lancet Infect Dis. r Clinical diagnosis based on history of contact with
Second Line 2008;8(5):302309.
r Albendazole 400800 mg/day (according to weight) warm, moist sand and physical findings of pruritic,
for 3 days (1,3,4); for children <2 yr, 200 mg/day 2. Heukelback J, Jackson A, Ariza L, et al. Prevalence serpiginous erythematous tunnels that advance
for 3 days and repeat in 3 wk, if necessary and risk factors of hookworm-related cutaneous r Though a self-limited disease, the intense pruritis
r Topical tiabendazole (thiabendazole) in a larva migrans in a rural community in Brazil. Ann
often mandates treatment.
Trop Med Parasitol. 2008;102:5361. r The best way to prevent CLM is to wear protective
concentration of 1015% t.i.d. for 57 days is as
effective as oral treatment with ivermectin (1). 3. Hochedez P, Caumes E. Hookworm-related
footwear at all times while on the beach.
r Antistaphylococcal/Streptococcal antibiotics for cutaneous larva migrans. J Travel Med.
2007;14(5):326333.
secondary bacterial infections/impetiginization:
Cephalexin 25100 mg/kg/day divided q68h, 4. Mosel G, Caumes E. Recent developments in
max dose 4 g/day dermatolgical syndromes in returning travelers.
Clindamycin 1030 mg/kg/day divided q68h, Curr Opin Infect Dis. 2008;21(5):495499.
max dose 1.8 g/day
Additional Therapies
As an alternative therapy, liquid nitrogen cryotherapy
can be applied to the progressive end of the larval
burrow. This is considered obsolete by some since it is
painful, ineffective, and may cause ulcerations (1).
DISPOSITION
Generally treated on an outpatient basis
Admission Criteria
Consider admission for severe secondary infections
not adequately treated with oral antibiotics.
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CYANOSIS
Marsha Ayzen Elkhunovich
Joshua Nagler
ETIOLOGY
BASICS r Respiratory: DIAGNOSIS
High altitude or any other reason for decreased
DESCRIPTION amount of inspired oxygen HISTORY
r Cyanosis is a blue tint of the skin and mucous r Acute or chronic/recurrent (duration of symptoms)
Neurologic causes of respiratory depression:
membranes that appears to be due to deoxygenated Apnea of prematurity, central apnea, seizure, r Birth history (eg, gestational age, problems with
blood near the skin surface. breath-holding, respiratory depression due to delivery, neonatal ICU stay, group B streptococcus
r Cyanosis becomes apparent when the amount of medication or toxin (eg, morphine, alcohol, status, mechanical ventilation, etc.)
deoxygenated hemoglobin (Hgb) is >5 g/dL. etc.), increased intracranial pressure r History of underlying conditions/surgeries
r Central cyanosis is defined by blue discoloration of Restrictive lung process: r History of aspiration
the skin and mucous membranes (particularly lips, External compression, pneumothorax, r Respiratory distress
mouth, head, and torso). hemothorax, pleural effusion or empyema, r Problems feeding, sweating with feeds
r Peripheral or acrocyanosis is a bluish tint of the skin mediastinal or lung mass, flail chest, congenital r History of possible ingestions/exposures
of the distal extremities and around the lips, which diaphragmatic hernia, diaphragmatic paralysis, r Current medications
may be a normal finding in neonates. congenital cystic adenomatoid malformation, r Systemic symptoms: Fevers, rash, etc.
r Causes of cyanosis range from benign and transient pulmonary sequestration, congenital lobar r Neurologic symptoms: Weakness, difficulty with
(eg, breath-holding spell) to severe and life emphysema
Neuromuscular disease such as spinal muscular movements
threatening (eg, congenital heart disease [CHD]). r Family history
For specific details of the various etiologies, please atrophy, botulism, Guillain-Barre syndrome,
transient myelitis, muscular dystrophy r Allergies
see the respective topics in this textbook.
r Cyanosis can be acute or long-standing, transient or Obstructive lung process: PHYSICAL EXAM
Asthma, bronchiolitis, croup, pertussis, foreign r Vital signs:
persistent, depending on its etiology.
body aspiration, epiglottitis, tracheitis, Tachypnea will be most commonly present:
EPIDEMIOLOGY laryngomalacia, tracheomalacia, anaphylaxis If tachypnea is not present and the patient is
Incidence Congenital obstruction secondary to a mass,
hypoxemic, assess for apnea or fatigue and
The incidence of cyanotic CHD is 0.1%, though with choanal atresia, Pierre Robin and other impending respiratory failure.
current prenatal screening, few of these children structural abnormalities Patients with long-standing cyanosis may not
initially present in the emergency department (1). Vocal cord paralysis, tracheostomy obstruction,
appear in distress but will have a mild baseline
hemorrhage tachypnea.
RISK FACTORS Diffusion abnormalities across the
r There are risk factors for specific conditions that Tachycardia will be commonly present.
alveolar-capillary wall: Fever can point to infectious causes such as
cause cyanosis. Some of these include: CLD or bronchopulmonary dysplasia
Advanced maternal age and gestational diabetes pneumonia, epiglottitis, etc.
Surfactant deficiency, acute respiratory distress
for CHD Hypotension can be present with septic or
syndrome, cystic fibrosis, pneumonia, acute cardiogenic shock.
Prematurity for chronic lung disease (CLD), apnea chest syndrome in sickle cell anemia, pulmonary
and asthma r Skin exam: Distinguish between central and
hemorrhage/edema
Cerebral palsy/developmental delay for aspiration r Cardiovascular: peripheral cyanosis:
pneumonias, seizures, and central apnea If peripheral, is it distributed equally on the upper
r Polycythemia will make patients appear cyanotic at Cardiac: and lower extremities? (Infants with coarctation of
Cardiogenic shock, CHF, pulmonary HTN,
a normal oxygen saturation even though they are the aorta and an open patent ductus arteriosus
persistent pulmonary HTN of the newborn (PDA) may have cyanosis in just the lower
not hypoxemic. Congenital cyanotic heart disease:
extremities.)
Atrioventricular canal defect, Ebstein anomaly,
PATHOPHYSIOLOGY r HEENT exam looking for evidence of choanal
r Central cyanosis is usually a manifestation of hypoplastic left heart syndrome, pulmonary
atresia, features of craniofacial abnormalities
hypoxemia, which appears when the amount of atresia/severe stenosis, tetralogy of Fallot, r Respiratory exam:
unsaturated Hgb is >5 g/dL, which at normal Hgb total anomalous pulmonary venous return,
transposition of the great arteries, tricuspid Tracheal deviation
levels corresponds to 7378% (2).
atresia, truncus arteriosus, severe aortic Diaphragmatic excursion
Such hypoxemia may result from:
Inadequate oxygen intake coarctation may cause cyanosis in the lower Stridor
Poor oxygen absorption from the lungs to the extremities Increased respiratory effort including grunting,
flaring, or retractions
circulation Vascular:
Intracardiac or intrapulmonary shunting, which Acrocyanosis of the newborn, cold exposure, Wheezing, crackles, or rales
Egophony
causes some blood to bypass oxygenation in the Raynaud syndrome (if only affecting fingers and
Assessment of tracheostomy, if present
lungs toes), pulmonary embolism (PE), septic shock r Cardiac exam:
r Methemoglobinemia may manifest as central r Other:
Evidence of heave, lift, or thrill
cyanosis but is not a result of hypoxemia. See Methemoglobinemia:
Congenital hemoglobin M or abnormalities in Evaluation of heart sounds with splitting
Methemoglobinemia topic. Sulfhemoglobinemia is
Presence of murmur
very rare dyshemoglobinemia that results in cyanosis methemoglobin reductase
Exposure to toxins/drugs such as quinines, Check for pulses and presence of radiofemoral
without hypoxemia.
delay
benzocaine, sulfonamide antibiotics r Neurologic exam: Thorough exam including an
assessment for decreased strength or tone and deep
tendon reflexes
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The lone arterial trunk sits over a large VSD. DIAGNOSTIC TESTS & INTERPRETATION
BASICS Pulmonary vascular resistance (PVR) and Lab
blood flow indicate pulmonary HTN. Initial Lab Tests
DESCRIPTION r Hypoplastic left heart syndrome (HLHS): r Serum electrolytes, calcium, glucose, and CBC:
r Varying degrees of deoxygenated venous blood
Hypoplasia of the L ventricle Electrolyte abnormalities ( sodium, chloride) can
shunting from the right (R) to left (L) side of the Hypoplastic aortic arch occur.
heart or circulation occurs in cyanotic heart disease Aortic and mitral valvular stenosis Calcium can present as prolongation of the QT
(CyHD). r Ebstein anomaly: interval, CHF, hypotension.
r Cyanosis occurs when >5 mg/dL of deoxygenated
Tricuspid valve leaflets are abnormally attached to Hypoglycemia can cause weakness and fatigue.
blood is in the capillary beds. its annulus. Depending on the heart lesion, polycythemia
EPIDEMIOLOGY An enlarged RA and smaller R ventricle = R to L (from chronic hypoxemia) or anemia (dilutional
shunting and pulmonary blood flow. effects) can be present.
Incidence r An arterial blood gas sample can determine the
In 2005, the CDC reported that CyHD occurred in 56.9 ETIOLOGY
per 100,000 live births in the U.S. r Exact cause of CyHD is unknown. degree of hypoxemia and metabolic acidosis.
r Factors associated with an increased risk of CyHD: Imaging
Prevalence r Chest radiographic imaging is essential.
CyHD accounts for 25% of all congenital heart Maternal risk factors, chromosomal abnormalities,
and single gene defects r Various degrees of ventricular hypertrophy and
disease (CHD).
r A multifactorial etiology is the theoretical basis for pulmonary congestion depend on CyHD type:
RISK FACTORS most forms of CyHD. A boot-shaped heart is seen in TOF.
Maternal risk factors: Snowman or figure of 8 sign = TAPVR.
r Infection (rubella) COMMONLY ASSOCIATED CONDITIONS Egg on a string sign = TGA.
r DiGeorge syndrome: TA, TOF
r Medication use (eg, anticonvulsants, lithium)
r Noonan syndrome: Supravalvular (SV) PS Diagnostic Procedures/Other
r Drug abuse (ethanol) r An echo should be performed on patients suspected
r Williams syndrome: SV aortic stenosis, pulmonary
r Disease states (phenylketonuria, systemic lupus of having CyHD.
artery stenosis r A 12-lead ECG should be obtained. Depending on
erythematosis, diabetes mellitus)
GENERAL PREVENTION the lesion, the ECG may show various arrhythmias,
Adequate prenatal care: Prenatal US can diagnose DIAGNOSIS hypertrophy, R or L axis deviations, and bundle
CyHD in utero. After delivery, transport to an branch blocks.
HISTORY r A hyperoxia test can differentiate between cyanotic
appropriate tertiary care center is warranted. r Not all CyHD is clinically evident at birth.
cardiac and pulmonary disease:
PATHOPHYSIOLOGY r Presence of a PDA can mask severe pulmonary or
r Tetralogy of Fallot (TOF): A baseline R radial artery (preductal) blood gas
systemic flow obstruction. sample is obtained on room air.
4 basic lesions: r Presentation in 1st 2 wk of life: AS, HLHS, TGA, A 2nd blood gas is obtained after a 10-min
Ventricular septal defect (VSD) TAPVR, TA, and TrA administration of 100% oxygen (O2 ).
R ventricular outflow obstruction from r Presentation within the 1st mo: TrA A PaO2 >200 mm Hg on 100% O2 makes
pulmonary stenosis (PS) r Presentation within 6 wk to 6 mo: TrA cyanotic CHD unlikely.
Overriding aorta r Patients can be stable, in CHF, or in shock. A PaO2 <150 mm Hg on 100% O2 suggests
R ventricular hypertrophy = pulmonary flow
r The most common presentations are acute CyHD with complete mixing without pulmonary
resulting in R to L shunting. blood flow restriction.
Pink TOF: Mild PS and L to R shunting respiratory distress and cyanotic episodes.
r Signs of CHF (fatigue, poor appetite and diaphoresis A PaO2 <50 mm Hg indicates a mixing lesion
TOF hypercyanotic spells or Tet spells: with restrictive pulmonary blood flow.
Agitated patient has extreme cyanosis in during feeding, pallor, tachypnea, tachycardia),
situations with sympathetic activity. failure to thrive, irritability, dehydration, and DIFFERENTIAL DIAGNOSIS
R ventricular outflow tract obstruction worsens recurrent lung infections are common signs and r In neonates, sepsis must be suspected prior to a
with infundibular septum spasms. symptoms. definitive diagnosis of CyHD.
Tet spells may cause end-organ damage, are r CHF is due to lesions that cause pulmonary flow: r Tracheal or bronchial foreign body
unpredictable, and potentially are lethal. TGA, TOF, TA, HLHS, and TAPVR. r Congenital anomalies: Vascular malformations,
r Transposition of the great arteries (TGA): hypoplastic mandible
PHYSICAL EXAM r Apparent life-threatening event
The aorta originates from the R ventricle, and the r Evaluation of general appearance and color is the
main pulmonary artery (PA) arises from the L r Pneumonia/Empyema/Effusion
most important part of the exam.
ventricle. r Pink color = CyHD (pink Tet), L to R shunt. r Pulmonary edema
A patent ductus arteriosus (PDA), atrial septal r Blue color typically = CyHD with R to L shunt. r Diaphragmatic hernia
defect (ASD), or VSD is critical for survival and r Grey color indicates outflow obstruction, systemic r Congenital pulmonary hypoplasia
allows mixing of the 2 systems to move r Breath-holding
oxygenated blood to the systemic system. hypoperfusion, and shock.
r Tachycardia and tachypnea may be out of proportion r Methemoglobinemia
r Total anomalous pulmonary venous return (TAPVR):
Pulmonary veins return oxygenated blood from to the patients general appearance.
r Cool skin and delayed capillary refill indicates shock
the lungs to the right atrium (RA).
An ASD or patent foramen ovale is needed to associated with severe cardiac disease.
r Distal pulses imply aortic arch obstruction.
cause mixing and shunting of blood to the L side
of the heart for survival. r Hydration status, mucosal color, and lung/heart
r Tricuspid atresia (TA): sounds should be assessed along with palpation of
Atresia of the tricuspid valve causes the R ventricle the precordium and a survey for organomegaly.
to be hypoplastic or absent. r Heart murmurs with or without thrills and gallop
The RA will become hypertrophied. rhythms suggest CyHD.
An ASD, VSD, or PDA is critical to survival. r CHF: Tachypnea, hyperactive precordium, S3 heart
R to L shunting occurs to drain the RA. sound, chest congestion, and hepatomegaly
r Truncus arteriosus (TrA): Failure of separation of the
aorta and PA leads to a single arterial trunk arising
from both ventricles:
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Richard G. Boles
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CYSTIC HYGROMA
Joseph B. House
Stuart A. Bradin
ETIOLOGY Imaging
BASICS Unknown r MRI is study of choice:
Best soft tissue detail
DESCRIPTION COMMONLY ASSOCIATED CONDITIONS
r Infection of cyst Delineate relationship to underlying structures
r A cystic hygroma is a congenital malformation of the Differentiates hemangiomas from lymphangiomas
r Hypertrophy of both bone and soft tissue:
lymphatic system with dilated lymphatic channels. Hyperintense signal in T2-weighted images
r Synonymous with macrocystic lymphatic Frequently seen as progressive distortion of Ring enhancement with contrast use
malformation and cystic lymphangioma mandibular body, can cause underbite and r CT scanning:
r Not a neoplasm open-bite deformity (5)
r First trimester often associated with trisomies 13, Faster than MRI
r Usually found in the posterior triangle of the neck, Detail is lost if surrounding tissue of similar
18, and 21; second trimesters often associated with attenuation
but can be in other neck locations as well as axillae,
monosomy X Contrast helps to enhance cyst wall
groin, popliteal fossae, or torso
r Can grow rapidly within the first few weeks r US:
r Categorized as unilateral or bilateral and suprahyoid DIAGNOSIS Least invasive
or infrahyoid (1): No radiation exposure
Stage I: Unilateral infrahyoid HISTORY Useful demonstrating relationship with
r Symptoms vary based on lesion location. surrounding structures
Stage II: Unilateral suprahyoid
r May present after sudden appearance of neck Limited in assessing mediastinal and
Stage III: Unilateral supra- and infrahyoid
Stage IV: Bilateral suprahyoid swelling secondary to infection or intralesional retropharyngeal lesions
Stage V: Bilateral supra- and infrahyoid bleeding Can be used in utero in the late 1st trimester: May
r Classification based on size (1): r Rarely, new-onset obstructive sleep apnea or stridor appear as excess nuchal fluid, largest in the
Microcystic or capillary lymphangiomas: <1 cm or cyanosis nuchal region, and may extend along entire length
Macrocystic: >1 cm r Feeding difficulties or failure to thrive: of the fetus
r Plain radiography: Generally unhelpful but may
May be early sign of impending airway obstruction
EPIDEMIOLOGY r Pelvic lesions cause bladder outlet obstruction, delineate gross airway compromise
Incidence constipation, or recurrent infection.
r 1 case per 6,00016,000 live births (2) Pathological Findings
r Large irregular sinuses with single layer of flattened
r 5065% evident at birth, with 90% detected at PHYSICAL EXAM
r Often, overlying skin is normal or has bluish hue. epithelial lining and fibrous adventitial coats:
<2 yr of age Hemorrhage within the cystic spaces is common
r Equal frequency in males and females r Less common, puckering or deep cutaneous
after trauma or with spontaneous intralesional
r Equal frequency in ethnic groups dimpling
r Soft, painless compressible mass bleeding.
r Most commonly occurs in head and neck (75%) r Thickness of vessel wall varies with striated and
r About 20% of cystic hygromas occur in the axilla r In contrast to thyroid cysts, does not move with
smooth muscle components.
In neck, most commonly in posterior triangle swallowing
50% of fetuses with cystic hygroma have an r Typically transilluminates DIFFERENTIAL DIAGNOSIS
r Microcystic form appears as clusters of clear, black, r Teratoma
abnormal karyotype, and chromosomal r Germ cell tumor
abnormalities are more frequent in septated or red vesicles on buccal mucosa or tongue.
r Macrocystic lesions usually are found above level of r Branchial cleft cyst
cystic hygroma (4):
r Thyroglossal duct cyst
Karyotypes include Klinefelter syndrome, Turner mylohyoid muscle and involve oral cavity, lip, and
tongue. r Goiter
syndrome, Down syndrome, trisomy 13 and 18,
Noonan syndrome, Fryns syndrome, multiple r Life-threatening airway compromise may present as r Soft tissue tumor
pterygium syndrome, and achondroplasia. noisy breathing, cyanosis, or tracheal deviation. r Neck abscess
r Those that develop in the third trimester or r Inspect the tongue and oral cavity for lesions that r Lymphadenopathy
postnatally usually are not associated with a may lead to airway compromise. r Lymphadenitis
chromosomal abnormality (3). r Lesions in the forehead and orbit can cause r Parotitis
r 33% of fetuses with cystic hygroma have a proptosis.
structural abnormality (4). r Diffuse thoracic lymphatic anomalies or
Prevalence abnormalities of thoracic duct can manifest as
r In 1st trimester, overall about 1 in 100 fetuses: recurrent pleural or pericardial chylous effusion or
Septated cystic hygroma occurs in 1 in 285 fetuses. ascites.
r Some authors believe all cystic hygromas are present r Lesions in an extremity may cause diffuse or
at birth (2). localized swelling or gigantism with soft tissue and
skeletal overgrowth.
RISK FACTORS r Diffuse soft tissue and skeletal lesions may cause
r Intrauterine substance exposure, including alcohol
progressive osteolysis, called Gorham-Stout
(2) syndrome, or disappearing bone or phantom bone
r Maternal viral infections, including parvovirus (3)
disease.
PATHOPHYSIOLOGY DIAGNOSTIC TESTS & INTERPRETATION
r Maldeveloped localized lymphatic network
r Combination of: Lab
Initial Lab Tests
Failure of lymphatics to connect to venous system r No initial lab testing is routinely required.
Abnormal budding of lymphatic tissue r Check white blood cell count and/or C-reactive
Sequestered lymphatic rests that retain embryonic protein, and check blood culture if infection of cyst
growth potential is suspected.
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CYSTIC HYGROMA
DISPOSITION REFERENCES
TREATMENT Admission Criteria
r Airway obstruction 1. Gross EG, Sichel J. Congential neck lesions. Surg
INITIAL STABILIZATION/THERAPY r Superinfection of lesion Clin North Am. 2006;86:383392.
r If airway compromise, consider aspiration: r Pericardial or pulmonary chylous effusions or ascites 2. Acevedo JL, Shah RK. Cystic hygroma. eMedicine
Prepare for a difficult airway if compromise is r Observation of rapidly expanding cyst Pediatrics: Surgery. July 18, 2008. Available at
suspected. http://emedicine.medscape.com/article/994055-
Emergent otolaryngology or anesthesiology Issues for Referral overview.
Referral to surgeon or surgical subspecialist depending
consult may be needed for airway evaluation.
Aspiration with large-bore (18- to 20-gauge) on anatomic location
3. Emory University School of Medicine. Cystic
Hygroma. 2008.
C
needle may temporarily alleviate immediate COMPLEMENTARY & ALTERNATIVE 4. Simpson LL. First trimester cystic hygroma and
airway compromise. THERAPIES enlarged nuchal translucency. UpToDate. May
Save aspirate for culture if necessary. r Observation: 15% spontaneous regress (1) 2008.
r If signs of infection, treat with antibiotics: r Laser resection: 5. Cummings CW. In Flint PW, Haughey BH, Lund VJ,
IV antibiotic indicated CO2 laser or et al, eds. Cummings Otolaryngology: Head & Neck
Treat with antibiotics for oral pathogens in head Neodymium:yyttrium-aluminum-ganet laser Surgery. 5th ed. Philadelphia, PA: Mosby; 2010.
and neck lesions. May be MRI controlled 6. Christison-Lagay ER, Fishman SJ. Vascular
Treat with antibiotics for enteric pathogens in the Oral cavity, tongue, and airway most amenable anomalies. Surg Clin North Am. 2006;86:393425.
trunk and perineum. 7. Townsend CM Jr., Beauchamp RD, Evers BM, et al,
r Bleeding may be treated with analgesics:
eds. Sabiston Textbook of Surgery. 18th ed.
Prophylactic antibiotics should be prescribed if FOLLOW-UP Philadelphia, PA: Saunders; 2008.
there is a large collection of intraluminal blood.
FOLLOW-UP RECOMMENDATIONS
MEDICATION Discharge instructions and medications:
Sclerotherapy: r Follow up with a surgical consult.
ADDITIONAL READING
r OK-432: Inactive strain of group A Streptococcus Al-Dajani N, Wootton SH. Cervical lymphadenitis,
pyogenes Patient Monitoring suppurative parotitis, thyroiditis, and infected cysts.
r Airway compromise
Mechanism: Inflammatory response r Signs of cyst infection Infect Dis Clin North Am. 2007;21:523541.
Option for large unilocular cysts
r Alcohol: Works well in vascular malformations with See Also (Topic, Algorithm, Electronic
PROGNOSIS Media Element)
low flow; often painful and may need general r Spontaneous resolution is uncommon.
r Recurrence is rare when gross disease is removed. Lymphangioma
anesthesia and postprocedural pain medication; can
result in local necrosis blistering and neuropathy; r If residual tissue is left behind after surgery, the
systemic absorption may lead to cardiac arrest, recurrence rate is about 15%.
pulmonary vasoconstriction, or systemic hypotension CODES
(6) COMPLICATIONS
r Fibrin sealant: r Intralesional bleeding ICD9
r Cyst infection 228.1 Lymphangioma, any site
Edema post-injection associated with prolonged
recovery and increased therapeutic effect r Cellulitis
Better results with macrocystic type lesions as r Airway compromise
compared to poor or absent results in microcystic r Deformation of surrounding bony structures or teeth PEARLS AND PITFALLS
type (7) if left untreated r Rapid enlargement may cause respiratory distress.
r Adverse psychosocial effects may result from social r Early administration of antibiotics is indicated for
SURGERY/OTHER PROCEDURES
Surgical resection:1 stigmatization in cysts resulting in deformation. superinfection.
r Primary treatment
r Macrocystic lesions: Ideally removed in 1 procedure,
repeated excisions complicated by fibrosis and
anatomic distortions
r Microcystic lesions: Most difficult to resect, no
distinct tissue planes between malformed and
normal structures
r Exception to excision at diagnosis includes close
proximity to crucial neurovascular structures; may
need to wait until child is older.
r Since not a neoplasm, removal of surrounding blood
vessels and nerves is not indicated.
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DACRYOCYSTITIS/DACRYOSTENOSIS
Donald T. Ellis II
Sandip A. Godambe
Kimberly A. Randell
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DECOMPRESSION SICKNESS
Carl P. Kaplan
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DECOMPRESSION SICKNESS
SURGERY/OTHER PROCEDURES
r Tube thoracostomy for associated pneumothorax
ADDITIONAL READING
TREATMENT r Myringotomy tube placement for patients with r Bennett MH, Lehm JF, Mitchell SJ, et al.
PRE HOSPITAL altered mental status undergoing HBO. (Others are Recompression and adjunctive therapy for
r Assess and stabilize airway, breathing, and able to use maneuvers to equilibrate eustachian decompression illness. Cochrane Database Syst Rev.
circulation. tube pressure.) 2007;(2):cd005277.
r Recompression dive to 60-foot seawater depth with r DeGorordo A, Vallejo-Manzur F, Chanin K, et al.
DISPOSITION Diving emergencies. Resuscitation. 2003;
slow ascent (only feasible with stable divers and
experienced oversight)
Admission Criteria 59:171180.
r Administer 100% oxygen. Critical care admission criteria: r MacDonald RD, ODonnell C, Allan GM, et al.
r Pulmonary complications such as pneumothorax,
r Maintain supine position. Interfacility transport of patients with decompression
r Administer isotonic fluids. acute respiratory distress syndrome, or endotracheal illness: Literature review and consensus statement.
r Avoid hypothermia. intubation Prehosp Emerg Care. 2006;10:482487.
r All patients requiring HBO should be considered for r Tintinelli JE , Gabor D, Stapczynski JS, et al., eds.
ALERT admission as an inpatient. Emergency Medicine: A Comprehensive Study D
r Divers Alert Network (DAN) Discharge Criteria Guide. 6th ed. New York, NY: McGraw-Hill;
r Emergency Hotline (800) 446-2671 r Resolution of symptoms within 46 hr following 2003:12131217.
r Tsung JW, Chou KJ, Martinez C, et al. An adolescent
r Transport assistance (800) DAN-EVAC (326-3822) prehospital 100% oxygen
r Stable patients with mild symptoms may be scuba diver with 2 episodes of diving related injuries
discharged after HBO therapy. requiring hyperbaric oxygen recompression therapy.
INITIAL STABILIZATION/THERAPY
r Assess and stabilize airway, breathing, and Pediatr Emerg Care. 2005;21(10):681686.
Issues for Referral
circulation. r Availability of HBO therapy See Also (Topic, Algorithm, Electronic
r Administer 100% oxygen. r Air transport should only occur if cabin altitude can Media Element)
r Identify and treat associated trauma. r http://www.diversalertnetwork.org
be maintained below 500 feet (152 meters) above
r Isotonic volume resuscitation the extraction point. r Pain, Extremity
r Rewarming as necessary
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DEHYDRATION
Alan L. Nager
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DEHYDRATION
r Maintenance hydration can be given based on the 3. Nager AL, Wang VJ. Comparison of nasogastric and
4-2-1 rule: FOLLOW-UP intravenous methods of rehydration in pediatric
For patients <10 kg, administer 4 mL/kg/hr. patients with acute dehydration. Pediatrics.
For patients between 10 and 20 kg, administer FOLLOW-UP RECOMMENDATIONS 2002;109:566572.
r Discharge instructions and medications:
[40 + 2 (weight 10)] mL/hr. 4. Allen C, Etzwiler L, Miller M, et al. Recombinant
For patients >20 kg, administer [60 + 1 Follow-up should occur when additional guidance human hyaluronidase-enabled subcutaneous
(weight 20)] mL/hr. is needed or if a hydration check is deemed pediatric rehydration. Pediatrics. 2009;124:
Additional fluid requirements (eg, 11/2 x appropriate. e858e867.
maintenance) can also be given. Instruct the patient and caregivers about hand 5. Nager A, Wang V. Comparison of ultra-rapid versus
hygiene and contagiousness. rapid intravenous hydration in pediatric patients
MEDICATION r Activity:
First Line with acute dehydration. Am J Emerg Med.
As tolerated 2010;28:123129.
Antiemetics such as ondansetron (Zofran) may be
attempted: Patient Monitoring 6. American Academy of Pediatrics. Practice
r <4 yr: 0.15 mg/kg/dose IV/PO q68h
r 412 yr: 4 mg 23 times/day IV/PO, max dose
Parent instructions should include watching for
diminished tears, decreased urine output including
parameter: The management of acute
gastroenteritis in young children. Pediatrics.
D
concentrated or bright yellow urine, diminished 1996;97:424436.
12 mg/day alertness, lethargy, and seizures.
r >12 yr: 8 mg 23 times/day IV/PO, max dose
24 mg/day DIET ADDITIONAL READING
r Encourage small amounts of oral rehydration fluids,
Second Line such as Pedialyte, Gatorade, or other sport drinks. World Health Organization. The treatment of diarrhea.
r Hyaluronic acid (Hylenex) 150 U single dose SC
r Give bland, nonspicy foods and avoid food or liquids WHO CDD/SER/80.2. Geneva, Switzerland: Author;
several minutes prior to SC fluid administration (4): 1995.
known to cause diarrhea, such as beans,
In preliminary stages of clinical use without clearly
high-fructosecontaining juices, and caffeinated
defined role in therapy
drinks (6).
Facilitates rehydration without IV use in children r BRAT (bananas, rice, applesauce, toast) diet may be CODES
For use with difficult or expected difficult vascular
access or based on clinician or patient/parent helpful.
preference
ICD9
PROGNOSIS r 276.51 Dehydration
r Other antiemetics such as diphenhydramine or r Most patients will recover within 35 days, although
r 775.5 Other transitory neonatal electrolyte
metoclopromide have limited use in nononcologic recovery time may vary depending on the cause of
the dehydration. disturbances
patients.
r Infectious agents causing diarrhea and dehydration
DISPOSITION
may require antibiotics (see Diarrhea topic).
Admission Criteria r The vast majority of patients recover without PEARLS AND PITFALLS
r Persistent moderate dehydration despite treatment,
complications. r Dehydration can cause significant morbidity and
usually related to ongoing losses (eg, vomiting
and/or diarrhea) COMPLICATIONS mortality.
r Electrolyte abnormalities requiring ongoing r Hypernatremia r Clinicians must understand diseases that cause
treatment r Hyponatremia dehydration.
r Moderate or severe dehydration necessitating r Shock r Categorize the severity of dehydration so that
further treatment, including the need for additional r Cerebrovascular accident treatment will be appropriate.
r Lab testing is clinically indicated based on dietary
fluid and electrolyte replacement and monitoring r Shock
r Critical care admission criteria: history or disease or in patients severely dehydrated
Unstable vital signs despite IV hydration or in shock.
r Consider PO, IV, or NG treatment modalities, as each
Severe hypo- or hypernatremia REFERENCES
may be used for specific circumstances.
Discharge Criteria 1. King CK, Glass R, Bresee JS, et al. CDC. Managing
Baseline or near-baseline vital signs and clinical acute gastroenteritis among children: Oral
evidence of adequate hydration (3,5) rehydration, maintenance and nutritional therapy.
Issues for Referral MMWR Recomm Rep. 2003;52(RR-16):116.
Refer to a subspecialist if the dehydration is caused by 2. Gorelick MH, Shaw KN, Murphy KO. Validity and
a subspecialty disease requiring additional evaluation. reliability of clinical signs in the diagnosis of
dehydration in children. Pediatrics. 1997;99(5):e6.
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DENGUE FEVER
Linda Szema
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DENGUE FEVER
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DEPRESSION
David Chao
Richard J. Scarfone
r School-age children:
BASICS DIAGNOSIS Depressed school-age children are cognitively able
to internalize environmental stressors (including
DESCRIPTION HISTORY family conflict) and display low self-esteem and
r Depression can refer to sadness but also describes a r Diagnostic and Statistical Manual of Mental
guilt.
syndrome with cognitive, physiologic, and affective Disorders (DSM) diagnosis of MDD: Presence of 5 of This inner turmoil is expressed through somatic
components (1). 9 of the following, occurring almost daily for 2 wk: complaints, anxiety, and irritability.
r Childhood depressive disorders include sadness Depressed/Irritable mood (must be present), Key features of childhood depression are
variation, bereavement, sadness problem, diminished interest or pleasure (must be present), dysphoric mood (looking or feeling sad,
adjustment disorder with depressed mood, major psychomotor agitation/retardation, recurrent moodiness/irritability, and crying easily) and
depressive disorder (MDD), dysthymic disorder, and thoughts of death/suicidality, fatigue/energy loss, self-deprecating ideation (low self-esteem,
bipolar disorder (2). weight change, feelings of worthlessness, poor feelings of worthlessness, and suicidality).
concentration (4): Depressed children often present with
EPIDEMIOLOGY DSM criteria were established for adults. Children
r In the U.S., the prevalence of MDD is about 1% of somatization (eg, stomach aches, headaches),
and adolescents with depression may not present school problems (including school phobia), temper
preschoolers, 2% of school-age children, and 58% with these classic symptoms. tantrums, runaway behavior, phobias, separation
of adolescents (2): It is critical to ascertain degree of functional anxiety, and fire setting.
1 in 5 teens has a history of depression at some impairment rather than attempting to fit Because many of these symptoms can be observed
point during adolescence (2). symptoms into a set of diagnostic criteria. in the school setting, teachers should be included
The prevalence of depression appears to be The Diagnostic and Statistical Manual for Primary in the evaluation process.
increasing, with onset at earlier ages (2). Care (DSM-PC), Child and Adolescent Version, r Adolescents:
Gender ratio is equal in prepubertal children and provides a concise guide for diagnosis of pediatric
but there is a 2:1 female predominance in Adolescents undergo a period of biopsychosocial
mental health disorders (5). maturation that is fertile for the development of
adolescents (2). r SIG E CAPS mnemonic (give energy capsules):
r Only 2035% of youth who meet full criteria for depressive symptoms in predisposed individuals.
Sleep, Interest, Guilt, Energy, Concentration, Adolescent depression is similar to adult-onset
depression currently receive treatment (2). Appetite, Psychomotor changes, Suicidality depression.
r The SHADDSSSS mnemonic can also be used to help
RISK FACTORS Red flags include somatization, academic
r Family history of depression address a complete inventory of psychosocial problems, promiscuity, drug/alcohol use,
r Previous depressive episodes functioning, including School, Home, Activities, aggressive behavior, and stealing.
r Family conflict Depression, Drugs/Alcohol, Sexuality, Suicide, Because of their developmental struggle with
r Sexuality conflict Safety, Strengths (1). autonomy from authority figures, it is particularly
r Children and adolescents often present to the important to establish a good rapport with
r Poor academic performance
r Dysthymia, anxiety disorders emergency department setting when symptoms adolescent patients.
have reached a crisis point (eg, suicide attempt).
r Substance abuse disorders (3) r Most children present with nonpsychiatric chief PHYSICAL EXAM
r Evaluation of the childs mental status takes place
PATHOPHYSIOLOGY complaints (eg, somatic symptoms, school problems,
r A multifactorial theory of depression is widely held, throughout the emergency department visit:
behavior problems, irritability).
r Diagnosis is challenging because many psychiatric Features of the mental status examination include
with biologic, environmental, psychological, and orientation, appearance, memory, cognition,
social inputs. illnesses (including psychotic disorders, ADHD, behavior, relatedness, speech, affect, thought
r Monoamine hypothesis: Depression results from anxiety disorders, disruptive behavior disorders content, and insight/judgment.
deficiency or abnormal functioning of serotonin, including oppositional defiant disorder and conduct r A depressed patient may appear withdrawn, lack
epinephrine, and norepinephrine in the CNS: disorder, and substance abuse disorders) present
spontaneous speech, express negativistic thoughts,
Medical therapy is based on this theory (eg, with similar symptoms:
and demonstrate psychomotor retardation and a
selective serotonin reuptake inhibitors). Patients may lack insight into their problems with
limited range of affect.
mood.
ETIOLOGY r The clinician cannot rule out depression based on DIAGNOSTIC TESTS & INTERPRETATION
r It is important to consider organic (nonpsychiatric)
patients rejection of this diagnosis. Lab
causes of depression, which include the following: r A comprehensive history to determine suicidality
r Neurologic: Stroke, subdural hematoma, Initial Lab Tests
should include method and timing, lethality, r Pregnancy test
postconcussive syndrome, brain tumors (especially r An initial presentation of depression may prompt an
circumstances, history of prior attempt(s), level of
frontal), Huntington disease, seizure disorder,
planning, current affect and psychological status, evaluation for organic causes:
syphilis
r Metabolic: Vitamin B deficiency, pellagra (niacin family consistency/dynamics, pharmaceuticals CBC
12 available to patient, history of interpersonal Electrolytes and LFTs
deficiency), hypercalcemia, hyponatremia, conflict/loss, history of substance abuse, history of Thyroid function tests
hypokalemia, Wilson disease psychological disorder or medical problem, history of Vitamin B12 level
r Endocrinologic: Thyroid disease (hypo- or
abuse/neglect/incest, social supports and coping Acetaminophen level if intentional ingestion and
hyperthyroid), adrenal disease (Addison disease, strategies, feelings of regret, or continued desire for possibly other toxicologic screening (2)
Cushing syndrome), diabetes mellitus self-harm (6).
r Medications and toxins: Beta-blockers, r The presentation of depression differs based on Imaging
Consider CT or MRI of brain
anticonvulsants, antipsychotics, corticosteroids, stages of development (2).
estrogens/oral contraceptives, amphetamines, r Infants and preschool-age children: Diagnostic Procedures/Other
stimulants (cocaine, crack), marijuana, alcohol, Manifestations of depression in infancy is typically The Pediatric Symptom Checklist and the Beck
heavy metals the result of loss of the mother and lack of Depression Inventory are widely accepted screening
r Other: Various infections (hepatitis, HIV, Epstein-Barr tools used to detect psychopathology in the pediatric
nurturance.
virus), malignancy, anemia, systemic lupus Symptoms include apathy, listlessness, staring, population (2).
erythematosus hypoactivity, poor feeding/failure to thrive, and
COMMONLY ASSOCIATED CONDITIONS increased rate of infections.
See Risk Factors and Etiology.
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DEPRESSION
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DERMATOMYOSITIS
Vincenzo Maniaci
Barbara M. Garcia Pena
Imaging
BASICS DIAGNOSIS r No imaging is necessary in the emergency
department.
DESCRIPTION HISTORY r As an outpatient or inpatient, MRI is useful in
r Dermatomyositis is a systemic autoimmune r Insidious vs. acute onset of muscle weakness and
detecting areas of disease activity and localization
vasculopathy primarily affecting the skeletal muscles rash for muscle biopsy (8).
and skin, causing symmetric muscle weakness and a r Muscle weakness may lead to limitations in
characteristic skin rash. performing activities of daily living such as brushing Diagnostic Procedures/Other
r Outpatient referral for electromyography of the
r Characteristic skin rash plus three of the following hair, getting out of bed, rising from a chair, or
climbing stairs. muscles
criteria are necessary for a definitive diagnosis (1,2): r Outpatient referral for muscle biopsy of a clinically
Symmetric proximal muscle weakness r May also complain of:
Elevated muscle enzymes Low-grade fever affected but not atrophied muscle
r Outpatient referral for pulmonary function testing to
Electromyographic changes of myositis Weight loss
Muscle biopsy evidence of myositis and muscle General weakness evaluate the progression of interstitial lung disease
necrosis Arthralgia Pathological Findings
Dysphagia Lymphocytic vasculitis of small arteries and veins of
EPIDEMIOLOGY Abdominal pain muscle, skin, subcutaneous tissue, and GI tract
Incidence Melena
r Peak age is 510 yr. DIFFERENTIAL DIAGNOSIS
r Girls are affected more than boys (ratio 2.3:1). PHYSICAL EXAM r Mixed connective tissue disease, scleroderma,
r Muscle: Symmetric, proximal muscle (deltoid,
r 2.54.1 cases per million children per year systemic lupus erythematosus
r Rates by race (3): quadriceps) weakness r Muscular dystrophy, Becker muscular dystrophy,
r Dermatologic:
3.4 cases per million white non-Hispanic limb-girdle muscular dystrophy, facioscapulohumeral
Heliotrope dermatitis: Reddish-purple rash of the dystrophy, spinal muscle atrophy
3.3 cases per million African American
upper eyelids, usually accompanied with r Myasthenia gravis, amyotrophic lateral sclerosis,
non-Hispanic
periorbital edema poliomyelitis, Guillain-Barre syndrome
2.7 cases per million Hispanic
Gottron papules: Erythematous, violaceous r Drug-induced myositis: Chloroquine, azathioprine,
RISK FACTORS plaques located over the bony prominences of the penicillamine, ipecac, ethanol, corticosteroids
r Strong association with HLA antigens B8/DR3, finger joints, elbows, knees, and ankles r Hypothyroidism, hyperthyroidism, Cushing syndrome
DQA1*0501 (4), HLA-DRB*0301, and DQA1*0301 Nailfold changes: Capillary dilatation and
allele (5) tortuosity
r Polymorphism of the tumor necrosis factor alpha Calcinosis:
Superficial plaques or nodules on the extremities
TREATMENT
and interleukin-1 receptor antagonist (6)
Deep muscle calcification potentially limiting PRE HOSPITAL
PATHOPHYSIOLOGY joint mobility r Assess and stabilize airway, breathing, and
r Involves activation of the cell-mediated and humoral
Linear calcification along myofascial planes circulation.
immune system, resulting in endothelial cell Subcutaneous calcium deposition of the torso r Suctioning of secretions from oral cavity if necessary
damage. The activation of cytotoxic CD8+ T cells, Skin ulceration is generally a sign of significant
macrophages, and autoantibodies against an vasculopathy. INITIAL STABILIZATION/THERAPY
unknown endothelial antigen leads to upregulation r Assess and stabilize airway, breathing, and
of the expression of major histocompatibility DIAGNOSTIC TESTS & INTERPRETATION circulation.
complex class I and II (7). Lab r Intubation and mechanical ventilation for patients
r Immune complexes are deposited, leading to Initial Lab Tests with respiratory failure or inability to protect upper
complement activation and subsequent vascular r Elevated muscle enzymes:
airway
injury and muscle inflammation. Aspartate aminotransferase r Suctioning of the oral cavity in those patients with
Aldolase dysphagia
ETIOLOGY
Creatine phosphokinase r Placement of an NG tube for gastric decompression
Unclear but proposed autoimmune vasculopathy
Lactate dehydrogenase r Intubation and mechanical ventilation for patients
provoked by a possible environmental trigger (group A r Myositis-specific antibodies seen in about 10% of
beta-hemolytic streptococci, coxsackievirus, ECHO with respiratory failure or inability to protect upper
virus, ultraviolet light) in a genetically susceptible patients:
airway
person Antisynthetase autoantibodies
Anti-Mi-2 autoantibodies
Antisignal recognition autoantibodies
r Antinuclear antibody, mainly speckled pattern,
elevated in about half of patients
r Nonspecific lab findings:
ESR may be normal or elevated
Elevated Von Willebrand factor
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DERMATOMYOSITIS
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DIABETES INSIPIDUS
Phillip Visser
Peter L. J. Barnett
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DIABETES INSIPIDUS
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DIABETIC KETOACIDOSIS
Mia L. Karamatsu
Lilit Minasyan
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DIABETIC KETOACIDOSIS
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DIAPER RASH
Solomon Behar
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DIAPER RASH
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DIARRHEA
Caroline Altergott
r Acute infectiousbacterial:
BASICS Salmonella: Initially fever (<48 hr), abdominal DIAGNOSIS
pain, and green mucoid stool may have blood.
DESCRIPTION Associated with poultry, livestock, and reptiles or HISTORY
r Diarrhea is an alteration in the normal bowel r Focus on signs of dehydration and symptoms of
ingestion of unsafe food. Increased invasive
pattern characterized by increase in water content, disease in children with diarrhea.
volume, or frequency of stools. r Dehydration: Tears, urine output, sticky saliva,
hemoglobinopathies/immune deficiency
r Can be acute (14 days), persistent (>14 and Shigella: 40 serotypes, Shigella sonnei most activity level
<30 days) or chronic (>30 days) common in the U.S. Range: Mild to severe. r Stool symptoms:
Abdominal cramps; high fever; and watery, green Color, consistency, volume, and number
EPIDEMIOLOGY Quantity of associated blood or mucus
diarrhea. 40% with bloody stools. Usually resolves
Incidence in 72 hr. Occasionally is associated with seizures Onset (acute, persistent, chronic)
r 2.6 episodes of diarrhea per year per child <5 yr r Travel history
and hemolytic uremic syndrome (HUS).
r Increased rate in children attending day care r Medications
Campylobacter: Watery diarrhea with abdominal
RISK FACTORS pain and fever; 2/3 with gross blood in stool; r Changes in diet or food intake
Infectious diarrhea: sometimes confused with appendicitis; r Associated symptoms:
r Travel to developing area immunoreactive complications (arthritis, erythema Vomiting (onset, frequency, quantity, quality)
r Ingestion of unsafe foods (raw meats, eggs, nodosum, Guillain-Barre). Abdominal pain (onset, location, degree,
Yersinia enterocolitica: Watery diarrhea usually consistency)
shellfish, unpasteurized milk or juices) mild and self-limited but can also be bloody. Older
r Swimming/Drinking untreated fresh water Systemic signs:
children can have mesenteric adenitis or Rashes, arthralgias with chronic diarrhea:
r Contact with animals known to be carriers
pseudoappendicitis syndrome. Consider IBD.
r Day care or residential facility Clostridium difficile: Pseudomembranous colitis. Dysuria, frequency, urgency: Consider urinary
r Recent antibiotic use Bloody diarrhea is associated with antibiotic use. tract infection.
r Contact with other infected individuals Escherichia coli: Altered sensorium: Severe dehydration or
Enteropathogenic (EPEC): Infantile diarrhea
GENERAL PREVENTION intussusception
Enterotoxigenic (ETEC): Travelers diarrhea
r Hand washing: The most important preventative
Enteroinvasive (EIEC): Similar to Shigella PHYSICAL EXAM
measure Enterohemorrhagic (EHEC 0157:H7): Bloody r Current and previous weight
r Rotavirus vaccine r Elevated temperature: Suspect infectious
diarrhea associated with HUS
r Typhoid vaccine: If traveling to endemic areas Vibrio cholera: Painless, voluminous diarrhea r Assess perfusion: Capillary refill, skin color, and
PATHOPHYSIOLOGY without abdominal cramps or fever. It is warm vs. cold extremities may be helpful.
r Fluid output overwhelms the absorptive capacity of associated with travel to or ingestion of food from r Tachycardia, poor skin turgor and dry mucous
the intestines. Latin America or Asia or eating raw or uncooked membranes indicate severe dehydration:
r Multifactorial: shellfish in Gulf Coast states. Skin turgor may be doughy with hypernatremia
r Parasitic: and therefore a poor marker of degree of
Secretory: Enterotoxins increase the secretion of
fluids and electrolytes from the mucosa. Entamoeba histolytica: Chronic episodic diarrhea; dehydration.
may have constipation episodes r Abdominal exam:
Osmotic: Increase in osmotic load to the bowel
lumen causes increased influx of water to the Giardia: Explosive, watery, foul-smelling stool Mass in the right upper quadrant: Intussusception
bowel lumen. Cryptosporidiosis: Immune-deficient patients with Right lower quadrant pain: Appendicitis
Inflammatory: Decreased absorption in the colon nonbloody diarrhea and abdominal pain Distension, rebound, and guarding: Peritonitis
r Malabsorption: Rectal exam for acute diarrhea:
from direct injury of the mucosa
Food allergy: Milk and soy most common Presence of blood: Food allergy or infection
ETIOLOGY Lactose deficiency: Congenital or acquired (usually Current jelly stools: Intussusception
r Acute Infectious: Viral (7080% of all infectious
after acute enteritis) Mucus in stools: Infection
diarrhea): Antibiotic use Rectal exam for chronic diarrhea:
Rotavirus: Vomiting and low-grade fever precedes Celiac disease: Intolerance to wheat gluten; Anal fistulas: Crohn disease
watery diarrhea; usually affects children 315 mo; failure to thrive with intermittent diarrhea Hard stool in vault: Overflow encopresis
26 day duration; more prevalent in winter Cystic fibrosis: Foamy, bulky, foul-smelling stools Empty vault: Hirschsprung disease
Norwalk: 12 day illness with explosive vomiting, Inflammatory bowel disease (IBD): Ulcerative
watery diarrhea, abdominal pain, and fever; colitis or Crohn disease DIAGNOSTIC TESTS & INTERPRETATION
school age; more prevalent in winter r Structural: Lab
Enterovirus: Fever and vomiting with diarrhea Intussusception Most patients with acute, nonbloody diarrhea, who
lasting days to weeks; more prevalent in summer Hirschsprung disease are well appearing and not dehydrated do not require
Encopresis: Overflow stool past obstruction any lab testing.
Short bowel syndrome
Overfeeding: Common in neonates
r Miscellaneous:
Toxins: Laxative abuse in adolescence
HUS: Several days of diarrhea followed by bloody
stools, hemolysis, and renal insufficiency
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DIARRHEA
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DIGOXIN TOXICITY
Amit K. Gupta
Mark Su
r Digoxin increases automaticity and shortens the r Serum electrolytes, magnesium, BUN, creatinine,
BASICS repolarization intervals of the atria and ventricles. glucose
r Virtually any type of dysrhythmia can occur with r Serum potassium is prognostic for dysrhythmia
DESCRIPTION toxicity, with the exception of the rapidly conduced (potassium >5.0 mEq/L).
r Digoxin is the most commonly prescribed r Assess acetaminophen and salicylate levels if
supraventricular tachydysrhythmias.
cardioactive steroid in the U.S. r Hypokalemia inhibits Na+ K+ ATPase activity and suicidal ingestion.
r Other internationally available preparations include r Urine drug screen usually is not indicated unless for
contributes to the toxicity induced by digoxin.
digitoxin, ouabain, lanatoside C, deslanoside, and r Hypomagnesemia also inhibits Na+ K+ ATPase forensic purposes such as suspected malicious intent
gitalin. activity and may result in refractory hypokalemia. or child abuse.
r Most cases of digoxin toxicity are seen in adults;
however, there is still a concern in children due to ETIOLOGY Imaging
The main causes of digoxin toxicity in the pediatric r A CT of the brain should be considered in individuals
the narrow therapeutic index and wide availability.
r Toxicity can be acute or chronic. population are: with altered mentation.
r Erroneous dosing in infants, which is usually r CXR may be performed to assess for pulmonary
r Plant sources of cardioactive steroids include
parenteral and frequently severe edema.
oleander (Nerium oleander), yellow oleander
r Unintentional ingestion in younger children Diagnostic Procedures/Other
(Thevetin peruviana), foxglove (Digitalis species), lily
r Intentional ingestion in older children and young r ECG should be performed. Sinus bradycardia and
of the valley (Convallaria maritime), dogbane
(Apocynum cannabinum), and red squill (Urginea adults, which may be the result of a suicidal attempt 1st-degree or 2nd-degree atrioventricular blocks are
maritime). more common in pediatric patients than in adults,
r Animal sources of cardioactive steroids include the COMMONLY ASSOCIATED CONDITIONS whereas ventricular ectopy is more common in
Congenital heart disease, CHF, cardiac dysrhythmia adults.
cane toad (Bufo marinus); toxicity from ingestion,
r Bidirectional ventricular tachycardia is virtually
instead of intended topical application, of a
purported aphrodisiac derived from the dried DIAGNOSIS pathognomonic for digoxin toxicity.
r Suspect digoxin toxicity with increased automaticity
secretion of this toad has been reported.
HISTORY and depressed conduction.
EPIDEMIOLOGY r Obtain history of exposure, other possible
Incidence coingestants, and events that led to exposure. DIFFERENTIAL DIAGNOSIS
r Ingestion of digoxin is often difficult to establish, r The peak effect with PO dosing is 26 hr, and that r Calcium channel blocker toxicity
and precise numbers of exposure are unknown. r Beta-blocker toxicity
with IV dosing is 530 min.
r The overall mortality rate and rate of response to r Ask parents to bring in pill bottles if possible. r Clonidine toxicity
Fab therapy in children are similar to those in adults. r Nausea and vomiting are common. r Cardiogenic shock
The mortality rate as a direct result of cardiac toxicity r Lethargy or weakness may occur. r Hemorrhagic shock
is 321%. r Visual disturbances can occur: Aberrations of color r Septic shock
r Gastroenteritis
RISK FACTORS vision, such as yellow halos around lights, scotoma,
Coingestants with other cardiotoxic agents such as blurry vision, or decreased visual acuity. r Acute MI
calcium channel blockers, beta-blockers, cyclic
antidepressants, and neuroleptics may exacerbate PHYSICAL EXAM
r Assess vital signs, with attention to cardiovascular TREATMENT
toxicity.
stability.
GENERAL PREVENTION r GI symptoms include anorexia, nausea, vomiting, PRE HOSPITAL
Poison-proofing homes and giving parents poison r Assess and stabilize airway, breathing, and
and nonspecific abdominal pain.
prevention advice is the most effective way to prevent r Lethargy, confusion, and weakness may occur with circulation.
exposure in children. r Supplemental oxygen
acute or chronic toxicity.
r Cardiovascular effects may include bradycardia. r Establishment of an IV line with cardiac monitoring
PATHOPHYSIOLOGY
r Digoxin inhibits sodium-activated and
DIAGNOSTIC TESTS & INTERPRETATION INITIAL STABILIZATION/THERAPY
potassium-activated adenosine triphosphatase r Activated charcoal (1 g/kg) may be given if the
(Na+ K+ ATPase) pump during repolarization. The Lab
Initial Lab Tests patient is protecting the airway.
result is an increase in the intracellular sodium and r Immediately assess capillary blood glucose. r Because of the enterohepatic circulation of digoxin,
calcium concentrations and a decrease in the r Digoxin level: Normal therapeutic range is 0.52.0 multiple-dose charcoal (1 g/kg/day) may be
intracellular potassium concentration. beneficial.
r Improved inotropy is due to an increased ng/mL. Always assure units reported are correct: r Syrup of ipecac is contraindicated.
concentration of cytosolic calcium ions during A 6-hr level postingestion is also recommended
systole, which increases the force of contraction of and is more representative of a postdistribution
the cardiac muscle. concentration.
r Hyperkalemia can occur with acute toxicity due to A digoxin level may be falsely elevated after
digoxin Fab fragment administration.
increased extracellular concentration.
r Digitalis also has a negative chronotropic action,
which is due to the vagal effect on the sinoatrial
node.
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DIGOXIN TOXICITY
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DIPHTHERIA
James M. Wu
Craig A. McElderry
ETIOLOGY Imaging
BASICS r C. diphtheriae: Gram-positive, aerobic pleomorphic Consider chest radiograph to evaluate for diphtheria
bacillus pneumonia, if indicated depending on the clinical
DESCRIPTION r 4 main toxin-producing strains with slight assessment.
r Diphtheria is an upper respiratory tract illness
differences in growth characteristics and toxin Pathological Findings
characterized by sore throat, low-grade fever, and production: Microscopy of the pseudomembrane will reveal fibrin
an adherent pseudomembrane of the nasopharynx, C. diphtheriae gravis: exudates, neutrophils, and colonies of C. diphtheriae.
oropharynx, and/or larynx. Most rapid growth rate
r Diphtheria can also present as primary cutaneous Most rapid and copious toxin production DIFFERENTIAL DIAGNOSIS
r Respiratory diphtheria: Most of the following can be
disease and, less commonly, vaginal, conjunctival, C. diphtheriae intermedius
and otic disease. C. diphtheriae mitis ruled out with a good clinical history of incomplete
r Disease is caused by Corynebacterium diphtheriae, a C. diphtheriae belfanti immunizations and physical exam findings of
gram-positive, aerobic, pleomorphic bacillus. gray-brown adherent membrane in nasopharynx or
oropharynx:
EPIDEMIOLOGY DIAGNOSIS Exudative pharyngitis (group A beta-hemolytic
Incidence streptococcus, Epstein-Barr virus)
r 05 cases per year in the U.S. HISTORY Acute necrotizing ulcerative gingivitis (Trench
r 0.001 cases per 100,000 in the U.S. since 1980 (1): r Respiratory diphtheria:
mouth, Vincent angina)
No data on cutaneous diphtheria, as it is not Low-grade fever Epiglottitis
reportable Sore throat Herpes simplex virus (HSV)
r Endemic in other countries where the population is Malaise Mucositis
not completely immunized: Serosanguinous nasal discharge Thrush
Recent epidemics in independent nations of the Difficulty swallowing r Cutaneous diphtheria: Lesions are relatively
former Soviet Union Respiratory distress nonspecific, and thus the differential diagnosis may
r Cutaneous diphtheria:
include a broad range of dermatologic diseases:
RISK FACTORS Generally lower extremity lesions Streptococcal or staphylococcal impetigo
Unimmunized or incompletely immunized children or History of skin lesions (eg, eczema, dermatitis), Ecthyma
adults trauma, or bruising Cutaneous TB
GENERAL PREVENTION Pain, tenderness with subsequent anesthesia Pyoderma gangrenosum
r Maintain up-to-date immunizations: (25 wk after infection) Insect bites
Immunization estimated efficacy is 97%. Erythema
Immunized patients have milder disease, but Initial vesicle or pustule with subsequent
immunization does not prevent asymptomatic ulceration and membrane formation TREATMENT
carriage of C. diphtheriae. PHYSICAL EXAM MEDICATION
r Avoid skin contact with cutaneous lesions. r Respiratory diphtheria:
Diphtheria is best treated using a 2-pronged approach
r Avoid contact with respiratory secretions. White to gray-brown membrane in nasopharynx, with antitoxin and antimicrobials (3).
r Avoid travel to endemic areas. oropharynx, tonsils, and/or larynx
r Prevention may be difficult due to asymptomatic Scraping of membrane causes bleeding. First Line
r Antitoxinneutralization of toxins and prevention
carriers. Serosanguineous nasal discharge
Cervical lymphadenitis, soft tissue swelling (bull of secondary effects:
PATHOPHYSIOLOGY neck) Available via the CDC
r Humans are the sole reservoir of C. diphtheriae. Administer as early as possible without waiting for
Low-grade fever
r Organisms are spread via respiratory droplets, direct bacteriologic confirmation.
Tachycardia
contact, and occasionally fomites. Airway obstruction Test for sensitivity to horse serum via cutaneous
r Incubation period is 27 days (2). r Cutaneous diphtheria: and then intradermal testing prior to
r C. diphtheriae colonizes, proliferates, and invades Ulceration with sharply demarcated borders
administration.
Desensitize if patient reacts.
superficial local tissues of the throat and produces Peripheral edema, erythema
Dosage is severity dependent:
exotoxins in low iron conditions. White to gray-brown membrane Cutaneous disease: 2040,000 units IV/IM 1
r Exotoxin causes local necrotic injury of epithelial
DIAGNOSTIC TESTS & INTERPRETATION Pharyngeal/Laryngeal disease <48 hr:
cells by irreversibly inhibiting protein synthesis. 2040,000 units IV/IM 1
r Pseudomembraneswhite to gray-brown adherent Lab
r Culture and PCR of specimens from nose, throat, or Nasopharyngeal disease: 4060,000 units IV/IM
membranes consisting of blood plasma, fibrin, 1
other mucosal or cutaneous lesions
epithelial cells, leukocytes, erythrocytes and r Culture on cystine-tellurite blood agar or modified Extensive disease 3 days or diffuse neck
C. diphtheriae cellsform at the areas of injury. swelling: 80120,000 units IV 1
r Toxin is absorbed and disseminated via lymph and Tinsdale agar
r If C. diphtheriae recovered, test for toxigenicity (Elek
blood, causing degenerative changes to tissues
including heart muscle, nerves, liver, kidneys, and test).
r May measure serum antibodies to diphtheria toxin
adrenals.
r Organisms are present in nasopharyngeal and r Other, if positive test results:
oropharyngeal secretions and skin lesions for Refer close patient contacts for culture and
26 wk after infection (3). treatment with empiric antibiotics.
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DIPHTHERIA
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DISCITIS
Katherine Remick
Marianne Gausche-Hill
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DISCITIS
DIFFERENTIAL DIAGNOSIS DISPOSITION 6. Offiah AC. Acute osteomyelitis, septic arthritis and
r Vertebral osteomyelitis discitis: Differences between neonates and older
Admission Criteria
r Septic arthritis of the sacroiliac joint Patients diagnosed with discitis should be managed in children. Eur J Radiol. 2006;60:221232.
r Paraspinal abscess an inpatient setting during the early stages to monitor 7. Karabouta Z, Bisbinas I, Davidson A, et al. Discitis
r Malignancy: Primary or metastatic for response to antimicrobial therapy. in toddlers: A case series and review. Acta
r Tuberculous spondylitis Issues for Referral Paediatr. 2005;94(10):15161518.
r Brucellosis r As inpatient, pediatric orthopedic or neurosurgical 8. Kayser, R, Mahlfield K, Greulich M, et al.
r Spondylolysis/Spondylolisthesis consultation is recommended. Spondylodiscitis in childhood: Results of a
r Transverse myelitis r Particular attention should be paid to evolving long-term study. Spine. 2005;30(3):318323.
r Scheuermann kyphosis neurologic deficits and the possible need for surgical 9. Arthurs OJ, Gomez AC, Set PAK. The toddler
consultation. refusing to bear weight: A revised imaging guide
and case series. Emerg Med J. 2009;26:797801.
Additional Therapies
TREATMENT Thoracolumbosacral orthosis is recommended if
r A delay in antibiotic therapy may lead to a
imaging reveals extensive bony destruction, sagittal or ADDITIONAL READING D
coronal deformity, or soft tissue involvement (4).
prolonged course, prolonged or recurrent symptoms, Cushing A. Diskitis in children. Clin Infect Dis.
and more severe infections (3,4). 1993;17:16.
r Duration of therapy should be guided by FOLLOW-UP
normalization of ESR with serial measurements,
FOLLOW-UP RECOMMENDATIONS
unrestricted passive spinal mobility, and resolution
Follow up with plain x-rays at regular intervals for CODES
of pain.
r Up to 75% of patients may have an associated 1218 mo to assess return of vertebral height (4).
ICD9
paravertebral inflammatory mass and may suggest PROGNOSIS r 722.90 Other and unspecified disc disorder of
the need for more aggressive or longer duration of r Several studies have shown the prognosis is good
unspecified region
antibiotic therapy (1). regardless of antimicrobial therapy. r 722.91 Other and unspecified disc disorder of
r In children who receive antibiotic therapy, the
cervical region
ALERT majority will have resolution of symptoms within r 722.92 Other and unspecified disc disorder of
Children with disc protrusion causing nerve root 3 wk and fewer long-term complications (3,4).
r Long term, 80% of children in 1 series were thoracic region
entrapment or the presence of paravertebral
abscess require immediate surgical consultation. asymptomatic with full mobility of the spine (8).
r Partial restoration of disc space height may be seen
MEDICATION PEARLS AND PITFALLS
r Antistaphylococcal antibiotics: as early as 23 mo following therapy. However, full
recovery of disc space height may take 13 yr (1). r Discitis is a rare cause of back pain in children but
Cefazolin (methicillin sensitive) 25100 often presents with other nonspecific symptoms.
mg/kg/day IV q6h; adult dose 12 g COMPLICATIONS r Rest and analgesia combined with
Clindamycin (methicillin resistant) 30 mg/kg/day r Chronic low back pain
r Loss of vertebral height, usually recovered within antistaphylococcal antibiotics is the mainstay of
IV q8h, max single dose 900 mg
therapy.
Vancomycin (methicillin resistant) 40 mg/kg/day 12 yr r Discitis should be considered in any child with
IV q6h, max single dose 1 g r Spinal fusion if >50% loss in vertebral height (1)
r If there is a poor response to standard antimicrobial r Limited physical activity refusal to bear weight.
r Any child with neurologic deficits should receive
therapy, further treatment should be guided by
results of PPD testing and/or biopsy (as indicated): immediate orthopedic or neurosurgical consultation.
r Poor response to antimicrobial therapy should raise
Authors vary on duration of antibiotic therapy. REFERENCES
Treatment should begin with IV antibiotics (714 the suspicion for less common infectious etiologies,
days) followed by transition to oral antibiotics 1. Brown R, Hussain M, McHugh K, et al. Discitis in the presence of a paravertebral abscess, or a
(16 mo) once the patient shows evidence of young children. J Bone Joint Surg Br. noninfectious pathology.
clinical and laboratory improvement (4,7,8). 2001;83(1):106111.
Choice of oral antibiotics depends on 2. Fernandez M, Carrol CL, Baker CJ. Discitis and
susceptibilities of the organism. vertebral osteomyelitis in children: 18 year review.
r Analgesia, rest, and immobilization: Pediatrics. 2000;105:12991304.
Acetaminophen 15 mg/kg/dose PO q4h PRN 3. Herman T, Siegel M. Thoracic discitis. Clin Pediatr.
Ibuprofen 10 mg/kg/dose PO q6h PRN 2009;48(1):120123.
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: 4. Early S, Kay R, Tolo V. Childhood diskitis. J Am Acad
Initial morphine dose of 0.1 mg/kg IV/SC may Orthop Surg. 2003;11:413420.
be repeated q1520min until pain is controlled, 5. Garron E, Viehweger E, Launay F, et al.
then q2h PRN. Nontuberculous spondylodiscitis in children.
J Pedatr Orthop. 2002;22:321328.
SURGERY/OTHER PROCEDURES
Surgical debridement is rarely indicated and should
only be performed in patients who fail to respond to
conventional therapy and demonstrate the presence of
an abscess or evolving neurologic deficits (4).
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DISLOCATION, KNEE
John Munyak
Kristopher Hunt
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DISLOCATION, KNEE
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DISLOCATION, PATELLA
John Munyak
Kristopher Hunt
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DISLOCATION, PATELLA
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Superior dislocations occur after a direct blow to a DIAGNOSTIC TESTS & INTERPRETATION
BASICS partially opened mouth: Imaging
Can result in facial nerve palsy, cerebral r Mandibular series of radiographs
DESCRIPTION contusions, or deafness r Panoramic radiographs
r The temporomandibular joint (TMJ) is comprised of r Once dislocated, the condyle stays out of the r TMJ radiographs
the articular surface lying between the mandibular temporal fossa due to spasms of the lateral r CT of mandible
condyles and the temporal bone. pterygoid and temporal muscles.
r Dislocation is defined as displacement of the Diagnostic Procedures/Other
condyle out of the mandibular fossa. ETIOLOGY Tongue blade test:
r Trauma (4099% of all TMJ dislocations)
r TMJ dislocation can result from both traumatic and r Patient attempts to grasp and hold a tongue blade
r Extreme mouth opening
nontraumatic processes. between the molars while the examiner twists the
r Most dislocations can be managed in the emergency COMMONLY ASSOCIATED CONDITIONS tongue blade to the point of breaking
department with outpatient follow-up. r Bruxism (abnormal grinding of the teeth) r Mandibular fractures can be ruled out (negative
r Anterior dislocation is most common, but posterior, r Malocclusion/Deep overbite predictive value 96%) if performed successfully (1).
lateral, and superior dislocations can also occur. r Lax ligaments r Both sides should be tested.
r Dislocations are classified as acute, chronic r Stress
DIFFERENTIAL DIAGNOSIS
recurrent, and chronic. r Rheumatoid arthritis r Mandibular fracture
r Osteoarthritis r Maxillary fracture
EPIDEMIOLOGY
r Viral infections (eg, mumps, measles) r Dystonic reaction
Prevalence
r Hypermobility syndromes
TMJ dislocations represent 3% of all dislocated joints
in the body.
TREATMENT
RISK FACTORS
r Shallow mandibular fossa
DIAGNOSIS
INITIAL STABILIZATION/THERAPY
r Previous TMJ dislocation or trauma HISTORY r Assess and stabilize airway, breathing, and
r Dystonic reactions r Jaw pain and trismus after extreme mouth opening
circulation.
r Seizures or after trauma to the jaw r Attend to life-threatening conditions 1st:
r Difficulty speaking or swallowing
r Hypermobility syndromes (eg, Marfan, TMJ dislocation is primarily a condition of
r Malocclusion
Ehlers-Danlos) morbidity.
r Prolonged dental procedures r There may be a history of previous dislocations. r Provide adequate analgesia.
r Psychiatric medications r Past medical history may include hypermobility r Reduce dislocation as rapidly as feasible.
syndromes.
GENERAL PREVENTION MEDICATION
PHYSICAL EXAM r Analgesia, sedation, and muscle relaxation may be
Avoid extreme mouth opening. r Must do a thorough exam of the head, neck, and
required for successful reduction:
PATHOPHYSIOLOGY nervous system. Procedural sedation may be necessary if the
r The dislocation is described by the position of the r Examine the oral cavity for any gingival lacerations patient is unable to cooperate.
mandibular condyle in relation to the temporal or extraoral chin lacerations, which may raise r Midazolam 0.1 mg/kg IV (max 2 mg) can be used as
articular groove: suspicion for an open fracture. a muscle relaxant.
Anterior dislocationsmost common: r Unilateral dislocations cause deviation of the jaw r Local injection of lidocaine 2%, 25 mL into the
Following direct trauma to mandible
away from the affected side. TMJ at the site of preauricular depression
Resulting from dystonic reaction or seizure r Bilateral dislocations cause an underbite or r Morphine 0.1 mg/kg IV/IM/SC q2h PRN:
Extreme mouth opening (yawning, lengthy
prognathia with pain over both TMJ areas. Initial morphine dose of 0.1 mg/kg IV/SC may be
dental procedures, general anesthesia, vomiting, r Pay special attention during the neurologic exam to
seizures, laughing, screaming, singing): The repeated q1520min until pain is controlled, then
masseter and temporalis muscles elevate the cranial nerves V and VII. q2h PRN.
r Assess hearing and inspect the external auditory r Ketorolac 0.41 mg/kg IV/IM:
mandible while the lateral pterygoid muscle is
still contracting, pulling the mandibular condyle canal, especially in suspected posterior TMJ Children >16 yr of age can be given 30 mg IV as
anteriorly out of the temporal fossa. dislocations. a single dose.
Posterior dislocations can occur after a direct blow
to the chin and may cause external auditory canal
injury.
Lateral dislocations are frequently associated with
mandibular fractures.
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MEDICATION REFERENCES
r Ondansetron for nausea/vomiting at 0.30.4 FOLLOW-UP
mg/kg/dose (adult dose 1216 mg) given by 1. Cohen BH, Shoffner J, DeBoer G. Anesthesia and
standard routes (IV or oral dissolving tablet): FOLLOW-UP RECOMMENDATIONS mitochondrial cytopathies. Available at
r Follow the management plan recommended by the http://www.umdf.org/atf/cf/%7B28038C4C-02EE-
Patients with mitochondrial disease do not
generally respond to the lower doses but generally specialist, including diet, activity, medications, and 4AD0-9DB5-D23E9D9F4D45%7D/mitoane.pdf.
respond to higher doses. cofactors:
r Give L-carnitine by oral or IV route if patient takes Adequate hydration and caloric intake are
this compound: essential. ADDITIONAL READING
r Patient/Family should contact the specialist or his or
Most patients receive 100 mg/kg/day divided r Haas RH, Parikh S, Falk MJ, et al. Mitochondrial
b.i.d. (adult dose 1 g b.i.d.) her office the following day.
r Amitriptyline is frequently used with chronic pain or r Return for: disease: A practical approach for primary care
physicians. Pediatrics. 2007;120:13261333.
other functional symptoms: Altered mental status (eg, lethargy, excessive r Parikh S, Saneto R, Falk MJ, et al. A modern
0.51 mg/kg/day qhs irritability, loss of abilities)
r In critically ill patients, an insulin drip with IV Significant vomiting
approach to the treatment of mitochondrial disease.
Curr Treat Options Neurol. 2009;11:414430.
D
dextrose (generally high concentration of both via Signs of dehydration r Wong LJ, Boles RG. Mitochondrial DNA analysis in
central access) can be lifesaving. Poor enteral intake
r Coenzyme Q10 at 5 mg/kg/dose b.i.d. (adult dose Increased urine ketones not responding to sugar clinical laboratory diagnostics. Clin Chim Acta.
solutions 2005;354:120.
200 mg b.i.d.)
r Riboflavin 100 mg/day or one B100 tablet/day Difficulty breathing
r Many patients take other cofactors including vitamin Increased weakness or pain
Other worrisome findings CODES
C (2501,000 mg/day), other antioxidants, and/or
creatine (140 mg/kg/day or 5 g/day) Patient Monitoring
r Mental status ICD9
r Urine ketones 277.87 Disorders of mitochondrial metabolism
ALERT
r Multiple medications frequently provoke adverse r Serum anion gap, if very ill
reactions in these patients:
PROGNOSIS PEARLS AND PITFALLS
Systemic corticosteroids (if absolutely needed, r Variable but generally good r Pearls:
watch ketones, can counter effect with IV r Mitochondrial disease is a chronic illness.
insulin): Avoid fasting, especially during illness and prior to
Moderate amounts of inhaled steroids are COMPLICATIONS medical/surgical procedures.
r Stroke Adverse reactions to anesthesia and many drugs
usually tolerated.
Oral and injected hormonal contraceptives r Seizures (many potential etiologies) are common.
r Liver failure GERD is very common in patients with
Valproic acid
r Surgery and anesthesia pose special risks in this r Functional bowel disorders mitochondrial disease. Frequently, GERD is
r Chronic pain syndromes misdiagnosed in these patients as asthma or
population (1): chronic sinusitis.
Avoid propofol. r Rhabdomyolysis
Urine ketone dipsticks are often effective for
Dysautonomia is common, including respiratory r Pancreatitis evaluation and monitoring.
arrest with sedative use. r Renal tubular dysfunction/acidosis: r Pitfalls:
Malignant hyperthermia precautions Rarely: Renal failure Lactic acid can be fictitiously elevated by use of a
r Cardiomyopathy tourniquet or improper specimen handling,
DISPOSITION r Apnea/Hypoventilation (especially drug related) especially in infants and toddlers.
Admission Criteria r Pancytopenia, or any element(s) thereof
r Failure to tolerate adequate caloric intake in a
r Chronic variable immunodeficiency:
patient on fasting avoidance (most are):
Especially: Line infections with sepsis
Less than half of the usual caloric intake often r Hypoglycemia
requires admission. r Any endocrinopathy (eg, hypoglycemia, diabetes,
r Serum anion gap 20 mM (sodium minus chloride
minus HCO3 ): hypothyroid, growth hormone deficiency)
r Depression, especially in adolescents
Serum anion gap 1819 is borderline.
r Large urine ketones (>40 mg/dL): r Malignant hyperthermia
r Any dysautonomia, especially tachycardia
Moderate is borderline.
r Loss of abilities, altered mental status (relative to r Multisystem failure
baseline), or new neurologic finding r Sudden death
r Pancreatitis, rhabdomyolysis, apnea, cardiac failure
Discharge Criteria
r Ability to tolerate adequate enteral intake
r Negative urine ketones
r Normal serum anion gap (<14 mM)
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DIZZINESS/VERTIGO
Steven Krebs
Faye E. Doerhoff
270
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DIZZINESS/VERTIGO
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DROWNING
Donna M. Simmons
GENERAL PREVENTION
BASICS r Supervise children at pools and at beaches. DIAGNOSIS
r Educate parents and children.
DESCRIPTION r Use secured fencing and gating around pools. HISTORY
r Drowning is an injury caused by submersion in a r Age and underlying medical problems
r Use appropriate flotation devices.
liquid and resulting in respiratory insufficiency: r Consider the use of drugs and alcohol.
r Avoid alcohol and drugs.
Ultimately, this can lead to significant morbidity or r Suspect head and spine injuries as possible causes
r Swim with a partner.
death (1). of near drowning.
r Near drowning is survival after a submersion injury. PATHOPHYSIOLOGY r Characteristic of the fluid (saltwater, freshwater,
r Secondary drowning is death due to respiratory r Panic leads to a loss of the normal breathing pattern sewage) determines risk of infection and aspiration
failure following a near-drowning event. and breath-holding as one struggles to keep above of sediment.
r Wet drowning is associated with aspiration of water. r Duration of submersion and temperature of fluid:
fluid into the lungs. r Gasping with aspiration and laryngospasm: Hypothermia is neuroprotective, and complete
r Dry drowning is asphyxia due to laryngospasm Loss of protective reflexes results in fluid recovery may occur even with prolonged
that occurs during submersion. aspiration in 85%, while persistent laryngospasm resuscitation.
r The difference between wet and dry drowning is not causes asphyxia without significant aspiration of r Timing of rescue and resuscitation efforts
clinically significant. Management is the same, and fluid in 15%. r Response to resuscitation
r Hypoxemia leads to loss of consciousness, r Associated injuries
this terminology is no longer used.
multiorgan failure, acidosis, and cardiac arrest.
EPIDEMIOLOGY r When the face is suddenly immersed in cold water, PHYSICAL EXAM
r Perform complete physical exam.
Incidence the diving reflex is thought to occur, resulting in
r There were 3,568 unintentional deaths due to r Assess for hypothermia and hypotension.
inhibition of respiration causing apnea;
drowning in the U.S. in 2006 in persons <85 yr: r Arrhythmias may occur:
vasoconstriction of blood vessels to nonessential
Of these deaths, 765 (21.4%) were children systems; and shunting of blood to the lungs, heart, Sinus bradycardia and atrial fibrillation are most
14 yr. and brain: common.
Drowning was the 2nd leading cause of Most pronounced in children relative to adults. Ventricular fibrillation and asystole may also occur.
unintentional injuryrelated death in this age Children have greater chance of surviving r Pulmonary insufficiency or respiratory distress will
group. prolonged submersion in cold water. manifest as shortness of breath or tachypnea,
r For children 4 yr, drowning was the cause of death coughing, nasal flaring, grunting, wheezing, stridor,
Resulting risk for dysrhythmia and neurologic
in 28.4% of the cases of fatal unintentional injuries. injury and/or retractions.
r The highest incidence occurs among children age r Theoretically, saltwater and freshwater drowning r Auscultation may reveal rales and wheezing with
4 yr and teens 1519 yr. will cause changes in serum electrolytes when a bronchospasm.
r Males are more likely to die from unintentional large amount of water is aspirated: r Neurologic signs include altered mental status,
drowning (2). During saltwater drowning, hypertonic saltwater confusion, lethargy, unconsciousness, and seizures.
r Children 14 yr drown most commonly in pools, and draws fluid into the lungs, leading to pulmonary
DIAGNOSTIC TESTS & INTERPRETATION
children 1 yr are more likely to drown in the edema, decreased blood volume, hypertonic
bathtub. serum, hypoxemia, and shock. Lab
r Teen drowning commonly occurs in natural bodies Freshwater drowning causes volume overload as Initial Lab Tests
r CBC, electrolytes, glucose, and renal function tests
of water with associated alcohol use (3). aspirated hypotonic water facilitates the
r Other tests should be performed to assess
r Drowning is most common in blacks (2). movement of water into the intravascular space.
r Near-drowning victims usually do not aspirate a end-organ injury and metabolic status including liver
Prevalence significant amount of fluid and do not have profile, coagulation studies, and lactate level.
The rate of unintentional drowning deaths in 2006 for r Blood gas in symptomatic patients
electrolyte imbalances.
children 14 yr was 1.26 cases per 100,000 r Loss of surfactant occurs with saltwater (dilutes
population (2). Imaging
surfactant) or freshwater (destroys surfactant): r CXR for symptomatic patients:
RISK FACTORS The resulting atelectasis and decreased lung May initially be normal or show pulmonary edema
r Children who are inadequately supervised compliance leads to V/Q mismatching, or atelectasis
r Lack of barriers around pools intrapulmonary shunting, and hypoxemia. r Consider CT scans for patients with altered mental
r Overestimating of capability to swim or inability to r Inflammatory mediators are released and may cause status or head and neck injuries.
swim pulmonary HTN and edema and result in the
r Hypothermia: Diagnostic Procedures/Other
development of acute respiratory distress syndrome r Continuous pulse oximetry
Can cause disorientation, early muscle fatigue, or (ARDS). r ECG to look for dysrhythmia
cardiac arrhythmias r CNS hypoxia and neuronal injury leads to cerebral
r Hyperventilating prior to a shallow dive lowers edema and elevated intracranial pressure (ICP), loss DIFFERENTIAL DIAGNOSIS
PaCO2 , as swimming uses oxygen and lowers PaO2. of autoregulation, and seizures. Consider other medical conditions, which may be the
The slow increase in PaCO2 delays the stimulus to r Autonomic instability may lead to HTN, tachycardia, initial inciting factor:
breathe, resulting in hypoxia, seizure, or loss of diaphoresis, agitation, muscle rigidity, r CNS injuries, cardiac arrhythmias, MI, complications
consciousness. rhabdomyolysis, and myoglobinuria. of diabetes, syncope, closed head injury, spinal cord
r Risk-taking behavior in adolescents r Cardiac dysrhythmia can develop secondary to injury, or seizures
r Impaired judgment due to drugs or alcohol hypoxia or hypothermia. Acidosis can result in
r Water sports myocardial dysfunction:
r Unexpected changes in the currents of the water, Tako-tsubo cardiomyopathy has been associated
such as rip currents in the ocean with near drowning (4).
r Underlying medical conditions: r Acute tubular necrosis from renal hypoxemia and
Cardiac arrhythmias such as congenital long QT or myoglobinuria may lead to renal failure.
familial polymorphic VT
MI, trauma
Seizures, syncope
Diabetes mellitus and hypoglycemia
Depression
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DROWNING
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DYSRYTHMIA, ATRIAL
Ameer P. Mody
Tommy Y. Kim
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DYSRYTHMIA, ATRIAL
r If hemodynamic compromise is present for SVT, Discharge Criteria 5. Sreeram N, Wren C. Supraventricular tachycardia
atrial flutter, or atrial fibrillation, proceed to r Simple, isolated PACs in asymptomatic patients with in infants: Response to initial treatment. Arch Dis
synchronized cardioversion (4): no risk factors require no additional intervention. Child. 1990;65:127129.
Synchronized cardioversion 0.51 J/kg r Patients with a known history of SVT, without 6. Kugler JD, Danford DA. Management of infants,
2 J/kg for subsequent attempts hemodynamic compromise, and structurally normal children, and adolescents with paroxysmal
Intubation/Airway protection may be required. hearts may be discharged home safely after supraventricular tachycardia. J Pediatr.
Sedation/Analgesia should be provided to awake adequate response to medical or vagal cardioversion 1996;129:324.
patients: and a period of observation: 7. Manole MD, Saladino RA. Emergency department
Decision to initiate anticoagulation prior to Discharge in consultation with a cardiologist. management of the pediatric patient with
cardioversion or after cardioversion of atrial supraventricular tachycardia. Pediatr Emerg Care.
fibrillation is best made in conjunction with a 2007;23:176118.
pediatric cardiologist. FOLLOW-UP 8. Dixon J, Foster K, Wyllie J, et al. Guidelines and
MEDICATION FOLLOW-UP RECOMMENDATIONS adenosine dosing in supraventricular tachycardia.
Arch Dis Child. 2005;90(11):11901191.
First Line
For stable SVT, adenosine is preferred (2,4,7,8):
Follow up with a pediatric cardiologist.
9. Kirk CR, Gibbs JL, Thomas R, et al. Cardiovascular
D
PROGNOSIS
r Adenosine 0.1 mg/kg (up to 6 mg) IV rapid push r 38% of children <4 mo of age and 19% of children collapse after verapamil in supraventricular
tachycardia. Arch Dis Child. 1987;62:12651266.
over 12 sec followed by a rapid 5 cc saline flush >4 mo of age initially present in heart failure (10).
r Repeat dose 0.2 mg/kg (up to 12 mg) if no response r Sudden death from SVT is uncommon in patients 10. Garson A Jr., Gillette PC, McNamara DG.
Supraventricular tachycardia in children: Clinical
to the 1st dose after 12 min; may repeat a 3rd dose with a normal structural heart.
r Use an antecubital vein or central line. r Increased risk of sudden death in patients with features, response to treatment, and long-term
r Transient asystole may occur. follow-up in 217 patients. J Pediatr. 1981;98:875.
WPW, 2.3% with a catastrophic event at 11. Russell MW, Dorostkar PC, Dick M II. Incidence of
r Contraindications to adenosine use include a presentation (11)
r The prognosis of atrial fibrillation and atrial flutter catastrophic events associated with the
deinnervated heart (eg, heart transplant), 2nd- or Wolff-Parkinson-White syndrome in young
3rd-degree heart block. depends on the underlying cardiac defect. patients: Diagnostic and therapeutic dilemma
Second Line COMPLICATIONS (abstract). Circulation. 1993;88:II484.
r In a hemodynamically stable patient with SVT who is r Atrial flutter and fibrillation can lead to atrial
unresponsive to adenosine or where adenosine is thrombus formation and subsequent risk of embolic
contraindicated: phenomena. CODES
Amiodarone 5 mg/kg IV (max 300 mg/dose) over r Untreated SVT can lead to heart failure.
2060 min, followed by a continuous infusion of r Adenosine can rarely precipitate a prolonged ICD9
10 mg/kg/day (3) OR r 427.9 Cardiac dysrhythmia, unspecified
asystole, ventricular tachycardia, atrial fibrillation,
Procainamide 15 mg/kg IV (max 100 mg/dose) and/or apnea. r 427.61 Supraventricular premature beats
over 3060 min; in children <1 yr of age, r 427.89 Other specified cardiac dysrhythmias
10 mg/kg. Follow with a continuous infusion of
50 g/kg/min (3). REFERENCES
May consider a beta-blocker such as propranolol
or esmolol in consultation with a cardiologist 1. Ko JK, Deal BJ, Strasburger JF, et al. PEARLS AND PITFALLS
Verapamil is contraindicated in infants and Supraventricular tachycardia mechanisms and r Pediatric patients can tolerate tachycardia for many
children <1 yr of age due to risk of shock and their age distribution in pediatric patients. Am J hours to days but should be treated promptly due to
cardiac arrest (9). Cardiol. 1992;69:1028. the risk of decompensation.
r If pharmacologic treatment fails, radiofrequency 2. Losek JD, Endom E, Dietrich A, et al. Adenosine r A 20 mL/kg bolus of normal saline may help
catheter ablation may be necessary. and pediatric supraventricular tachycardia in the differentiate sinus tachycardia from SVT.
emergency department: Multicenter study and r Preparation for emergent cardioversion should be
SURGERY/OTHER PROCEDURES review. Ann Emerg Med. 1999;33:185191.
For AVNRT or WPW, the accessory pathway can be made prior to administration of adenosine:
3. The International Liaison Committee on Use the largest pads or paddles that can fit on the
ablated by radiofrequency catheter.
Resuscitation (ILCOR) consensus on science with chest wall without the pads touching to minimize
DISPOSITION treatment recommendations for pediatric and transthoracic impedance.
Admission Criteria neonatal patients: Pediatric basic and advanced r Adenosine failure may be related to inadequate IV
Critical care admission criteria: life support. Pediatrics. 2006;117(5):e955e977. access, insufficient rapidity of administration, or use
r Most patients with an atrial dysrhythmia should be 4. 2005 American Heart Association (AHA) of caffeine or theophylline.
admitted to a monitored pediatric unit, preferably a guidelines for CPR and emergency cardiovascular r Consultation with a pediatric cardiologist is advised
pediatric ICU, for observation and cardiology care (ECC) of pediatric and neonatal patients: for all cases of atrial dysrhythmia.
consultation. Pediatric advanced life support. Pediatrics.
2006;117:e1005.
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DYSRYTHMIA, VENTRICULAR
Tommy Y. Kim
278
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DYSRYTHMIA, VENTRICULAR
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DYSTONIA
Katherine Remick
Patricia Padlipsky
DYSTONIA
DISPOSITION REFERENCES
TREATMENT Admission Criteria
r Patients in dystonic storms should be managed in a 1. Poston KL, Frucht SJ. Movement disorder
r The primary goals of treatment are aimed at pediatric ICU. emergencies. J Neurol. 2008;255(S4):213.
decreasing abnormal postures, decreasing pain, and r Patients with acute laryngeal dystonia should be 2. Nutt JG, Muenter MD, Aronson A, et al.
limiting contracture formation. admitted for monitoring. Epidemiology of focal and generalized dystonia in
r Primary and secondary dystonia may require chronic Rochester, Minnesota. Mov Disord.
Issues for Referral 1988;3(3):188194.
palliative management. r Any child who presents with primary or secondary
r In the case of acute dystonic reactions, the risks and 3. Sachdev P. Tardive and chronically recurrent
dystonia should be referred to a neurologist or oculogyric crises. Mov Disord. 1993;8:9397.
benefits of stopping all suspicious medications movement disorder specialist.
should be strongly considered. r Secondary causes of dystonia (eg, Wilson disease) 4. Yoshida I, Sakaguchi Y, Matsuishi T, et al. Acute
accidental overdosage of haloperidol in children.
MEDICATION may require referral to additional subspecialists Acta Paediatr. 1993;82:877880.
First Line depending upon the underlying diagnosis. 5. Defazio G, Abbruzzese G, Livrea P, et al.
r Acute dystonic reactions: Following initial treatment r A neurologist should be consulted in the emergency
Epidemiology of primary dystonia. Lancet Neurol. D
with one of the medications listed below, oral department if the etiology or diagnosis of dystonia 2004;3:673678.
anticholinergic therapy should be continued for remains unclear. 6. Schwarz CS, Bressman SB. Genetics and treatment
2 wk (especially if long-acting dopamine Additional Therapies of dystonia. Neurol Clin. 2009;27:697718.
receptorblocking agents had been used) (9): r Deep brain stimulation may be considered in cases
7. Shanker V, Bressman SB. Whats new in dystonia?
Anticholinergic agents: A prompt response to of generalized primary dystonia refractory to medical Curr Neur Neurosci Rep. 2009;9:278284.
anticholinergic medications helps to confirm the management (11): 8. Tinazzi M, Fiorio M, Fiaschi A, et al. Sensory
diagnosis: Approved for use in children 7 yr old functions in dystonia: Insights from behavioral
Trihexyphenidyl PO dosing is not well A relatively new technology that requires further studies. Mov Disord. 2009;24(10):14271436.
established in pediatrics (antiparkinsonian use to assess target populations
r Physical therapy: To help prevent the development 9. Rodnitzky, RL. Drug-induced movement disorders
medication of the antimuscarinic class).
Benztropine 0.020.05 mg/kg/dose IV or IM per in children and adolescents. Expert Opin Drug Saf.
of contractures (12) 2005;4(1):91102.
day b.i.d. r Speech and language therapy
Diphenhydramine 12 mg/kg IV or IM q6h 10. Albright AL, Ferson SS. Intraventricular baclofen
r Occupational therapy
Benzodiazepines: Diazepam and clonazepam have for dystonia: Techniques and outcomes. J
r Transcutaneous electrical nerve stimulation (TENS) Neurosurg Peds. 2009;3:1114.
been used when anticholinergic agents fail to r Sensory and motor training
provide an immediate response. 11. Marks WA, Honeycutt J, Acosta F, et al. Deep
Carbidopa/Levodopa: Treatment is initiated at a brain stimulation for pediatric movement
low-dose, 1/2 tablet (25/100 mg) b.i.d. and disorders. Semin Pediatr Neurol. 2009;16:9098.
gradually titrated to effectiveness.
FOLLOW-UP 12. Delnooz CC, Horstink MW, Tijssen MA, et al.
Botulinum neurotoxin injection: Treatment of FOLLOW-UP RECOMMENDATIONS Paramedical treatment in primary dystonia: A
choice in focal dystonia (7) r Patients who develop acute laryngeal dystonia systematic review. Mov Disord. 2009;24(15):
Baclofen: Intrathecal or intraventricular (10) should be monitored closely for recurrence. 21872198.
r Acute laryngeal dystonia: Immediate treatment with r The family should be educated regarding future
IV diphenhydramine: avoidance of offending agents if known.
Botulinum toxin injection of the vocal chords has r Movement disorder specialists should be directly ADDITIONAL READING
been used in chronic cases (1). involved in the ongoing treatment of any patient Vidailhet M, Grabli D, Roze E. Pathophysiology of
r Oculogyric dystonia: IM or IV anticholinergics. Oral
with chronic dystonia. dystonia. Curr Opin Neurol. 2009;22:406413.
clonazepam may be effective for chronic oculogyric
crises resistant to anticholinergics. PROGNOSIS
r Dystonic storm: May be resistant to all of the above r The prognosis for patients with acute dystonic
reactions is excellent if treated promptly. Immediate CODES
listed medicines
r Focal or generalized dystonia: use of anticholinergics and/or botulinum toxin
injection is lifesaving in acute laryngeal dystonia. ICD9
Anticholinergics at high doses (trihexyphenidyl) r Patients with dopa-responsive dystonia show r 333.89 Other fragments of torsion dystonia
alone or with baclofen r 333.90 Unspecified extrapyramidal disease and
r Trial with L-dopa (up to 10 mg/kg/day for 3 mo) is marked improvement following treatment with
carbidopa/levodopa. Additionally, other primary abnormal movement disorder
the 1st choice in all patients with early-onset
dystonias may also respond to treatment with r 781.0 Abnormal involuntary movements
dystonia:
levodopa.
This may also be considered in any patient with r Primary dystonias are highly variable with respect to
focal or generalized dystonia of unknown etiology,
to evaluate for dopa-responsive dystonia. treatment response and prognosis. PEARLS AND PITFALLS
r If a secondary cause of dystonia can be identified, r The prognosis of secondary dystonia varies greatly
r The onset and presentation of dystonia is highly
treatment should be directed toward the underlying depending upon the primary disease process.
variable.
disease. COMPLICATIONS r The ability to recognize acute laryngeal dystonia can
r Rhabdomyolysis be lifesaving.
Pregnancy Considerations
r Compression of the spinal cord, plexus, and r Patients who present in dystonic storms should be
It is best to avoid all antihistamines in pregnancy,
especially during the 1st trimester. peripheral nerves. managed in an intensive care setting with careful
r Scoliosis attention to the development of rhabdomyolysis.
Second Line r Limited physical function r Anticholinergics and benzodiazepines are
The combination of benzhexol, tetrabenazine, and r Medical treatment may lead to sedation, confusion, considered first-line therapy for dystonia.
pimozide has been proven effective in refractory r Consider the use of botulinum toxin, baclofen, or
dystonic storms. In severe cases, patients may require and decreased memory function.
r Deep brain stimulation with electrode placement antiparkinsonian medication early.
sedation and paralysis (1). r In refractory cases a child may benefit from sedation
can be complicated by hemorrhage, stroke,
migration, infection, and electrode malfunctions. and paralysis.
r The etiologies of secondary dystonia are diverse, and
treatment should be directed at the primary disease.
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EATING DISORDERS
Kalyani Samudra
Charles W. Pruitt
282
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EATING DISORDERS
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ECTOPIC PREGNANCY
Ilene Claudius
ETIOLOGY Imaging
BASICS Anything that delays movement of the blastocyst r Endovaginal US: Absence of gestational sac with
through the fallopian tube, allowing implantation -hCG >1,500 mIU/mL (generally 5.5 wk estimated
DESCRIPTION outside of an appropriate location in the uterus; can gestational age) indicates probable ectopic
r Ectopic pregnancy is implantation and maturation of be due to scarring or anomaly of the fallopian tube pregnancy.
the conceptus outside of the endometrial cavity. r Other US findings include free fluid (25%),
9597% are found in the fallopian tubes, while the COMMONLY ASSOCIATED CONDITIONS
1/10,0001/30,000 heterotopic pregnancies pseudogestational sac (20%), or adnexal mass.
remaining are accounted for by pregnancies in the
cornea of the uterus, ovary, cervix, and abdomen (1). (increases to 1% with fertility drug use) Diagnostic Procedures/Other
r Laparoscopy
r Rupture of ectopic pregnancy leads to internal
r Negative uterine curettage
bleeding: DIAGNOSIS r Culdocentesis yielding nonclotting blood is
Current mortality is 0.05%.
Remains a leading cause of pregnancy related HISTORY suggestive of a ruptured ectopic pregnancy.
death in the 1st trimester, accounting for 10% of r Classic triad: Abdominal pain, amenorrhea, and Pathological Findings
all pregnancy-related deaths (2) vaginal bleeding r Products of conception: Extrauterine gestational sac,
Death rates are highest in girls 1519 yr old (3). r May or may not be aware of or disclose knowledge yolk sac, or fetal parts
of pregnancy r If a dilation and curettage is performed to assist
EPIDEMIOLOGY r Typically occurs 58 wk after the last menstrual with diagnosis, frozen sections are 93% sensitive for
Incidence
period presence of chorionic villi if pregnancy is intrauterine.
100,000 cases per year r Abdominal/pelvic pain
Prevalence r 50% have a history of vaginal bleeding DIFFERENTIAL DIAGNOSIS
r Early normal intrauterine pregnancy
2% of all live pregnancies r Miscarriage
PHYSICAL EXAM
RISK FACTORS r Abdominal/pelvic tenderness (8097% of cases) r Early abnormal intrauterine pregnancy (eg, blighted
r Previous ectopic pregnancy (number 1 risk factor)
r Peritoneal signs if ruptured (tenderness, Cullen sign, ovum)
r History of pelvic inflammatory disease
r Tubal ligation or surgery etc.)
r Adnexal tenderness (7598% of cases)
r Intrauterine device use (at time of conception) r Abdominal mass (50% of cases) TREATMENT
r Congenital abnormalities r Closed cervical os on speculum exam
r Fallopian tube tumors PRE HOSPITAL
r Material passing through os, if present, will not r Address any issues related to ABCs.
r Advanced maternal age r Administer oxygen and IV fluid as needed.
contain products of conception.
r Smoking r May have paradoxical bradycardia/lack of
r In utero exposure to diethylstilbestrol INITIAL STABILIZATION/THERAPY
compensatory tachycardia if the ectopic pregnancy r Oxygen
r History of infertility increases ectopic rate ruptures and results in intraperitoneal blood r If hypovolemic due to hemorrhage, support BP with
GENERAL PREVENTION DIAGNOSTIC TESTS & INTERPRETATION normal saline or blood transfusion if necessary.
Education on STI prevention Lab
MEDICATION
PATHOPHYSIOLOGY Initial Lab Tests
r Urine -hCG (frequently positive) First Line
Conceptus implants and grows in the fallopian tube,
r Quantitative serum -hCG (rises more slowly than Analgesics if indicated
abdomen, ovary, cervix, or abdomen. As it grows, it
may present as a nonruptured mass or as a tubal intrauterine pregnancy) Second Line
r Rh type r Methotrexate (50 mg/m2 IM) can be used after
rupture.
r CBC obstetric consultation in select patients for
r Progesterone level alone is not a reliable marker of termination (5).
r Rh (D) immune globulin (RhoGAM) in Rh-negative
ectopic pregnancies. o
r Type and cross if hemodynamically unstable women: If <12 wk pregnant, 50 g IM; if 13 wk
r Check CBC, LFTs, and creatinine if methotrexate is pregnant, 300 g IM. Administer within 72 hr of
hemorrhage.
planned (4).
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ECTOPIC PREGNANCY
SURGERY/OTHER PROCEDURES Patient Monitoring 3. Mukul LV, Teal SB. Current management of ectopic
Laparoscopy/laparotomy for ruptured ectopic Return for severe abdominal pain, signs of pregnancy. Obstet Gynecol Clin North Am. 2007;
pregnancies or those who are not candidates for hemodynamic instability 34(3):403419.
methotrexate 4. Practice Committee of the American Society for
DIET
DISPOSITION If medically treated with methotrexate, avoid folic Reproductive Medicine. Medical treatment of
acidcontaining foods (eg, folate-fortified foods; ectopic pregnancy. Fertil Steril. 2008;90(Suppl 3):
Admission Criteria S206S212.
r Critical care admission criteria: green leafy vegetables; many beans, peas, and lentils;
beets; fruits such as oranges, bananas, strawberries). 5. McWilliams GD, Hill MJ, Dietrich CS. Gynecologic
Hemodynamic instability unresolved with
emergencies. Surg Clin North Am. 2008;88(2):
transfusion and/or surgery PROGNOSIS
r Other indications for floor admission: 265283.
r Risk of future ectopic pregnancies is increased by
6. Helmy S, Sawyer E, Ofili-Yebovi D, et al. Fertility
Need for surgical intervention (severe pain, 1025%. outcomes following expectant management of
hemodynamic instability, evidence of rupture, not r Chances of normal pregnancy are dependent on
tubal ectopic pregnancy. Ultrasound Obstet
eligible for medical therapy) what abnormalities contributed to the ectopic, Gynecol. 2007;30(7):988993.
Inability to ensure follow-up in candidate whether advanced maternal age or fertility issues
otherwise eligible for medical therapy existed, and the management. 1 large study showed See Also (Topic, Algorithm, Electronic
Discharge Criteria subsequent fertility rates of 83% in a group of Media Element)
r Follow-up ensured women managed expectantly and 64% in those Vaginal Bleeding During Pregnancy (<20 week
r Candidate for either medical treatment or needing managed surgically (5). gestation)
further workup
r No severe pain or evidence of rupture
COMPLICATIONS E
r Rupture leading to hemodynamic instability and/or
r Hemodynamic stability death
CODES
r Failure of medical management with methotrexate
Issues for Referral ICD9
r Patients in whom diagnosis is unclear due to a (10% risk for single-dose protocol) r 633.00 Abdominal pregnancy without intrauterine
quantitative -hCG <1,000 mIU/mL and no r Transient abdominal separation pain 37 days
pregnancy
intrauterine gestational sac should be followed in after methotrexate use, which is thought to be due r 633.10 Tubal pregnancy without intrauterine
2 days for repeat testing by an obstetrician to assess to an expanding hematoma within the fallopian
pregnancy
doubling time of -hCG. tube and is self-limited r 633.20 Ovarian pregnancy without intrauterine
r Patients receiving medical therapy with r Failure of surgical management to remove ectopic
pregnancy
methotrexate need 2-day follow-up to assess need pregnancy (520% risk with laparoscopic
for subsequent doses. salpingostomy)
PEARLS AND PITFALLS
FOLLOW-UP REFERENCES r 50% of ectopic pregnancies are missed at initial
FOLLOW-UP RECOMMENDATIONS 1. Ferentz KS, Nesbitt LS. Common problems and visit.
r Discharge instructions and medications: emergencies in the obstetric patient. Prim Care. r Not all patients with ruptured ectopic pregnancies
Follow-up within 2 days for either serial -hCG 2006;33(3):727750. have tachycardia or peritoneal signs.
testing or assessment of methotrexate 2. Chandrasekhar C. Ectopic pregnancy: A pictorial r Dont forget to administer RhoGAM if the patient is
effectiveness. review. Clin Imaging. 2008;32:468473. Rh negative.
Counsel regarding side effects of methotrexate, if
used: Nausea, stomatitis, dizziness, alopecia,
neutropenia, pneumonitis, vaginal bleeding,
increase in abdominal pain.
r Activity:
No heavy lifting
No sexual intercourse until -hCG is undetectable
No breast-feeding if methotrexate used
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ECZEMA HERPETICUM
Kyle A. Nelson
286
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ECZEMA HERPETICUM
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EDEMA
David J. Mathison
Dewesh Agrawal
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EDEMA
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ELECTRICAL INJURY
Tzvi Aaron
Nikhil B. Shah
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ELECTRICAL INJURY
DISPOSITION PROGNOSIS
TREATMENT Admission Criteria Patients with exposure to low voltage and without
r Inpatient care is required for all patients with major electrical events, prolonged unconsciousness, or
PRE HOSPITAL anything other than minor low-voltage injuries: cardiac arrest have excellent outcomes (5).
r For high-voltage incidents, the source voltage LOC or neurologic insult COMPLICATIONS
should be turned off before rescue attempt. Dysrhythmias or myocardial insult r Delayed labial artery hemorrhage
r Separate victim from source. Rhabdomyolysis/myoglobinuria or acidosis r Amputation (high-voltage injuries)
r Rescuers should be aware of scene safety and threat Trauma necessitating admission r Infection/sepsis in deep tissue injury
to bystanders or responders. Concerns of deep tissue damage or internal organ r Acute renal failure
r Approach victims of electrical injuries as both injury
r Neurologic sequelae including loss of sensation,
trauma and cardiac patients: Major burns
r Early initiation of burn and trauma care, preferably myelopathy, paraplegialike syndrome and
C-spine immobilization prior to movement
at a specialized center, is recommended. neurapraxia
Cardiopulmonary monitoring
r Assess and stabilize airway, breathing, and r Critical care admission criteria:
circulation. Patients with cardiac or respiratory arrest, LOC, REFERENCES
abnormal ECG, hypoxia or respiratory distress,
INITIAL STABILIZATION/THERAPY chest pain, myoglobinuria, acidosis, or significant 1. Wright RK, Davis JH. The investigation of electrical
r Assess and stabilize airway, breathing, and
burns or traumatic injuries should be admitted to deaths: A report of 200 fatalities. J Forensic Sci.
circulation. the ICU. 1980;25:514.
r Electrical injuries are more similar to a crush injury
Discharge Criteria 2. Kopp J, Loos B, Spilker G, et al. Correlation E
rather than a thermal injury due to potentially r Healthy children with household current exposures between serum creatinine kinase levels and extent
extensive deep tissue damage in the absence of of muscle damage in electrical burns. Burns.
significant cutaneous injury. who are asymptomatic can be safely discharged
r Resuscitation as per Advanced Trauma Life Support after 4 hr of observation (3). 2004;30(7):680683.
r Minor burns (including oral burns) or patients with 3. Chen EH, Sareen A. Do children require ECG
(ATLS) and Pediatric Advanced Life Support (PALS) evaluation and inpatient telemetry after household
protocols: mild symptoms can be observed for several hours
and discharged if symptoms resolve and there is no electrical exposures? Ann Emerg Med. 2007;49(1):
Cardiopulmonary monitoring: 6467.
Cardiac medications as needed for arrhythmias elevation in CK or myoglobinuria.
4. Pizano LR, Corallo JP, Davies J. Nonoperative
IV hydration with normal saline or lactated Issues for Referral
r Consider additional consultations with management of pediatric burn injuries. J Craniofac
Ringer:
Reduces morbidity in severe burns Surg. 2008;19(4):877881.
trauma/critical care, orthopedics, plastic surgery,
Prevents renal failure ophthalmology, and general surgery, depending on 5. Garcia CT, Smith GA, Cohen DM, et al. Electrical
Large volumes may be required due to the type and severity of traumatic injuries. injuries in a pediatric emergency department. Ann
significant 3rd spacing r Oral or plastic surgeons should evaluate children Emerg Med. 1995;26(5):604608.
Sodium bicarbonate 50 mEq/L (1 ampule per with oral burns. 6. Gronert GA. Succinylcholine-induced hyperkalemia
liter) to alkalinize the urine (pH 7.5) to increase and beyond. Anesthesiology. 2009;111(6):
rate of myoglobin clearance COMPLEMENTARY & ALTERNATIVE 13721377.
Adequate tissue perfusion, vital signs, and urine THERAPIES
r Burn care should include tetanus immunization as
output should guide fluid resuscitation.
Place Foley catheter and maintain urine output indicated. ADDITIONAL READING
r Prophylactic antibiotics are not routinely
0.52 mL/kg/hr, depending on degree of Bailey B, Gaudreault P, Thivierge RL. Experience with
myoglobinuria. recommended (4).
r Oral burns can be splinted to prevent microstomia guidelines for cardiac monitoring after electrical
Immobilize fractures and dislocations. injuries in children. Am J Emerg Med. 2000;18:
Hourly vascular checks for palpable or audible and hold commissure at constant tension. 671675.
Doppler pulses for extremity burns r Splint injured extremities in functional position as
r Adequate pain control indicated.
r Essential tests: r Physical and occupational therapy should be CODES
Cardiopulmonary monitoring: instituted early.
Arrhythmia after electrical injury ranges from ICD9
benign (15%) to fatal. r 994.0 Effects of lightning
Most common fatal arrhythmia is ventricular FOLLOW-UP r 994.8 Electrocution and nonfatal effects of electric
fibrillation (from AC); asystole (from FOLLOW-UP RECOMMENDATIONS current
high-voltage or DC) may also occur r Discharged patients should follow up with a primary
MEDICATION care physician in 2448 hr.
r Discharge instructions and medications: PEARLS AND PITFALLS
First Line
r Morphine 0.1 mg/kg IV/IM/SC q2h PRN: Continue hydration and monitor urine output. r Succcinylcholine is contraindicated in electrical injury
Initial morphine dose of 0.1 mg/kg IV/SC may be Observe for any new bleeding with oral burns.
Analgesics due to risk of hyperkalemia (6).
repeated q1520min until pain is controlled, then r Extensive deep tissue damage may be present
q2h PRN. Awareness of possible long-term neurologic or
r Fentanyl 12 g/kg IV q2h PRN: ocular effects. Follow up as indicated. despite minimal cutaneous injury.
r Severe morbidity is possible after initial period with
Initial dose of 1 g/kg IV may be repeated Physical and occupational therapy as needed
Appropriate follow-up with specialists minimal or no symptoms.
q1520min until pain controlled, then q2h PRN
r Codeine/acetaminophen dosed as 0.51 mg/kg of Patient Monitoring
codeine component PO q4h PRN Immediate re-evaluation is necessary for:
r Tetanus prophylaxis r Decreased urine output
r Change in mental status
Second Line
Furosemide (0.5 mg/kg IV) or mannitol r Chest pain or palpitations
(0.250.5 mg/kg IV) for myoglobin clearance r Bleeding or neurologic deficits
r Respiratory distress
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EMERGENCY CONTRACEPTION
Janet Semple-Hess
ETIOLOGY
BASICS r Vaginal intercourse without contraception
r Failure of contraception:
TREATMENT
DESCRIPTION Condom breakage PRE HOSPITAL
r Emergency contraception is the use of either
Displacement of diaphragm, hormone patch, or Stabilization of injuries or bleeding for the sexual
combination oral contraceptives (COC), copper IUD assault patient
progestin-only pills, or an intrauterine device (copper Missed OCP for 3 days
IUD) postcoitally to prevent pregnancy. INITIAL STABILIZATION/THERAPY
Being 2 wk late for Depo-Provera injection
r Although levonorgestrel (Plan B) is the simplest and Stabilize injuries/bleeding for sexual assault patient
is well tolerated, 20 other brands of oral COMMONLY ASSOCIATED CONDITIONS
MEDICATION
contraceptives are approved for use for emergency Sexually transmitted infections
First Line
contraception. r Levonorgestrel comes in 2 dose regimens:
r Use of emergency contraception may reduce the risk
DIAGNOSIS Plan B: 1.5 mg single dose within 3 days of coitus
of pregnancy by: Levonorgestrel (generic): 0.75 mg, 2 pills once
7589% with oral contraceptive pills (OCPs) (1) HISTORY only, given within 72 hr of coitus (some authors
99% with a copper IUD (2) r Identify time of unprotected coitus.
extend to 120 hr)
r Background: r Date of last menstrual period Antiemetics are generally not needed with
Median age of first intercourse in the U.S. is 16 yr. r Confirm consensual nature of coitus or levonorgestrel.
900,000 girls and women ages 1219 yr will circumstances of sexual assault. If patient vomits within 1 hr of dose, this is
become pregnant each year in the U.S. r Inquire about other symptoms. considered a missed dose. Administer antiemetic
90% of adolescent pregnancies are unintended: and readminister dose.
35% end in abortion. PHYSICAL EXAM r Numerous other contraceptive pills may be used.
r Pelvic exam for STIs or for injuries if sexually
The following is a partial list of medications for this
ALERT assaulted
r Pelvic exam and Pap smear are not required prior to purpose; 2 doses 12 hr apart are necessary:
Contraception counseling should include a
Alesse: 5 pink pills
discussion of safe sex, future contraception, and STI emergency contraception use. Cryselle: 4 white pills
and HIV prevention. r Pelvic exam is required for copper IUD placement.
Enpresse: 4 orange pills
r Copper IUD as emergency contraception may be Jolessa: 4 pink pills
PATHOPHYSIOLOGY contraindicated if concurrent STI is suspected. Levlen: 4 light orange pills
The exact mechanism of action of the Yuzpe method, Levora: 4 white pills
first described in 1974 (then with ethinyl DIAGNOSTIC TESTS & INTERPRETATION
Lo/Ovral: 4 white pills
estradiol/levonorgestrel) is unknown and may depend Lab Low-Ogestrel: 4 white pills
r Pregnancy testing is typically obtained in all cases. If
upon the stage of the menstrual cycle at the time Nordette: 4 light orange pills
given: the patient is pregnant, no emergency contraception
Ogestrel: 2 white pills
r May inhibit ovulation, interfere with fertilization, or is used.
Ovral: 2 white pills
r Pregnancy test is required prior to copper IUD
prevent implantation Ovrette: 20 yellow pills
r Emergency contraception with OCPs does not insertion. Quasense: 4 white pills
r STI screening, HIV testing, and hepatitis B testing,
terminate an implanted fertilized ovum or fetus. Seasonique: 4 blue-green pills
r Copper IUD interferes with implantation, which especially if sexual assault has occurred, are Tri-Levlen: 4 yellow pills
preferred but not required to give OCPs as Triphasil: 4 yellow pills
occurs between days 6 and12 after ovulation.
emergency contraception.
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EMERGENCY CONTRACEPTION
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EMPYEMA
Todd P. Chang
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EMPYEMA
r In patients suspected of having TB empyema, such r It is unclear if thoracotomy should be the initial REFERENCES
as recent immigrants or those with recent travel to therapy or if surgical treatment should be reserved
an endemic area, appropriate airborne precautions for children for whom medical management has 1. Buckingham SC, King MD, Miller ML. Incidence and
should also be taken. failed. etiologies of complicated parapneumonic effusions
r Open thoracotomy: Now relatively rare in children, 1996 to 2001. Pediatr Infect Dis J.
MEDICATION r Video-assisted thorascopic surgery (VATS): 2003;22(6):499504.
r Parenteral antibiotic therapy should be started as
VATS has better postoperative and cosmetic 2. Clark JE. Empyema. In Finn A, Curtis N, Pollard AJ,
soon as possible, although in stable patients this eds. Hot Topics in Infection and Immunity in
may be delayed if pleural fluid will be procured. results than open thoracotomy.
r Intrapleural fibrinolytic therapy: Children V. Vol. 634. New York, NY: Springer;
Doing so can increase the yield on pleural cultures. 2009.
r S. aureus and S. pneumoniae are the most common Tissue plasminogen activator, streptokinase, or
urokinase may be infused into the chest tube to 3. Brook I. Microbiology of empyema in children and
pathogens. However, coverage of MRSA and adolescents. Pediatrics. 1990;85:722726.
Gram-negative species is recommended: disrupt the fibrinopurulent mass.
r Fibrinolytics may prevent operative therapy, though 4. Cameron R, Davies HR. Intra-pleural fibrinolytic
Vancomycin 1015 mg/kg/dose IV q6h (adult max
operative therapy may still be required after therapy versus conservative management in the
1,000 mg/dose) PLUS
intrapleural fibrinolytics. treatment of pediatric pleural effusions and
Ceftriaxone 50 mg/kg/dose IV q8h (adult max
2,000 mg/dose) r Antibiotic-only therapy empyema. Cochrane Database Syst Rev. 2008;(2):
r If anaerobes or P. aeruginosa are suspected due to cd002312.
DISPOSITION 5. Coote N. Surgical versus non-surgical management
lung abscess or aspiration pneumonia:
Admission Criteria of pleural empyema. Cochrane Database Syst Rev.
SUBSTITUTE ceftriaxone with
piperacillin/tazobactam 100 mg/kg/dose IV q8h
r A child in no distress with a small empyema may not 2005;(2):cd001956. E
need admission if follow-up is assured within 12
(adult max 3,000 mg/dose)
days. Otherwise, most patients with empyema are
Consider an aminoglycoside to broaden coverage ADDITIONAL READING
admitted.
for P. aeruginosa. r The admitting hospital should have a surgery team
r For penicillin/cephalosporin allergy: Vancomycin plus r Baldwin S, Terndrup TE. Thoracostomy and related
comfortable with pediatric empyema.
meropenem 20 mg/kg/dose IV q8h (adult max r Critical care admission criteria: procedures. In King C, Henretig FM, eds. Textbook
1,000 mg/dose) of Pediatric Emergency Procedures. 2nd ed.
r If TB is suspected, contact your local infectious Sepsis, unstable vital signs, mechanically Philadelphia, PA: Lippincott Williams & Wilkins;
ventilated patients, and other severely ill patients 2008.
disease authority or the Centers for Disease Control
and Prevention prior to triple therapy:
should be admitted to an ICU. r Wheeler JG, Jacobs RF. Pleural effusions and
Isoniazid 1015 mg/kg/dose PO qd (adult max Discharge Criteria empyema. In Feigin RD, Cherry JD, Demmler GJ,
300 mg/dose) PLUS r Generally, patients with empyema are admitted and et al., eds. Textbook of Pediatric Infectious Diseases.
Rifampin 1020 mg/kg/dose PO qd (adult max not discharged from the emergency department. 5th ed. Philadelphia, PA: Saunders; 2004.
600 mg/dose) PLUS r However, a very small empyema may be observed as
Pyrazinamide 2040 mg/kg/dose PO qd (adult an outpatient in a select few stable patients.
max 2,000 mg/dose) CODES
SURGERY/OTHER PROCEDURES FOLLOW-UP
r No one treatment modality is universally superior to ICD9
any other treatment (4,5). FOLLOW-UP RECOMMENDATIONS 510.9 Empyema without mention of fistula
r Thoracentesis: r Parenteral antibiotics should be continued even with
This procedure can be recommended for patients surgical intervention.
with stage I parapneumonic effusions for r The patient should be followed for any worsening of PEARLS AND PITFALLS
symptomatic relief and diagnosis. the empyema. r Consider empyema in a patient with signs and
Repeated thoracenteses may be required. Patient Monitoring symptoms of pneumonia
r Chest tube thoracotomy: r Fevers >72 hr in duration with appropriate r Consider empyema if a large pneumonia
This may be performed in the emergency antibiotic treatment warrant surgical drainage. r Consider the airway when sedating a child for
department to drain a stage I or II empyema. r Serial CXRs empyema drainage
It should be considered for patients with r Serial CBC, CRP, and ESR r Large empyema or loculated empyema warrants
significant respiratory distress or significant
more aggressive management.
amount of effusion on imaging studies. PROGNOSIS
Because the drainage for empyema is likely Patients who have early recognition and treatment for
viscous, empyema chest tube sizes should be of empyema do well, and the majority will return to
adequate caliber. normal function.
COMPLICATIONS
r Restrictive lung disease
Age Weight Tube Size (French)
r Airway compromise
Neonate <5 kg 812 r Thoracentesis and chest tube complications include
01 yr 510 kg 1014
pneumothorax, hemothorax, infection, or damage to
12 yr 1015 kg 1420 mediastinal structures.
25 yr 1520 kg 2024 r Fibrinolytic complications involve bleeding either
510 yr 2030 kg 2028 locally or elsewhere in the thorax.
r Operative complications can also occur with both
>10 yr 3050 kg 2840
Adult >50 kg 3240 VATS and open thoracotomy.
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ENCEPHALITIS
Todd P. Chang
296
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ENCEPHALITIS
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ENDOMETRIOSIS
Jeranil Nunez
298
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ENDOMETRIOSIS
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DIAGNOSTIC TESTS & INTERPRETATION r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN COMPLICATIONS
r 1:1,000 epinephrine for anaphylaxis dosed at r Cellulitis, impetigo
Lab
Initial Lab Tests 0.01 mg/kg (max 0.3 mg/dose) IM repeated q5min r Corneal abrasions
r There are no routinely indicated lab tests. PRN for anaphylaxis r Patients with comorbidities are at risk for
r Serum tryptase levels may be helpful in follow-up in r Prednisone 12 mg/kg PO/IM/IV per day uncommon sequelae (ie, patients with coronary
diagnosing allergic reactions when there is r Dexamethasone 0.150.5 mg/kg IV/SC/PO, max artery disease are at increased for MI) such as MI,
uncertainty. single dose 10 mg acute tubular necrosis, or multiorgan failure.
r Albuterol 0.1 mg/kg up to 2.5 mg/dose in 3 mL r Anaphylactic reactions may result in shock,
DIFFERENTIAL DIAGNOSIS
r Food/Environmental allergy, food syndrome (eg, saline by nebulizer q15min multisystem organ failure, or death.
scombroid) trauma from sharp objects, and insect or Second Line
other bite/sting r For refractory hypotension during anaphylaxis,
r Altered mental status: Head trauma, CNS infection,
ADDITIONAL READING
titrate IV epinephrine 1:10,000 to appropriate BP
hypoglycemia, metabolic or electrolyte disturbance r Consider glucagon (2030 g/kg bolus, then r Hahn IH, Lewin NA. Arthropods. In Goldfrank LR,
515 g/min) for epinephrine-resistant Flomenbaum NE, Lewin NA, et al., eds. Goldfranks
hypotension. Toxicologic Emergencies. 8th ed. Stamford, CT:
TREATMENT Appleton & Lange; 2006:16291642.
DISPOSITION r Moffitt JE. Allergic reactions to insect stings and
PRE HOSPITAL Admission Criteria bites. South Med J. 2003;96(11):1073.
Assess and stabilize airway, breathing, and r Consider admission for patients with anaphylactic
circulation: reactions that are severe, even if symptoms are See Also (Topic, Algorithm, Electronic E
r If anaphylactic reaction, administer epinephrine controlled with medications in the emergency Media Element)
department. r Anaphylaxis
and/or albuterol as per local protocol.
r Critical care admission criteria: r Cellulitis
INITIAL STABILIZATION/THERAPY Persistence of unstable vital signs, anaphylaxis r Rash, Urticaria
r Assess and stabilize airway, breathing, and
requiring epinephrine infusion, or airway
circulation. compromise
r Pain control and local wound care are the mainstays
Discharge Criteria CODES
of treatment. r Most patients may be discharged home.
r Retained stingers (eg, honey bees) or embedded
r Patients with generalized symptoms that resolve ICD9
hairs should be removed.
r Treatment of anaphylaxis and severe systemic should always be observed for 46 hr in the 989.5 Toxic effect of venom
toxicity are similar. emergency department:
Patients presenting with respiratory distress or
MEDICATION anaphylaxis should be admitted. PEARLS AND PITFALLS
First Line Issues for Referral r Avoid granuloma formation by considering stingers
r Itching: r Allergist: Patients with anaphylaxis or generalized as foreign bodies that must be removed.
Diphenhydramine 1 mg/kg PO/IM/IV q6h PRN reactions for further testing and immunotherapy r Children will often scratch injuries, which may lead
Nonsedating antihistamines such as loratadine r Ophthalmologist: Patients with eye complaints to bacterial infections; consider topical antibiotic
510 mg per day. These are less sedating but also prophylaxis with diffuse stings, or at the very least,
less effective than diphenhydramine. schedule follow-up with a pediatrician.
Topical anesthetic lotions may contain a variety of FOLLOW-UP r It is a common pitfall to underestimate the severity
substances, such as benzocaine, ammonia, baking
FOLLOW-UP RECOMMENDATIONS of an anaphylactic reaction. Carefully assess the
soda, and essential oils.
r Topical steroids: Discharge instructions and medications: airway and cardiovascular status, give IM
r Patients with anaphylaxis should be provided with epinephrine early, and reassess the patient
Hydrocortisone 12.5% cream/ointment topical frequently.
b.i.d.q.i.d. appropriately dosed epinephrine autoinjectors in r Failure to provide an epi-pen is a frequent source of
Triamcinolone 0.1% cream topical b.i.d. addition to 35 days of oral steroids and
litigation.
Mometasone 0.1% cream/ointment topical per antihistamines.
day
r Analgesia: PROGNOSIS
Most patients recover without complications within
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN days.
Ketorolac 0.5 mg/kg IV/IM q6h PRN
Naproxen 5 mg/kg PO q8h PRN
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ENVENOMATION, MARINE
Mohan Punja
Robert J. Hoffman
Catfish: Dorsal and pectoral fins contain spines r Tiny spicules may be visible within an abrasion.
BASICS causing self-limited local irritation and pain, r Linear papules or beaded streaks in a whip mark
typically to patients attempting to handle without pattern may be seen with the Portuguese
DESCRIPTION gloves. Man-of-War.
r Marine creatures may cause injury by envenomation, Exotic fish: r Pruritic lesions occurring under clothing in the
trauma, or ingestion. Stone fish: Native Australian fish kept as pets. distribution of swimming trunks or clothes are seen
r Injury by envenomation is extremely common, Highly toxic venom causes smooth and skeletal with sea bathers eruption.
especially in coastal areas and specific parts of the muscle paralysis. Locate antivenin (1 vial/sting)
world (eg, Australia); organisms found in and via a poison control center. DIAGNOSTIC TESTS & INTERPRETATION
around North America are generally less toxic. Lion fish: An exotic, colorful pet fish commonly Lab
r Children may be unable to describe the specific causing mild, self-limited but painful Initial Lab Tests
envenomation by heat-labile toxin. r There are no routinely indicated lab tests.
offending organism, increasing the difficulty of
directing treatment. r Echinoderms: Sea urchins or starfish have hard, r CBC, basic metabolic panel, LFTs, and coagulation
r Dead organisms washed ashore may cause injury to brittle spines filled with venom that may break off studies in patients who appear systemically ill
children playing in sand. and lodge in skin. The animal is not itself venomous, Imaging
but the spines may be coated with a heat-labile r Plain films are indicated in evaluating for
EPIDEMIOLOGY toxin. radiopaque retained foreign bodies such as the barb
Incidence r Sponges: Stationary animals attached to the
of a stingray.
Injuries are extremely common, and the incidence seafloor or coral; they penetrate the skin with tiny r Advanced imaging (or surgical exploration) for
varies widely depending on location: spicules to cause a contact dermatitis and a delayed
r Cnidarians, which include jellyfish and fire coral, are penetrating trauma
irritant dermatitis.
responsible for most envenomations. r Coral, particularly fire coral, may cause a very DIFFERENTIAL DIAGNOSIS
r 2008 poison center data reported 785 jellyfish painful sting. This is distinct from a cut or abrasion, Sunburn, trauma from sharp objects, insect or other
stings, 1/2 of which occurred in patients <19 yr of which often will become infected and ulcerate bite/sting
age. The numbers of unreported envenomations are within days of the injury.
likely dramatically higher.
ETIOLOGY TREATMENT
RISK FACTORS See Pathophysiology.
Injuries are concentrated during warm months; PRE HOSPITAL
occasionally, mass numbers of injuries may occur at a Decontamination: The patient should be separated
single location. DIAGNOSIS from the offending organism, and the area should be
irrigated with saline or saltwater:
GENERAL PREVENTION HISTORY r Vinegar or 5% acetic acid can be doused on the
r Children should wear protective footwear at the r The patient may be able to identify the specific
beach and protective clothes/wetsuits. organism after an obvious bite or sting. wound, or compresses soaked in a solution can be
r Parents should be aware of posted warnings r Patients may report reaching into an aquarium or applied.
r Hot water is known to deactivate specific venoms
concerning infestations or local wildlife. attempting to handle pet fish, etc.
r Patients often report immediate local effects such as (scorpion fish, lionfish, stonefish, sea urchins or sea
PATHOPHYSIOLOGY stars, stingrays and skates). Water must be around
r The mechanism of injury varies widely depending on stinging, itching, paresthesias, and exquisite pain.
r Large numbers of patients from the same location 45 C, and the involved area should be immersed for
the organism involved. 3060 min. Take care not to scald patients.
r Jellyfish (including the Portuguese Man-of-War): may be due to an infestation of jellyfish. r Urinating on the wound for the purpose of applying
r Intensely pruritic lesions occurring diffusely under
Tentacles of jellyfish have stinging cells that inject warm liquid against the skin is an unproven folk
venom that may be myotoxic, neurotoxic, or even clothing may be sea bathers eruption, a remedy to treat heat-labile toxins:
cardiotoxic. Local adverse reactions are common; hypersensitivity reaction to the larval form of thimble We do not recommend such use, but it may be an
anaphylaxis is rare. jellyfish. option if no medical care or source of hot water is
r Fish: r Nausea, vomiting, and abdominal pain may be from
available to irrigate the wound.
Stingrays or skates: Tail contains a barb that can the systemic effects of venom. r Generally, animals causing puncture wounds are
cause significant penetrating trauma in addition to r Stridor, syncope, and difficulty breathing may signal
treated with hot water, while those causing urticaria
significant localized pain and mild systemic anaphylaxis. and vesicular eruptions are treated with vinegar.
toxicity from venom, which is heat labile. PHYSICAL EXAM r Use a flexible straight edge, such as a credit card or
These organisms typically must be directly stepped r Erythema, blistering, vesicles, and urticaria often driving license, to scrape adherent tentacles from
on to cause injury to a human. appear at the site of contact with the offending the skin.
organism. r Antibiotics for patients presenting with signs and
r Generalized edema of the affected extremity symptoms of infection from injuries in salt or
r In the case of stingrays, a visible barb may be brackish water should cover gram-negative rods
present in addition to gaping lacerations or only a such as Vibrio vulnificus.
small puncture wound. r Patients with nonhealing lesions or granulomas may
need extended therapy for Mycobacterium marinum
infection.
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ENVENOMATION, MARINE
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ENVENOMATION, SCORPION
Frank LoVecchio
r Somatic effects
BASICS DIAGNOSIS Involuntary muscle contractions
Restlessness
DESCRIPTION HISTORY r Cranial nerve effects:
r Scorpion venom is neurotoxic. r Usually a history of scorpion exposure and sting are
Roving eye movements
r Autonomic, somatic, and cranial nerve excitation readily available. Blurred vision
r Particularly in toddlers or nonverbal children, history
occurs. Nystagmus
r Symptoms begin within minutes of sting. of exposure might not be known. Tongue fasciculations
r Symptoms persist 172 hr. r These cases may be particularly difficult.
Loss of pharyngeal muscle control
r Local effects: r Grading of envenomation exists:
EPIDEMIOLOGY Pain Grade I: Local pain and/or paresthesias at site
Incidence Hyperesthesia Grade II: Local pain and pain and/or paresthesias
In 2007, 5,629 scorpion stings in patients <19 yr of r Systemic effects: at a remote site
age were reported in the U.S.: Coughing or dyspnea Grade III: Either cranial/autonomic or somatic
r Including 1 fatality in a 2-yr-old child Neurologic: skeletal neuromuscular dysfunction
Altered mental status Grade IV: Both cranial/autonomic and somatic
PATHOPHYSIOLOGY Agitation
r Scorpion venom is neurotoxic. skeletal muscle dysfunction
r Autonomic, somatic, and cranial nerve excitation Involuntary muscle contractions
Blurred vision DIAGNOSTIC TESTS & INTERPRETATION
occurs. Seizure Lab
r The mechanism of action is caused by prolonged
Agitation Initial Lab Tests
opening of sodium channels. Hypersalivation r Grade I and II envenomations:
r In children, envenomation may result in severe None
illness, with altered behavior, excitation, and PHYSICAL EXAM r Grade III and IV envenomations:
r Assess vital signs.
seizures. BUN, creatinine
r Onset occurs within minutes and progresses to r A variety of abnormalities may result:
Electrolytes
maximum severity in about 12 hr but may persist Tachycardia is typical, but bradycardia may occur. Urinalysis
for up to 4872 hr. HTN initially but hypotension later during severe CBC
toxicity r Severely agitated patients:
ETIOLOGY Hyperthermia
r Centruroides sculpturatus, or bark scorpion: r Local tissue effects: Creatine kinase
Urine myoglobin
The only toxic scorpion species in the U.S. Lack of erythema r Severe respiratory distress:
Found in the southern U.S., Mexico, Central Pain
America, and the Caribbean Blood gas analysis
Hyperesthesia
r Many other species in Asia, Africa, Israel, South r Autonomic effects: Imaging
America, and the Middle East r Chest radiograph for respiratory symptoms
Sympathetic symptoms:
Pulmonary edema r ECG for tachycardia
Agitation Diagnostic Procedures/Other
Perspiration ECG in grade II and greater
Parasympathetic effects:
Hypersalivation DIFFERENTIAL DIAGNOSIS
r Snake, spider, insect envenomation
r Tetanus
r Diphtheria
r Botulism
r Overdose, dystonic reaction
r Seizures
r Infections
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ENVENOMATION, SCORPION
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ENVENOMATION, SNAKE
Dean Olsen
306
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ENVENOMATION, SNAKE
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ENVENOMATION, SPIDER
Sophia Sheikh
Brent W. Morgan
308
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ENVENOMATION, SPIDER
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SURGERY/OTHER PROCEDURES 4. Knight PJ, Vassey LE. The diagnosis and treatment
TREATMENT Surgical indications: of the acute scrotum in children and adolescents.
r Scrotal abscess Ann Surg. 1984;200:664673.
INITIAL STABILIZATION/THERAPY r Inability to exclude testicular torsion 5. Nussbaum Blask AR, Bulas D, Shalaby-Rana E,
IV access and fluids if systemically ill r Suspected or proven ischemia caused by severe et al. Color Doppler sonography and scintigraphy of
epididymitis the testis: A prospective, comparative analysis in
MEDICATION
r Neonatal epididymitis: children with acute scrotal pain. Pediatr Emerg
DISPOSITION Care. 2002;18:6771.
Initial antimicrobial therapy directed against
Admission Criteria 6. Yin S, Trainor JL. Diagnosis and management of
uropathogens such as E. coli, E. faecalis: r Toxic appearance
If Gram stain suggests E. coli, consider testicular torsion, torsion of the appendix testis, and
r Scrotal abscess epididymitis. Clin Pediatr Emerg Med. 2009;10:
3rd-generation cephalosporin such as r Infectious epididymo-orchitis that is severe or
cefotaxime (50 mg/kg/dose IV q8h) 3844.
If Gram stain suggests E. faecalis, consider requires systemic antibiotics, such as brucellosis 7. Al-Taheini KM, Pike J, Leonard M. Acute
ampicillin (50 mg/kg/dose IV q6h) plus Discharge Criteria epididymitis in children: The role of radiologic
aminoglycoside, such as gentamicin r Ability to take oral antibiotics studies. Urology. 2008;71:826829.
(2.5 mg/kg/dose IV q8h) r Well-appearing without scrotal abscess
r Nonbacterial epididymitis in prepubertal boys
(culture negative):
ADDITIONAL READING
FOLLOW-UP r Berger RE. Acute epididymitis. In Holmes KK, Mardh
Consider NSAID medication in anticipation of
prolonged pain and inflammation PA, Sparling PF, eds. Sexually Transmitted Diseases.
E
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN FOLLOW-UP RECOMMENDATIONS
r Bed rest: 2nd ed. New York, NY: McGraw-Hill. 1990:
Ketorolac 0.5 mg/kg IV/IM q6h PRN 641651.
Naproxen 5 mg/kg PO q8h PRN Scrotal support with elevation r Shortliffe LM. Infection and inflammation of the
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: Follow up with urology.
r Failure of symptoms to improve within 3 days pediatric genitourinary tract. In Wein AJ, Kavoussi
Initial morphine dose of 0.1 mg/kg IV/SC may LR, Novick AC, et al., eds. Campbell-Walsh Urology.
be repeated q1520min until pain is controlled, requires re-evaluation and possible hospitalization.
9th ed. Philadelphia, PA: Saunders; 2007.
then q2h PRN. Patient Monitoring
Codeine or codeine/acetaminophen dosed as r Follow up with urology for adjunctive imaging: See Also (Topic, Algorithm, Electronic
0.51 mg/kg of codeine component PO q4h PRN Renal and bladder US and voiding cystourethrogram Media Element)
r Epididymitis in prepubertal boys (urinalysis positive): r Scrotal Pain
(VCUG).
r Neonates and infants diagnosed with epididymitis r Scrotal Swelling
Specific antimicrobial agents are dependent on
regional susceptibilities: r Testicular Torsion
have a higher rate of anatomic abnormalities (6).
Cephalexin 2550 mg/kg/day PO divided r Given the low yield of abnormal findings in older
q6hours 10 days patients with a 1st episode of culture-negative
Sulfamethoxazole/Trimethoprim (based on epididymitis, consider selective use of VCUG CODES
612 mg/kg trimethoprim component) divided evaluation after US (7).
q12h 10 days ICD9
Amoxicillin and clavulanic acid 2040 mg/kg PROGNOSIS r 604.90 Orchitis and epididymitis, unspecified
divided q8h 10 days Complications such as scrotal abscess or orchiectomy r 604.91 Orchitis and epididymitis in diseases
r Epididymitis in adolescents (STI pathogens): are seldom seen with directed therapy and close
classified elsewhere
Ceftriaxone 250 mg IM 1 PLUS follow-up of epididymitis. r 604.99 Other orchitis, epididymitis, and
Doxycycline 100 mg PO b.i.d. 10 days COMPLICATIONS epididymo-orchitis, without mention of abscess
r Epididymitis/epididymo-orchitis (due to systemic r Scrotal abscess
infection): r Chronic epididymitis
Antimicrobial therapy, 3rd-generation r Testicular infarction PEARLS AND PITFALLS
cephalosporins, directed against the suspected or r Infertility
r It may be difficult to differentiate testicular torsion
isolated pathogens (typically H. influenzae type b,
Salmonella species, S. pneumoniae, from epididymitis based on history and physical
Mycobacterium tuberculosis, or Brucella species), REFERENCES exam.
r Color Doppler US and testicular scintigraphy are
typically hematogenous spread from primary
focus: 1. Somekh E, Gorenstein A, Serour F. Acute both highly specific in detecting testicular torsion
Ceftriaxone 50 mg/kg/day IV for hematogenous epididymitis in boys: Evidence of a post-infectious but may miss the diagnosis of early or intermittent
spread etiology. J Urol. 2004;171:391394. torsion if blood flow is still present.
Ceftriaxone is not first-line therapy for 2. Gislason T, Noronha RFX, Gregory JG. Acute r Urology evaluation may be critical.
brucellosis; consider gentamicin 5 mg/kg IV/IM epididymitis in boys: A 5 year retrospective study.
per day 7 days plus doxycycline as dosing J Urol. 1990;14:533534.
above. 3. Kadish H, Bolte R. A retrospective review of
r Orchitis: Management of viral orchitis is supportive. pediatric patients with epididymitis, testicular
r Epididymo-orchitis is treated with antimicrobial torsion, and torsion of testicular appendages.
therapy if the urinalysis is suspicious for a bacterial J Pediatr. 1998;102:7376.
pathogen. Please refer to the antibiotics discussion
above.
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EPIDURAL HEMATOMA
Kara E. Hennelly
Lois K. Lee
312
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EPIDURAL HEMATOMA
r The admitting hospital should have emergency 4. Young KD, Okada PJ, Sokolove PE, et al. A
TREATMENT access to head CT scanning, an appropriate randomized, double-blinded, placebo-controlled
operating room if needed, and experienced trial of phenytoin for the prevention of early
PRE HOSPITAL personnel who are able to monitor for neurologic posttraumatic seizures in children with moderate to
r Prehospital care includes airway management based changes in pediatric patients. severe blunt head injury. Ann Emerg Med. 2004;
upon the skill level of the prehospital care providers. r Criteria for transfer to a pediatric trauma center 43(4):435446.
r Cervical spine immobilization must be maintained if after stabilization include: 5. Schutzman SA, Barnes PD, Mantello M, et al.
there is suspicion of C-spine injury. GCS 12 in the field Epidural hematomas in children. Ann Emerg Med.
r If the history is concerning by mechanism or Pediatric trauma score 8 1993;22(3):535541.
symptoms for EDH but the initial neurologic exam is Discharge Criteria
normal, serial neurologic exams must be performed. r Patients should be observed for at least 2448 hr
after the injury or evacuation of EDH to evaluate for
ADDITIONAL READING
INITIAL STABILIZATION/THERAPY
r The initial management of any patient with closed signs of hematoma expansion. Greenes D. Neurotrauma. In Fleisher GR, Ludwig S,
r Repeat CT scan is recommended prior to discharge eds. Textbook of Pediatric Emergency Medicine. 6th
head injury should include a basic ABCs approach.
r Oxygen should be administered to keep oxygen to evaluate for a potentially expanding hematoma. ed. Philadelphia, PA: Lippincott Williams & Wilkins;
saturation >95%. Issues for Referral 2010.
r Endotracheal intubation is required to maximize If a pediatric neurosurgeon is not available,
oxygenation and ventilation and protect against endotracheal intubation should be performed to
CODES
possible aspiration in the following situations:
Depressed mental status (GCS <9)
secure the airway in any patient with depressed GCS,
neurologic abnormality, or concerning radiologic
E
Rapidly deteriorating mental status findings (temporal location, >10 mm in size). ICD9
r 852.40 Extradural hemorrhage following injury,
Pupillary abnormalities
Respiratory distress without mention of open intracranial wound, with
Hemodynamic instability FOLLOW-UP state of consciousness unspecified
r In patients who are endotracheally intubated, r 852.50 Extradural hemorrhage following injury, with
FOLLOW-UP RECOMMENDATIONS open intracranial wound, with state of
hyperventilation should be avoided unless there are r Resuming activity is at the discretion of the
signs of impending herniation. PaCO2 should be consciousness unspecified
neurosurgeon and depends on the age of the child
maintained between 35 and 40 mm Hg to prevent and extent of associated bony injury.
cerebral ischemia. r Pediatric patients with severe traumatic brain injury
r Patients with hypotension should receive fluid PEARLS AND PITFALLS
may require ongoing neurorehabilitation.
resuscitation (normal saline boluses of 20 mL/kg) to r Early consultation with a neurosurgeon is necessary,
maintain cerebral perfusion pressure (CPP). Patient Monitoring
Patients typically are reimaged in 46 wk to confirm as patients may rapidly deteriorate as the EDH
MEDICATION there is no recurrent hemorrhage. expands.
r Infants with open sutures may initially have a better
First Line
PROGNOSIS tolerance for an expanding EDH. Anemia from blood
Mannitol (0.51 g/kg over 20 min) should be given for r Better neurologic outcomes are obtained in patients
patients with impending herniation. loss into the EDH may present before signs of
who undergo rapid diagnosis by CT scan and increased ICP.
Second Line surgical intervention, if indicated. r Children more commonly sustain EDH in the frontal,
Loading with antiepileptic medication (eg, r The most important factor in determining outcome
parieto-occipital, or posterior fossa regions, in
fosphenytoin) is controversial. The rate of early in patients with EDH is their neurologic status prior contrast to adults who more typically sustain EDH
posttraumatic seizures in patients with moderate to to surgery. around the temporal bone with middle meningeal
severe head injury is low (57%), and fosphenytoin r Neurologic sequelae such as seizures, hemiplegia, or
artery shearing.
minimally affects this rate (5). The risks and benefits of cranial nerve abnormalities are more likely with r Posterior fossa EDH occurs after a fall onto the
antiepileptic drugs must be carefully considered. acute deterioration, neurologic abnormalities, or occiput and is usually associated with a skull
COMPLEMENTARY & ALTERNATIVE altered LOC. fracture. Children may present with LOC, headache,
THERAPIES r 85% of patients with EDH have a good neurologic
and vomiting as well as dizziness, stiff neck, or
Elevate the head of the bed 1530 degrees. This mild outcome. cerebellar signs. They may have a subacute
elevation may lower ICP without adversely affecting COMPLICATIONS presentation but can deteriorate quickly due to
CPP. Delayed diagnosis can result in permanent neurologic brainstem compression.
SURGERY/OTHER PROCEDURES sequelae such as seizures, hemiplegia, cranial nerve
r Surgical craniotomy with hematoma evacuation and abnormalities, or death.
vessel repair is the standard treatment.
r Emergent craniotomy is indicated for EDH with:
REFERENCES
Deterioration of mental status, evidence of
elevated ICP, pupillary changes, hemiparesis, other 1. Choux M, Grisoli F, Peragut JC. Extradural
focal neurologic findings, or cerebellar signs hematomas in children. 104 cases. Childs Brain.
Radiologic findings on CT: Temporal location, 1975;1(6):337347.
large size (thickness >10 mm), and midline shift 2. Pillay R, Peter JC. Extradural haematomas in
r Nonoperative management with close observation is children. S Afr Med J. 1995;85(7):672674.
an option with neurosurgical agreement in patients 3. Chiaretti A, Piastra M, Pulitano S, et al. Prognostic
with normal neurologic exams and CT findings of factors and outcome of children with severe head
small EDH (usually <30 mL and <10 mm thickness). injury: An 8-year experience. Childs Nerv Syst.
DISPOSITION 2002;18(34):129136.
Admission Criteria
r All patients with a diagnosis of EDH should be
admitted to the hospital for close observation for at
least 2448 hr, especially postoperatively. Patients
with a known epidural hematoma should be
admitted to an ICU for close neurologic exam
monitoring.
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EPIGLOTTITIS/SUPRAGLOTTITIS
Rachel Gallagher
Joshua Nagler
314
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EPIGLOTTITIS/SUPRAGLOTTITIS
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EPISTAXIS
Audrey Le
Sandip Godambe
316
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EPISTAXIS
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ERYTHEMA INFECTIOSUM
Craig A. McElderry
318
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ERYTHEMA INFECTIOSUM
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ERYTHEMA MULTIFORME
Cynthia Lodding
Garth Meckler
320
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ERYTHEMA MULTIFORME
DIFFERENTIAL DIAGNOSIS DISPOSITION 3. Sun Y, Chan RK, Tan SH, et al. Detection and
r Stevens-Johnson syndrome (SJS): genotyping of human herpes simplex viruses in
Admission Criteria
Systemic symptoms often present r EM is a self-limited disease and should not require cutaneous lesions of erythema multiforme by
Lesions are widely distributed but <10% BSA, hospital admission. nested PCR. J Med Virol. 2003;71:423428.
atypical, and flat (rather than typical raised acral r Rarely, patients with inability to tolerate oral intake 4. Riley M, Jenner R. Towards evidence based
targets in EM). despite analgesics may require hospitalization for emergency medicine: Best BETs from the
Multiple mucous membranes involved: Oral pain management and IV fluids. Manchester Royal Infirmary. Bet 2. Steroids in
(buccal, palatal, vermillion border, with children with erythema multiforme. Emerg Med J.
hemorrhagic erosions, pseudomembranes, ulcers, Discharge Criteria 2008;25:594595.
r The patient must have reliable caregivers and follow
crusts), ocular, and genital
Nikolsky sign positive up with a primary care physician.
r Toxic epidermal necrolysis (TEN): r The diagnosis of EM should be clear and must be ADDITIONAL READING
Systemic symptoms usually present distinguished from life-threatening rashes such as
r Assier H, Bastuji-Garin S, Revuz J, et al. Erythema
Lesions are widespread (>10% BSA), poorly SJS, TEN, and purpura fulminans.
multiforme with mucus membrane involvement and
defined erythematous macules and flat targets. Issues for Referral
r Doubt as to the diagnosis should prompt referral to Stevens-Johnson Syndrome are clinically different
Epidermal detachment in >10% of BSA
disorders with distinct causes. Arch Dermatol.
Multiple mucous membranes involved: Oral dermatology.
r Ocular involvement should prompt consultation with 1995;131:539543.
(similar to SJS), ocular, esophageal, genital, rarely r Leaute-Labreze C, Lamireau T, Chawki D, et al.
colonic ophthalmology.
r Urticaria
r Kawasaki disease
Diagnosis, classification, and management of
erythema multiforme and Stevens-Johnson
E
r Drug eruptions FOLLOW-UP syndrome. Arch Dis Child. 2000;83:347352.
r Contact dermatitis See Also (Topic, Algorithm, Electronic
FOLLOW-UP RECOMMENDATIONS
r Behcet disease r Discharge instructions and medications: Media Element)
r DermNet NZ: http://dermnetnz.org/reactions/
r Rocky Mountain spotted fever Anticipatory guidance:
r Serum sicknesslike reaction Rash will typically resolve in 13 wk without erythema-multiforme.html
r DermAtlas: http://dermatlas.med.jhmi.edu/derm/
r Herpes gingivostomatitis scarring
r Purpura fulminans Temporary hypo- or hyperpigmentation may result.cfm?Diagnosis=34
occur.
Recurrence may be seen in up to 1/3 of children
TREATMENT with EM. CODES
Oral analgesics as needed
INITIAL STABILIZATION/THERAPY r Activity: ICD9
r EM does not cause severe systemic symptoms. If No restrictions r 695.10 Erythema multiforme, unspecified
stabilization is required, this suggests an alternate r 695.11 Erythema multiforme minor
diagnosis.
PROGNOSIS r 695.12 Erythema multiforme major
r The expected duration is 13 wk, with an average of
r Symptomatic treatment for pain associated with
7 days. The rash is usually self-limited, and there are
mucosal involvement is detailed below. no serious or long-term sequelae.
MEDICATION r Recurrences are possible if associated with HSV or PEARLS AND PITFALLS
First Line with accidental exposure to an offending antigen. r Consider SJS and TEN, which are life-threatening
r Oral analgesics as needed: r Reactive hyper- or hypopigmentation may be seen.
illnesses with high morbidity and mortality. These
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r Scarring is unusual in EM. typically have more severe clinical features,
Ketorolac 0.5 mg/kg IV/IM q6h PRN especially when multiple mucous membranes are
Naproxen 5 mg/kg PO q8h PRN COMPLICATIONS
r Dehydration is a complication of severe oral involved.
Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r EM is rare in children under 3 yr of age, and
Codeine or codeine/acetaminophen dosed as involvement.
r Recurrence is possible, particularly in alternate diagnoses should be considered.
0.51 mg/kg of codeine component PO q4h PRN
r Topical analgesics for oral lesions as needed HSV-associated disease.
(eg, viscous lidocaine)
Second Line REFERENCES
r Recurrent HSV-associated disease may benefit from
suppressive therapy: 1. Bastuji-Garin S, Rzany B, Stern RS, et al. Clinical
Acyclovir 4080 mg/kg/day divided t.i.d.; classification of cases of toxic epidermal necrolysis,
adolescent/adult, 400 mg PO b.i.d. or Stevens-Johnson syndrome, and erythema
200 mg t.i.d. multiforme. Arch Dermatol. 1993;129:9296.
Famciclovir (adolescent/adult) 250 mg PO b.i.d. 2. Auquier-Dunant A, Mockenhaupt M, Naldi L, et al.
Valacyclovir (adolescent/adult) 500 mg or 1 g PO Correlations between clinical patterns and causes
daily of erythema multiforme majus, Stevens-Johnson
r Systemic steroid therapy may be of limited value for syndrome, and toxic epidermal necrolysis: Results
symptomatic treatment but does not change of an international prospective study. Arch
morbidity or mortality and is not recommended (4). Dermatol. 2002;138(8):10191024.
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ERYTHEMA NODOSUM
Solomon Behar
322
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ERYTHEMA NODOSUM
323
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ERYTHEMA TOXICUM
Solomon Behar
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Neonatal herpes simplex infection:
Vesicular lesions
DESCRIPTION HISTORY Infant is ill appearing.
r Erythema toxicum is the most common pustular rash r Rash appearing on day 2 or 3 of life r Miliaria
of the newborn period, with an unclear etiology and r Most common in a full-term baby r Infantile acropustulosis: Pruritic on distal extremities
a benign course. r Baby is otherwise afebrile and healthy. r Bacterial folliculitis: Tender, red papules/macules
r Also known as erythema toxicum neonatorum r Lesions typically resolve spontaneously in days to r Transient neonatal pustular melanosis:
r Erythema toxicum is rare in preterm infants. weeks.
r Recurrence of lesions is possible but rare. Usually present at birth
r Only 10% of babies with erythema toxicum have it
More common in African Americans
at birth. PHYSICAL EXAM r Eosinophilic pustular folliculitis: Recurrent lesions
EPIDEMIOLOGY r 23-mm macules, papules, and pustules on face, tending to be on scalp
4070% of full-term babies trunk, and extremities, sparing palms and soles r Scabies: Rare
r Classically described as flea-bitten appearance
RISK FACTORS r Absence of signs of systemic illness
r Full-term babies
r Vaginal birth DIAGNOSTIC TESTS & INTERPRETATION
r Primiparous mothers Lab
PATHOPHYSIOLOGY Initial Lab Tests
Possible mechanism is mast cell degranulation as a None needed (peripheral eosinophilia may be noted if
reaction to commensal microbes (1,2) a CBC is sent)
Diagnostic Procedures/Other
ETIOLOGY
Skin scraping if diagnosis in doubt
Unknown
Pathological Findings
COMMONLY ASSOCIATED CONDITIONS Scraping of pustule reveals eosinophils with Gram,
Associated with a normal newborn Wright, or Giemsa stain.
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ERYTHEMA TOXICUM
REFERENCES
TREATMENT CODES
1. Marchini G, Nelson A, Edner J, et al. Erythema
toxicum neonatorum is an innate immune response
Erythema toxicum is a benign neonatal rash that ICD9
to commensal microbes penetrated into the skin of
requires no treatment. Once distinguished from other 778.8 Other specified conditions involving the
the newborn infant. Pediatr Res. 2005;58(3):
rashes, no further intervention is necessary. integument of fetus and newborn
613616.
DISPOSITION 2. Nelson A, Ulfgren A-K, Marchini G, et al. Urticaria
Discharge Criteria neonatorum: Accumulation of tryptase-expressing PEARLS AND PITFALLS
All newborns with erythema toxicum may be safely mast cells in the skin lesions of newborns with
erythema toxicum. Pediatr Allergy Immunol. r If lesions are present on the palms and soles,
discharged home.
2007;18:652658. consider a different diagnosis.
3. Liu C, Feng J, Qu R, et al. Epidemiologic study of r The most dangerous rash in the differential diagnosis
FOLLOW-UP the predisposing factors in erythema toxicum is neonatal herpes, which causes lesions that may
neonatorum. Dermatology. 2005;210:269272. be initially erythematous macules that progress to
FOLLOW-UP RECOMMENDATIONS vesicular lesions rather than to ulcers. Certainty that
r Discharge instructions and medications:
neonatal herpes is not causal is critical.
Routine care ADDITIONAL READING
r Activity:
Regular r Wagner A. Distinguishing vesicular and pustular
DIET
disorders in the neonate. Curr Opin Pediatr. E
1997;9:396405.
No special diet is necessary. Feeding with powdered
formula may be associated with the development of See Also (Topic, Algorithm, Electronic
erythema toxicum (3). Media Element)
r Herpes Simplex
PROGNOSIS r Rash, Maculopapular
Excellent; typically resolves without sequelae r Rash, Neonatal
COMPLICATIONS
Secondary bacterial infections
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ESOPHAGEAL VARICES
Emily L. Willner
326
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ESOPHAGEAL VARICES
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ESOPHAGITIS
Michael E. Valente
Janet Semple-Hess
328
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ESOPHAGITIS
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ETHANOL POISONING
David J. Story
Sari Soghoian
330
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ETHANOL POISONING
DIFFERENTIAL DIAGNOSIS
r Carbon monoxide poisoning
DISPOSITION ADDITIONAL READING
Admission Criteria r American Academy of Pediatrics. Alcohol use and
r Closed head injury r Loss of airway protective mechanisms
r Diabetic ketoacidosis r Profound serum concentration that will take several abuse: A pediatric concern. Pediatrics. 2001;
r Ethanol intoxication 108(1):185189.
hours to metabolize r Yip L. Ethanol. In Goldfrank LR, Flomenbaum NE,
r Hypoglycemia r Concern for patient safety at home
r Sedative/hypnotic ingestion r Labile glucose levels Lewin NA, et al., eds. Goldfranks Toxicologic
r Seizures r Concern for coingestion Emergencies. 8th ed. Stamford, CT: Appleton &
Lange; 2006.
r Starvation hetoacidosis r Seizure
r Toxic alcohol ingestion r Critical care admission criteria:
Unstable vital signs, particularly respiratory CODES
depression or hypotension unresponsive to IV fluid
TREATMENT therapy
ICD9
Associated trauma requiring intensive care
PRE HOSPITAL 980.0 Toxic effect of ethyl alcohol
r Assess and stabilize airway, breathing, and Discharge Criteria
circulation. Return to baseline mental status and ability to
r Assess for trauma, utilizing cervical collar and/or ambulate PEARLS AND PITFALLS
Issues for Referral r Smaller children lack significant liver mass and have
backboard as needed.
r Concern for child safety at home should prompt
fewer glycogen stores than adults and therefore are
E
INITIAL STABILIZATION/THERAPY child protective services or social work consultation.
r Assess and stabilize airway, breathing, and at increased risk for hypoglycemia in the setting of
r Intentional use warrants consideration for referral to ethanol intoxication.
circulation. r Children metabolize ethanol more rapidly than
r Intubation for unprotected airway psychiatrist, psychologist, or substance abuse
r Supportive care counselor. adults.
r Always check for ethanol content when assessing a
r IV fluids as needed
r Serial monitoring of capillary blood glucose FOLLOW-UP pediatric patient who has ingested household or
body care products.
MEDICATION FOLLOW-UP RECOMMENDATIONS r Proof of alcohol is numerically twice the
r Dextrose for hypoglycemia: Feed, if capable, or 1 Discharge instructions and medications: percentage of ethanol present. A 100-proof product
g/kg IV r Refrain from drinking alcohol. contains 50% alcohol.
r Antiemetics for nausea/vomiting: r Patients who reach emergency medical services in
PROGNOSIS
Metoclopramide 0.1mg/kg PO/IV q6h r Excellent for rapid, normal recovery for minor the setting of ethanol or other alcohol intoxication
Ondansetron 0.1 mg/kg PO/IV q8h may represent a subset of drinkers at higher risk of
r IV fluids: ingestions
r Prognosis worsens as blood alcohol level rises. trauma, comorbid psychiatric illness, and alcoholism.
Normal saline 20 mL/kg IV bolus 1 for
Blood alcohol level >500 mg/dL may result in
hypotension, repeat up to 2 times
severe morbidity and mortality.
COMPLEMENTARY & ALTERNATIVE r Unrecognized hypoglycemia causing seizure activity
THERAPIES places patient at increased risk for aspiration,
Use of caffeine-containing beverages, such as tea or traumatic bodily injury, and anoxic brain injury.
coffee, is commonly attempted by laypersons in an
COMPLICATIONS
attempt to make patient less sedated. r Hypoglycemia
r This is not demonstrated to be effective or safe and r Seizures
is not recommended for clinical use. r Permanent neurologic or neurocognitive injury
331
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EYE, RED
Eric C. Hoppa
Atima Chumpa Delaney
332
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EYE, RED
333
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EYE, STRABISMUS
Atima Chumpa Delaney
334
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EYE, STRABISMUS
335
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336
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LWBK822-driver-E LWBK822-Hoffman ch167.xml April 18, 2011 8:57
337
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338
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FAILURE TO THRIVE
Michael E. Valente
Janet Semple-Hess
r Inadequate caloric absorption: r Birth history: To differentiate FTT from small for
BASICS Celiac disease gestational age
Cystic fibrosis r Chronic medical conditions
DESCRIPTION Protein-losing enteropathy r Stool pattern: Frequency and nature (diarrhea and
r Failure to thrive (FTT) is a term used to describe Food allergy constipation)
inadequate growth in early childhood. Inflammatory bowel disease r GI symptoms (evidence of milk protein allergy, GI
r Most definitions are based on failure to attain Vitamin or mineral deficiencies reflux)
growth parameters or growth velocity, with weight Hepatobiliary disease r Social history:
being the most commonly used indicator: Short gut syndrome
Changes at home at the time of onset
Weight for age <3rd or 5th percentile Parasitism
Availability of food
Weight as a percentage of median weight for age, Chronic constipation
Economic hardship
<80% or <90% Hirschsprung disease
Restrictive diet for social or religious reasons
Downward crossing (of weight for age) in 2 Malrotation
Home stressors
major percentile lines on a standard growth chart r Excessive caloric expenditure/Increased
Homelessness
EPIDEMIOLOGY metabolism:
Endocrine disorders (hyperthyroidism, diabetes PHYSICAL EXAM
Prevalence r Vital signs
r The prevalence of FTT in the general population is mellitus, diabetes insipidus, adrenal or pituitary
disease) r Plot weight, height/length, and head circumference
unknown. Malignancy on standard growth charts
r In 2007, the prevalence of underweight children r General assessment, including body fat and muscle
Chronic infection (HIV, immunodeficiency, TB)
(birth to age 5 yr) participating in U.S. nutrition and Renal disease (chronic renal insufficiency, renal mass
public health programs was 4.5% (1). tubular acidosis, recurrent urinary tract infections) r Assessment of respiratory status, including signs of
RISK FACTORS Hypoxemia (congenital heart defects, chronic lung hypoxemia
The following are associated with FTT: disease) r Pulmonary exam for evidence of chronic lung
r Underlying disease (diagnosed or undiagnosed) r Defective utilization:
disease or infection
r Lower socioeconomic status Inborn errors of metabolism r Cardiovascular assessment for congenital heart
r Crowded or unsanitary living environment Congenital infections disease and arrhythmia
r Poor emotional environment Genetic abnormalities r Abdominal exam evaluating for masses,
r Prematurity organomegaly, obstruction, constipation, and ascites
DIAGNOSIS r Assessment of hydration and evidence of renal
PATHOPHYSIOLOGY disease
Multiple disease (organic causes) and psychosocial r Plotting growth on standard growth charts is the r Neurologic exam including mental status,
factors (inorganic causes) can lead to FTT via: typical manner of diagnosis. developmental level, and tone
r Inadequate caloric intake r The goal of history, physical exam, and diagnostic r Signs of neglect or abuse
r Inadequate caloric absorption testing is to: r Dysmorphism suggestive of chronic disease or
r Excessive caloric expenditure Aid in the determination of the etiology genetic abnormalities
Guide therapy r Skin/mucosal changes
ETIOLOGY Determine appropriate follow-up
r Most children with FTT have mixed etiologies. These r Observe child/infant while eating/feeding:
etiologies can be organized by their HISTORY Caregiver and child interaction while eating
pathophysiology: r Complete dietary history: Positioning
r Inadequate caloric intake: Amount of food or formula in order to quantify Oral motor difficulties
Incorrect preparation of formula total caloric intake Distractibility
Recall of their last 24-hr intake is useful. r Quality of caregiver and child interaction
Inappropriate feeding (milk intake, juice intake)
Psychosocial factors (behavior problems, poverty, How formula is prepared
Intake of milk, juice, sodas, sugary drinks, and DIAGNOSTIC TESTS & INTERPRETATION
parentchild relationship problems, child
abuse/neglect, Munchausen syndrome by proxy) water Lab
r Feeding history: r Lab assessment has limited value in determining the
Mechanical feeding difficulties (cleft lip/palate,
Feeding routine: etiology of FTT, so diagnostic testing should be
choanal atresia, gastroesophageal reflux, pyloric
When? individualized based on the clinicians differential
stenosis)
Where? diagnosis after a thorough history and physical.
Neurologic (cerebral palsy, hypertonia or r Reasonable initial tests to be completed in the
hypotonia, generalized weakness) With/by whom?
Anorexia and nausea associated with chronic Food refusals emergency department:
illness Oversnacking Glucose
Appropriateness of feeding techniques for CBC with differential
developmental age Urinalysis
Problems with chewing, swallowing, emesis, or Urine culture
spit ups Electrolytes, including BUN and creatinine
Speed of feedings LFTs, including total protein and albumin
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FAILURE TO THRIVE
r Further tests as indicated can be done in the MEDICATION r Bithoney WG, Dubowitz H, Egan H. Failure to
emergency department or an outpatient/inpatient Medication is dependent on the etiology. thrive/growth deficiency. Pediatr Rev. 1992;13;
setting depending on the case: 453459.
DISPOSITION r Gahagan S, Holmes R. A stepwise approach to
Lead level
PPD placement Admission Criteria evaluation of undernutrition and failure to thrive.
r Significant FTT, particularly in young infants or
HIV testing Pediatr Clin North Am. 1998;45:169187.
Sweat tests patients who lack follow-up to track catch-up r Krugman SD, Dubowitz H. Failure to thrive. Am Fam
IgA and antitransglutaminase (to evaluate for growth
r Patient without weight gain after appropriate close Physician. 2003;68(5):879884.
celiac disease) r Olsen EM. Failure to thrive: Still a problem of
Stool microscopy and culture outpatient treatment and follow-up
r Negligent or abusive caretakers definition. Clin Pediatr (Phila). 2006;45(1):16.
Stool fat
Urine organic and serum amino acids r Severe dehydration, malnutrition, or electrolyte See Also (Topic, Algorithm, Electronic
ESR abnormality with concern for refeeding syndrome Media Element)
Thyroid function tests r Medical causes of FTT identified in the emergency r Gastroesophageal Reflux
Iron studies department that require further inpatient workup r http://www.cdc.gov/growthcharts/
Serum insulinlike growth factor I (IGF-I) and/or treatment
Insulinlike growth factor binding protein (IGF-BP3)
Issues for Referral
Imaging r Social services for patients who have psychosocial CODES
r A CXR can be obtained in the emergency factors as a component to their FTT
department if there is clinical suspicion for TB, r Child protective services are required if neglect or ICD9
pneumonia, or cardiomegaly. r 779.34 Failure to thrive in newborn
abuse is suspected.
r Bone age, typically performed as an outpatient, may r Lactation consultant, nutritionist, and occupational r 783.41 Failure to thrive
be helpful to distinguish genetic short stature from therapist to guide appropriate feeding and maximize
constitutional delay of growth. caloric intake
DIFFERENTIAL DIAGNOSIS
r Medical specialist depending on etiology PEARLS AND PITFALLS F
It is important to differentiate FTT from normal r It is important to differentiate FTT from normal
variants in growth, including: variants in growth.
r Children who are following appropriate growth FOLLOW-UP r Most children with FTT have mixed etiologies.
curves for: FOLLOW-UP RECOMMENDATIONS r Admit all patients with FTT who lack follow-up to
Chromosomal abnormalities: Trisomy 13,18, and r Discharge only those patients in which follow-up is
track catch-up growth.
21, etc. OR ensured. r Child protective services notification is required if
Other syndromes affecting growth: Noonan r Children with FTT need a high-calorie diet for
neglect or abuse is suspected.
syndrome, Russell-Silver syndrome, fetal alcohol catch-up growth.
syndrome, and Prader-Willi syndrome, etc. r Diet modification may be needed in certain cases,
r Constitutional delay in growth
including high-protein diets and elemental formula
r Familial short stature in the case of milk protein allergy.
r Premature infants and infants with history of
intrauterine growth retardation who have normal
growth velocity: REFERENCE
When charting growth, corrections for gestational
1. Polhamus B, Dalenius K, Borland E, et al. Pediatric
age are necessary until at least 2 yr of age.
Nutrition Surveillance 2007 Report. Atlanta, GA:
CDC; 2009.
TREATMENT
r In the emergency department: ADDITIONAL READING
Evaluation and treatment of: r American Academy of Pediatrics, Committee on
Hypoglycemia Genetics. Health supervision for children with Down
Electrolyte abnormalities syndrome. Pediatrics. 2001;107(2):442449.
Dehydration r American Academy of Pediatrics, Committee on
Additional emergent treatment is guided by Genetics. Health supervision for children with Turner
etiology of FTT. syndrome. Pediatrics. 2003;111(3):692702.
r As an outpatient:
High-calorie diet and close follow-up to document
catch-up growth.
Vitamin and mineral supplementation
Additional workup and admission if failure to gain
weight in the outpatient setting
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FASCIITIS
Emily L. Willner
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FASCIITIS
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FEBRILE SEIZURE
Jennifer H. Chao
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FEBRILE SEIZURE
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FELON
Yu-Tsun Cheng
Alan L. Nager
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FELON
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Imaging r Occult bacteremia: Empiric treatment: 4. Lee GM, Fleisher GR, Harper MB. Management of
r Chest radiograph for suspicion of pneumonia: Ceftriaxone 50 mg/kg IM/IV (single dose) febrile children in the age of the conjugate
Wheezing and fever in the infant or toddler may r Meningitis: 3rd-generation cephalosporin: pneumococcal vaccine: A cost-effectiveness
be a sign of viral bronchiolitis, for which a chest Ceftriaxone 50100 mg/kg IV daily analysis. Pediatrics. 2001;108:835844.
radiograph is not routinely necessary. Cefotaxime 100200 mg/kg/day IV divided q6h 5. Rudinsky SL, Carstairs KL, Reardon JM, et al.
r CT scan or US of the specific site as indicated for r Septic arthritis: IV antibiotics for suspected Serious bacterial infections in febrile infants in the
suspicion of deep tissue infection, such as abscess, etiologies and operative intervention (see Arthritis, post-pneumococcal conjugate vaccine era. Acad
appendicitis, etc. Septic topic) Emerg Med. 2009;16:585590.
r Osteomyelitis: IV antibiotics for suspected etiologies 6. Hsiao AL, Chen L, Baker MD. Incidence and
Diagnostic Procedures/Other
r Transurethral catheterization or suprapubic bladder (see Osteomyelitis topic) predictors of serious bacterial infections among 57-
aspiration for urine testing r Bacterial gastroenteritis: Routine antibiotic to 180-day-old Infants. Pediatrics. 2006;117(5):
r Arthrocentesis for septic arthritis administration is not warranted until the stool 16951701.
r Suprapubic aspiration and arthrocentesis may be culture results are available. 7. Fleisher GR, Rosenberg N, Vinci R, et al.
guided by US. Intramuscular versus oral antibiotic therapy for the
SURGERY/OTHER PROCEDURES prevention of meningitis and other bacterial
r Operative irrigation for septic arthritis
DIFFERENTIAL DIAGNOSIS sequelae in young febrile children at risk for occult
r Incision and drainage for abscesses:
See Etiology section. bacteremia. J Pediatr. 1994;124:504512.
Abscess drainage may be guided by US
TREATMENT DISPOSITION
Admission Criteria
ADDITIONAL READING
r Ill appearance r Wang VJ. Fever and serious bacterial illness. In
INITIAL STABILIZATION/THERAPY
r If ill appearing, address ABCs per Pediatric r Unreliable follow-up Tintinalli JE, Stapczynski J, Ma OJ, et al., eds.
Advanced Life Support algorithm. r Bacterial meningitis, septic arthritis, osteomyelitis, Tintinallis Emergency Medicine: Comprehensive
r Treat infection as diagnosed. pyelonephritis, rapidly spreading cellulitis Study Guide. 7th ed. New York, NY: McGraw-Hill;
r Most causes of fever are viral and require supportive r Pneumonia with hypoxemia or respiratory distress 2010. F
care alone. Discharge Criteria See Also (Topic, Algorithm, Electronic
r In well-appearing, febrile patients 336 mo of age r Well appearing Media Element)
without a focal source, if a CBC is obtained and the r Reliable follow-up r Arthritis, Septic
WBC >15,000/mm3 : r Ability to tolerate PO medications r Bacteremia
Consider treatment for occult bacteremia (7). r Fever in Infants 03 Months of Age
Treatment may also be limited to higher r Fever of Unknown Origin
thresholds of WBC count. FOLLOW-UP r Meningitis
MEDICATION r Osteomyelitis
FOLLOW-UP RECOMMENDATIONS
First Line r 24-hr follow-up with the primary care provider (with r Otitis Media
r Acetaminophen or ibuprofen PRN r Pneumonia
access to culture results)
r The diagnosis guides antibiotic selection. r Discharge instructions and medications: r Urinary Tract Infection
r UTI: Acetaminophen or ibuprofen PRN
Cefixime 8 mg/kg/day PO daily or divided b.i.d. for Return for increased irritability, poor feeding,
10 days lethargy, decreased urine output CODES
Cephalexin 3060 mg/kg/day PO divided t.i.d. for
710 days PROGNOSIS
Depends on the results of the evaluation (eg, presence ICD9
Trimethoprim/sulfamethoxazole (dose on
of meningitis, bacteremia, pyelonephritis, etc.) 780.60 Fever, unspecified
trimethoprim component) 610 mg/kg/day PO
divided b.i.d. for 10 days COMPLICATIONS
r Pneumonia: r Complications depend on the site of infection.
r Death, urosepsis, seizures, hearing loss,
PEARLS AND PITFALLS
Amoxicillin (high dose) 8090 mg/kg/day PO
divided b.i.d. or t.i.d. for 10 days r Pearls:
developmental delay/mental retardation, abscess,
Amoxicillin/clavulanic acid (high dose amoxicillin limp, amputation, renal insufficiency/failure Recent vaccination improvements have
component) 8090 mg/kg PO divided b.i.d. or substantially decreased the incidence of SBI in this
t.i.d. for 10 days population. Check the vaccination status.
Azithromycin 10 mg/kg PO daily for 3 days REFERENCES Herd immunity does help, even for the
Cefuroxime 2030 mg/kg/day divided b.i.d. for unimmunized.
10 days 1. American Academy of Pediatrics. Practice r Pitfalls:
r Cellulitis or abscess: parameter: The diagnosis, treatment, and Not recognizing patients at risk for HSV infection
evaluation of the initial urinary tract infection in Performing an inadequate or incomplete
Cephalexin 60100 mg/kg/day PO divided q.i.d.
febrile infants and young children. Committee on evaluation
for 10 days
Quality Improvement, Subcommittee on Urinary Not applying vaccination status to your
Amoxicillin/clavulanic acid (see above)
r Cellulitis, abscess, MRSA: Tract Infection. Pediatrics. 1999;103(4):843852. decision-making process
2. Shaw KN, Gorelick M, McGowan KL, et al.
Clindamycin 30 mg/kg/day PO divided t.i.d. for
Prevalence of urinary tract infection in febrile young
10 days
children in the emergency department. Pediatrics.
Trimethoprim/sulfamethoxazole (see above) and
1998;102:e16.
cephalexin (see dose for cellulitis)
r Pharyngitis: 3. Invasive pneumococcal disease in children 5 years
after conjugate vaccine introductioneight states,
Penicillin VK 2550 mg/kg/day divided t.i.d. to
19982005. MMWR. 2008;57(6):144148.
q.i.d. max dose 3 g/day
Amoxicillin 4050 mg/kg/day divided b.i.d. or
t.i.d. for 10 days
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r Age >1 mo, admitted (failed established protocols): PROGNOSIS ADDITIONAL READING
Ceftriaxone or cefotaxime (consider adding Depends on the results of the evaluation (eg, presence
ampicillin) of meningitis, bacteremia, pyelonephritis, etc.) r American College of Emergency Physicians Clinical
r Age >1 mo, discharged: Policies Subcommittee on Pediatric Fever. Clinical
COMPLICATIONS policy for children younger than three years
No antibiotics (Philadelphia or Rochester criteria) r Complications depend on the site of infection
Ceftriaxone for low-risk patients (Boston protocol) r Death presenting to the emergency department with fever.
Ann Emerg Med. 2003;42(4):530545.
Second Line r Urosepsis r Bachur RG, Harper MB. Predictive model for serious
r Vancomycin (1015 mg/kg IV q68h) for suspected r Seizures
bacterial infections among infants younger than 3
S. aureus or S. pneumoniae meningitis r Hearing loss months of age. Pediatrics. 2001;108(2):311.
r Acyclovir (20 mg/kg/day IV q8h) for suspected HSV
r Developmental delay/mental retardation r Wang VJ. Fever and serious bacterial illness. In
infection r Abscess
r Dexamethasone (0.6 mg/kg/day IV divided q6h) for Tintinalli JE, Stapczynski J, Ma OJ, et al., eds.
r Limp Tintinallis Emergency Medicine: Comprehensive
presumed bacterial meningitis for infants >6 wk old r Amputation Study Guide. 7th ed. New York, NY: McGraw-Hill;
DISPOSITION r Renal insufficiency/failure 2010.
Admission Criteria See Also (Topic, Algorithm, Electronic
r Neonates <1 mo of age
Media Element)
r Ill appearance REFERENCES r Bacteremia
r Unreliable follow-up r Fever in Children Older than 3 Months
r Serum WBC >15,000/mm3 in Philadelphia protocol 1. Baker MD, Avner JR, Bell LM. Failure of infant
observation scales in detecting serious illness in r Meningitis
(may follow Rochester or Boston criteria instead) febrile 4- to 8-week-old infants. Pediatrics. r Urinary Tract Infection
(35) 1990;85(6):1040.
r CSF WBC >10/mm3
2. Maniaci V, Dauber A, Weiss S, et al. Procalcitonin
r CSF Gram stain showing bacteria
r Evidence of pyelonephritis
in young febrile infants for the detection of serious CODES F
bacterial infections. Pediatrics. 2008;122(4):701.
r Pneumonia 3. Baker MD, Bell LM, Avner JR. Outpatient ICD9
r Hypoxemia or respiratory distress management without antibiotics of fever in selected r 778.4 Other disturbances of temperature regulation
Discharge Criteria patients. N Engl J Med. 1993;329(20):1437. of newborn
r Well appearing 4. Baskin MN, ORourke EJ, Fleisher GR. Outpatient r 780.60 Fever, unspecified
r Reliable follow-up treatment of febrile infants 28 to 89 days of age
r Serum WBC 15,000/mm3 in Philadelphia protocol with intramuscular administration of ceftriaxone.
(may follow Rochester or Boston criteria instead)
J Pediatr. 1992;120:22. PEARLS AND PITFALLS
5. Jaskiewicz JA, McCarthy CA, Richardson AC, et al.
(35) r Pearls:
r Normal CSF indices Febrile infants at low risk for serious bacterial
infection an appraisal of the Rochester criteria Recent vaccination improvements (H. influenzae
r Urinalysis not suggestive of UTI type b and pneumococcal conjugate vaccines)
and implications for management. Pediatrics.
1994;94(3):390. have not substantially decreased the incidence of
6. Bramson RT, Meyer TL, Silbiger ML. The futility of SBI in this population.
FOLLOW-UP r Pitfalls:
the chest radiograph in the febrile infant without
FOLLOW-UP RECOMMENDATIONS respiratory symptoms. Pediatrics. 1993;92(4):534. Applying the fever criteria incorrectly
r 24-hr follow-up with the primary care provider (with 7. Byington CL, Enriquez FR, Hoff C, et al. Serious (Philadelphia, Boston, and Rochester criteria) by
access to culture results) bacterial infections in febrile infants 1 to 90 days selectively using and mixing the criteria
r If ceftriaxone was given, a repeat dose of old with and without viral infections. Pediatrics. Not recognizing patients at risk for HSV infection
ceftriaxone is optional. 2004;113(6):1662. Performing an inadequate or incomplete
r Discharge instructions and medications: evaluation
Not applying the birth and postpartum history
Acetaminophen 1015 mg/kg PO/PR q46h
Return for increased irritability, poor feeding,
lethargy, decreased urine output
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FLAIL CHEST
Cathy E. Shin
ETIOLOGY Imaging
BASICS r Blunt chest wall trauma: r The AP CXR will identify most significant chest wall
Motor vehicle crashes (high speed) injuries but will not identify all rib fractures in the
DESCRIPTION Falls pediatric population. Lateral or anterior rib fractures
r A flail chest occurs when a segment (at least 2 r Nonaccidental trauma (5) will often be missed on the initial plain film.
fractures per rib) of the chest wall is separated from r Chest films may also identify:
the rest of the thoracic cavity: COMMONLY ASSOCIATED CONDITIONS
r Pulmonary contusion Subcutaneous emphysema
Respiratory distress is identified with paradoxical Broken ribs or other broken bones
r Rib fractures
movement of a segment of the chest wall (moving Hemothorax
inward on inspiration and moving outward on r Pneumothorax
Pneumothorax
expiration). r Hemothorax
Pulmonary contusion
r Compared to adults, flail chest is far less common in Diaphragmatic rupture
infants and children. r There is no role for chest CT scans to diagnose flail
r Due to the nature of the injury, the pediatric DIAGNOSIS
chest, but CT may be helpful to identify associated
population is at higher risk for associated pulmonary HISTORY injuries such as pulmonary contusion.
injuries (1). r High-speed motor vehicular crashes involving blunt
r Generally, the presence of a flail chest is associated DIFFERENTIAL DIAGNOSIS
chest or upper abdominal trauma
r Falls involving blunt chest or upper abdominal Other clinical diagnoses with similar presentations
with a mortality rate ranging from 1035%.
include:
EPIDEMIOLOGY trauma r Rib fractures: Clinically similar without paradoxical
r Conscious patients will complain of:
Prevalence chest wall movement
Flail chest complicates 513% of patients with Pain on palpation of the chest wall or on r Pulmonary contusion: Respiratory distress without
blunt chest trauma in the general population (2,3). inspiration
Shortness of breath flail chest or rib fractures
r Chest wall muscular strain: Chest wall splinting may
RISK FACTORS Difficulty with inspiration
r High-speed motor vehicle collisions Chest pain mimic flail chest
r Blunt trauma
PHYSICAL EXAM
PATHOPHYSIOLOGY r Respiratory distress: TREATMENT
r A transfer of significant kinetic energy in blunt Tachypnea
trauma to the rib cage or a crushing rollover injury is Intercostal and substernal retractions PRE HOSPITAL
r Assess and stabilize airway, breathing, and
the most frequent cause of flail chest. Air hunger
r The paradoxical movement of the rib cage will Nasal flaring circulation.
r All patients should initially be placed on 100%
adversely affect respiratory function via diminished Grunting
ventilation, pulmonary contusions, and atelectasis Chest wall splinting oxygen via a nonrebreathing face mask.
r Bruising, grazes, abrasions or seat belt signs are r IV analgesia as noted below
from hypoventilation.
r The negative intrathoracic pressure generated under visible on inspection. INITIAL STABILIZATION/THERAPY
the flail segment during inspiration results in the flail r Palpation may reveal the crepitus associated with r Management of chest wall injury is directed toward
segment being pulled inward. Similarly, the positive broken ribs. protecting the underlying lung and allowing
pressures with expiration cause the same segment r Decreased pulse oximetry readings adequate oxygenation, ventilation, and pulmonary
to push outward, thus creating a paradoxical r KEY EXAM: Paradoxical movement of a segment of toilet. This strategy is aimed at preventing the
appearance. the chest wallmoving inward on inspiration and development of pneumonia, which is the most
r Respiratory distress can be caused by the dynamics moving outward on expiration: common complication of chest wall injury.
of the chest wall or the underlying pulmonary injury. This is often better appreciated by palpation than r Pain management, judicious fluid resuscitation, and
r Derangement of chest wall mechanics results in by inspection. excellent pulmonary toilet are essential to stabilizing
reduced tidal volume, increased pulmonary the patient.
DIAGNOSTIC TESTS & INTERPRETATION r Isolated flail chest may be successfully managed
secretions, atelectasis, and cough, which in turn
increase the risk of pneumonia. Lab
with aggressive pulmonary toilet including face
r In pediatric patients, the ribs are more pliable and Initial Lab Tests
r No lab testing is necessary for the diagnosis of flail mask oxygen, CPAP, and chest physiotherapy.
less likely to fracture, although there may still be r Adequate analgesia is of paramount importance in
chest:
significant contusion of chest wall structures. patient recovery and may contribute to the return of
r In children, who have a more compliant chest wall, Consider obtaining a baseline arterial blood gas.
r The following may be helpful as part of the trauma normal respiratory mechanics.
flail chest is observed with lower frequency than r Early intubation and mechanical ventilation is
evaluation:
injury to the underlying structures, including the important in patients with refractory respiratory
CBC
lungs, heart, and mediastinal structures (4). failure or other serious traumatic injuries.
PT, PTT, INR
MEDICATION
First Line
r Analgesia is the mainstay of therapy for rib fractures.
r IV opioids:
Morphine 0.1 mg/kg IV/IM/SC q2h PRN
Initial morphine dose of 0.1 mg/kg IV/SC may
be repeated q1520min until pain is controlled,
then q2h PRN
Fentanyl 12 g/kg IV q2h PRN:
Initial dose of 1 g/kg IV may be repeated
q1520min until pain is controlled, then q2h
PRN
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FLAIL CHEST
Second Line In several studies, the surgically repaired group 4. Smyth BT. Chest trauma in children. J Pediatr Surg.
r Once admitted, patient-controlled administration demonstrated: 1979;14(1):4147.
(PCA) is the best method for age-appropriate and Significantly fewer days on the ventilator and in 5. Gipson CL, Tobias JD. Flail chest in a neonate
cooperative patients. the ICU resulting from nonaccidental trauma. South Med J.
r An alternative is a continuous epidural infusion of a Lower incidence of pneumonia 2006;99(5):536538.
local anesthetic agent (with or without an opioid Better pulmonary function at 1 mo 6. Nirula R, Diaz JJJr., Trunkey DD, et al. Rib fracture
analgesic). Higher return to work percentage at 6 mo than repair: Indications, technical issues, and future
This provides complete analgesia allowing normal the nonoperative group (7,8) directions. World J Surg. 2009;33(1):1422.
inspiration and coughing without the risk of r In summary, most pediatric patients with flail chest
7. Voggenreiter G, Neudeck F, Aufmkolk M, et al.
respiratory depression. These can be placed in the may be treated successfully with intubation and pain Operative chest wall stabilization in flail
thoracic or high-lumbar positions. management alone, but a small group may benefit chestoutcomes of patients with or without
r Regional anesthesia by rib block may provide from operative correction of the flail segment. pulmonary contusion. J Am Coll Surg. 1998;
tremendous pain relief. DISPOSITION 187(2):130138.
COMPLEMENTARY & ALTERNATIVE Admission Criteria 8. Ahmed Z, Mohyuddin Z. Management of flail chest
THERAPIES Critical care admission criteria: injury: Internal fixation versus endotracheal
r Simple chest wall injury rarely requires intubation r Inpatient management is necessary for patients with intubation and ventilation. J Thorac Cardiovasc
and mechanical ventilation. Surg. 1995;110(6):16761680.
flail chest.
r Where ventilation is necessary, it is usually for r Poor respiratory effort requires early intubation and
hypoxemia due to underlying pulmonary contusions. mechanical ventilation. ADDITIONAL READING
Positive pressure ventilation may be required for
severe chest wall instability resulting in inadequate r Mayberry JC, Ham LB, Schipper PH, et al. Surveyed
spontaneous ventilation.
r Prolonged mechanical ventilation is associated with
FOLLOW-UP opinion of American trauma, orthopedic, and
thoracic surgeons on rib and sternal fracture repair.
FOLLOW-UP RECOMMENDATIONS
the development of pneumonia and a poor
outcome. Tracheotomy and frequent flexible
r Discharge instructions and medications after
J Trauma. 2009;66(3):875879.
r Pettiford BL, Luketich JD, Landreneau RJ. The F
bronchoscopy should be considered to provide inpatient admission: management of flail chest. Thorac Surg Clin.
effective pulmonary toilet. Oral pain medications 2007;17(1):2533.
r Activity:
SURGERY/OTHER PROCEDURES Ad lib but no airplane travel if pneumothorax is See Also (Topic, Algorithm, Electronic
r Chest tube placement: Patients with rib fractures
present Media Element)
who are intubated are at an increased risk of http://www.trauma.org
developing a pneumothorax or tension Patient Monitoring
r Follow-up CXR 1 wk after the traumatic injury
pneumothorax due to laceration of the lung by the
sharp fracture end. In these cases, a prophylactic r Pulmonary function testing
CODES
chest tube is recommended. PROGNOSIS
r In most cases, positive pressure ventilation (CPAP or r Overall, patients with flail chest have 510% ICD9
intubation) allows for a nonoperative internal reported mortality if they reach the hospital alive. 807.4 Flail chest
stabilization of the chest wall, and fixation is not r Patients who do not need mechanical ventilation do
necessary. This is the conservative approach and is better statistically, and overall mortality seems to
applicable to most patients who have a flail chest.
r However, there is a small subgroup that may benefit increase with severity, age, and number of total rib PEARLS AND PITFALLS
fractures involved. r The diagnosis of flail chest is largely clinical.
from operative repair:
Internal fixation may: COMPLICATIONS Diagnosis: Observe paradoxical respirations while
Shorten duration of mechanical ventilation r Pneumonia the examiners hand is on the thorax (feel broken
Decrease the complication rate r Empyema ribs and crepitus).
Decrease the length of hospital stay r Bronchial pleural fistula r Consider associated injuries, particularly
Be cost-effective (68) r Chest wall deformity intrathoracic injuries.
Some indications for surgical repair include: r Chronic chest wall pain r Immediate treatment: Oxygen and pain
Failure to wean from the ventilator r Dyspnea on exertion management followed by possible intubation and
Paradoxical movement visualized during chest tube
weaning
Absence of pulmonary contusion REFERENCES
Absence of significant brain injury
Refractory pain despite narcotics or epidural 1. Garcia VF, Gotschall CS, Eichelberger MR, et al. Rib
pain catheter fractures in children: A marker of severe trauma.
J Trauma. 1990;30(6):695700.
2. Wanek S, Mayberry JC. Blunt thoracic trauma: Flail
chest, pulmonary contusion, and blast injury. Crit
Care Clin. 2004;20(1):7181
3. Ciraulo DL, Elliott D, Mitchell KA, et al. Flail chest
as a marker for significant injuries. J Am Coll Surg.
1994;178:466470.
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FOOD POISONING
Nahar D. Alruwaili
Brent W. Morgan
r Ciguatera toxin: Produced by dinoflagellates that r Botulism presents with impaired cranial nerve
BASICS bioaccumulate, ultimately concentrating in reef fish. activity such as difficulty swallowing or handling oral
The mechanism of intoxication may involve secretions, constipation, hypotonia with progressive
DESCRIPTION increased sodium permeability in sodium channels symmetric paralysis, absent deep tendon reflexes,
r There are many lay definitions of food poisoning. and stimulation of central or ganglionic cholinergic and apnea.
This topic will focus on illness created by receptors. r Patients with scombroid poisoning may present with
microorganism-generated toxins contained in foods. skin flushing, urticaria, bronchospasm, tachycardia,
r The most common bacterial toxins causing ETIOLOGY
See Pathophysiology. and hypotension.
foodborne illness will be discussed, including: r Ciguatera toxin may present with myriad symptoms:
Staphylococcal enterotoxin B (SEB) COMMONLY ASSOCIATED CONDITIONS Diarrhea; abdominal cramps and/or vomiting; CNS
Bacillus cereus toxin r Vomiting
symptoms, including sensory changes such as
Scombroid toxin r Diarrhea blurred vision, change in temperature perception
Ciguatera toxin (temperature reversal, which is considered specific
Botulinum toxin is discussed briefly. Also see the for ciguatoxin); sensation of teeth being painful or
Botulism topic. DIAGNOSIS loose; paralysis; and respiratory arrest.
EPIDEMIOLOGY HISTORY PHYSICAL EXAM
r An estimated 76 million cases of foodborne disease r Food poisoning most often presents as r The most important element of the physical exam is
occur each year in the U.S. gastroenteritis with nausea, vomiting, diarrhea, and the assessment of the patients hydration status,
r 325,000 hospitalizations in the U.S. annually abdominal pain. signs of bacteremia, sepsis, or shock.
r Estimated 5,000 deaths in the U.S. annually r Constitutional symptoms (fever, malaise, myalgias) r Vital signs: Tachycardia, tachypnea, hypotension
r SEB, B. cereus, botulism, and scombroid occur may be suggestive of invasive bacteria or systemic with dehydration, or toxin related
throughout the U.S. disease. r The patients general appearance: Well or ill or in
r Ciguatera poisoning occurs most frequently in r Oliguria may be suggestive of dehydration or renal
shock
Florida and Hawaii. failure. r HEENT: Presence or absence of tears; dry or moist
r Ask about:
RISK FACTORS mucous membranes; whether the eyes appear
r Risk factors vary with specific etiology. Timing of illness in relation to ingestions sunken; depressed or flat fontanelles
r Improper storage of food
Associated abdominal and systemic symptoms r Chest: Decrease of the air entry or wheezing
History of similarly exposed persons with related (bronchospasm); dysrhythmia may occur with
GENERAL PREVENTION symptoms ciguatera.
Proper cooking and storage of foods Type of food consumed: r Skin: Skin turgor, capillary refill, skin flushing,
Prepared foods: Meats, pastries, salads (SEB)
PATHOPHYSIOLOGY Contaminated fried rice (emetic B. cereus toxin) urticaria
r Toxins released by microorganisms into food may r CNS: Evaluate for neurologic involvement such as
or meatballs (diarrheal B. cereus toxin)
cause a variety of diseases. Carnivorous reef fish such as mackerel, paresthesias, motor weakness, ataxia, visual
r SEB: Heat-stable enterotoxin acts by stimulating barracuda, amberjack, and grouper (ciguatera disturbances, cranial nerve palsies, and temperature
release of cytokines from T cells in the intestines, toxin) reversal.
leading to inflammatory reaction and cell Large fishpoorly refrigerated: Tuna, bonito, DIAGNOSTIC TESTS & INTERPRETATION
destruction: albacore, mackerel (scombrotoxin) Lab
Enterotoxins also may act on receptors in the gut Home-canned foods No lab testing is absolutely necessary, but consider the
that transmit impulses to the emesis center in the r SEB:
following:
brain. Characterized by the abrupt onset of vomiting r Bedside glucose: Hypoglycemia can occur in patients
In severe poisoning, SEB may cause systemic within minutes to hours; vomiting is the most
illness, shock, and multisystem organ failure. with inadequate oral intake.
prominent finding. Severe abdominal cramps and r Serum electrolytes, BUN, creatinine
r B. cereus toxin: 2 recognized types of illness are diarrhea may occur. In severe illness, r CBC and C-reactive protein to evaluate inflammation
caused by 2 distinct toxins: low-gradefever or mild hypothermia can occur.
r B. cereus toxin2 clinical syndromes: r Urinalysis
The vomiting (emetic) type of illness (short
incubation and duration) is believed to be caused r Blood gas to evaluate oxygenation and perfusion
Emetic syndrome: Like staphylococcal foodborne
by a heat-stable toxin. r Stool culture and WBC: For severe diarrhea, fever,
illness with severe vomiting, but presentation may
The diarrheal type of illness (long incubation and be delayed, occurring in several to 15 hr after persistently bloody stools, neurologic findings,
duration) is caused by heat-labile toxins that ingestion. severe abdominal pain, or if patient is
increase intestinal secretions by activation of Differentiation between the B. cereus emetic immunocompromised or very young
adenylate cyclase in the intestinal epithelium. syndrome and SEB is difficult and may be based r Blood culture: If the patient is notably febrile
r Scombroid: Results from improper refrigeration or on the type of food involved. r When epidemic poisoning is suspected, state public
preservation of large fish, which results in bacterial Diarrhea syndrome has a slightly longer health departments or the CDC may be able to
degradation of histidine to histamine: incubation period of 816 hr. analyze suspect food for toxins.
Scombrotoxin is a term sometimes used to Both syndromes are mild and usually are not r Botulinum: Stool sample for botulinum spores and
describe histamine in this scenario. associated with fever. toxin
The histamine poisoning resembles an allergic r The health department may assay food for SEB, B.
reaction, with any combination of flushing, cereus, botulinum, ciguatoxin, and scombroid.
urticaria or other acute pruritic rash, vomiting,
diarrhea, cough, wheezing, stridor, or diaphoresis.
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FOOD POISONING
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DIFFERENTIAL DIAGNOSIS Issues for Referral 4. Fontoba JEB, Gutierrez C, Lluna J, et al. Bronchial
r Asthma Patients with low suspicion for FB with negative exam foreign body: Should bronchoscopy be performed in
r Bronchiolitis and radiographs may follow up with their primary care all patients with a choking crisis? Pediatr Surg Int.
r Croup providers, with referral to otolaryngology/surgery if 1997;12:118120.
r Epiglottitis symptoms recur or persist. 5. Black RE, Johnson DG, Matlak ME. Bronchoscopic
r Laryngotracheal malacia removal of aspirated foreign bodies in children.
r Pneumonia J Pediatr Surg. 1994;29:682684.
FOLLOW-UP
r Tracheitis 6. White DR, Zdanski CJ, Drake AF. Comparison of
r Vascular rings or slings FOLLOW-UP RECOMMENDATIONS pediatric airway foreign bodies over fifty years.
Patients discharged from the hospital are presumed South Med J. 2004;97:434436.
not to have FBA and should follow up with primary 7. Assefa D, Amin N, Stringel G, et al. Use of
TREATMENT care provider in 2448 hr to ensure symptoms have decubitus radiographs in the diagnosis of foreign
improved or resolved. body aspiration in young children. Pediatr Emerg
PRE HOSPITAL Care. 2007;23:154157.
r Administer supplemental oxygen. Patient Monitoring
r All patients with possible FBA should be on
r Basic life support for airway obstruction
continuous cardiopulmonary monitoring including ADDITIONAL READING
INITIAL STABILIZATION/THERAPY pulse oximetry until definitive care is provided.
r Complete airway obstruction per Basic Life Support r Capnography may be a useful adjunct for impending Schunk JE. Foreign body aspiration/ingestion. In
guidelines: respiratory failure. Fleisher GR, Ludwig S, eds. Textbook of Pediatric
Heimlich, chest thrusts may relieve complete Emergency Medicine. 6th ed. Philadelphia, PA:
DIET Lippincott Williams & Wilkins; 2010:307314.
obstruction. Keep patient NPO for possible anesthesia.
Needle cricothyrotomy may be necessary pending
surgical cricothyrotomy or tracheostomy. PROGNOSIS
r Patients generally have a favorable prognosis. CODES
High-flow oxygen and vascular access
Consult anesthesia or otolaryngology PRN. r Worse prognosis with: F
Rapid transfer to OR for bronchoscopy Complete airway obstruction ICD9
r Partial obstruction: Missed aspiration r 933.1 Foreign body in larynx
Keep patient comfortable, and avoid painful r 934.0 Foreign body in trachea
COMPLICATIONS
procedures. r Increased risk of complications with delayed r 934.9 Foreign body in respiratory tree, unspecified
High-flow oxygen diagnosis
Anesthesia and otolaryngology consultation r Due to FB:
r Stable patients with supportive history and/or
Early: PEARLS AND PITFALLS
exam: Asphyxiation
Radiographic evaluation to help localize FB r Pearls:
Postobstructive pulmonary edema
Rigid bronchoscopy is diagnostic and therapeutic. A careful history is the most useful diagnostic
r Stable patients with low suspicion: Late:
Pneumonia evaluation for FBA.
Screening CXR or fluoroscopy; if negative, consider Lung abscess Expiratory films may exaggerate localized
close observation and repeat films in 2448 hr. Bronchiectasis hyperinflation on chest films and are more helpful
Erosion with airway perforation or hemoptysis than inspiratory films.
MEDICATION In young children, evaluating for persistent
Fistula formation
First Line r Due to bronchoscopy: hyperinflation in the dependent hemithorax may
r No specific medications for FBA itself suggest air trapping.
r Nebulized racemic epinephrine 2.25% (0.5 mL in Anesthetic complications Radiographic changes evolve over time, so in the
2.5 mL normal saline): Oral trauma stable patient, follow-up films may provide an
May temporarily decrease swelling and Laryngeal edema alternative to immediate bronchoscopy.
obstruction in patients with stridor Bronchospasm r Pitfalls:
r Antibiotics for associated pneumonia: Atelectasis
A normal exam or negative radiographic studies
Retained fragments
Ampicillin/Sulbactam 50 mg/kg IV q6h cannot exclude FBA.
Ceftriaxone 50100 mg/kg IV q24h
Second Line REFERENCES
Dexamethasone 0.15 mg/kg IV q6h for 24 hr:
r If significant inflammation noted on bronchoscopy 1. Ciftci AO, Bingol-Kologlu M, Senocak ME, et al.
Bronchoscopy for evaluation of foreign body
SURGERY/OTHER PROCEDURES aspiration in children. J Pediatr Surg. 2003;38:
r Rigid bronchoscopy is the gold standard and is 99% 11701176.
effective in removal of large solid FB. 2. Mu LC, Sun DQ, He P. Radiological diagnosis of
r Thoracotomy is required for failed bronchoscopy. aspirated foreign bodies in children: Review of 343
cases. J Laryngol Otol. 1990;104:778782.
DISPOSITION
3. Digoy GP. Diagnosis and management of upper
Admission Criteria aerodigestive tract foreign bodies. Otolaryngol Clin
r Patients being evaluated by bronchoscopy require
North Am. 2008;41:485496, viiviii.
admission.
r Persistent hypoxia, respiratory distress, or
pneumonia
r Critical care admission criteria:
Patients with significant respiratory distress or
airway inflammation after bronchoscopy
Endotracheal intubation
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Fentanyl 12 g/kg IV q2h PRN: Discharge Criteria 6. Sharma A, Chauhan N, Alexander A, et al. The risks
Initial dose of 1 g/kg IV may be repeated r Asymptomatic patients with a blunt FB below the and the identification of ingested button batteries
q1520min until pain is controlled, then q2h diaphragm (except multiple magnets) can be safely in the esophagus. Pediatr Emerg Care. 2009;25(3):
PRN. discharged with expectant outpatient management: 196199.
Codeine or codeine/acetaminophen dosed as Patients in whom esophageal bougienage has 7. Cauchi JA, Shawls RN. Multiple magnet ingestion
0.51 mg/kg of codeine component PO q4h PRN successfully pushed the FB into the stomach and gastrointestinal morbidity. Arch Dis Child.
Hydrocodone/Acetaminophen dosed as 0.1 mg/kg r Esophageal FB has been removed. 2002;87(6):539540.
of hydrocodone component PO q46h PRN
Issues for Referral
Second Line Asymptomatic ingested FBs that fail to pass
Glucagon has not been demonstrated to increase the spontaneously after 23 wk should be referred to a
ADDITIONAL READING
rate of spontaneous passage of esophageal coins in pediatric gastroenterologist or surgeon for possible r Loh KS, Tan LKS, Smith JD, et al. Complications of
children and is not recommended (4). endoscopic or surgical removal. foreign bodies in the esophagus. Otolaryngol Head
SURGERY/OTHER PROCEDURES Neck Surg. 2000;123(5):613616.
r Endoscopic removal may be necessary: r Louie JP, Alpern ER, Windreich RM. Witnessed and
FOLLOW-UP unwitnessed esophageal foreign bodies in children.
Sharp objects are a greater risk for complications,
though there is no consensus on guidelines for FOLLOW-UP RECOMMENDATIONS Pediatr Emerg Care. 2005;21(9):582585.
endoscopic or surgical removal. r Waltzman M. Management of esophageal coins.
Patient Monitoring
Button batteries are a risk for erosive r Parents may be instructed to examine the stool for Pediatr Emerg Care. 2006;22(5):367373.
complications that may occur within hours in the r Wyllie R. Foreign bodies in the intestinal tract. Curr
the ingested FB over the ensuing days to weeks.
esophagus (6). When past the pylorus, they r Discharged patients with ingested distal FBs should Opin Pediatr. 2006;18:563564.
usually pass uneventfully; when retained in the seek immediate medical care if there is fever,
esophagus or stomach >12 hr, they usually abdominal pain, vomiting, or bloody stools.
require removal. CODES
Magnets, when multiply ingested, are at risk for DIET
impaction and pressure necrosis across adjacent No dietary restrictions
ICD9
F
loops of bowel and should be endoscopically or PROGNOSIS r 935.1 Foreign body in esophagus
surgically removed (7). r >90% of ingested FBs pass spontaneously without r 935.2 Foreign body in stomach
r No single strategy for the management of
complication. r 938 Foreign body in digestive system, unspecified
esophageal FBs exists, and several options can r Prolonged impaction, ingested button batteries,
be considered (see Foreign Body, Esophagus sharp objects, and multiple magnets are associated
topic):
A brief period (816 hr) of observation with
with serious complications (3,9,10). PEARLS AND PITFALLS
maintenance of NPO status and repeat x-rays may COMPLICATIONS r Ingested button batteries in the esophagus can
r Esophageal perforation with abscess formation,
be appropriate, as 2530% of FBs will pass cause erosion or perforation within hours and
without complication (1). mediastinitis, sepsis
r Arterial-esophageal fistula with hemorrhage should be emergently removed.
Esophageal bougienage with or without sedation r Ingestion of multiple small magnets can lead to
may be effective to push the esophageal FB into r Stricture formation
pressure necrosis of adjacent loops of bowel and
the stomach (2). r GI perforation with peritonitis, sepsis
require removal regardless of location within the GI
Removal using McGill forceps (for proximal FB) or tract.
a balloon-tipped catheter (usually under r Though >50% of patients with ingested FB are
fluoroscopy, performed in the Trendelenberg REFERENCES asymptomatic, 7590% will have a history of
position) may be effective in a minority of cases
1. Waltzman ML, Baskin M, Wypij D, et al. A ingestion when specifically questioned.
(3). r The rate of spontaneous passage of esophageal
Endoscopy using a rigid or flexible endoscope is randomized clinical trial of the management of
the mainstay of removal of most impacted esophageal coins in children. Pediatrics. foreign bodies is highest for those located in the
esophageal FBs (4). 2005;116(3):614619. distal 1/3, followed by the middle 1/3, and finally
r Ingested FB with signs or symptoms of perforation 2. Arms JL, Mackenbergo-Mohn MD, Bowen MV, the proximal 1/3; a brief period of observation may
et al. Safety and efficacy of a protocol using be warranted.
or distal GI impaction may require surgical
exploration and removal. bougienage or endoscopy for the management of
coins acutely lodged in the esophagus: A large case
DISPOSITION series. Ann Emerg Med. 2008;51(4):367372.
Admission Criteria 3. Soprano JV, Mandl KD. Four strategies for the
r Symptomatic patients, patients with ingestion if
management of esophageal coins in children.
multiple magnets, signs and symptoms of Pediatrics. 2000;105(1):e5e10.
perforation 4. Mehta D, Attia M, Quintana E, et al. Glucagon use
r Patients with ingested button batteries that have
for esophageal coin dislodgment in children: A
not passed the esophagus within 12 hr and stomach prospective, double-blind, placebo-controlled trial.
within 24 hr are at risk for erosive complications and Acad Emerg Med. 2001;8(2):200203.
should be admitted. 5. Lee JB, Ahmad S, Gale CP. Detection of coins
r Asymptomatic patients with impacted esophageal
ingested by children using a handheld metal
FBs who fail 816-hr observation should be detector: A systematic review. Emerg Med J.
admitted for endoscopic removal. 2005;22(12):839844.
r Critical care admission criteria:
Signs and symptoms of GI perforation:
Mediastinitis or peritonitis with unstable vital
signs may require admission to an ICU.
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PATHOPHYSIOLOGY Imaging
BASICS r Alkaline or lithium batteries cause corrosion and r Plain abdominal and chest radiographs to locate the
coagulation necrosis of esophageal or GI mucosa, battery should be obtained on any patient with
DESCRIPTION skin, or nasal/ear mucosa. potential ingestion:
r Disc batteries are an exception to the benign nature r Less commonly, batteries may cause pressure In small children, it is often possible to include a
of most ingested foreign bodies: necrosis, mucosal burns (from small electrical significant portion of the abdomen with a chest
Found in watches, hearing aids, and other small activity), or toxic metal absorption if corrosion radiograph.
electronics, these small round candy-sized objects occurs: r If these radiographs are negative, consider a lateral
can be enticing to small children. Disc batteries may contain lithium (Li), manganese neck radiograph. This may locate a battery in the
r These batteries are often alkaline in composition (Mn), mercury (Hg), nickel (Ni), silver (Ag), or zinc hypopharynx or nasopharynx.
(consisting of metal oxidesusually silver, mercury, (Zn). r The structure of a disc battery gives it a double-ring
or manganese) and can result in corrosive injuries. r Ingested batteries with higher voltage or of larger appearance on plain radiographs. Coins appear as a
r Older toys or those from other countries may have size (sizes range from 823 mm) have a higher rate homogeneous circle without a 2nd ring.
higher risk due to inadequate seal/coating. of complications:
r The increasingly popular lithium batteries contain Diagnostic Procedures/Other
Additionally, larger batteries are less likely to pass Endoscopy can be used both for removal and to assess
several organic solvents and can also cause severe into the stomach. the extent of injury.
corrosive injuries.
r Ingestion is the most common cause of injury, but ETIOLOGY Pathological Findings
r Placement of a disc battery into an orifice for
disc batteries can be inserted into other orifices such Burns, coagulation necrosis, and mucosal sloughing
curiosity or entertainment by a child given the may be seen on endoscopy.
as the ear or nose. semblance to candy or age-appropriate oral behavior
r While generally benign once past the esophagus, r Primarily unintentional ingestions: DIFFERENTIAL DIAGNOSIS
disc or button batteries can result in rapid r Other foreign body ingestion
Only 446 of 10,213 cases reported in 2007 were
esophageal corrosion and/or hemorrhage and r Pill esophagitis
described as intentional.
should be removed emergently when identified to r Coin ingestion (coin is generally larger)
be in the esophagus. r Caustic ingestion
EPIDEMIOLOGY
DIAGNOSIS
Incidence HISTORY
r Disc batteries account for 2% of foreign body r Note time of exposure or insertion of battery into TREATMENT
ingestions (1). the orifice. PRE HOSPITAL
r The American Association of Poison Control Centers r Most often asymptomatic after observed or reported
Children with airway compromise should be managed
reports thousands of disc battery ingestions per year ingestion according to the Pediatric Advanced Life Support
(10,213 in 2007) (1). r Patients or their guardians may report history of
algorithm.
r The overall incidence of nasal button batteries is drooling, vomiting or gagging, throat or chest pain,
unknown (2). dysphagia, anorexia, abdominal pain or distension, INITIAL STABILIZATION/THERAPY
r 2 cases of severe corrosive burns to the skin have r Assess and stabilize airway, breathing, and
hematemesis, or diarrhea.
been reported when a button battery has been circulation.
PHYSICAL EXAM r Batteries should be removed emergently, regardless
lodged under a hard cast (3). r Usually asymptomatic, though fever, tachycardia,
r Button battery aspiration, with coagulation necrosis of time of last oral intake:
and/or hypotension are suggestive of GI tract Patients should be made NPO and prepared for
of the hypopharynx and respiratory mucosa, has perforation surgery.
also been reported: r Drooling may be a sign of pharyngeal or esophageal r Antibiotics should be given if there are concerns of
May lead to the formation of tracheoesophageal obstruction (more common with larger batteries) or
fistulas (4). GI tract perforation.
represent late effects such as necrosis or perforation. r Analgesic agents should be administered as needed
RISK FACTORS r Nasal bleeding or erythema
r Age (preschool years most common): for pain.
r Ear discharge or bleeding r Neutralizing agents have not been shown to
Over half of reported ingestions in 2007 occurred decrease complications.
in children <6 yr. DIAGNOSTIC TESTS & INTERPRETATION
r Agents that increase GI motility also have not been
r Developmental delay in older children Lab
r Ingestions often occur in a grandparent or elderly Initial Lab Tests shown to be effective (5).
r Unnecessary for uncomplicated cases
relatives home. MEDICATION
r For cases in which obstruction or perforation is
First Line
GENERAL PREVENTION suspected, CBC, serum electrolytes, BUN, and r Opioids:
r Prevent toddlers from having access to button
creatinine should be obtained. Morphine 0.1 mg/kg IV/IM/SC q2h PRN:
batteries. Avoid toys with button batteries. r If the removed battery containing mercury or Initial morphine dose of 0.1 mg/kg IV/SC may
r Make sure that a toys battery compartment is
cadmium is not intact, mercury or cadmium levels be repeated q1520min until pain is controlled,
properly secured. may need to be assayed. However, cases of systemic then q2h PRN.
toxicity have not been reported. Codeine/Acetaminophen dosed as 0.51 mg/kg of
codeine component PO q4h PRN
Hydrocodone or hydrocodone/acetaminophen
dosed as 0.1 mg/kg of hydrocodone component
PO q46h PRN
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r NSAIDs: Issues for Referral 4. Slamon NB, Hertzog JH, Penfil SH, et al. An unusual
Relatively contraindicated in oral ingestions r Any significant esophageal injury necessitates close case of button battery-induced traumatic
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN follow-up with the surgeon for stricture formation tracheoesophageal fistula. Pediatr Emerg Care.
Ketorolac 0.5 mg/kg IV/IM q6h PRN and new or recurrent fistulas. 2008;24(5):313316.
Naproxen 5 mg/kg PO q8h PRN r ENT or pediatric surgery specialists should be 5. Litovitz T, Butterfield AB, Holloway RR, et al.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN contacted for operative removal of nasal or ear Button battery ingestion: Assessment of
Second Line foreign bodies in the operating room under direct therapeutic modalities and battery discharge state.
Broad-spectrum antibiotics with anaerobic coverage visualization and for follow-up if necrosis. J Pediatr. 1984;105(6):868873.
for perforation:
r Cefoxitin: FOLLOW-UP ADDITIONAL READING
80160 mg/kg/day IV divided q46h
Adult dose: 12 g IV q68h FOLLOW-UP RECOMMENDATIONS r Fergusson JA. Lead foreign body ingestion in
r Clindamycin: r Discharge instructions and medications: children. J Ped Child Health. 1997;33(6):542544.
30 mg/kg/day IV divided q8h, max single dose Return for respiratory distress, poor feeding, fever, r Kost KM, Shapiro RS. Button battery ingestion: A
900 mg IV q8h or chest pain. case report and review of the literature.
r Piperacillin/Tazobactam (Zosyn): r Activity: J Otolaryngol. 1987;16(4):252257.
<6 mo old: 150300 mg/kg/24 hr IV div q68h Regular activity as tolerated
See Also (Topic, Algorithm, Electronic
>6 mo old and children: 240400 mg/kg/24 hr IV Patient Monitoring Media Element)
div q68h Children will need to be monitored as outpatients by r Burn, Chemical
Adult dose: 3 g IV q6h the primary care provider, surgeon, or r Burn, Thermal
SURGERY/OTHER PROCEDURES gastroenterologist for further complications. r Foreign Body Aspiration
r Removal techniques vary by institution: r Foreign Body, Ear
DIET
Disc batteries in the esophagus should typically be In patients with esophageal injury, NG tube feeds or r Foreign Body, Esophagus
removed promptly without delay:
Improvements in the sealing of such batteries,
pureed foods may be necessary until wounds are fully r Foreign Body Ingestion F
healed. r Foreign Body, Nose
making them less prone to leak their caustic
contents, has led some clinicians to allow a brief PROGNOSIS
period of hours to see if battery will pass to the Patients with prompt removal (prior to any esophageal
stomach. burns) of the foreign body have excellent prognosis. CODES
We do not recommend this strategy. COMPLICATIONS
Techniques include endoscopy under anesthesia, r Esophageal perforation and tracheoesophageal ICD9
magnet extraction (orogastric tube with attached r 931 Foreign body in ear
fistula formation if the battery remains in the
magnet) using fluoroscopy, and surgical removal. r 932 Foreign body in nose
esophagus or stomach more than 34 hr
r Nasal and ear foreign bodies require surgical r Gastric hemorrhage and aortoesophageal fistulas r 935.1 Foreign body in esophagus
removal if not easily extracted with an ear curette or with hemorrhage have also been described.
other small hook in the emergency department: r Children with esophageal injuries are at risk for
Alligator forceps may rarely break or damage the developing esophageal strictures, feeding PEARLS AND PITFALLS
cell, causing increased tissue damage and should difficulties, or tracheoesophageal fistulas with r Pearls:
not be routinely used. (See Foreign Body, Nose resultant pulmonary complications.
and Foreign Body, Ear topics for more details.) r Nasal septal perforation and saddle-nose deformity Esophageal disc batteries are highly concerning
for their ability to cause caustic or electrical injury.
DISPOSITION are common complications when disc batteries are Prompt removal is recommended.
Admission Criteria nasal foreign bodies. Prompt recognition and treatment can prevent
r Patients with minor esophageal burns should be significant morbidity and mortality.
monitored in the hospital. The frequent lack of initial symptoms and rapid
r NG tube feedings are recommended until wounds REFERENCES onset of mucosal injury place children at high risk
heal. 1. Bronstein AC, Spyker DA, Cantilena LR, et al. 2007 for potentially life-threatening esophageal injuries.
r Critical care admission criteria: Annual Report of the American Association of r Pitfalls:
Known esophageal rupture or hemorrhage Poison Control Centers National Poison Data Failure to appreciate the significant morbidity that
Patients with respiratory difficulty or unstable vital System (NPDS): 25th annual report. Clin Toxicol. may result from button battery ingestion, even in
signs 2008;46(10):9271057. initially asymptomatic children, may be disastrous.
Discharge Criteria 2. Glynn F, Amin M, Kisella J. Nasal foreign bodies in
r If a battery located in the ear, nose, nasopharynx, or children. Pediatr Emerg Care. 2008;24(4):
esophagus has been removed without complication, 217218.
the patient may be discharged after appropriate 3. Moulton SL, Thaller LH, Hartford CE. A wound
postsedation recovery. caused by a small alkaline cell battery under a
r Hospitalized patients should demonstrate ability to plaster cast. J Burn Care Res. 2009;30(2):355357.
tolerate feeds (either by mouth or by NG tube if
wounds necessitate).
r Consider follow-up endoscopy prior to discharge to
assess for any damage not seen on the initial
evaluation.
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r Once a swallowed foreign body reaches the stomach r Physical findings may be due to complications of
BASICS within a normal GI tract, it is likely to pass through foreign body migration or esophageal perforation. In
within 46 days and less likely to lead to this situation, the following will be found:
DESCRIPTION complications: Drooling, pooling of secretions
r Foreign bodies discussed here are coins, sharp Possible problem sites more distal include the Rales, swelling or crepitus in neck, or peritonitis
foreign bodies, long or large objects, magnets and pylorus, the fixed curves of the C loop of the Respiratory distress that can manifest as:
lead, and impacted food. duodenum (ie, secondary to its retroperitoneal Stridor
r Coins are the most common ingested foreign body location), and the ileocecal valve. Wheezing
in the U.S. and Europe. Increased work of breathing
r In Asia and other countries where fish is a large ETIOLOGY
r Food boluses DIAGNOSTIC TESTS & INTERPRETATION
component of the diet, fish bone ingestion and r Esophageal abnormalities
impactions are common.
Imaging
r Oral behavior of younger children r Chest/Abdominal radiography is most useful given
r Meat/Food impaction is common in adolescents and
that most foreign bodies ingested by children are
adults. COMMONLY ASSOCIATED CONDITIONS radiopaque.
Esophageal abnormalities r Coins in the esophagus appear in an en face
EPIDEMIOLOGY
Data from the American Association of Poison Control position on an AP view and the edge of the coin will
Centers suggest that in 2007 there were more than DIAGNOSIS be seen on the lateral view, while the opposite if the
125,000 cases of foreign body ingestion by children coin is in the trachea.
<19 yr old: HISTORY r If the swallowed object is below the diaphragm,
r Incidence is highest in children ages 6 mo to 4 yr of r Children present after a caregiver witnesses the
further radiography is generally unnecessary since
age. ingestion of a foreign body or after a child reports the object should pass through the GI tract in the
r 98% of foreign body ingestions in children are ingestion to a caregiver. setting of normal anatomy.
r Often presents asymptomatically r Radiolucent objects in the esophagus may be better
accidental (1).
r May have vague symptoms that do not promptly visualized if the study is done after having the
RISK FACTORS suggest foreign body ingestion patient drink a small amount of dilute contrast (ie,
r Foreign body entrapment and subsequent
r The child may present with signs or symptoms of a should not be done if endoscopy is planned).
perforation are more likely at the site of a congenital r CT scan or MRI is rarely indicated.
complication of ingestion.
malformation or at the site of prior surgery. r Esophageal foreign body symptoms:
r 95% of meat impaction has underlying esophageal Diagnostic Procedures/Other
Dysphagia Handheld metal detectors have been shown to have
pathology that contributes to impaction:
Food refusal 100% sensitivity and 92.4% specificity in experienced
Pathology includes peptic ulcers, caustic injury, or
Drooling hands in identifying the location of ingested metallic
postoperative strictures.
Emesis/Hematemesis objects (2).
A more recently recognized pathology is
Foreign body sensation
eosinophilic esophagitis. DIFFERENTIAL DIAGNOSIS
r Food impaction may also be associated with Chest pain
r Esophagitis
Sore throat
underlying motility disorders. Stridor r Viral or streptococcal pharyngitis
r Mental retardation and psychiatric illness are r Croup or retropharyngeal abscess
Cough
associated with foreign body ingestion. Unexplained fever r Upper respiratory tract infection
r Stomach/Lower GI tract foreign body symptoms: r Psychological sensation or hysteria
GENERAL PREVENTION
r Parents should be advised to keep coins, sharp Abdominal distention/pain
foreign bodies, long or large objects, magnets, and Vomiting
lead-based toys out of reach of small children. Hematochezia TREATMENT
r Education on cutting food into manageable Unexplained fever
proportions and complete mastication of food prior PRE HOSPITAL
PHYSICAL EXAM Assess and stabilize airway, breathing, and
to swallowing r Physical exam is usually normal.
r Signs mentioned in the History section may be circulation.
PATHOPHYSIOLOGY r Using abdominal thrusts to dislodge a foreign body
r 3 main locations: Esophagus, stomach, and lower GI present.
r Abrasions, blood streaks, or edema in the in a spontaneously breathing patient without
tract respiratory distress is not advised.
r Esophagus has 3 typical locations of impaction: hypopharynx may be evidence of proximal
6070% impact at thoracic inlet, 1020% lodge swallowing-related trauma. INITIAL STABILIZATION/THERAPY
r Inspection of the oropharynx may reveal an r Patients with drooling, marked emesis, or altered
in the mid-esophagus at the level of the aortic
notch, and 20% lie just above the lower impacted foreign body. mental status may need supportive measures to
esophageal sphincter: r Drooling or pooling of secretions suggests an protect the airway.
The thoracic inlet is the area between the r Coin ingestion:
esophageal foreign body but may be due to an
clavicles on CXR. esophageal abrasion. Emergent endoscopic removal of esophageal coins
In the esophagus, there is an anatomic change should be performed in symptomatic patients
from skeletal muscle to the smooth muscle. unable to swallow their secretions or who are
The cricopharyngeus sling at C6 may provide an experiencing acute respiratory symptoms.
area of further entrapment of foreign body.
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DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Nasal tumor or mass
r Nasal polyp
DESCRIPTION HISTORY r Septal hematoma
r Nasal foreign bodies are most commonly found on r Most nasal foreign bodies are often asymptomatic
r Foreign body that has already been removed or
floor of nasal passage, below the inferior turbinate. and incidentally noted by the caregiver or patient.
r Common types of foreign bodies inserted: r Can often elicit a history of child placing a foreign dislodged by the time of the emergency department
visit
Food: Corn kernels, seeds, beans body in the nose
Toys: Crayons, beads, play dough, plastic toy parts r Foul chronic nasal discharge, usually unilateral
Miscellaneous: Paper, Styrofoam, magnets, rocks, r Epistaxis TREATMENT
buttons, erasers r Pain or discomfort
r Sneezing PRE HOSPITAL
EPIDEMIOLOGY Assess and stabilize airway, breathing, and
r Snoring
Incidence circulation.
r Mouth breathing
0.1% of pediatric emergency department visits
INITIAL STABILIZATION/THERAPY
Prevalence PHYSICAL EXAM r Assess and stabilize airway, breathing, and
r Most common in children between 2 and 4 yr of age r Foreign body visualized in nasal cavity
circulation.
r Gender ratio depends on type of foreign body: r Fever r Prevent child agitation to decrease the risk of airway
Beads: Male to female ratio is 1:1.9. r Nasal discharge
aspiration.
Plastic toys: Male to female ratio is 1:1. r Epistaxis r Patient may need to be appropriately restrained with
r May have septal laceration or perforation a papoose or sedated to achieve optimal conditions
GENERAL PREVENTION
r Keep small objects out of the reach of children. r Enlarged nasal turbinate or mucosal edema to remove the object.
r Parental and child education r Bony destruction
r Granulation tissue from chronic foreign body MEDICATION
r Proper child supervision r 1% lidocaine without epinephrine drops to nasal
r Requires a light source for visualization such as an
PATHOPHYSIOLOGY cavity for local anesthesia, up to 5 mg/kg:
otoscope, a nasal speculum, or an illuminated Consider using 2% viscous lidocaine as lubricant
Pathophysiology depends on the composition of the
magnifying glass to fully examine the patient when using a Foley catheter for removal.
foreign body:
r 0.5% phenylephrine spray to decrease mucosal
r Battery corrosion may release alkaline material DIAGNOSTIC TESTS & INTERPRETATION
Lab swelling, 12 sprays in affected nostril
when in contact with moist mucosa, producing r Antibiotics:
thermal burn. CBC, ESR, C-reactive protein, and/or blood culture if
r Nasal foreign bodies may exert a mass and pressure infection is suspected Consider Cephazolin if suspected facial cellulitis:
25100 mg/kg/24 hr q68h IV.
effect. Imaging
r Certain items such as food can cause a local and Consider ampicillin/sulbactam if suspected sinus
Consider radiographic imaging of nasal bones if involvement: 100200 mg/kg/24 hr q6h IV or IM.
systemic inflammatory response that results in unable to visualize a radiopaque foreign body in the
increased swelling. nasal cavity.
ETIOLOGY Diagnostic Procedures/Other
Insertion of a foreign body for curiosity or r Visualization using an otoscope, an illuminated
entertainment by a child magnifying glass, or a nasal speculum
r Use of a fiberoptic scope either by an emergency
COMMONLY ASSOCIATED CONDITIONS
Foreign body in the opposite nasal passage or another department physician or an otolaryngologist
body orifice
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SURGERY/OTHER PROCEDURES
r Use a light source and nasal speculum during
Discharge Criteria
r Well appearing with normal vital signs
ADDITIONAL READING
foreign body removal. r No airway compromise or concerns r Davies PH, Benger JR. Foreign bodies in the nose
r Techniques for removal: and ear: A review of techniques for removal in the
Issues for Referral emergency department. J Accid Emerg Med.
Parents kiss: Otolaryngology referral if removal is anticipated to be
Caretaker applies positive pressure through the 2000;17(2):9194.
difficult, attempt at removal is unsuccessful, or r Hein SW, Maughan KL. Foreign bodies in the ear,
childs mouth and simultaneously occludes the perforation or mass is suspected
contralateral nostril nose and throat. Am Fam Physician. 2007;76(8):
Oral insufflations with a bag valve mask: 11851189.
Positive pressure applied similar to parents FOLLOW-UP r Kadish HA, Corneli HM. Removal of nasal foreign
kiss bodies in the pediatric population. Am J Emerg Med.
Hooked probe or alligator forceps for foreign body FOLLOW-UP RECOMMENDATIONS 1997;15(1):5456.
r Discharge instructions and medications: r Kiger JR, Brenkert TE, Losek JD. Nasal foreign body
close to anterior nares
Balloon catheter: Follow up with a primary care physician or return removal in children. Pediatr Emerg Care. 2008;
Insert a 58 French Foley or 46 Fogarty to the emergency department if there is prolonged 24(11):785789.
catheter past foreign body, inflate balloon epistaxis, respiratory difficulty, or signs and
23 mL, then withdrawal catheter with foreign symptoms of infection.
body. Routine antibiotics are not recommended for CODES
Suction catheter for round, smooth object close to patients without septal perforation or signs of
the anterior nares bacterial infection.
r Activity: ICD9
Saline washout: 932 Foreign body in nose
Use a high-pressure bulb syringe filled with May resume normal routine without activity
isotonic sodium chloride to the contralateral restrictions
nostril.
PROGNOSIS PEARLS AND PITFALLS
Saline can also cause objects to swell or change
in consistency.
Usually full recovery after retrieval of foreign body r Pearls: F
Organic matter/food COMPLICATIONS Sedation may reduce the cough or gag reflex if a
Forceful injection of saline can be a powerful r Nasal foreign body gets into trachea foreign body is pushed into the pharynx, resulting
choking stimulus. r Epistaxis in airway compromise.
Cyanoacrylate glue: r Nasal septal ulceration or perforation Reinspect the nose and other orifices for a 2nd
Apply a small amount on a cotton swab, press r Nasal meatal stenosis foreign body prior to discharge.
onto object for 60 sec, then attempt removal. r Thermal burn with button batteries Consider using viscous lidocaine as a lubricant
Magnet for use for retrieval of metallic objects r Pressure necrosis with magnets when using a Foley catheter for removal.
r Pitfalls:
DISPOSITION r Pain and discomfort from removal
r Laceration Risk of aspiration or pushing object further into
Admission Criteria the nasal cavity, particularly if removal is
r Aspiration of foreign body resulting in airway r Barotrauma from positive pressure
attempted in an uncooperative child
compromise r Accidental adhesion of glue to mucosa
r Removal requiring surgical intervention r Infection risks:
r Infection requiring parenteral antibiotics
Acute otitis media
Sinusitis
Facial cellulitis
Periorbital cellulitis
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Diagnostic Procedures/Other
BASICS DIAGNOSIS r DRE
r Anoscopy
DESCRIPTION HISTORY r Rigid sigmoidoscopy
r The frequency of rectal foreign bodies encountered r There may be a history of anal manipulation, foreign
in the emergency department is increasing. body insertion, or sexual abuse: Pathological Findings
r Patients are reluctant to disclose their presence, Ask how long the foreign body has been in the r Intra-abdominal free air
rectum. r Peritoneal signs on abdominal exam
which only delays their removal.
r The most serious complication is perforation of the Inquire as to how many attempts have been made r Rectal bleeding
rectum or colon. to remove the object.
If self-introduced or concealing an object, the DIFFERENTIAL DIAGNOSIS
r There is a high success rate for outpatient r Constipation
history is often vague or inconsistent. r Rectal tear
management. r The patient may complain of anal or abdominal
r Hemorrhoids
EPIDEMIOLOGY pain, constipation, rectal bleeding, difficulty voiding,
r Intestinal polyp
Incidence or fever.
r Increasing incidence due to increasing popularity of r Perirectal abscess
PHYSICAL EXAM
anal eroticism r On external exam, look for signs of trauma.
r 33% of patients with self-introduced rectal foreign r Attempt to palpate the foreign body on digital rectal TREATMENT
bodies do not initially admit to the act (1). exam (DRE) or anoscopy for better visualization,
Prevalence only if a sharp object is not suspected: PRE HOSPITAL
Unknown r Pain management
Low-lying objects are normally palpable by DRE
and are often easily removed in the emergency r NPO for possible sedation/general anesthesia
RISK FACTORS r Do not attempt to remove a rectal foreign body.
r Young children department.
r Psychiatric patients High-lying objects above the rectosigmoid
junction are difficult to visualize and remove. INITIAL STABILIZATION/THERAPY
r Victims of assault r Sphincter relaxation is mandatory for removal of
High-lying objects are 2.25 times more likely to
require operative intervention (2). large foreign bodies.
GENERAL PREVENTION r In consultation with surgery, consider the
Careful insertion of rectal thermometers and enema r Abdominal exam may reveal tenderness to palpation
or peritoneal signs if perforation or obstruction is following methods of analgesia and foreign body
tips
present. removal (4):
PATHOPHYSIOLOGY r There may be bloody discharge from the rectum or Local infiltrative anesthesia or IV sedation is
r Delay in presentation and multiple attempts at useful.
loose sphincter tone.
self-removal may lead to mucosal edema and injury For digital extraction, lubricate the area with
as well as muscular spasm. DIAGNOSTIC TESTS & INTERPRETATION lidocaine jelly and use the other hand to apply
r Perforation of the rectal wall can lead to extension Lab abdominal pressure.
of injury into the peritoneum or perineum: Initial Lab Tests Grasp the edge of the object with forceps and
2/3 of the rectum is extraperitoneal. r No labs are required for emergency department apply traction while the patient bears down to
management. perform a Valsalva maneuver.
ETIOLOGY r CBC may reveal leukocytosis, which is suggestive of For anal block, inject local anesthetic with a
r Most objects found in children are self-introduced or
perforation. 30-gauge needle. Raise an intradermal wheal at 6
placed iatrogenically (ie, tip of thermometer).
r They are also found in psychiatric patients, victims of r Preoperative labs may be indicated if the patient is and 12 oclock positions. Then, with a larger
needle, inject circumferentially along the internal
assault, cases of concealment (ie, weapons or drug requiring surgical removal of the object.
sphincter muscles along the anal canal.
packets), patients with constipation, and from sex Imaging If the object has created a vacuumlike effect, pass
practices. r Plain abdominal radiographs can detect
a well-lubricated Foley catheter beyond the object
r It is possible to have an ingested foreign body intra-abdominal free air: and inflate a balloon to break the seal and aid in
lodged in the rectum (ie, toothpick, chicken bone). An upright image can assist in looking for free air removal.
r Sexual assault and child abuse must be considered. under the diaphragm. For removal, you may need to use a vaginal
r Radiographs are also used to determine the number speculum, obstetric forceps, or an obstetric
COMMONLY ASSOCIATED CONDITIONS
r Psychiatric disorder of foreign bodies as well as the shape, surface vacuum extractor.
outline, location, and direction (3). r Limit time for attempts at removal to 30 min (4).
r Constipation
r May need serial images to follow progress of object r In patients where multiple exams or attempts to
through rectum remove the foreign body occur, admit the patient for
r Radiographic study with contrast: a higher level of anesthesia and more invasive exam
Use water-soluble contrast if perforation is techniques.
suspected.
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r MRI is superior to CT for soft tissue and ligamentous SURGERY/OTHER PROCEDURES REFERENCES
injuries. It has limited utility in the emergent setting Surgical management is reserved for neurologic injury
because of availability and accessibility. and/or unstable fractures: 1. Kokoska ER, Keller MS, Rallo MC, et al.
r SCIWORA: r Conservative treatment includes skeletal traction Characteristics of pediatric cervical spine injuries.
See objective signs of myelopathy as a result of and closed reduction (halo vest). J Pediatr Surg. 2001;36(1):100105.
trauma in the absence of findings on plain r Surgical treatment includes cervical spine 2. Fesmire F, Luten R. The pediatric cervical spine:
radiographs and CT. decompression and fusion. Developmental anatomy and clinical aspects.
535% of patients with myelopathy may have J Emerg Med. 1989;7:133142.
SCIWORA (7) DISPOSITION 3. Viccellio P, Simon H, Hoffman JR, et al. A
MRI should be performed or CT myelography if Admission Criteria prospective multicenter study of cervical spine
MRI is unavailable. r Radiographic evidence of cervical spine fracture or injuries in children. Pediatrics. 2001;108:e20.
dislocation 4. Patel J, Tepas JJ. Pediatric cervical spine injuries:
Diagnostic Procedures/Other r Symptoms of spinal cord injury with negative
Somatosenosry evoked potentials: Defining the disease. J Pediatr Surg. 2001;36(2):
r Electrical impulse in response to stimuli radiographic imaging (SCIWORA) 373376.
r Critical care admission criteria: 5. Khanna G, El-Khoury GY. Imaging of cervical spine
DIFFERENTIAL DIAGNOSIS All patients with proven or suspected spinal cord injuries in childhood. Skeletal Radiol. 2007;36:
r Ligamentous injury injuries and progressing neurologic exam or 477494.
r Muscles strain abnormal vital signs 6. Ralston ME, Chung K, Barnes PD, et al. Role of
r Cauda equina syndrome Unstable fractures or dislocations at high risk for flexion-extension radiographs in blunt pediatric
r Spinal cord infections, neoplasms causing spinal cord injury cervical spine injury. Acad Emerg Med.
r Vertebral artery dissection Discharge Criteria 2001;8:237245.
r Resolution or improvement/stabilization of 7. Pang D, Polack I. Spinal cord injury without
neurologic symptoms: radiographic abnormality in childrenthe
TREATMENT Disposition to physical rehabilitation facility as SCIWORA syndrome. J Trauma. 1989;29:654664.
PRE HOSPITAL
required
r Adequate pain control
8. Short DJ, Masry WS, Jones PW. High dose F
r Assess and stabilize airway, breathing, and methylprednisolone in the management of acute
spinal cord injurya sytematic review. Spinal
circulation. Issues for Referral
Cord. 2000;38(5):273286.
r Immobilization of spine with cervical collar and long Suspected spinal cord injury should have neurosurgery
spine board is necessary: and/or orthopedic consultations.
If properly fitting cervical collars are unavailable, ADDITIONAL READING
splinting the head and body with towels or foam FOLLOW-UP
blocks and tape is a reasonable option. Kilmo P, Ware ML, Gupta N, et al. Cervical spine
Maintain the patient in a neutral position, and FOLLOW-UP RECOMMENDATIONS trauma in the pediatric patient. Neurosurg Clin North
avoid head and neck movement while full spinal r Discharge instructions and medications: Am. 2007;18(4):599620.
immobilization is being applied. Maintain cervical spine immobilization. See Also (Topic, Algorithm, Electronic
INITIAL STABILIZATION/THERAPY Adequate pain control Media Element)
r Assess and stabilize airway, breathing, and r Activity: r Fracture, Coccyx
circulation per Advanced Trauma Life Support (ATLS) Restricted with no contact activities until cleared r Spinal Cord Compression
and Pediatric Advanced Life Support guidelines: by physician r Strangulation
If suspicion for cervical spine fracture, immobilize Patient Monitoring r Trauma, Neck
the patient with a rigid cervical collar and a long r Monitor for any new neurologic deficits or r Trauma, Spinal Cord
spine board if not done earlier. progression of pre-existing deficits.
Evaluate for associated injuries. r Monitor for parathesias or inability to void or
Perform serial neurologic exams. incontinence. CODES
r Control of pain, preventing further injury, and
stabilize associated injuries PROGNOSIS
r Related to associated spinal cord injury ICD9
r Early, timely consultations with neurosurgery and/or r 805.00 Closed fracture of cervical vertebra,
r Mortality from spinal cord injury decreased 24%
orthopedic surgery: unspecified level
over past 30 yr; 80% of patients hospitalized for
If subspecialty care is not available, arrange r 805.01 Closed fracture of first cervical vertebra
transfer to trauma center. spinal cord injury survive (1).
r 805.02 Closed fracture of second cervical vertebra
MEDICATION COMPLICATIONS
r Spinal or neurogenic shock
First Line r Paralysis
r Morphine 0.1 mg/kg IV/IM/SC q2h PRN: PEARLS AND PITFALLS
r Cord syndromes (complete, incomplete, anterior
Initial morphine dose of 0.1 mg/kg IV/SC may be r Pearls:
repeated q1520min until pain is controlled, then cord, Brown-Sequard)
r Horner syndrome Younger children are more susceptible to upper
q2h PRN.
r Fentanyl 12 g/kg IV q2h PRN: cervical injuries, unlike older children who are
more likely to have lower cervical spine
Initial dose of 1 g/kg IV may be repeated
involvement.
q1520min until pain is controlled, then q2h PRN. r Pitfalls:
Second Line Improper immobilization
Consider methylprednisolone: 30 mg/kg IV over Do not remove a cervical collar on a patient with
15 min, then 5.4 mg/kg/hr over the next 23 hr. abnormal mental status.
(Caution: Dosage based on adult guidelines; lack of
high-level pediatric evidence):
r Previously, steroids were recommended by the ATLS
guidelines, but based on recent data this
recommendation has been withdrawn.
r Routine use is institution dependent (8).
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FRACTURE, CLAVICLE
Louis A. Spina
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FRACTURE, CLAVICLE
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FRACTURE, COCCYX
Nazreen Jamal
Bruce L. Klein
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FRACTURE, COCCYX
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FRACTURE, FEMUR
Tara Webb
Marc Gorelick
382
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FRACTURE, FEMUR
383
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FRACTURE, FOOT
Bhawana Arora
Usha Sethuraman
384
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, FOOT
385
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FRACTURE, FOREARM/WRIST
Dante Pappano
Darshan Patel
386
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FRACTURE, FOREARM/WRIST
387
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FRACTURES, GREENSTICK/BOWING
Rasha Dorothy Sawaya
Cindy Ganis Roskind
r Playing on playgrounds with safe surfaces Greenstick fractures: Usually rotational and generally advised (4).
r Proper adult supervision visually dramatic with skin-line changes at the Degree of bowing:
level of the fracture >1020-degree bowing and >6 yr old:
PATHOPHYSIOLOGY Swelling Closed reduction is recommended (1,2).
r Long bones have an elastic limit and a plastic Tenderness Associated fractures or dislocations:
limit. Pain Lack of reduction of a bowing fracture
r Bowing fracture: Limitation of motion, especially pronation and associated with a fracture or dislocation of a
An axial compression force applied to a long bone supination second bone impedes appropriate healing of
r Neurovascular exam: the latter (2,4).
in an amount exceeding its elasticity results in a
bowing deformity maintained after the force is Sensation and movement distal to the site of injury Amount of functional limitation upon initial
removed. Pulse and capillary refill distal to the site of injury exam:
Multiple microfractures seen on histopathology r Evaluate the other bones and joints of the injured Significant loss of supination or pronation or
without evidence of hematoma or callus formation limb. clinical deformity requires reduction (4,7).
(3) r Greenstick fracture:
r Greenstick fracture: DIAGNOSTIC TESTS & INTERPRETATION
Angular deformity remodels well, however
Imaging rotational deformity (most common) often
An axial compression force with a twisting force r Plain radiographs of affected limb:
applied to a long bone in an amount exceeding its requires closed reduction.
At least 2 views: AP and lateral 2 types of reduction techniques: Rotational
plasticity results in a classic fracture with cortical
Always include the joints above and below the method of reduction and fracture method of
and periosteal disruption of the convex surface.
suspected fracture. reduction:
The cortex and periosteum of the inner curvature r A certain degree of bowing may be normal for a
remains intact though deformed. Rotational method: Rotating the bone in the
Hematoma and callus formation child: direction opposite to the deforming force (1):
r Case reports of transverse forces causing bowing Comparison films of the unaffected limb may be Easier and less painful
helpful to assess the degree of abnormal (excess) Most commonly used
(2,4)
bowing. Fracturing method: Completing the fracture:
Has lower refracture rate
Risk of reangulation if not adequately rotated
More painful and traumatic (8)
Associated complete fracture may require
completing the greenstick fracture for better
outcome of closed reduction and alignment of
now both completely fractured bones.
388
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FRACTURES, GREENSTICK/BOWING
MEDICATION Issues for Referral 5. Huang K, Pun WK, Coleman D. Entrapment and
r Transfer to a center with a pediatric orthopedic transection of the median nerve associated with
First Line
r Oral opioids: specialist if: greenstick fractures of the forearm: Case report
Codeine or codeine/acetaminophen dosed as Nerve impingement and review of the literature. J Trauma. 1998;
0.51 mg/kg of codeine component PO q4h PRN Vascular supply injury 44(6):11011102.
Hydrocodone or hydrocodone/acetaminophen Compartment syndrome 6. Prosser AJ, Hooper G. Entrapment of the ulnar
dosed as 0.1 mg/kg of hydrocodone component r Associated supracondylar fractures or joint nerve in a greenstick fracture of the ulna. J Hand
PO q46h PRN dislocation Surg Br. 1986;11(2):211212.
r Oral NSAIDs: r Refer all bowing and greenstick fractures to a 7. Komara J, Kottamasu L, Kottamasu S. Acute
Consider NSAID medication in anticipation of pediatric orthopedic specialist for follow-up. plastic bowing fractures in children. Ann Emerg
prolonged pain and inflammation: Med. 1986;15(5):585588.
Some clinicians prefer to avoid NSAIDs due to 8. Noonan K, Price C. Forearm and distal radius
theoretical concern over influence on FOLLOW-UP fractures in children. J Am Acad Orthop Surg.
coagulation and callus formation. FOLLOW-UP RECOMMENDATIONS 1998;6:146156.
Animal studies have raised concerns that r Timely orthopedic follow-up within 510 days, 9. Clarke D, Lecky F. Best evidence topic report. Do
NSAIDs may negatively influence bone healing; depending on initial management non-steroidal anti-inflammatory drugs cause delay
however, there is no clinical evidence in humans r Oral pain management: Ibuprofen as first-line in fracture healing? Emerg Med J. 2005;22(9):
(9). 652653.
therapy in the 1st 72 hr (10)
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r Rest, ice, and elevation of cast or splint for at least 10. Drendel AL, Gorelick MH, Weisman SJ, et al. A
Naproxen 5 mg/kg PO q8h PRN randomized clinical trial of ibuprofen versus
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN 48 hr post cast/splint to avoid compartment
syndrome acetaminophen with codeine for acute pediatric
Second Line arm fracture pain. Ann Emerg Med. 2009;
IV pain management: ACTIVITY 54(4):553560.
r Morphine 0.1 mg/kg IV/IM/SC q2h PRN: No physical activity until further recommendation by a
Initial morphine dose of 0.1 mg/kg IV/SC may be
pediatric orthopedic surgeon.
ADDITIONAL READING
F
repeated q1520min until pain is controlled, then PROGNOSIS
q2h PRN. r Generally favorable
See Also (Topic, Algorithm, Electronic
r Fentanyl 12 g/kg IV q2h PRN: r Children have good remodeling potential of the
Media Element)
Initial dose of 1 g/kg IV may be repeated forearm. r Fracture, Forearm/Wrist
q1520min until pain is controlled, then q2h PRN. r Depends on age, degree of angulation, and r Fracture, Supracondylar
r Ketorolac 0.5 mg/kg IV/IM q6h PRN supination/pronation of the affected area r Fracture, Torus
SURGERY/OTHER PROCEDURES COMPLICATIONS
r When possible, pediatric orthopedic consultation in r Bowing fractures if untreated or incompletely
the emergency department is suggested prior to treated: CODES
splinting/casting or reduction. Limitation of motion:
r Closed reduction depending on significance of Loss of complete supination, pronation, and ICD9
bowing (see above) and other associated fractures especially rotator motion r 813.04 Other and unspecified closed fractures of
r Rarely, open reduction may be required. May prevent proper healing of concurrent proximal end of ulna (alone)
fractures (7) r 813.07 Other and unspecified closed fractures of
DISPOSITION r Greenstick fractures if incomplete reduction/rotation proximal end of radius (alone)
Admission Criteria or immobilization: r 813.14 Other and unspecified open fractures of
r Open fractures
1020% redisplacement rate with volar proximal end of ulna (alone)
r Fractures with compartment syndrome or angulation (1)
neurovascular compromise Refracture
r Suspected nonaccidental trauma r Medullary cyst formation PEARLS AND PITFALLS
r Posttraumatic cortical cysts
Discharge Criteria r Pearls:
r Stable vital signs and no other associated injuries
A 2nd adjacent bone is often involved.
that may require hospitalization
r Intact neurovascular exam REFERENCES Greenstick fractures have been described in
patients with vitamin D deficiency.
r Pain adequately controlled with oral medications 1. Davis D, Green D. Forearm fractures in children: r Pitfalls:
r Adequate reduction and immobilization of affected Pitfalls and complications. Clin Orthop Relat Res. Bowing fractures may be subtle on radiographs.
bone with a double sugar tong splint or long arm 1976;(120):172183. Injuries to the proximal or distal joint must be
cast 2. Vorlat P, De Boeck H. Bowing fractures of the ruled out when the radius or ulna are fractured or
r Ability to follow-up with pediatric orthopedic forearm in children: A long-term followup. Clin bowed.
surgeon: Orthop Rel Res. 2003;413:233237. Consider child abuse if the history does not fit the
Document intact neurovascular function after 3. Chamay A. Mechanical and morphological aspects injury.
emergency department therapy and casting. of experimental overload and fatigue in bone. Inadequate rotation during reduction of greenstick
J Biomech. 1970;3:263270. fractures
4. Vorlat P, De Boeck H. Traumatic bowing of
childrens forearm bones: An unreported
association with fracture of the distal metaphysis.
J Trauma. 2001;51(5):10001003.
389
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FRACTURE, HUMERUS
Donna M. Simmons
390
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, HUMERUS
391
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FRACTURE, MANDIBULAR
Hnin Khine
r Condylar fractures are common in younger children r Assess the difficulty of mouth opening, range of
BASICS and decrease with increasing age. motion, and stability of the temporomandibular joint
r Multiple fracture sites along the mandible can be (TMJ):
DESCRIPTION found in 4060% of the cases. This is especially Place a finger into the external auditory canal and
r The mandible makes up the lower jaw of the face locate the TMJ. Then, ask the patient to move his
more common in older children.
and houses the lower teeth. or her jaw to assess its stability.
r It is the largest and strongest bone of the face. ETIOLOGY Place a wooden tongue blade laterally between
r In younger children, most mandibular fractures are
r The mandible is composed of 2 hemimandibles the teeth on either side and assess for the
the result of motor vehicle accidents (MVAs) or falls. patients ability to hold the blade in place without
fused at midline by a vertical symphysis. r With increasing age, altercations (35%), MVAs
r Facial fractures are rare in children for the following pain while the examiner attempts to pull the blade
(28%), bicycle accidents (12%), and falls (7%) with twisting motions.
reasons:
cause the majority of mandibular fractures (2). Assess the bite status (normal or abnormal).
Underdeveloped facial skeleton and paranasal
COMMONLY ASSOCIATED CONDITIONS r Paresthesia of the lower lip or gums suggests
sinuses
Unerupted teeth provide additional strength. r Among hospitalized trauma patients, facial fractures damage to the inferior alveolar nerve, which also
Lower center of gravity during falls with less are associated with: provides sensation to the teeth.
resultant force on impact (1) Higher injury severity score DIAGNOSTIC TESTS & INTERPRETATION
r Many patients with mandibular fractures (3060%) Longer ICU stays
Longer hospital stays (1)
Imaging
have serious associated injuries: r Dental panoramic views (Panorex)
Strong forces are required to break the mandible r Can see concomitant thoracoabdominal,
8692% sensitive
(2): intracranial, spine, extremity, and other facial Require the patients cooperation
This is especially true for the mandibular injuries.
r Chin lacerations or contusions should raise suspicion Useful in isolated mandibular injury
symphysis, which is rarely fractured due to its r A series of plain radiographs may be more useful in
thickness. for mandibular fractures (3).
r Among the hospitalized trauma patients, r Mandibular dislocations patients who are unable to cooperate to take
panoramic views:
mandibular fractures are the most common type of Lateral oblique view: To view the condyle,
facial fracture (1).
DIAGNOSIS coronoid process, body, ramus, and angle of
EPIDEMIOLOGY mandible
r Very rare in children <5 yr of age HISTORY PA view: To view the ramus, angle, and body of
r Incidence increases with increasing age r Obtain the mechanism of injury, including the mandible
r Mandibular fractures were found in 1.5% of all time of injury and circumstances surrounding the Towne view: To view the condyles
hospitalized trauma patients (1). injury: Mandibular occlusal views: To view a symphyseal
r Male to female ratio of 3:1 Mechanism of injury will help determine the fracture
possible site of fracture. Dental radiograph: To view alveolar or dental root
RISK FACTORS r Symptoms of mandibular fracture include: fractures
r Lack of proper restraints in motor vehicles r Computerized tomogram (CT):
Facial swelling with localized pain
r Participating in sports without proper protective gear Pain and difficulty with mouth opening and closing 100% sensitive
r Interpersonal violence Dental pain or abnormal bite May be useful when other facial fractures are
r Use of substances that impair mental abilities Numbness of the lip and chin suspected as well.
CXR to look for unaccounted teeth
GENERAL PREVENTION ALERT
r Use of appropriate protective equipment during r Important to correlate the history with physical DIFFERENTIAL DIAGNOSIS
r Mandibular dislocations or contusions
sports findings
r Use of proper restraints in motor vehicles r Suspect child abuse if there are inconsistencies in r Traumatic hemarthrosis of TMJ
r Appropriate use of child safety precautions at each r Dental trauma resulting in referred pain
the history or physical exam. r Related skull fractures
developmental stage
r Proper adult supervision of children during play
PHYSICAL EXAM
r General exam using Advanced Trauma Life Support
PATHOPHYSIOLOGY TREATMENT
r Fractures can occur along any part of mandible: (ATLS) protocols to exclude life-threatening injuries
Greenstick fractures are common in the younger r Maintain cervical spine immobilization until PRE HOSPITAL
age group due to the high elasticity of bone with significant spine injuries are excluded. r Assess ABCs per ATLS and Pediatric Advanced Life
thick medullary spaces and thin bony cortices. r Assess for associated injuries focusing on the CNS, Support (PALS) guidelines:
r Pediatric fractures are less likely to be comminuted. spine, airway, and other facial injuries. Cervical spine immobilization if necessary
r The site of fracture is dependent on the mechanism r Inspection: r Collect and preserve any avulsed teeth:
of injury: Deformity or swelling See Trauma, Dental topic for proper technique for
Forces directed to the chin can cause fractures of Ecchymosis: External or inner mucosa of mouth preservation of teeth.
the condyles or symphysis. Lacerations: External or intraoral INITIAL STABILIZATION/THERAPY
Direct assaults usually result in a fracture of the Any tooth trauma, including dental avulsion; r Address ABCs per ATLS and PALS guidelines:
body or angle of the mandible at the point of dental luxation, subluxation, concussion, Look for other life-threatening injuries.
impact. intrusion, and extrusion; or enamel, crown, root, Recognize that mandible fractures may make
and alveolar bone fractures orotracheal intubation difficult.
r Palpation: r Ensure a patent airway by removing any material
Palpate along the entire mandible to look for that could obstruct the airway, such as blood,
step-off, bony disruption, or point tenderness. vomitus, bone fragments, and foreign bodies.
Palpate each tooth for pain and stability. r Control bleeding locally with pressure. Consider
nasal packing if there is persistent epistaxis.
392
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FRACTURE, MANDIBULAR
r Consider use of an antiemetic (eg, ondansetron) to Discharge Criteria 3. Zachariades N, Mezitis M, Mourouzis C, et al.
prevent vomiting. r Stable vital signs Fractures of the mandibular condyle: A review of
r Judicious pain therapy r Adequate pain control achieved 446 cases. Literature review, reflection on
r Use of routine antibiotic prophylaxis is controversial. r No respiratory difficulties and associated CNS treatment and proposal. J Craniomaxillofac Surg.
r Consider prophylactic antibiotics in: issues 2006;34:421432.
Heavily contaminated wounds r Reliable family for follow-up 4. Norholt SE, Krishnan V, Sindet-Pedersen S. Pediatric
Severely comminuted fractures condylar fractures: A long term follow-up study of
Issues for Referral 55 patients. J Oral Maxillofac Surg. 1993;51(12):
Severely macerated soft tissues Follow up with the surgical service that initiated initial
Delayed fracture treatment 13021310.
therapy.
Prolonged operative time 5. Leake D, Doykos J, Habal MB. Long-term follow-up
Uncomplicated fractures in patients with valvular of fractures of mandibular condyle in children. Plast
heart disease FOLLOW-UP Reconstr Surg. 1971;47(2):127131.
MEDICATION FOLLOW-UP RECOMMENDATIONS
First Line r Discharge instructions and medications: ADDITIONAL READING
r Pain therapy is guided by severity:
Soft or liquid diet
Mild pain: Pain control as needed See Also (Topic, Algorithm, Electronic
Acetaminophen 15 mg/kg PO q4h PRN Antibiotics to be taken as prescribed Media Element)
r Dislocation, Temporomandibular Joint
Moderate to severe pain: Consider antiemetic agent as needed
Codeine/Acetaminophen dosed as 0.51 mg/kg r Activity: r Trauma, Dental
of codeine component PO q4h PRN r Trauma, Facial
Avoid rigorous activity.
Hydrocodone or hydrocodone/acetaminophen No contact sports until the treating surgeon clears
dosed as 0.1 mg/kg of hydrocodone component the patient
PO q46h PRN
Patient Monitoring
CODES
Morphine 0.1 mg/kg IV/IM/SC q2h PRN:
Initial morphine dose of 0.1 mg/kg IV/SC may Return sooner for re-evaluation if:
ICD9
F
r Worsening pain
be repeated q1520min until pain is r 802.20 Closed fracture of unspecified site of
controlled, then q2h PRN. r Difficulty breathing or swallowing
r Ondansetron: mandible
r Severe headache, drowsiness, or weakness r 802.30 Open fracture of unspecified site of mandible
0.15 mg/kg IV/PO q48h, max single dose 8 mg r Fever or other serious complaints
Second Line DIET
r Consider tetanus prophylaxis: PEARLS AND PITFALLS
Soft or liquid diet
Td 0.5 mL IM or DTaP 0.5 mL IM r Pearls:
r If antibiotics are considered, use: PROGNOSIS
r Dysfunction resulting from condylar fractures Remember to assess for associated injuries since
Penicillin G sodium aqueous:
100,000400,000 units/kg/day IV divided increases with increasing age at the time of trauma patients admitted with facial fractures have a
q46h, max single dose 24 million units/day, OR (4). higher injury severity score than those without
r If occlusion is normal after swelling has resolved, facial fractures.
Amoxicillin:
2550 mg/kg/day PO divided b.i.d. or t.i.d. early mobilization is associated with excellent results Remember to assess for mandibular injuries in
orally for 35 days (5). patients with chin lacerations.
r Pitfalls:
For penicillin-allergic patients, clindamycin: COMPLICATIONS
1030 mg/kg/24 hr PO or IV divided q68h for r Immediate: Beware that bilateral mandibular fractures may be
35 days, max single dose 2.7 g/day PO/IV present.
Wound infection or sepsis
r Delayed:
SURGERY/OTHER PROCEDURES
r Definitive repair of a mandibular fracture is not a Growth disturbance with facial asymmetry
surgical emergency. Malocclusion or trismus
r Wide range of management available: Nonunion or malunion
Analgesia alone Tooth loss or ankylosis
r Paresthesias
Physiotherapy
Mandibulomaxillary fixation r TMJ dysfunction
Open reduction with internal fixation
r Most pediatric mandibular fractures can be
managed with closed reduction. REFERENCES
r Every attempt should be made to manage
1. Imahara SD, Hopper RA, Wang J, et al. Patterns
prepubertal children with mandibular fractures and outcomes of pediatric facial fractures in the
conservatively to minimize trauma to permanent United States: A survey of the National Trauma
dentition. Data Bank. J Am Coll Surg. 2008;207:710716.
DISPOSITION 2. Smartt JM Jr., Low DW, Bartlett SP. The pediatric
Admission Criteria mandible: II. Management of traumatic injury of
r Patients with significant dental or mandibular fracture. Plast Reconstr Surg. 2005;116:28e.
trauma who cannot tolerate PO intake
r Other associated system trauma requiring admission
r Critical care admission criteria:
As determined by the injury severity score
Unstable fracture with potential airway
compromise
393
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FRACTURE, NASAL
Hnin Khine
394
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, NASAL
395
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, ORBITAL
Victoria Shulman
396
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, ORBITAL
397
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FRACTURE, PATELLA
Sara Ahmed
Michele M. Nypaver
398
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FRACTURE, PATELLA
DISPOSITION REFERENCES
TREATMENT Admission Criteria
Admission may be required if the patient requires 1. Jerosch JG, Castro WH, Jantea C. Stress fracture of
PRE HOSPITAL surgery. the patella. Am J Sports Med. 1989;17:579580.
r Immobilization 2. Zionts LE. Fractures around the knee in children.
r Nonweight bearing Discharge Criteria J Am Acad Orthop Surg. 2002;10:345355.
r Intact lower extremity neurovascular status
r Analgesia r Adequate pain control with oral medications 3. Pietu G, Hauet P. Stress fracture of the patella. Acta
r Ice Orthop Scand. 1995;66:481482.
Issues for Referral 4. Frank JB, Jarit GJ, Bravman JT, et al. Lower
INITIAL STABILIZATION/THERAPY Children with patellar fractures should be referred to extremity injuries in the skeletally immature athlete.
r Immobilization: Casting from groin to ankle or knee an orthopedic specialist. J Am Acad Orthop Surg. 2007;15:356366.
bracing with the knee in extension 5. Teitz CC, Harrington RM. Patellar stress fracture.
r Analgesia
Am J Sports Med. 1992;20:761765.
FOLLOW-UP
MEDICATION 6. Norfray JF, Schlachter L, Kernahan WT Jr., et al.
r Opioids: FOLLOW-UP RECOMMENDATIONS Early confirmation of stress fractures in joggers.
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: r Discharge instructions and medications: JAMA. 1980;243:16471649.
Initial morphine dose of 0.1 mg/kg IV/SC may Rest, ice, elevation 7. Ogden JA, Tross RB, Murphy MJ. Fractures of the
be repeated q1520min until pain is controlled, Follow-up with orthopedics tibial tuberosity in adolescents. J Bone Joint Surg
then q2h PRN. Follow-up with physical therapy Am. 1980;62:205215.
Fentanyl 12 g/kg IV q2h PRN: Complete immobilization for 46 wk
Initial dose of 1 g/kg IV may be repeated Crutch walking to keep affected extremity
q1520min until pain is controlled, then q2h nonweight bearing ADDITIONAL READING
PRN. Pain control
r Activity: Harris RM. Fractures of the patella. In Bucholz RW,
Codeine/acetaminophen dosed as 0.51 mg/kg of
codeine component PO q4h PRN Complete immobilization for 46 wk followed by:
Heckman JD, eds. Rockwood and Greens Fractures in
Adults. 5th ed. Philadelphia, PA: Lippincott Williams &
F
Hydrocodone or hydrocodone/acetaminophen Physical therapy involving passive range of
Wilkins; 2002:1775.
dosed as 0.1 mg/kg of hydrocodone component motion and quadriceps strengthening
PO q46h PRN
r NSAIDs: Patient Monitoring
Consider NSAID medication in anticipation of
Check for distal extremity perfusion and presence of CODES
adequate pulses.
prolonged pain and inflammation:
Some clinicians prefer to avoid NSAIDs due to PROGNOSIS ICD9
r 822.0 Closed fracture of patella
theoretical concern over influence on Good prognosis for full recovery
r 822.1 Open fracture of patella
coagulation and callus formation. COMPLICATIONS
Animal studies have raised concerns that r Infection
NSAIDs may negatively influence bone healing; r Loss of reduction
however, there is no clinical evidence in humans. r Failure of fixation
PEARLS AND PITFALLS
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r Avascular necrosis r Pearls:
Ketorolac 0.5 mg/kg IV/IM q6h PRN
r Delayed union or nonunion/malunion Bipartite patella can mimic patellar fracture on
Naproxen 5 mg/kg PO q8h PRN
Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r Chondromalacia radiographs.
r Traumatic arthritis Physical therapy will improve outcome.
COMPLEMENTARY & ALTERNATIVE r Pitfalls:
r Quadriceps weakness
THERAPIES r Extensor lag Assuming that weight bearing on the affected leg
Physical therapy once healing is complete excludes a patellar fracture
SURGERY/OTHER PROCEDURES Prolonged immobilization will result in muscle
Consultation with orthopedic surgery indicated for: atrophy.
r Open fractures requiring debridement:
Disruption of extensor mechanism
>2-mm displacement
>3-mm fragment separation
Dislocation with fracture
Associated patellar tendon rupture
399
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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400
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
LWBK822-driver-F LWBK822-Hoffman ch199.xml April 15, 2011 14:11
Patient Monitoring
Orthopaedist will order follow-up x-rays at 46 wk. ADDITIONAL READING
F
See Also (Topic, Algorithm, Electronic
Media Element)
r Dislocation, Hip
r Pain, Abdomen
r Trauma, Abdominal
401
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FRACTURE, RIB
Kristin McAdams Kim
Michele M. Nypaver
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Pathologic fracture
r Chest wall contusion
DESCRIPTION HISTORY r Pneumothorax
r Rib fractures can occur as a result of both major and r Multisystem trauma
r Sternal fracture or dislocation
minor trauma with and without concurrent r Severe blow to chest with blunt object
r Nontraumatic causes of chest pain:
intrathoracic injury: r Nonaccidental trauma, especially with posterior rib
Cardiac injury or compromise
Involves the fracture of 1 rib fractures
r 2 causes: r Difficulty breathing Pulmonary embolus
r Abdominal pain with trauma Pneumonia
Acute trauma Musculoskeletal chest wall strain
Stress fractures GI:
r Stable fractures are minimally displaced and do not PHYSICAL EXAM
r Expose the body to assess the nature of injury and GERD
involve >2 consecutive segments. Esophagitis
other associated injuries as outlined in the Advanced
RISK FACTORS Trauma Life Support (ATLS) recommendations. Dermatologic:
r Thoracic trauma r Pain with palpation of chest wall Herpes zoster
r Vigorous force such as rowing, weight lifting r Flail chest wall/unstable chest wall
r Osteopenia r Chest wall hematoma (due to intercostal vessel
r Osteogenesis imperfecta TREATMENT
laceration)
r May have shallow or rapid respirations PRE HOSPITAL
PATHOPHYSIOLOGY r Evaluate for any crepitus, bony deformity, or
r Fractures are due to significant force: Assess and stabilize airway, breathing, and
Elastic chest wall makes rib fractures rare in decreased breath sounds. circulation:
r Muffled heart sounds may indicate associated r Administer supplemental oxygen, preferably by
younger children.
r Mortality and morbidity are usually due to pericardial effusion. nonrebreather mask.
r Distended neck veins may suggest cardiac r Provide pain control.
associated internal injuries (1).
tamponade or tension pneumothorax. r Consider possible tension pneumothorax if clinically
ETIOLOGY
r Multiple trauma DIAGNOSTIC TESTS & INTERPRETATION evident.
r Blunt trauma to chest Imaging INITIAL STABILIZATION/THERAPY
r Stress fracture in athlete (2) r CXR (PA and lateral): Assess and stabilize airway, breathing, and circulation
r Nonaccidental trauma, especially in those <3 yr of To assess for pneumothorax or hemothorax as per ATLS and Pediatric Advanced Life Support
age (3): To assess heart size and width of mediastinum (PALS) guidelines:
Need to correlate injury with reported mechanism Very difficult to detect fracture on plain r Administer supplemental oxygen, preferably by
and make sure that there are not any radiograph: nonrebreather mask.
inconsistencies Rib plain film series with oblique views r Pain control
r Consider bone scan for high suspicion and negative r Treat pneumothorax/hemothorax.
COMMONLY ASSOCIATED CONDITIONS plain films. r Evaluate for flail chest.
r Pneumothorax r Consider CT or MRI for suspected costochondral
r Hemothorax r Look for paradoxical chest wall movement.
injury or internal thoracic injuries. r Look for other associated injuries during secondary
r Pulmonary contusion r If concerned about abdominal injury, consider FAST
r Injury to trachea, large neck vessels, brachial plexus, survey.
(Focused Assessment with Sonography for Trauma)
or spine is seen with fractures of 1st, 2nd, or 3rd ribs. and/or abdominal CT.
r Splenic and liver injuries are seen with injuries to r Consider skeletal survey for child abuse.
lower ribs.
r Flail chest:
Flail chest occurs when 3 consecutive ribs are
fractured in 2 places.
402
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403
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FRACTURE, SCAPHOID
Mark X. Cicero
DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Scapholunate dissociation:
An increased gap between these bones is evident
DESCRIPTION HISTORY on radiograph.
r Scaphoid, the name of the most commonly injured r FOOSH, as noted previously, is almost always r Fractures of other metacarpals
carpal bone, comes from the Greek skaphos, present and followed by deep dull pain in the wrist. r Fracture of the distal radius, including the radial
meaning boat. r Alternately, there may be a history of activity or
styloid
r The scaphoid is alternately referred to as the sports with repeated hyperextension and flexion, r Radioulnar joint injuries
navicular in some texts. such as tennis, gymnastics, or wood chopping. r De Quervain tenosynovitis:
r Its articulations include the distal radius, trapezium, r The pain worsens with gripping or squeezing.
Lateral wrist pain and tenderness over radial
and capitate bones. PHYSICAL EXAM styloid:
r Blood supply is from a branch of the radial artery r Snuffbox tenderness (100% sensitive, 80% specific) The tendons of the abductor pollicis longus and
and enters the bone distally: (2) extensor pollicis brevis are affected.
Blood vessels enter at the distal tubercle and the r Pain with supination against resistance, gripping, or Perform the Finklestein test where the examining
waist of the scaphoid. squeezing is sensitive but not specific. physician grasps the thumb while the hand is
The proximal portion of the bone has tenuous r Scaphoid tubercle tenderness while the wrist is in ulnarly deviated:
arterial blood flow and is prone to ischemia, extension has greater positive predictive value than If there is a sharp pain along the distal radius,
nonunion, and avascular necrosis with fracture. snuffbox tenderness (2). then De Quervain tenosynovitis is likely.
EPIDEMIOLOGY r Pain with axial compression of the thumb is
Incidence suggestive of scaphoid fracture.
r 350,000 new scaphoid fractures occur annually in r Contusion, swelling, or snuffbox fullness are seen TREATMENT
the U.S. (1). infrequently: PRE HOSPITAL
r The scaphoid is the most commonly fractured carpal A recent series suggested that 3 findings are r Immobilization with a simple splint
bone across all age groups. highly suggestive of scaphoid fracture (3): r Compression, such as an elastic bandage
r Among pediatric patients, males in late adolescence Volar scaphoid tenderness r Pain management
most frequently sustain scaphoid fractures. Pain with radial deviation of the hand r Ice
Pain with active wrist range of motion
RISK FACTORS r Elevation
Gymnastics, skateboarding, and other activities DIAGNOSTIC TESTS & INTERPRETATION
Imaging INITIAL STABILIZATION/THERAPY
increase the risk for a forceful fall onto outstretched r When a radiographically proven nondisplaced
hand (FOOSH); as a result, a scaphoid fracture occurs. r Obtain AP, lateral, and oblique radiographs of the
fracture is present, a short arm thumb spica cast is
wrist.
GENERAL PREVENTION r Additionally, a dedicated scaphoid view, in which applied with the wrist in neutral position. There is no
Wrist guards prevent hyperextension during skating added benefit to long arm casting.
the wrist is ulnarly deviated, is useful. r Clinically suspected fractures with no radiographic
and cycling-related falls. r Initial radiography has 7090% sensitivity for
PATHOPHYSIOLOGY evidence or nondisplaced fractures are managed
fracture.
r Momentum of the fall determines the likelihood of r If radiographs are negative and occult fracture is with the thumb spica splint or casting.
r Scaphoid fractures with displacement are splinted
wrist fracture. suspected, there are 3 options (listed below). The
r Wrist hyperextension determines whether the wrist should be immobilized if occult fracture is
until operative management occurs.
r Pain control will be necessary.
scaphoid is at risk for fracture. suspected (see Initial Stabilization/Therapy):
r Wrist flexion or extension <90 degrees is protective. Bone scintigraphy (bone scan) is a cost-effective MEDICATION
The force of the fall is transmitted proximally along option, either during the emergency department r Opioids:
the upper extremity in these situations. evaluation or soon after. Morphine 0.1 mg/kg IV/IM/SC q2h PRN:
MRI is an excellent choice for detecting occult Initial morphine dose of 0.1 mg/kg IV/SC may
ETIOLOGY
r FOOSH is the etiology. The forearm is prone during fractures of the scaphoid and adjacent bones as be repeated q1520min until pain is controlled,
well as ligamentous injuries. then q2h PRN.
the fall.
r There are rare reports of scaphoid stress fractures in Follow-up radiographs performed 2 wk after the Fentanyl 12 g/kg IV q2h PRN:
injury. Fractures should then be evident due to Initial dose of 1 g/kg IV may be repeated
athletes who compete in diving and racquet sports. remodeling and periosteal elevation. q1520min until pain is controlled, then q2h
COMMONLY ASSOCIATED CONDITIONS r The role of ultrasound is unclear. PRN.
Infrequently (512% of the time), there are concurrent Codeine/Acetaminophen dosed as 0.51 mg/kg of
fractures of another carpal bone or the distal radius. codeine component PO q4h PRN
Hydrocodone or hydrocodone/acetaminophen
dosed as 0.1 mg/kg of hydrocodone component
PO q46h PRN
404
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, SCAPHOID
r Oral NSAIDs:
REFERENCES
Consider NSAID medication in anticipation of FOLLOW-UP
prolonged pain and inflammation: 1. Christodoulou AG, Colton CL. Scaphoid fractures in
Some clinicians prefer to avoid NSAIDs due to FOLLOW-UP RECOMMENDATIONS children. J Pediatr Orthop. 1986;6(1):3739.
r Discharge instructions and medications:
theoretical concern over influence on 2. Freeland P. Scaphoid tubercle tenderness: A better
coagulation and callus formation. Patients with a clinical suspicion for a displaced or indicator of scaphoid fractures? Arch Emerg Med.
Animal studies have raised concerns that nondisplaced fracture should be re-evaluated in 1989;6(1):4650.
NSAIDs may negatively influence bone healing; 12 wk by an orthopedic surgeon. 3. Evenski AJ, Adamczyk MJ, Steiner RP, et al.
however, there is no clinical evidence in humans. Displaced fractures are prone to mal- or nonunion Clinically suspected scaphoid fractures in children.
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN and are managed with operative fixation. Patients J Pediatr Orthop. 2009;29(4):352355.
Naproxen 5 mg/kg PO q8h PRN need to be seen promptly by orthopedic surgery.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN Patients and their families are given instructions
using the PRICE mnemonic: ADDITIONAL READING
SURGERY/OTHER PROCEDURES Pain control
r Displaced fractures require stabilization to prevent Rest r Anz AW, Bushnell BD, Bynum DK, et al. Pediatric
mal- or nonunion (see Complications). Orthopedic Ice, especially in the 1st 24 hr after the injury scaphoid fractures. J Am Acad Orthop Surg.
surgery needs to be consulted for these cases. Compression, achieved with the splint or cast 2009;17(2):7787.
r Orthopedic interventions include: Elevation: A sling can assist this goal. r Elhassan BT, Shin AY. Scaphoid fracture in children.
Percutaneous pin fixation r Activity: Hand Clin. 2006;22(1):3141.
Internal fixation with Kirschner wires or a screw Activities that risk reinjury during the healing r Perron AD, Brady WJ, Keats TE, et al. Orthopedic
Nonunions may require excision of the avascular process are to be avoided. pitfalls in the ED: Scaphoid fracture. Am J Emerg
proximal portion of the scaphoid, bone grafting, r Immobilization precludes wrist range of motion: Med. 2001;19(4):310316.
or radial stylectomy. Later management of scaphoid injuries includes See Also (Topic, Algorithm, Electronic
DISPOSITION rehabilitation with an occupational therapist or Media Element)
Admission Criteria
r Even displaced fractures are not routine grounds for
physical therapist.
Patient Monitoring
Fracture, Hand F
admission. Internal fixation is done as an outpatient r Caregivers are instructed to monitor the patient for:
operative procedure. Worsening pain in the wrist CODES
r Open fractures or the presence of other serious Numbness or paresthesias in the ipsilateral fingers
injuries will require admission. Cold, discolored, or swollen digits ICD9
r Patients with chronic fractures or malunion may be r These findings should prompt a speedy return to the r 814.01 Closed fracture of navicular (scaphoid) bone
admitted after surgical repair, especially if bone emergency department or a call to the primary care of wrist
grafting is involved. doctor or managing orthopedist. r 814.11 Open fracture of navicular (scaphoid) bone
Discharge Criteria PROGNOSIS of wrist
r Appropriate immobilization r Nondisplaced scaphoid fractures have an excellent
r Adequate pain control rate of union (95%), but the limb may be casted for
r Caretaker understands discharge instructions up to 10 wk when the fracture is through the PEARLS AND PITFALLS
r Follow-up with a pediatric or general orthopedist is scaphoid waist or more proximal. r Missed and misdiagnosed scaphoid fractures may
arranged. r Displaced fractures are more prone to mal- or
result in a lawsuit for malpractice.
Issues for Referral nonunion and have a more guarded prognosis. r Displaced fractures are prone to mal- or nonunion
r Refer all patients with scaphoid fractures to r Even with good union of the bony fragments,
and are managed with operative fixation. The
orthopedic surgery. In some centers, scaphoid patients may suffer chronic pain and limitation of emergency physician should arrange prompt
fractures are managed by hand-specific services: range of motion. consultation.
Displaced fractures are grounds for urgent referral. COMPLICATIONS r All clinically suspected scaphoid fractures should
r Advise patients about the concerns of scaphoid r Fractures through the middle (waist) of the scaphoid prompt thumb spica immobilization and referral to
malunion and avascular necrosis. and the proximal 3rd of the bone are prone to an orthopedic surgeon.
avascular necrosis and chronic wrist dysfunction.
r As noted previously, malunion of the scaphoid is of
particular risk when there is displacement.
Nonunion may occur even with nondisplacement:
Degenerative joint disease and osteoarthritis may
result.
405
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FRACTURE, SCAPULA
Asha S. Payne
Bruce L. Klein
406
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, SCAPULA
DISPOSITION REFERENCES
TREATMENT Admission Criteria
r For surgical repair or irrigation/debridement 1. Cole PA. Scapula fractures. Orthop Clin North Am.
PRE HOSPITAL r When there is inadequate pain control with 2002;33:118.
r Immobilize the spine, including the cervical spine, 2. Newton EJ, Love J. Emergency department
immobilization (sling and swathe) and oral analgesia
when injury is due to a high-energy force or if there r For other associated injuries management of selected orthopedic injuries. Emerg
is concern for spinal injury. r Critical care admission criteria: Med Clin North Am. 2007;25:763793.
r Immobilize the ipsilateral upper extremity with a 3. Lapner PC, Uhthoff HK, Papp S. Scapula fractures.
For associated life-threatening injuries
sling and swathe. necessitating mechanical ventilation or inotropic Orthop Clin North Am. 2008;39:459474.
support 4. Thompson DA, Flynn TC, Miller PW, et al. The
INITIAL STABILIZATION/THERAPY
r Defer the scapula and shoulder exam and treat A scapula fracture alone usually does not require significance of scapular fractures. J Trauma.
intensive care admission. 1985;25:974977.
other, more life-threatening injuries 1st.
r Stabilize airway, breathing, and circulation per 5. Brown CVR, Velmahos G, Wang D, et al.
Discharge Criteria Association of scapular fractures and blunt thoracic
Advanced Trauma Life Support and Pediatric r No need for surgical repair or irrigation/debridement
r Pain is well controlled. aortic injury: Fact or fiction? Am Surg. 2005;71:
Advanced Life Support guidelines:
5457.
Immediately evaluate for and treat any r No associated injuries that require admission
life-threatening conditions (eg, severe pulmonary 6. Baldwin KD, Ohman-Strickland P, Mehta S, et al.
contusion, tension pneumothorax). Issues for Referral Scapula fractures: A marker for concomitant injury?
r Consult an orthopedic surgeon, ideally one with A retrospective review of data in the National
MEDICATION expertise in scapular fractures: Trauma Database. J Trauma. 2008;65:430435.
First Line Consult emergently or urgently for:
r Analgesia for comfort as well as to enable a good Neurologic or vascular compromise
exam Open fracture ADDITIONAL READING
r Opioids: Intra-articular fracture
Deutsch A, Craft JA, Williams GR. Injuries to the
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: Fracture/Dislocation
Significantly displaced or angulated fracture glenoid, scapula, and coracoid: 1. Glenoid and scapula F
Initial morphine dose of 0.1 mg/kg IV/SC may
r Physical therapy eventually: fractures in adults and children. In DeLee JC, Drez D,
be repeated q1520min until pain is controlled, Miller MD, eds. DeLee and Drezs Orthopaedic Sports
then q2h PRN. Passive range of motion exercises as pain abates Medicine: Principles and Practice. 3rd ed.
Codeine or codeine/acetaminophen dosed as Active range of motion exercises later Philadelphia, PA: Saunders; 2009.
0.51 mg/kg of codeine component PO q46h
PRN See Also (Topic, Algorithm, Electronic
Hydrocodone or hydrocodone/acetaminophen FOLLOW-UP Media Element)
dosed as 0.1 mg/kg of hydrocodone component r Fracture, Clavicle
FOLLOW-UP RECOMMENDATIONS r Fracture, Humerus
PO q46h PRN
Discharge instructions: r Trauma, Chest
Second Line r Rest the shoulder.
r NSAIDs: r Trauma, Shoulder
r Wear a sling and swathe.
Consider NSAID medication in anticipation of r Take an oral analgesic for pain.
prolonged pain and inflammation: r Make follow-up appointments with the orthopedic
Some clinicians prefer to avoid NSAIDs due to CODES
theoretical concern over influence on surgeon and, eventually, a physical therapist.
coagulation and callus formation. Patient Monitoring ICD9
Animal studies have raised concerns that Follow-up immediately for: r 811.00 Closed fracture of scapula, unspecified part
NSAIDs may negatively influence bone healing; r New-onset numbness, tingling, or weakness r 811.01 Closed fracture of acromial process of
however, there is no clinical evidence in humans. r Uncontrolled pain scapula
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN r 811.02 Closed fracture of coracoid process of
Ketorolac 0.5 mg/kg IV/IM q6h PRN DIET
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN scapula
No dietary limitations
SURGERY/OTHER PROCEDURES PROGNOSIS
r Nondisplaced, minimally displaced, or minimally Well-aligned scapular fractures tend to heal well: PEARLS AND PITFALLS
angulated scapular fractures are usually treated r Nonunion is rare.
r Pearls:
nonoperatively.
r Significantly displaced or angulated fractures of the COMPLICATIONS Concern for a scapula fracture should prompt a
Potential complications of intra-articular fractures thorough evaluation for more life-threatening
glenoid neck, intra-articular glenoid, acromion include: injuries.
process, or coracoid process are usually repaired via r Chronic shoulder pain If necessary, CT scan of the scapula with
open reduction with internal fixation. r Decreased range of motion 3-dimensional reconstruction can better define
r Open fractures are generally irrigated and debrided
r Premature arthritis the extent of injury.
in the operating room. r Pitfalls:
An acromion, coracoid, or scapular tip ossification
center (in a pediatric patient) or an os acromiale
(in an older individual) may be confused with a
fracture.
407
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, SKULL
Antonio Riera
David M. Walker
408
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
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FRACTURE, SKULL
MEDICATION Issues for Referral 4. Brody AS, Frush DP, Huda W, et al. Radiation risk
r Opioids: r Skull fractures diagnosed on head CT should be
to children from computed tomography. Pediatrics.
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: managed in consultation with a pediatric 2007;120(3):677682.
Initial morphine dose of 0.1 mg/kg IV/SC may neurosurgeon. 5. Dunning J, Batchelor J, Stratford-Smith P, et al. A
be repeated q1520min until pain is controlled, r Child protection specialists if concern for
meta-analysis of variables that predict significant
then q2h PRN. nonaccidental trauma intracranial injury in minor head trauma. Arch Dis
Fentanyl 12 g/kg IV q2h PRN: r Neuropsychiatric testing if prolonged concussion Child. 2004;89(7):653659.
Initial dose of 1 g/kg IV may be repeated symptoms 6. Decarie JC, Mercier C. The role of ultrasonography
q1520min until pain is controlled, then q2h in imaging of pediatric head trauma. Childs Nerv
PRN. Syst. 1999;15:740742.
Codeine/Acetaminophen dosed as 0.51 mg/kg of FOLLOW-UP 7. Trenchs V, Curcoy AI, Castillo M, et al. Minor head
codeine component PO q4h PRN trauma and linear skull fracture in infants: Cranial
FOLLOW-UP RECOMMENDATIONS
Hydrocodone or hydrocodone/acetaminophen r 24-hr follow-up with primary care provider ultrasound or computed tomography? Eur J Emerg
dosed as 0.1 mg/kg of hydrocodone component r Discharge instructions and medications: Med. 2009;16(3):150152.
PO q46h PRN
r NSAIDs: Pain control
Keep child at home for 24 hr after injury.
Consider NSAID medication in anticipation of
For children <2 yr of age:
ADDITIONAL READING
prolonged pain and inflammation: Watch for poor feeding, lethargy, persistent
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN See Also (Topic, Algorithm, Electronic
Ketorolac 0.5 mg/kg IV/IM q6h PRN vomiting, irritability, seizures Media Element)
Naproxen 5 mg/kg PO q8h PRN For older children and adolescents: r Trauma, Head
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN Watch for worsening headache, persistent r Traumatic Brain Injury
r Prophylactic antibiotics: vomiting, changes in mental status, seizures,
visual complaints, problems with balance
For open skull fractures to prevent osteomyelitis:
Cefazolin 25 mg/kg/dose IV q6h DIET CODES F
If allergic, clindamycin 10 mg/kg/dose IV q8h Resume a regular diet.
Tetanus prophylaxis 0.5 mL IM if necessary PROGNOSIS ICD9
r Excellent for isolated, linear, nondepressed skull r 803.00 Other closed skull fracture without mention
SURGERY/OTHER PROCEDURES
r Depressed and open skull fractures: fractures without intracranial involvement of intracranial injury, with state of consciousness
Usually require operative management r Prognosis for other skull fractures depends on the unspecified
r Basilar skull fractures: r 803.10 Other closed skull fracture with cerebral
degree and extent of associated intracranial injuries.
May require operative management laceration and contusion, with state of
COMPLICATIONS consciousness unspecified
r See Trauma, Head topic for management of r Growing skull fractures due to a tear of the
r 803.20 Other closed skull fracture with
intracranial injuries. underlying dura and subsequent bone remodeling
subarachnoid, subdural, and extradural hemorrhage,
DISPOSITION can be seen in a small number of cases of linear
with state of consciousness unspecified
skull fractures. Can present months to years after
Admission Criteria
r Ill-appearing children with persistent emesis initial injury as a skull defect or swelling.
r Depressed skull fractures:
r Symptoms suggesting neurologic injury: PEARLS AND PITFALLS
Intracranial hemorrhage, dural laceration,
Disorientation r Linear skull fractures are the most common injury
parenchymal injury, seizures
Repetitive questioning r Basilar skull fractures:
Agitation or other mental status change after blunt injury to the head.
r Intracranial injury CSF leak, meningitis, hearing loss, cranial nerve r The presence of a skull fracture is associated with an
r High suspicion of nonaccidental trauma impairment intracranial injury in 1530% of cases.
r Open skull fractures: r Isolated, linear, nondisplaced skull fractures may be
Critical care admission criteria: Nonunion, infection/meningitis managed as outpatients after consultation with a
r Admission to a critical care unit is recommended for r Developmental delay/persistent neurologic deficits pediatric neurosurgeon.
the following situations: can result from all fractures. r Depressed, open, or basilar skull fractures should be
Depressed skull fractures managed in an inpatient setting, as they often
Open skull fractures require neurosurgical intervention.
Basilar skull fractures REFERENCES r High index of suspicion for nonaccidental trauma,
Linear skull fractures associated with: especially in nonmobile younger children
Intracranial injury 1. Greenes DS, Shutzman SA. Infants with isolated
Cervical spine injury skull fracture: What are their clinical characteristics,
Depressed mental status and do they require hospitalization? Ann Emerg
Abnormal neurologic exam Med. 1997;30:253259.
Abnormal vital signs, especially development of 2. Schutzman SA, Barnes P, Duhaime AC, et al.
Cushing triad Evaluation and management of children younger
than two years old with apparently minor head
Discharge Criteria trauma: Proposed guidelines. Pediatrics. 2001;107:
r Discharge from the emergency department if patient
983993.
meets following criteria:
3. Kupperman N, Holmes JF, Dayan PS, et al.
Nondepressed linear skull fracture and >6 mo of
Identification of children at very low risk of
age
clinically-important brain injuries after head
Isolated injury
trauma: A prospective cohort study. Lancet.
Normal neurologic exam
2009;374:11601170.
Neurosurgical consultation, if obtained, agrees
Reliable follow-up
Child can tolerate PO intake without vomiting
r Possibility of nonaccidental injury reliably excluded
409
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FRACTURE, SUPRACONDYLAR
Louis A. Spina
Lana Friedman
410
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FRACTURE, SUPRACONDYLAR
MEDICATION
r Opioids:
DISPOSITION REFERENCES
Admission Criteria
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: All displaced supracondylar fractures require 1. Shrader MW. Pediatric supracondylar fractures and
Initial morphine dose of 0.1 mg/kg IV/SC may admission for neurovascular monitoring. pediatric physeal elbow fractures. Orthop Clin
be repeated q1520min until pain is controlled, North Am. 2008;39(2):163171.
then q2h PRN. Discharge Criteria 2. Kumar R, Trikha V, Malhotra R. A study of vascular
Fentanyl 12 g/kg IV q2h PRN: Only stable fractures with minimal swelling (usually injuries in pediatric supracondylar humeral
Initial dose of 1 g/kg IV may be repeated type I) can be safely discharged. fractures. J Orthop Surg. 2001;9(2):3740.
q1520min until pain is controlled, then q2h Issues for Referral 3. Villarin LA Jr., Belk KE, Fried R. Emergency
PRN. All displaced fractures require emergent consultation department evaluation and treatment of elbow and
Codeine or codeine/acetaminophen dosed as with an experienced orthopedic surgeon. forearm injuries. Emerg Med Clin North Am.
0.51 mg/kg of codeine component PO q4h PRN 1999;17:843.
Hydrocodone or hydrocodone/acetaminophen
dosed as 0.1 mg/kg of hydrocodone component FOLLOW-UP
PO q46h PRN FOLLOW-UP RECOMMENDATIONS
ADDITIONAL READING
r NSAIDs: r Discharge instructions and medications: r Baratz M, Micucci C, Sangimino M. Pediatric
Consider NSAID medication in anticipation of The affected elbow and hand should be iced and supracondylar humerus fractures. Hand Clin.
prolonged pain and inflammation: kept elevated for the 1st 23 days.
Some clinicians prefer to avoid NSAIDs due to 2006;22(1):6975.
The cast should be kept clean and dry. r Kasser JR, Beaty JH. Supracondylar fractures of the
theoretical concern over influence on Adequate pain control distal humerus. In Beaty JH, Kasser JR, eds.
coagulation and callus formation. r Activity:
Animal studies have raised concerns that Rockwood and Wilkins Fractures in Children. 5th
The child should avoid any activities that increase ed. Philadelphia, PA: Lippincott Williams & Wilkins;
NSAIDs may negatively influence bone healing; the risk of tripping or falling.
however, there is no clinical evidence in humans. 2001.
Patient Monitoring r Lins RE, Simovitch, RW, Waters PM. Pediatric elbow
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN
Ketorolac 0.5 mg/kg IV/IM q6h PRN
r The childs fingers should be monitored often for trauma. Orthop Clin North Am. 1999;30(1): F
Naproxen 5 mg/kg PO q8h PRN restriction in movement and circulation and sensory 119132.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN changes for the 1st few days following surgery r Sharieff GQ. Pediatrics. In Simon RR, Koenigsknecht
and/or cast placement. SJ, Sherman SC, et al., eds. Emergency Orthopedics:
SURGERY/OTHER PROCEDURES r Monitor for signs of pin-tract infection, including The Extremities. 5th ed. Columbus, OH:
r Gartland type I fractures are treated with closed
increasing elbow pain, fever, and drainage from the McGraw-Hill; 2006.
reduction and casting. cast:
r Gartland type II fractures require closed reduction See Also (Topic, Algorithm, Electronic
3% of patients develop pin-tract infection,
and percutaneous fixation if a long arm cast does Media Element)
usually at 14 wk post-pin placement.
not adequately hold the reduction. Trauma, Elbow
r Gartland type III fractures are managed by closed COMPLICATIONS
reduction and percutaneous fixation followed by 3 Complications of supracondylar fractures include:
r Vascular injury: CODES
wk of immobilization in a long arm cast.
r Extension-type supracondylar fractures that are Occurs with posterior displacement of the distal
nondisplaced and are of <20-degrees angulation fragment stretching the brachial artery across the ICD9
fractured surface of the proximal fragment r 812.41 Supracondylar fracture of humerus, closed
are immobilized in a posterior long arm splint
extending from the axilla to a point just proximal to Vascular insufficiency or swelling may lead to r 812.51 Supracondylar fracture of humerus, open
the metacarpal heads with the elbow in >90 Volkmann ischemic contracture of the forearm,
degrees of flexion: markedly limiting function of the extremity.
r Neurologic injury: PEARLS AND PITFALLS
The splint should encircle 3/4 of the circumference
of the extremity. Occurs in up to 8% of supracondylar humeral
r Pearls:
The distal pulses should be checked; if absent, the fractures and most frequently involves the anterior
elbow should be extended 515 degrees or until interosseous branch of the median nerve: Immediate therapy consisting of pain management
the pulses return. When the anterior interosseous nerve is injured, and application of a splint for comfort with
r For nondisplaced extension fractures with there is loss of thumb interphalangeal joint expedited imaging and definitive therapy
flexion and index distal interphalangeal joint Emergent consultation with an experienced
>20-degree angulation, the emergency
flexion. orthopedic surgeon is recommended.
management includes immobilization in a posterior r Pitfalls:
long arm splint and emergent orthopedic referral for Can also see ulnar nerve palsy
r Compartment syndrome Neurovascular injuries must be a consideration
reduction under anesthesia.
r Flexion-type supracondylar fractures are also r Joint stiffness: since key structures pass through the elbow,
Diminished range of motion may be secondary to including the anterior interosseus nerve, ulnar and
immobilized in a posterior long arm splint with the
inadequate reduction or callus formation within radial nerves, and brachial artery.
elbow positioned at 35 degrees short of full
the joint. Neurovascular status must be assessed both prior
extension to avoid the development of delayed
elbow stiffness. r Cubitus varus and valgus deformities (due to to and after splinting.
r Open reduction with internal fixation is indicated malposition of the distal humeral fragment after
under the following circumstances: reduction)
Inability to achieve a satisfactory closed reduction
Complicating fractures to the forearm
Inability to maintain a closed reduction
Vascular compromise
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r Opioids:
REFERENCES
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: FOLLOW-UP
Initial morphine dose of 0.1 mg/kg IV/IM may 1. Hosalkar FS, Cameron DB, Cameron DB, et al.
be repeated q1520min until pain is controlled, FOLLOW-UP RECOMMENDATIONS Tibial tuberosity fractures in adolescents. Child
r Discharge instructions and medications: Orthop. 2008;6:469474.
then q2h PRN.
Codeine or codeine/acetaminophen dosed as Keep leg elevated. 2. Mosier SM, Stanitski CL. Acute tibial tubercle
0.51 mg/kg of codeine component PO q4h PRN Monitor the color, warmth, motion, and sensation avulsion fractures. J Pediatr Orthop. 2004;24:
Hydrocodone or hydrocodone/acetaminophen of the toes. 181184.
dosed as 0.1 mg/kg of hydrocodone component Keep the cast dry. 3. Pape JM, Goulet JM, Hensinger RN. Compartment
PO q46h PRN Patient should return for: syndrome complicating tibial tubercle avulsion. Clin
Increasing pain
SURGERY/OTHER PROCEDURES Orthop Rel Res. 1993;295:201204.
Numbness or tingling in the toes
r The vast majority of these fractures require open
Inability to move the toes
reduction and internal fixation followed by long leg r Activity:
cast application (1,2). CODES
r Closed treatment (with closed reduction and a long Nonweight bearing for 6 wk or until radiographic
and clinical healing occurs
leg cast) may be undertaken for those with fractures Quadriceps exercises can be started after 6 wk. ICD9
displaced <2 mm and with full active knee Return to sports: 823.00 Closed fracture of upper end of tibia
extension. Follow-up x-rays are needed to confirm After radiographically and clinically healed
anatomic reduction (1,2). When quadriceps strength is equal
When there is full range of motion of the knee
PEARLS AND PITFALLS
DISPOSITION
r Patients should be taught to sit out of any activity
Admission Criteria PROGNOSIS
r Patients with severe swelling and tense that elicits pain at the tibial tuberosity.
Good (2) r If x-rays do not show a tibial tuberosity fracture but
hemarthrosis should be admitted for observation to
COMPLICATIONS
rule out compartment syndrome.
r Patients with displaced fractures should be admitted r Compartment syndrome (3)
the patient is unable to extend the knee, refer for
MRI to look at the extensor mechanism.
F
r Genu recurvatum can result in skeletally immature
to orthopedics for surgery.
children <11 yr of age due to premature anterior
Discharge Criteria physeal closure.
r Adequate pain control r Pain can develop at screw heads after fracture
r No neurovascular compromise
fixation.
Issues for Referral
Follow up with an orthopedic surgeon.
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FRACTURE, TODDLERS
Louis A. Spina
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FRACTURE, TODDLERS
SURGERY/OTHER PROCEDURES
r Toddlers fractures are typically treated by casting.
r Clinician and institutional practice typically dictate
whether a short or long leg cast is chosen:
It is unclear if there is any difference in the benefit
of short leg vs. long leg casting.
Short leg weight-bearing cast
Long leg cast for up to 56 wk (2)
Patients with a limp or a history strongly
suggestive of toddlers fracture and who have no
fracture evident on tibial radiography may have a
cast or splint placed and follow-up radiographs.
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DIFFERENTIAL DIAGNOSIS
BASICS DIAGNOSIS r Greenstick fracture
r Bowing fracture
DESCRIPTION HISTORY r Growth plate (physeal) fracture:
r Trauma resulting in longitudinal axial compression
Torus fractures are stable, nondisplaced fractures that Salter-Harris IIV fractures
commonly are sustained when axial compression of a on a long bone:
long bone causes it to buckle on itself: Usually FOOSH
r Typically involve the distal radius or ulna after a fall r Torus fractures may occur in cases of very minor TREATMENT
on outstretched hand (FOOSH) trauma or in cases with no known trauma.
r Less commonly involves the distal tibia, fibula, r Degree of pain and disability associated with torus PRE HOSPITAL
r Immobilize the injured extremity.
scaphoid, humerus, or femur fractures is typically much less severe than with
other fractures: r Ice and elevation
GENERAL PREVENTION As a result, patients with torus fractures often
Wrist guards may provide some protection against INITIAL STABILIZATION/THERAPY
present later than those with other fractures, r Immobilize the injured extremity.
wrist fractures when in-line skating, skateboarding, or which typically are brought to medical care r Provide appropriate analgesia.
roller skating (1). immediately. r Casting:
PATHOPHYSIOLOGY PHYSICAL EXAM Distal radial torus fractures are traditionally
Longitudinal forces cause the trabeculae in the r Localized pain, swelling, tenderness, and decreased managed with plaster or fiberglass short arm
transitional zone (junction between the metaphysis range of motion around site of fracture casting (below the elbow) for 24 wk.
and diaphysis) to buckle: r Assess vascular integrity of extremity. Casting practices vary by institution, but
r The cortex on 1 or both sides is compressed and r Examine motor and sensory function. placement of short arm and short leg casts is
bulges outward. r Search for concomitant injuries. within the scope of pediatric emergency medicine
r If unilateral cortical buckling occurs, there may be and emergency medicine practice.
angulation but often no appreciable deformity since DIAGNOSTIC TESTS & INTERPRETATION r Splinting:
the periosteum and cortex on the side opposite to Imaging Recent literature suggests that 3 wk of continuous
the fracture are intact. Radiographs: immobilization with a removable splint is equally
This is in contrast to a greenstick fracture, where a r Multiple views in different planes safe and effective as a cast for distal radius torus
fracture through the cortex on 1 side extends r Standard evaluation includes 23 views (depending fractures (2,3):
incompletely through to the opposite side, on site of fracture): No significant difference in clinical or radiologic
producing a plastic deformity with convex Commonly an AP and lateral view outcomes
angulation on the side of fracture. r Bilateral or unilateral outward bulging of cortex Better physical functioning
(with or without angulation) Less difficulty with daily activities
ETIOLOGY
r Sports activities (in-line skating, skateboarding, r Identify concomitant injuries (eg, Salter-Harris type II Earlier return to sports
fracture) accompanying an angulated distal radius No significant difference in pain experienced
roller skating, biking, and scooters)
r Wrist torus fractures result from pure axial loading torus fracture: Reduces the need for follow-up (4)
Consider radiographic assessment of the joint Commercially available or individually fitted
(bilateral bulging) or axial loading with
above and below the site of injury. (plaster or fiberglass) splints:
hyperextension, hyperflexion, valgus, or varus stress Volar or sugar tong splint for distal radial torus
(unilateral bulging with angulation). r When evaluating distal forearm fractures, consider
AP and lateral views of the wrist, forearm, and fracture
elbow.
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MEDICATION REFERENCES
r Opioids: FOLLOW-UP
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: 1. Lewis LM, West OC, Standeven J, et al. Do wrist
Initial morphine dose of 0.1 mg/kg IV/SC may FOLLOW-UP RECOMMENDATIONS guards protect against fractures? Ann Emerg Med.
r Discharge instructions and medications: 1997;29:766769.
be repeated q1520min until pain is controlled,
then q2h PRN. Rest, ice, and elevation. 2. Plint AC, Perry JJ, Correll R, et al. A randomized,
Fentanyl 12 g/kg IV q2h PRN: Adequate pain control controlled trial of removable splinting versus
Initial dose of 1 g/kg IV may be repeated Educate about the signs of tight casts/splints. casting for wrist buckle fractures in children.
q1520min until pain is controlled, then q2h Follow up with orthopedics as necessary: Pediatrics. 2006;117:691697.
PRN. Review of the literature supports the safe 3. Abraham A, Handoll HHG, Khan T. Interventions for
Codeine/Acetaminophen dosed as 0.51 mg/kg of discharge of distal radius torus fractures in treating wrist fractures in children. Cochrane
codeine component PO q4h PRN removable splints without orthopedic follow-up Database Syst Rev. 2008;(2):CD004576.
Hydrocodone or hydrocodone/acetaminophen (4). 4. May G, Grayson A. Do buckle fractures of the
dosed as 0.1 mg/kg of hydrocodone component r Activity:
paediatric wrist require follow up? Emerg Med J.
PO q46h PRN As tolerated, but restrict use of affected extremity 2009;26:819822.
r NSAIDs:
Patient Monitoring 5. Plint A, Perry JJ, Tsang JYL. Pediatric wrist buckle
Consider NSAID medication in anticipation of r Neurovascular exam fractures: Management and outcomes. Can J
prolonged pain and inflammation: r Uncontrollable pain Emerg Med. 2004;6:397401.
Some clinicians prefer to avoid NSAIDs due to
theoretical concern over influence on PROGNOSIS
coagulation and callus formation. Excellent if appropriately immobilized ADDITIONAL READING
Animal studies have raised concerns that
COMPLICATIONS Lawton LJ. Fractures of the distal radius and ulna. In
NSAIDs may negatively influence bone healing; r Torus fractures are generally considered stable
however, there is no clinical evidence in humans. Letts MR, ed. Management of Pediatric Fractures.
(refracture rate <1% [2,5]):
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN Philadelphia, PA: Churchill Livingstone;
Ketorolac 0.5 mg/kg IV/IM q6h PRN
Torus fractures may share a similar radiographic
appearance with nondisplaced greenstick
1994:345368. F
Naproxen 5 mg/kg PO q8h PRN fractures. See Also (Topic, Algorithm, Electronic
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN
In 1 study, 15 children managed as torus fractures Media Element)
in the emergency department were later r All fracture/trauma of the extremity topics
DISPOSITION
rediagnosed with greenstick fractures (3). r Fracture, Greenstick/Bowing
Discharge Criteria
r No evidence of more serious injury Greenstick fractures are unstable (with a high
r Normal neurovascular exam refracture rate), necessitating closed reduction
r Provision of appropriate short arm cast or removable and casting. CODES
r Potential for unscheduled return emergency
splint
department visits for cast-related problems (eg, ICD9
Issues for Referral broken or wet cast) r 813.45 Torus fracture of radius (alone)
r Uncertainty or concern for greenstick, bowing, or
r 813.46 Torus fracture of ulna (alone)
physeal fractures requires orthopedic consultation.
r Require immediate orthopedic consultation for:
Open reduction with internal fixation
Compound fracture
PEARLS AND PITFALLS
Compartment syndrome r Pearls:
Unless reinjury occurs, torus fractures are expected
to heal fully without complication.
Casting or splinting is to provide support to
prevent a complete fracture from occurring in the
event of further trauma.
r Pitfall:
Although a torus and greenstick fracture may
share similar radiographic features, their
management is different (splinting vs. reduction
and casting).
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FRACTURE, ZYGOMA
Usha Sethuraman
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FRACTURE, ZYGOMA
r Displaced fractures require open fixation (8). Discharge Criteria 4. Ferreira P, Marques M, Pinho C, et al. Midfacial
r Analgesia may need to be given. r Undisplaced or greenstick fractures of the zygoma fractures in children and adolescents: A review of
r Tetanus status needs to be updated, especially for r Absence of functional defects (eg, diplopia) 492 cases. Br J Oral Maxillofac Surg.
open fractures. r Absence of other associated injuries (eg, head injury) 2004;42(6):501505.
r Antibiotics for open wounds and animal bites 5. McMullin BT, Rhee JS, Pintar FA, et al. Facial
Issues for Referral
r All nondisplaced stable fractures should be referred fractures in motor vehicle collisions:
MEDICATION Epidemiological trends and risk factors. Arch Facial
First Line to an oral and maxillofacial surgeon within 72 hr.
r Displaced fractures require urgent referrals. Plast Surg. 2009;11(3):165170.
r Opioids:
6. Hatef DA, Cole PD, Hollier LH Jr. Contemporary
Morphine 0.1 mg/kg IV/IM/SC q2h PRN: management of pediatric facial trauma. Curr Opin
Initial morphine dose 0.1 mg/kg IV/SC may be
repeated q1520min until pain is controlled,
FOLLOW-UP Otolaryngol Head Neck Surg. 2009;17:308314.
7. Evans BG, Evans GR. MOC-PSSM CME article:
then q2h PRN. FOLLOW-UP RECOMMENDATIONS Zygomatic fractures. Plast Reconstr Surg.
Fentanyl 12 g/kg IV q2h PRN: r Discharge instructions and medications:
2007;121:111.
Initial dose of 1 g/kg IV may be repeated Pain control is important in children. 8. Kaufman Y, Stal D, Cole P, et al. Orbitozygomatic
q1520min until pain is controlled, then q2h Soft diet fracture management. Plast Reconstr Surg.
PRN. Most need follow-up with surgeon. 2008;121:13701374.
Codeine/Acetaminophen dosed as 0.51 mg/kg of Close follow-up and exam every 3 days for 24
codeine component PO q4h PRN wk for nondisplaced, greenstick fractures is
Hydrocodone or hydrocodone/acetaminophen recommended. ADDITIONAL READING
dosed as 0.1 mg/kg of hydrocodone component r Activity:
PO q46h PRN Refrain from contact sports during recuperation. See Also (Topic, Algorithm, Electronic
r NSAIDs: Media Element)
Consider NSAID medication in anticipation of Patient Monitoring r Fracture, Orbital
Patients should be monitored at home for increasing r Fracture, Skull
prolonged pain and inflammation:
Some clinicians prefer to avoid NSAIDs due to pain, diplopia, CSF rhinorrhea, and malocclusion. r Globe Rupture F
theoretical concern over influence on PROGNOSIS r Trauma, Dental
coagulation and callus formation. r Bony facial injuries are associated with significant r Trauma, Head
Animal studies have raised concerns that morbidity. r Trauma, Facial
NSAIDs may negatively influence bone healing; r Children with facial fractures have a 3 times longer
however, there is no clinical evidence in humans. ICU stay, 2 times longer hospital stay, and 63%
Ibuprofen 10 mg/kg/dose PO/IV q6h PRN higher mortality:
Ketorolac 0.5 mg/kg IV/IM q6h PRN This is due to higher association with head injuries
CODES
Naproxen 5 mg/kg PO q8h PRN: (2).
Some clinicians prefer to avoid due to r However, prognosis for isolated zygoma fractures is ICD9
theoretical concern over influence on 802.4 Closed fracture of malar and maxillary bones
good.
coagulation and callus formation. r Postoperative complications are unusual.
r Acetaminophen 15 mg/kg/dose PO/PR q4h PRN r Infections, malunions, and nonunions are less PEARLS AND PITFALLS
Second Line common in children.
r Pearls:
Antibiotics for open fractures:
r Cefazolin 2550 mg/kg IV q8h COMPLICATIONS Zygoma fractures are less common in children
r Trismus
than adults.
SURGERY/OTHER PROCEDURES r Paresthesias
Nondisplaced zygoma fractures can be managed
r Only 25% of children need operative repair (3): r Enophthalmos conservatively.
Comminuted fractures need open reduction and r Facial asymmetry Complications are rare.
fixation (6). r Ocular dystopia r Pitfalls:
In the absence of orbital entrapment, treatment is Zygoma fractures have a high association with
done after the edema has resolved, usually in 35 other major trauma.
days. REFERENCES Fractures of the zygoma may involve the orbital
Delay in orbital repair may result in higher rates of floor.
posttraumatic enophthalmos and the need for 1. Adams CD, Januszkiewcz JS, Judson J. Changing
additional surgery. patterns of severe craniomaxillofacial trauma in
r Zygomatic arch fractures, once reduced, are stable Auckland over eight years. Aust N Z J Surg.
and require no further fixation. 2000;70:401404.
r Displaced Le Fort fractures are treated by open 2. Imahara SD, Hopper RA, Wang J, et al. Patterns
reduction with rigid internal fixation. and outcomes of pediatric facial fractures in the
United States: A survey of the National Trauma
DISPOSITION Data Bank. Am Coll Surg. 2008;207:710716.
Admission Criteria 3. Haug RH, Foss J. Maxillofacial injuries in the
r Zygoma fractures associated with other severe pediatric patient. Oral Surg Oral Med Oral Pathol
cranial and extremity injuries Oral Radiol Endod. 2000;90:126134.
r Critical care admission criteria:
Severe head injuries
Hemorrhage
Tenuous airway
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FROSTBITE
Cara Bornstein
William I. Krief
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FROSTBITE
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GANGLION CYST
P. Micky Heinrichs
Alan L. Nager
If larger, it can compress branches of the r Small dorsal ganglions, which may be tender, may
BASICS superficial radial nerve (3). be only palpable in full wrist extension.
Volar ganglions can present with sensory or motor r Occult ganglions may not be palpable but are tender
DESCRIPTION nerve palsy involving the palmar cutaneous branch (3).
r A ganglion cyst is a benign, generally painless, of the median nerve, the median nerve itself, the r Transillumination will confirm that there is clear fluid
fluid-filled mass mainly found at the dorsum of the ulnar nerve, or the deep ulnar motor branch (3). in the ganglion cyst, unless the ganglion is very
wrist near the radiocarpal joint or the volar radial r A high percentage of ganglions resolve small and deep or the patient is dark skinned.
aspect of the wrist (1). spontaneously between 1.5 and 12 mo after
r Ganglion cysts may occur at any tendon sheath appearance. Ganglions rarely persist >2 yr (4,5). DIAGNOSTIC TESTS & INTERPRETATION
throughout the musculoskeletal system, such as the Lab
foot or the ankle (2). ETIOLOGY No lab tests are needed for a ganglion cyst.
r 70% are located at the dorsal wrist, and 75% of Unknown
Imaging
these are connected with the scapholunate joint (3). r A ganglion cyst is a clinical diagnosis, and, in
r While common in adults, wrist ganglia are unusual DIAGNOSIS general, no imaging is required.
and rare in children (4). r Imaging may be helpful in ambiguous cases,
r Colloquial term: Bible Cyst due to the use of the HISTORY
r Complaints about a spontaneously appearing, especially when ganglions cannot be easily palpated
Bible (commonly being the heaviest book in a or patients present with pain (3). US should be the
household) for forceful destruction of the cyst: usually painless, cystic growth almost always
initial imaging modality of choice for suspected
Due to the high recurrence rate and the increased located near a joint capsule or tendon sheath of the
ganglia. It is equally effective as MRI (3) but can be
likelihood of trauma to adjacent structures, this is wrist, the foot, or any other location in the
obtained more readily (although it is more operator
not a recommended procedure. musculoskeletal system
r Occasionally, a specific traumatic event can be dependent).
EPIDEMIOLOGY recalled, but usually there is none (3). DIFFERENTIAL DIAGNOSIS
r Estimated incidence of 10% in patients <20 yr of r The patient may complain of pain secondary to r Any mobile mass that moves with excursion of the
age and 2% in patients <2 yr (1). pressure on the branches of nerves (depending on extensor tendons:
r Pediatric population: Proportion of affected females Ganglion of tendon sheath
location) (3).
to males has been reported as ranging from r Pain can also occur in ganglia of the feet or ankles Tenosynovitis of inflammatory, rheumatoid, or
1.6:14.7:1 (1,2,4). when external pressure is applied (eg, wearing infectious origin
shoes) (2). Extensor digitorum brevis manus muscle belly
PATHOPHYSIOLOGY r Firm mass more radial and slightly more distal:
r Defect in 1 of the joint capsules allowing r Questioning the parent or child should reveal no
fever, erythema, pulsation, bleeding, or drainage. Osteophyte (more common in adult patients)
accumulation of synovial fluid in an outpouching of r Compressible mass: Venous aneurysm
a tendon sheath or joint capsule (1) PHYSICAL EXAM r Pulsating mass: Arterial aneurysms of the radial or
r Depending on the location of the ganglion, pain, r Firm or fluctuant, well-defined, <3 cm mass near a
sensory changes, or nerve palsy may occur when ulnar artery
joint capsule or tendon sheath without skin r Other types of tumors: Lipoma, posterior
nerves or branches of nerves are compressed by the changes, such as redness, warmth, or drainage
ganglion (3): r Most commonly found over the dorsal or volar interosseous neuroma, hamartoma, sarcoma
Dorsal ganglions can cause pain because of aspect of the wrist (3):
pressure on the branches of the posterior Volar ganglia have the highest occurrence rate (4)
interosseous nerve. with a general tendency to develop on the radial
side.
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GANGLION CYST
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GASTRITIS
Sabina Zavolkovskaya
Barbara M. Garcia Pena
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GASTRITIS
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GASTROENTERITIS
Carla Maria P. Alcid
PATHOPHYSIOLOGY
BASICS r Infection acquired through the fecaloral route by DIAGNOSIS
direct person-to-person contact or by ingestion of
DESCRIPTION contaminated food and water: HISTORY
r Gastroenteritis (GE) refers to: r Clinical spectrum ranges from asymptomatic to
Presence of preformed toxins (Bacillus cereus)
Infections of the GI tract caused by bacteria, Production of enterotoxins: Enteroinvasive severe symptoms, dehydration, and death.
viruses, or parasites r Assess the onset, frequency, and quantity of both
Escherichia coli (EIEC), enterotoxigenic Escherichia
Noninfectious causes of inflammation of the GI coli (ETEC) vomiting and diarrhea.
tract secondary to drugs and toxins Direct invasion of intestinal mucosa (villi surface r Determine the character, such as the presence of
r The majority are foodborne illnesses. destruction by viruses; wall adherence by bile, blood, or mucus.
r GE most commonly manifests as nausea, vomiting, parasites) r Note most recent oral intake, including quantifying
diarrhea, abdominal pain, and cramping. r Noninfectious: breast milk and other food or fluids.
r Usually the presence of vomiting and diarrhea, Chemical toxins most often found in food r Elicit a most recent preillness weight and amount of
together with a detailed history and physical exam (especially seafood), heavy metals, antibiotics, and urine output.
excluding other serious illnesses, constitute a other medications r Note presence of other associated symptoms such
diagnosis of acute GE. Toxins adhere to the intestinal wall, causing as fever, mental status changes, and presence of
irritation and swelling, which leads to water, rashes, as it may signify more serious disease.
EPIDEMIOLOGY mucus, or blood to leak from the wall of the r Past medical history should include any underlying
Incidence intestine. illnesses or recent medical problems.
r In the U.S., GE accounts for >1.5 million pediatric
ETIOLOGY r Include a list of medications and presence of any
outpatient visits and 200,000 hospitalizations r Viruses cause the majority of GE:
annually: immunodeficiency (HIV).
Rotavirus r Social history should include day care exposures and
There are 300 deaths per year.
r Worldwide, the WHO estimates >700 million Noroviruses and other caliciviruses presence of outbreaks in the community.
Hepatitis A r Recent travel should also be documented, including
episodes of diarrhea annually in children <5 yr of
age in developing countries (1): Astroviruses, adenoviruses, parvoviruses travel on cruise ships (noroviruses).
r Bacterial infections:
Globally, death estimates are 1.8 million deaths PHYSICAL EXAM
per year. Salmonella species, Shigella, Yersinia r Body weight and vital signs:
enterocolitica, Campylobacter species,
Prevalence Tachycardia is an early sign of dehydration.
r Accounts for 3% pediatric office visits and 10% Staphylococcus aureus, Bacillusacute food
Deep respirations suggest metabolic acidosis.
poisoning r Assess mental status for listlessness or
hospitalizations in children <5 yr of age EIEC, ETEC
r Attack rate ranges from 0.51.9 illnesses per person inconsolability.
Less commonly: Listeria, Clostridium species r Note presence or absence of tears, sunken eyes, or
annually and is higher in the 1st 23 yr of life: Vibrio cholera: Most common etiology in
2.55 illnesses per child in day care developing countries dry mucous membranes and the appearance of the
r Parasitic infections: lips, mouth, and tongue.
RISK FACTORS r Absence of bowel sounds can indicate an ileus,
r Poor hygiene Giardia lamblia, Entameoba histolytica: Mostly
r Young age (<6 mo) from uncooked foods signifying hypokalemia.
r Severe abdominal pain and tenesmus indicate
r Prematurity Toxoplasma; Cryptosporidium, Trichinella species:
r Presence of an immunodeficiency Less common involvement of the large intestines and rectum.
r Noninfectious agents: r Periumbilical pain with watery diarrhea indicates
r Malnutrition
Heavy metals small bowel involvement.
r Coexisting infection r General perfusion of the extremities helps assess the
r Lack of exclusive or predominant breast-feeding in Mushrooms (toxins)
Nitrites and pesticides level of dehydration.
small infants Fish and shellfish poisoning (scombroid, ciguatera r Delayed capillary refill and prolonged skin tenting
GENERAL PREVENTION toxins, tetrodotoxins) may be helpful clues to assess hydration.
r Strict hand hygiene with improvement in water and Antibiotics and other medications
DIAGNOSTIC TESTS & INTERPRETATION
sanitation facilities COMMONLY ASSOCIATED CONDITIONS
r Contact tracing and source identification to prevent Lab
r Poverty r Not necessary for diagnosis but may be helpful to
outbreaks from occurring r Poor environmental hygiene assess dehydration and identify etiology or
r Immunization may prevent rotavirus, some r Childs delayed developmental status complications
salmonella, and hepatitis A r Assess serum electrolytes if there is possibility of
r Proper cleaning and complete cooking of all meals,
dehydration or oral intake suggests potential
especially meats and vegetables abnormalities.
r Consider stool studies selectively:
If there is concern for acute bacterial diarrhea,
stool for WBCs may reveal >5 WBC/hpf.
Rotavirus is identified on electron microscopy or
rapid ELISA.
Stool for ova and parasites
r CBC, urine studies, and blood cultures may be
indicated in the context of sepsis.
r Clostridium difficile testing for patients with recent
antibiotic use
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GASTROENTERITIS
r Procalcitonin has been suggested as a diagnostic r Bismuth subsalicylate (Kaopectate) (antiemetic and
REFERENCES
marker for bacterial GE but has not been helpful (2). antidiarrheal):
r C-reactive protein (CRP) has also been studied as a 100 mg/kg/day divided in 5 equal doses, max 1. King CK, Glass R, Bresee JS, et al. Managing acute
biologic marker (CRP >95 mg/L in 1st 48 hr single dose 4 g/day gastroenteritis among children: Oral rehydration,
suggests bacterial disease) and may serve as a maintenance, and nutritional therapy. MMWR
COMPLEMENTARY & ALTERNATIVE Recomm Rep. 2003;52(RR-16):116.
useful predictor of bacterial GE in children (3).
THERAPIES 2. Thia KT, Chan ES, Ling KL, et al. Role of
Imaging r Zinc supplementation reduces the incidence,
procalcitonin in infectious gastroenteritis and
Not generally warranted unless the possibility of a duration, and recurrence of diarrhea: inflammatory bowel disease. Dig Dis Sci.
surgical abdomen exists (obstruction, appendicitis, <6 mo of age: 10 mg/day 2008;53(11):29602968.
volvulus, or intussusception) >6 mo: 20 mg/day
r Probiotic (Lactobacillus, Bifidobacterium) bacteria to 3. Marcus N, Mor M, Amir L, et al. The quick-read
DIFFERENTIAL DIAGNOSIS C-reactive protein test for the prediction of
r Non-GI illnesses, including meningitis, sepsis, prevent/reduce diarrhea bacterial gastroenteritis in the pediatric emergency
pneumonia, otitis media, and urinary tract infections DISPOSITION department. Pediatr Emerg Care. 2007;23(9):
r Isolated vomiting can be the initial manifestation of 634637.
Admission Criteria
a metabolic disorder, CHF, toxic ingestions, r Severely dehydrated patients 4. Freedman SB, Adler M, Seshadri R, et al. Oral
intracranial injury, or trauma. r Moderately dehydrated patients unable to take ondansetron for gastroenteritis in a pediatric
adequate oral rehydration fluids emergency department. N Engl J Med. 2006;354:
r Consider admission for the following: 16981705.
TREATMENT 5. Rossignol JF, Abu-Zekry M, Hussein A, et al. Effect
Severe metabolic acidosis
Abnormal serum sodium (high or low) of nitazoxanide for treatment of severe rotavirus
Most GE can be effectively managed at home with diarrhea: Randomized, double-blind, placebo
oral rehydration solutions. Abnormal or changing mental status
controlled trial. Lancet. 2006;368(9530):124129.
Discharge Criteria
PRE HOSPITAL r Normal vital signs
r Assess and stabilize airway, breathing, and
r Ability to tolerate oral fluids ADDITIONAL READING
circulation. r Follow up with the primary care provider.
r Administer fluid bolus as necessary for dehydration.
r Reliable caregivers who can provide adequate care Salvatore S, Hauser B, Devreker T, et al. Probiotics and
INITIAL STABILIZATION/THERAPY at home zinc in acute infectious gastroenteritis in children: Are
r Initial assessment must focus on hydration status they effective? Elsevier. Nutrition. 2007;23:498506.
and presence of any toxicity. Issues for Referral
r If concern exists for other possible illnesses that may See Also (Topic, Algorithm, Electronic G
r IV rehydration with isotonic fluids boluses
complicate the clinical course Media Element)
(20 mL/kg) r Any social concerns that might prevent returning for r Dehydration
r See Dehydration topic for further management. r Diarrhea
evaluation
r Vomiting
MEDICATION
First Line FOLLOW-UP
r Expired American Academy of Pediatrics practice
guideline previously recommended no FOLLOW-UP RECOMMENDATIONS CODES
antiemetic/antidiarrheal use in children <5 yr of age. r Discharge instructions and medications:
r Ondansetron (antiemetic) (4): Early feeding with age-appropriate diet ICD9
0.15 mg/kg PO or IV r Activity: r 005.9 Food poisoning, unspecified
r Antibiotics not typically useful but may be useful for No restrictions once able to tolerate oral feeds r 009.0 Infectious colitis, enteritis, and gastroenteritis
specific pathogens: r 558.9 Other and unspecified noninfectious
Patient Monitoring
Shigellosis: Trimethoprim/Sulfamethoxazole at If patient is discharged home, strict instructions on gastroenteritis and colitis
810 mg/kg trimethoprim dosing PO divided criteria to return, such as inability to tolerate oral feeds
b.i.d., if susceptible or decreased urine output
Campylobacterif severe: PEARLS AND PITFALLS
Erythromycin 3050 mg/kg/day PO divided DIET
r Overly restricted diets should be avoided. r Obtain appropriate stool cultures early in the course
b.i.d.q.i.d. for 5 days OR
Ciprofloxacin 2030 mg/kg/day PO divided b.i.d. r Lactose-free formulas can be used in infants if of the disease in children with bloody diarrhea and
G. lamblia or E. histolytica: lactose malabsorption is of concern. suspected HUS.
Metronidazole 15 mg/kg/day PO divided t.i.d. r Avoid carbonated drinks or juices with a high r Early nutritional support is key in successful
AND concentration of simple carbohydrates. management of the majority of cases of GE.
Iodoquinol 3550 mg/kg/day PO divided t.i.d. r Breast-fed infants should nurse ad libitum. r Lower osmolality oral rehydration fluids are more
to prevent spread of the disease effective in reducing stool output.
Rotavirus GE has sometimes been effectively PROGNOSIS r The practice of withholding food for >24 hours
controlled with nitazoxanide (5). Good prognosis when early therapy is instituted and should be avoided.
no concurrent illnesses are present
Second Line
r Metoclopramide (antiemetic): COMPLICATIONS
r Bacteremia, urinary tract infection, vaginitis,
0.1 mg/kg IV/PO, max single dose 10 mg
If metoclopramide is given IV, administer as piggy endocarditis, meningitis, pneumonia, hepatitis, soft
back with normal saline over >30 min to prevent tissue infections (especially Salmonella)
akathisia. r Guillain-Barre syndrome from Campylobacter
r Loperamide (antidiarrheal): infection
68 yr (2030 kg): 2 mg PO b.i.d. r Hemolytic uremic syndrome (HUS) from Shigella
912 yr (>30 kg): 2 mg PO t.i.d. dysenteriae 1 or E. coli 0157:H7
Adolescent/Adult (>45 kg): 4 mg PO initial dose, r Hemolytic anemia from Campylobacter and Yersinia
then 2 mg/dose each stool, max single dose r Reactive arthritis and glomerulonephritis from
16 mg/day Shigella, Campylobacter, and Yersinia
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GASTROESOPHAGEAL REFLUX
Sandra L. Grossman
Barbara M. Garcia Pena
r GER becomes GERD when there are disturbances in r Consider causes other than GER when the following
BASICS protective mechanisms: occur in the vomiting infant (2):
Delayed gastric emptying Forceful vomiting
DESCRIPTION Abnormal epithelial repair Bilious vomiting
r Gastroesophageal reflux (GER) is the retrograde Insufficient clearance and buffering of refluxate Onset of vomiting after 6 mo of life (GER most
passage of gastric contents into the esophagus. Decreased neural protective reflexes of commonly manifests prior to this age.)
r GER is a normal physiologic process, occurring aerodigestive tract GI bleeding (hematochezia, hematemesis)
several times per day in healthy infants, children, Failure to thrive
ETIOLOGY
and adults. r GER is a normal physiologic process. Diarrhea
r In healthy people, most episodes of GER occur in the Constipation
r GERD is due to LES incompetence as a result of loss
postprandial period, last <3 min, and cause few or Lethargy
of tone or recurrent inappropriate transient Hepatosplenomegaly
no symptoms.
r Gastroesophageal reflux disease (GERD) occurs relaxation. Seizures
when clinical symptoms result from GER. Fever
r GERD is usually minimally symptomatic but must be DIAGNOSIS Genetic/Metabolic disorders
distinguished from life-threatening causes of Micro-/Macrocephaly
r In the infant presenting before 6 mo of age with Bulging fontanelle
vomiting.
uncomplicated emesis, a thorough history and Abdominal distension/tenderness
EPIDEMIOLOGY physical should be adequate to make the diagnosis.
r This is also true for verbal older children presenting PHYSICAL EXAM
Incidence r Normal physical exam
r 4067% of healthy full-term infants (1)
with typical heartburn symptoms (substernal, r Significant GERD may lead to dental erosions.
r >50% of children with moderate to severe burning chest pain) and regurgitation. r Dystonic torso/head posturing (Sandifer syndrome)
neurologic disorders/developmental delay r There is no symptom or symptom complex in infants
is a specific manifestation of GERD.
Prevalence and toddlers that is diagnostic of GERD or predicts r Unlikely GERD if the following are present:
r 50% of infants 03 mo of age (2) response to therapy:
Appears malnourished
r 67% of infants 4 mo of age However, the presence of the bothersome
Decreased activity level
r 5% of infants 1012 mo of age signs/symptoms associated with GER often leads
Evidence of dehydration
r 1.48.2% of children 317 yr of age to the clinical diagnosis of GERD in infants and
Hypotonia
children.
Abnormal respiratory or abdominal exam
RISK FACTORS HISTORY
r Asthma DIAGNOSTIC TESTS & INTERPRETATION
r Effortless, painless vomiting is the most common
r Neurologic disorders (eg, cerebral palsy) Imaging
historical feature in healthy-appearing
r Obesity Indicated to investigate other sources of vomiting,
infants/children.
r Smoking r Vomiting, recurrent abdominal pain, and/or chest based on history and physical exam
r Caffeine use pain are more common features in adolescents and DIFFERENTIAL DIAGNOSIS
r Pregnancy adults. r Other sources of vomiting (2):
r Cystic fibrosis r Signs and symptoms associated with GER are GI obstruction (pyloric stenosis, foreign body,
r Repaired esophageal atresia or achalasia nonspecific. Not all children with GER have these malrotation/volvulus, intermittent intussusception,
r Other congenital esophageal disease symptoms, which can be caused by conditions other gastric outlet obstruction)
r Chronic lung disease than GER. Other GI (pancreatitis, cholelithiasis, appendicitis,
r Premature birth r Signs/Symptoms associated with GER: gastritis/peptic ulcer disease)
r Lung transplant Recurrent regurgitation with or without vomiting Toxins (iron, lead, caffeine, theophylline,
r Hiatal hernia Weight loss and poor weight gain medications)
Choking, gagging, arching during or after feeds Infection (gastroenteritis, Helicobacter pylori,
r Family history of GERD, Barrett esophagus, or
Feeding refusal urinary tract infection, pneumonia, hepatitis,
esophageal adenocarcinoma Irritability (infants) meningitis, sepsis)
PATHOPHYSIOLOGY Chest pain or heartburn Neurologic (intracranial bleed or mass lesion,
r Multifactorial process that involves airway Dysphagia, odynophagia intracranial injury, migraine)
responsiveness, acidity, frequency of reflux events, Cough, wheezing, stridor, or hoarseness Renal (uremia, nephrolithiasis)
and esophageal clearing mechanisms (2,3) Apnea spells Cardiac (CHF)
r Occurs during the spontaneous transient relaxation Apparent life-threatening event (ALTE) Endocrine (congenital adrenal hyperplasia,
r Other historical features associated with GER: adrenal insufficiency)
of the lower esophageal sphincter (LES)
unaccompanied by swallowing Past history of prematurity, surgery, asphyxia, Metabolic (urea cycle defects, aminoacidopathies)
r Increased intra-abdominal pressure may contribute neurologic/respiratory disease, atopic Food intolerance (celiac disease, milk/soy protein
r Vomiting associated with GER is due to stimulation dermatitis/other allergy symptoms allergy)
Tobacco, alcohol use Pregnancy
of pharyngeal sensory afferents by refluxed gastric Eating disorder
contents. Family history of GERD
r Other sources of chest pain:
Cardiac
Other GI (eosinophilic esophagitis, gastritis/peptic
ulcer disease)
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GASTROESOPHAGEAL REFLUX
Respiratory (pneumothorax, asthma, pneumonia) Avoidance of caffeine, spicy food, high-fat food, REFERENCES
Costochondritis acid-containing food (eg, tomato sauce),
Mass carbonated beverages, chocolate, and alcohol if 1. Gold BD, Freston JW. Gastroesophageal reflux in
r If presence of dysphagia, need to consider: they provoke symptoms children: Pathogenesis, prevalence, diagnosis, and
Eosinophilic esophagitis Consume smaller, more frequent meals. roleof proton pump inhibitors in treatment. Pediatr
Stricture Avoid eating late at night. Drugs. 2002;4(10):673685.
Achalasia r Positioning therapy: 2. Vandenplas Y, Rudolph CD, Di Lorenzo C, et al.
Infants: Prone position (NOT endorsed by the Pediatric gastroesophageal reflux clinical practice
American Academy of Pediatrics [5]); upright guidelines: Joint Recommendations of the North
TREATMENT position American Society of Pediatric Gastroenterology,
Children and adolescents: Sleeping in left lateral Hepatology, and Nutrition and the European
INITIAL STABILIZATION/THERAPY decubitus position with elevation of the head of Society of Pediatric Gastroenterology, Hepatology,
r For infants who are healthy, feeding well, thriving,
the bed (2) and Nutrition. J Pediatr Gastroenterol Nutr.
and not excessively fussy, treatment is directed 2009;49(4):498547.
toward parental education and reassurance. SURGERY/OTHER PROCEDURES
r If diagnosed with GERD, consider: 3. Orenstein SR, McGowan JD. Efficacy of conservative
For children with persistent reflux refractory to
therapy as taught in the primary care setting for
Conservative management (lifestyle changes) maximal medical therapy or those with severe
symptoms suggesting infant gastroesophageal
Medication complications of GERD (1,2,4):
r Nissen fundoplication (open and laparoscopic) reflux. J Pediatr. 2008;152(3):310314.
Surgery 4. Shepherd RW, Wren J, Evans S, et al.
r Total esophagogastric dissociation (children with
MEDICATION Gastroesophageal reflux in children. Clinical profile,
Duration of therapy is variable depending on the neurologic impairment or other conditions causing course, and outcome with active therapy in 126
patient and practitioner. life-threatening aspiration during oral feedings) cases. Clin Pediatr (Phila). 1987;26(2):5560.
r Endoluminal endoscopic gastroplication
First Line 5. Task Force on Sudden Infant Death Syndrome.
r H2 blockers to reduce acid reflux, improve DISPOSITION Policy statement: The changing concept of sudden
symptoms, and aid in healing esophageal Discharge Criteria infant death syndrome: Diagnostic coding shifts,
mucosa: r Should be discharged home if the history and controversies regarding the sleeping environment,
Ranitidine (Zantac): PO: 410 mg/kg/day divided physical exam clearly suggests GER or GERD and new variables to consider in reducing risk.
b.i.d, max 300 mg/day; IV/IM: 24 mg/kg/day r For the most part, only parental education, Pediatrics. 2005;116(5):12451255.
divided q68h, max 200 mg/day; adult anticipatory guidance, and feeding modifications 6. Campanozzi A, Boccia G, Pensabene L, et al.
dosePO: 150 mg b.i.d. or 300 mg qhs; IM/IV:
50 mg/dose q68h, max 400 mg/day
(composition, frequency, and volume) are necessary Prevalence and natural history of gastroesophageal
reflux: Pediatric Prospective Survey. Pediatrics.
G
for the management of uncomplicated infant GERD
Famotidine (Pepcid): 112 yrs of age: 1 mg/kg/day (2). 2009;123:779783.
PO/IV divided b.i.d., max 80 mg/day; >12 yr:
Issues for Referral
2040 mg PO/IV b.i.d. r Uncomplicated GER can be easily managed by
Cimetidine (Tagamet): 2040 mg/kg/day PO/IM/IV
ADDITIONAL READING
general pediatricians (2). r Grossman AB, Liacouras CA. Gastroesophageal
divided t.i.d.q.i.d.; adult dose: 8001,200 mg r Consider referring to gastroenterologist if:
PO/IM/IV b.i.d.t.i.d. reflux. In: Liacouras CA, Piccoli DA, eds. Pediatric
r Proton pump inhibitors: The most effective Symptoms worsen or do not resolve by 1218 mo
of age Gastroenterology: The Requisites in Pediatrics.
medications for acid suppression; work best when Philadelphia, PA: Mosby Elsevier; 2008:7485.
Signs/Symptoms of significant GERD develop r Michail S. Gastroesophageal reflux. Pediatr Rev.
administered 1530 min before a meal. Not
approved for use in infants <1 yr of age: 2007;28:101110.
Omeprazole (Prilosec): 12 mg/kg/day PO divided FOLLOW-UP
daily b.i.d.; adult dose: 2040 mg PO daily
Lansoprazole (Prevacid): 10 kg: 7.5 mg PO daily; FOLLOW-UP RECOMMENDATIONS CODES
1130 kg: 15 mg PO dailyb.i.d.; >30 kg: 30 mg r Reassurance, parental education, anticipatory
PO daily-b.i.d.; adult dose: 1530 mg PO/IV daily guidance
r Instructions on dietary/lifestyle changes ICD9
Esomeprazole (Nexium): 111 yr of age: 10 mg
r Follow up with primary care provider. 530.81 Esophageal reflux
PO/IV daily; 12 yr: 2040 mg PO/IV daily
Second Line PROGNOSIS
r Prokinetic agents: Potential adverse effects PEARLS AND PITFALLS
Resolves spontaneously in most by 1 yr of age and
outweigh the potential benefits of treatment: almost all by 2 yr of age. In full-term infants, r All that vomits is not reflux.
Metoclopramide (Reglan): 0.10.2 mg/kg/dose symptoms disappear (6): r A thorough history and physical exam is usually
PO/IM/IV q.i.d., max single dose 0.8 mg/kg/day; r In 55% by 10 mo of age
adult dose: 1015 mg PO/IM/IV qac and qhs sufficient to make the diagnosis of GER or GERD.
r In 81% by 18 mo of age r Parental education, anticipatory guidance, and
Associated with extrapyramidal reactions r In 98% by 2 yr of age
(dystonia, oculogyric crisis, tardive dyskinesia) reassurance are necessary and usually sufficient to
r Antacids PO (magnesium hydroxide, calcium COMPLICATIONS manage healthy, thriving infants with uncomplicated
carbonate, aluminum hydroxide); may be used for r Erosive esophagitis GER.
symptomatic relief but not for chronic therapy r Esophageal stricture
r Barrett esophagus
COMPLEMENTARY THERAPY
r Dietary changes (14):
Formula changes usually do not improve
symptoms in GERD.
If milk protein sensitivity/allergy: A 24 wk trial of
an extensively hydrolyzed protein formula may be
beneficial.
Thickened feeds with rice cereal (helps with visible
emesis but no measurable decrease in frequency
of esophageal reflux episodes)
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DISPOSITION COMPLICATIONS
r Gastric or duodenal ulcers may perforate, causing
TREATMENT Admission Criteria
r Critical care admission criteria: peritonitis and septic shock.
PRE HOSPITAL Hemodynamic instability r Varices and arterial bleeding can result in
r Oxygen via nasal cannula or face mask Profuse and ongoing bleeding life-threatening blood loss.
r Normal saline 20 mL/kg IV or IO for patients with r Inpatient admission criteria:
hemodynamic compromise History of significant bleeding without
hemodynamic instability (eg, self-limited but REFERENCES
INITIAL STABILIZATION/THERAPY
r Establish 2 large-bore, short-length IVs if large-volume blood loss, anemia suggestive of 1. Chawla S, et al. Upper gastrointestinal bleeding in
chronic bleeding) children. Clin Pediatr. 2007;46:1621.
tachycardia or hypotension is present.
r Crystalloid infusion 20 mL/kg; may repeat as Discharge Criteria 2. McCollough M, Shareiff GQ. Abdominal surgical
r Self-limited, minor bleeding in a hemodynamically emergencies in infants and young children. Emerg
necessary
r Blood transfusion 10 mL/kg for life-threatening stable patient Med Clin North Am. 2003;21:909935.
r Benign etiology of upper GI bleed (eg, 3. Gold BD, Colletti RB, Abbott M, et al. North
blood loss; may repeat as necessary
Mallory-Weiss tear, mild gastritis, or esophagitis) American Society for Pediatric Gastroenterology
MEDICATION and Nutrition. Helicobacter pylori infection in
First Line Issues for Referral
r Outpatient referrals (routine): Chronic or recurrent children: Recommendations for diagnosis and
r Medications for gastric acid reduction:
upper GI bleeding should prompt referral to a treatment. J Pediatr Gastroenterol Nutr. 2000;
H2 receptor antagonists 31(5):490497.
Ranitidine 12 mg/kg IV q6h, max single dose gastroenterologist for possible endoscopy and
further management.
50 mg r Immediate referrals (within 1 wk): Congenital
Proton pump inhibitors ADDITIONAL READING
Omeprazole 1 mg/kg/day PO per dayb.i.d., malformations of the GI tract (eg, Meckel
max single dose 20 mg diverticulum, intestinal duplication) require referral Molleston JP. Variceal bleeding in children. J Pediatr
Lansoprazole 1530 mg/kg/day IV/PO per to a pediatric surgeon. Gastroenterol Nutr. 2003;37:538545.
dayb.i.d. See Also (Topic, Algorithm, Electronic
Pantoprazole 1 mg/kg IV/PO per day, max single
dose 40 mg
FOLLOW-UP Media Element)
r Gastritis
r Antibiotics for suspected or confirmed H. pylori FOLLOW-UP RECOMMENDATIONS r Pain, Abdomen
r Discharge instructions:
infection (see Additional Reading for all
recommended regimens) (3): Recurrent bleeding associated with symptoms of
G
Triple therapy (all 3 in combination): dizziness, light-headedness, fainting, or severe CODES
Amoxicillin 50 mg/kg/day PO divided abdominal pain should prompt immediate medical
b.i.d.q.i.d., max single dose 1 g PO b.i.d. care
Clarithromycin 15 mg/kg/day up to 500 mg PO r Discharge medications: ICD9
b.i.d. for 714 days 578.9 Hemorrhage of gastrointestinal tract,
Continue medications as described in medication
Proton pump inhibitor (as noted above) unspecified
section (eg, acid suppression therapy, antibiotics
Triple therapy as noted above, substituting for H. pylori)
clarithromycin with: r Activity:
Metronidazole 20 mg/kg/day up to 500 mg PO
PEARLS AND PITFALLS
Normal activity is recommended for most cases of
b.i.d. for 714 days upper GI bleeding. r Consider swallowed maternal blood in
Second Line breast-feeding neonates, and inquire about
r Octreotide (1 g/kg bolus to 50 g followed by
Patient Monitoring
r Monitor stool color, and inform the physician if maternal nipple irritation.
r Carefully examine the entire skin for cutaneous
14 g/kg/hr continuous infusion) for active stools are tarry, black, or maroon in color.
bleeding from varices r Avoid excessive use of NSAIDs in cases of suspected vascular malformations that may signal occult GI
r Fresh frozen plasma, cyroprecipitate, or specific vascular malformations.
gastritis or ulcer disease. r Consider accidental toxic ingestions in toddlers with
factor replacement for ongoing bleeding with
coagulopathy DIET upper GI bleeding (eg, iron).
r Soy-based or elemental formula may be indicated r Look for signs of portal HTN such as spider
COMPLEMENTARY & ALTERNATIVE for infants with milk protein allergy. angiomata, palmar erythema, and
THERAPIES r Regular diet is otherwise recommended. hepatosplenomegaly as a clue to possible variceal
r Licorice and zinc have been recommended as
PROGNOSIS bleeding.
alternative therapies for ulcer disease. r Gastric lavage with ice or epinephrine is no longer
r Chamomile and garlic are thought to have r The prognosis depends on the underlying etiology;
however, upper GI bleeding is rarely life threatening recommended.
antiH. pylori activity.
in children.
SURGERY/OTHER PROCEDURES r Etiologies with guarded prognoses include those
r Endoscopy is often indicated for bleeding requiring
associated with cirrhosis, portal HTN, esophageal
transfusion, chronic or recurrent bleeding, and in varices, or multiple vascular malformations.
some instances of variceal or vascular bleeding.
r Banding and sclerotherapy may be performed
endoscopically.
r Angiography may be indicated for massive bleeding
in patients too unstable for endoscopy.
r Surgical exploration is indicated for patients with
persistent bleeding of undetermined cause who
remain hemodynamically unstable.
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GASTROINTESTINAL POLYPS
Daniel A. Green
Barbara M. Garcia Pena
Laura Umbrello
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GASTROINTESTINAL POLYPS
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GENITAL WARTS
Shira Yahalom
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GENITAL WARTS
DIAGNOSTIC TESTS & INTERPRETATION r Hager WD. Human papilloma virus infection and
Lab FOLLOW-UP prevention in the adolescent population. J Pediatr
r No tests are required in the emergency department Adolesc Gynecol. 2009;22:197204.
for diagnosis of genital warts. FOLLOW-UP RECOMMENDATIONS r Middleman AB. Immunization update: Pertussis,
r Testing for other STIs such as gonorrhea, chlamydia, Discharge instructions and medications: meningococcus, and human papillomavirus. Adolesc
r Follow up with a clinician who can provide Med. 2006;17:547563.
syphilis, and HIV should be considered based on the
history and physical exam. long-term treatment as warranted. r Wellington MA, Bonnez W. Consultation with the
r Emphasize infectivity, need for evaluation, and specialist: Genital warts. Pediatr Rev. 2005;26:
DIFFERENTIAL DIAGNOSIS treatment of sexual partners. 467471.
r Neoplasm
r Nevi PROGNOSIS See Also (Topic, Algorithm, Electronic
r Vulvar neurofibromatosis r Spontaneous regression is more common with Media Element)
r Darier disease children than adults. r Herpes Simplex
r Hailey-Hailey disease r Recurrence after treatment may occur. r Sexually Transmitted Infection
r Since HPV cannot be eradicated, the risk of
malignant transformation remains despite treatment
TREATMENT of warts. CODES
COMPLICATIONS
MEDICATION r Cervical, vaginal, penile, and anal cancer ICD9
r Only symptomatic treatment is required in the
r Bleeding from lesions 078.11 Condyloma acuminatum
emergency department setting. r Obstruction of urethral meatus
r Imiquimod 5% cream applied to warts 3 times
r Transmission to sexual partners and neonates
weekly for 13 mo:
r Malignant transformation
PEARLS AND PITFALLS
May be prescribed if the emergency department
r Recurrence after treatment r Suspect abuse in children presenting with genital
clinician is comfortable with dispensing
Side effects include burning, pain, and vesicle r RRLP warts.
formation often mistakenly diagnosed as herpes r Examine and treat for concomitant STIs.
simplex virus. r Suspect immunodeficiency in a patient presenting
r Treat coexistent STIs as warranted. ADDITIONAL READING with recurrent disease.
r Do not ignore the significant psychological and
r Darville T. Genital warts. Pediatr Rev. 1999;20:
DISPOSITION
Issues for Referral 271272.
social implications of diagnosis. G
r It is advisable to avoid engaging in patients
All patients with genital warts should be referred to a r Diaz ML. Human papilloma virusprevention and
dermatologist, OB/GYN, or urology specialist for attempts to temporally implicate the contact from
treatment. Obstet Gynecol Clin North Am. 2008;
treatment and follow-up: which the infection may have been contracted.
35:199217. r In females, cervical HPV clearance typically occurs
r Treatment of genital warts includes topical r Erb T, Beigi RH. Update on infectious diseases in
within 2 yr.
applications, cryotherapy, or surgical excision. adolescent gynecology. J Pediatr Adolesc Gynecol. r Classically it was presumed that the infection
2008;21:135143.
persists for life, but the accuracy of this is unknown.
r CDC experts believe that persistent infections
actually involve re-exposure and reinfection.
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GIARDIASIS
Sujit Iyer
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GIARDIASIS
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GLOBE RUPTURE
Mark X. Cicero
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GLOBE RUPTURE
Diagnostic Procedures/Other r Morphine 0.1 mg/kg IV/IM/SC q2h PRN: r Sympathetic ophthalmia:
r Slit lamp Initial morphine dose of 0.1 mg/kg IV/SC may be An autoimmune response in the uninjured eye
r Fluorescein is to be avoided. repeated q1520min until pain is controlled, then weeks to months after the injury
q2h PRN. Presents with pain, photophobia, and decreased
DIFFERENTIAL DIAGNOSIS visual acuity
r Subconjunctival hemorrhage Second Line
r Corneal abrasion or laceration Lorazepam 0.1 mg/kg IV up to 2 mg hourly PRN for
r Orbital fracture agitation REFERENCES
r Lens dislocation or detached retina COMPLEMENTARY & ALTERNATIVE
r Traumatic iritis THERAPIES 1. Brophy M, Sinclair SA, Hostetler SG, et al. Pediatric
The interventions of a child life specialist can be eye injury-related hospitalizations in the United
invaluable in calming a child with globe rupture. States. Pediatrics. 2006;117(6):e1263e1271.
TREATMENT 2. Kuhn F, Morris R, Witherspoon CD, et al. The
SURGERY/OTHER PROCEDURES Birmingham Eye Trauma Terminology system
PRE HOSPITAL An ophthalmologist performs all surgical interventions. (BETT). J Fr Ophtalmol. 2004;27(2):206210.
r Apply a loose-fitting eye shield:
DISPOSITION 3. Lee CH, Lee L, Kao LY, et al. Prognostic indicators
An eye patch should not be placed on the eye. of open globe injuries in children. Am J Emerg Med.
A commercially available eye shield may be used,
Admission Criteria
All children with ruptured globe(s) are admitted to the 2009;27(5):530535.
or one may be created using the bottom of a 4. Unver YB, Kapran Z, Acar N, et al. Ocular trauma
hospital following operative management by the
paper or plastic drinking cup. score in open-globe injuries. J Trauma. 2009;66(4):
ophthalmology service:
No pressure should be applied to the eyelids. 10301032.
r Penetrating objects, such as writing instruments, are r Transfer to a referral hospital may be necessary.
left in place until the patient is in the operating
room. FOLLOW-UP ADDITIONAL READING
r The patient and caretakers are encouraged to
remain calm: FOLLOW-UP RECOMMENDATIONS Uysal Y, Mutlu F, Sobac G. Ocular Trauma Score in
Any straining and activities that increase Patients with a history of globe rupture are instructed childhood open-globe injuries. J Trauma. 2008;
intraocular pressure should be avoided. to wear eye protection in all sporting events and when 65(6):12841286.
working with tools:
INITIAL STABILIZATION/THERAPY r Patients with previous globe rupture may be prone
r If not previously done, eye shielding and securing of
to subsequent rupture.
CODES G
penetrating objects is done as outlined previously:
r Patients are monitored for endophthalmitis and
Timely consultation of ophthalmology ICD9
r IV access should be established for medication sympathetic ophthalmia. r 871.0 Ocular laceration without prolapse of
administration: PROGNOSIS intraocular tissue
In some situations, IV access is obtained after the r Blunt trauma has a better prognosis than sharp r 871.1 Ocular laceration with prolapse or exposure
patient has been sedated in the operating room injuries, as there is less risk of endophthalmitis. of intraocular tissue
using inhaled anesthetics. r Serious eye injuries regularly result in permanent r 871.2 Rupture of eye with partial loss of intraocular
Associated trauma may necessitate IV fluid visual deficit or blindness. Early, baseless optimism tissue
resuscitation. about visual outcome is to be avoided.
r No eye drops are administered for ruptured globe. r Early poor prognostic signs and symptoms include:
r Broad-spectrum IV antibiotics with good intraocular
PEARLS AND PITFALLS
penetration are indicated. The need to provide Vision loss or pupillary defect
antibiotic coverage is tempered by the risk of r Concurrent injuries may be the only sign of globe
Hyphema or vitreous hemorrhage
increased intraocular pressure due to pain from IV Retinal detachment rupture, as the globe maintains its integrity. The
catheter placement. Decreased intraocular pressure choroid and/or the iris may close the defect.
r Again, efforts should be made to keep the child r Injuries and findings that should prompt
calm: COMPLICATIONS ophthalmologic consultation include:
r Blindness and loss of visual acuity are the most
Provide analgesia (IV or PO) to decrease pain and, Hyphema
ultimately, intraocular pressure. serious consequences of globe rupture. Complete or near-complete subconjunctival
r A blind and painful eye is an indication for
Sedation with a benzodiazepine should be hemorrhage
considered: enucleation. Often, the globe may be closed and left Vision loss or blindness
Ketamine may raise intraocular pressure and in place despite blindness.
r Endophthalmitis:
should be avoided.
Antiemetics, such as ondansetron, should be An inflammatory condition of the intraocular
administered to a child with nausea or vomiting. cavities usually resulting from an infection:
Can involve aqueous or vitreous humor
MEDICATION Occurs hours to weeks later depending on the
First Line organism:
r Antibiotics with good intraocular penetration Common organisms are coagulase-negative
include: Staphylococcus epidermidis, Staphylococcus
Gram-negative coverage: aureus, and Streptococcus species.
Ceftazidime 50 mg/kg dose IV q8h OR In penetrating injuries, gram-negative organisms
Gentamicin 2.5 mg/kg IV q8h like Pseudomonas species, Escherichia coli, and
Ciprofloxacin 2030 mg/kg/day IV divided Enterococcus species are more commonly
q812h encountered.
Include ceftazidime if concerned about
Pseudomonas species
Gram-positive coverage:
Cefazolin 25 mg/kg IV q8h OR
Vancomycin 10 mg/kg IV q6h
441
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GLOMERULONEPHRITIS
Colette C. Mull
442
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GLOMERULONEPHRITIS
DIFFERENTIAL DIAGNOSIS
r Renal interstitial disease: Pyelonephritis, acute
ADDITIONAL READING
FOLLOW-UP r Anthony BF, Kaplan EL, Wannamaker LW, et al.
interstitial nephritis, tubulointerstitial nephritis with
uveitis r Well children with isolated microhematuria and Attack rates of acute nephritis after type 49
r Vascular pathology: Trauma, sickle cell disease and proteinuria should be referred back to their primary streptococcal infection of the skin and of the
trait, renal artery/vein thrombosis, arteriovenous care physician for repeat urinalysis, a diagnostic respiratory tract. J Clin Invest. 1969;48:16971704.
thrombosis, nutcracker syndrome, malignant HTN, workup if appropriate, and a referral to a pediatric r Barratt J, Feehally J. IgA nephropathy. J Am Soc
sports- and exercise-related hematuria, nephrologist when indicated. Nephrol. 2005;16:20882097.
hemangioma, hamartoma r All other discharged patients require initial and r Donadio JV, Grande JP. IgA nephropathy. N Engl J
r Neoplasms: Wilms tumor, renal cell carcinoma, long-term primary care provider follow-up to Med. 2002;347:738748.
uroepithelial tumors, rhabdoid tumors, congenital monitor: r Eddy A. Molecular basis of renal fibrosis. Pediatr
mesoblastic tumor, angiomyolipoma Urine output Nephrol. 2000;15:290301.
r Urinary tract pathologycystitis: Bacterial, viral Weight r Feld LG, Meyers KEC, Kaplan MB, et al. Limited
(adenovirus), parasitic (schistosomiasis), TB BP evaluation of microscopic hematuria in pediatrics.
r Medications: Cyclophosphamide cystitis Adherence to a low-sodium diet: Pediatrics. 1998;102:15.
r Other: Urethritis, urolithiasis, trauma, severe Young child: 23 mEq sodium/kg/day r Hudson BG, Reeders ST, Tryggvason K. Type IV
Older child: 2,000 mg/day
hydronephrosis, foreign body r HSP patients require weekly urinalysis for 4 wk, then collagen: Structure, gene organization, and role in
r Bleeding disorders: Hemophilia A or B, platelet human diseases. Molecular basis of Goodpasture
at 2 mo and at 3 mo following diagnosis. and Alport syndromes and diffuse leiomyomatosis.
disorders, thrombocytopenia, congenital or acquired r Pediatric nephrologist referral:
coagulopathies J Biol Chem. 1993;268:2603326036.
r Miscellaneous: Idiopathic hypercalciuria without Determines need for fluid restriction r Lau KK, Wyatt RJ. Glomerulonephritis. Adolesc Med.
urolithiasis, autosomal dominant polycystic kidney PROGNOSIS 2005;16:6785.
disease r PSAGN: r Narchi H. Risk of long term renal impairment and
Majority: Spontaneous, complete recovery duration of followup recommended for
Clinical signs resolve within weeks. Henoch-Schonlein purpura with normal or minimal
TREATMENT Hematuria resolves within 612 mo. urinary findings: A systematic review. Arch Dis Child.
Rare progression to nephrotic syndrome and/or 2005;90:916920.
INITIAL STABILIZATION/THERAPY r Pan CG. Evaluation of gross hematuria. Pediatr Clin
r Emergently stabilize patients presenting with CHF renal failure requiring dialysis
2nd cases of PSAGN in the same child have been North Am. 2006;53:401412.
and/or malignant HTN.
r Restrict sodium intake. well documented.
r IgA nephropathy:
r Seligman VA, Lum RF, Olson JL, et al. Demographic G
r Restrict fluid intake in ill patients only. differences in the development of lupus nephritis: A
r Consult a pediatric nephrologist. Variable clinical course retrospective analysis. Am J Med. 2002;112:
Remission in up to half of cases 726729.
r Treat the underlying disorder as appropriate. r Stetson CA, Rammelkamp CH Jr., Krause RM, et al.
Recurrent gross hematuria during viral respiratory
MEDICATION illnesses is common. Epidemic acute nephritis: Studies on etiology,
r There are no specific medications that are used to Chronic renal failure in <50% of cases natural history, and prevention. Medicine
r Alport syndrome and MPGN: (Baltimore). 1955;34:431450.
treat or reverse GN in the emergency department
setting. Rapidly progressive forms of AGN r Wyatt RJ, Kritchevsky SB, Woodford SY, et al. IgA
r Inpatient medication and fluid management should End-stage renal failure is common. nephropathy: Long-term prognosis for pediatric
r HSP GN: patients. J Pediatr. 1995;127:913919.
be individualized and determined in consultation
with a pediatric nephrologist: Excellent prognosis r Yoshikawa N, Ito H, Yoshiara S, et al. Clinical course
Anti-inflammatory agents: IV or oral <2%: Long-term impairment of IgA nephropathy in children. J Pediatr.
corticosteroids, cyclophosphamide, azathioprine Presentation with nephritis or nephritic syndrome 1987;110:555560.
Proteinuria-reducing agents inhibit tubular injury elevates risk of long-term impairment to close to
and fibrosis: Angiotensin-converting enzyme 20%.
inhibitors, angiotensin 2 receptor blockers, statins, r SLE GN: CODES
antioxidants. Markers of poor prognosis: Severity of histology,
Diuretics for renal failure, CHF black race ICD9
r Plasmapheresis for rapidly progressive GN r Goodpasture syndrome: Poor prognosis r 580.0 Acute glomerulonephritis with lesion of
r ANCA-positive GN: proliferative glomerulonephritis
COMPLEMENTARY & ALTERNATIVE r 580.9 Acute glomerulonephritis with unspecified
High morbidity if patient presents with renal
THERAPIES insufficiency
Fish oil supplements containing omega-3 fatty acids pathological lesion in kidney
r 583.9 Nephritis and nephropathy, not specified as
have been used to control inflammation. COMPLICATIONS
r See Prognosis. acute or chronic, with unspecified pathological
SURGERY/OTHER PROCEDURES r Most common: CHF, malignant hypertensive lesion in kidney
r Renal transplant is not always curative.
r Recurrence of GN may lead to loss of allograft. encephalopathy
443
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GONORRHEA
Cynthia J. Mollen
444
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GONORRHEA
DIFFERENTIAL DIAGNOSIS r Fluoroquinolones are not routinely recommended r Cook RL, Hutchison SL, Ostergaard L, et al.
r Patients with GC who present predominantly with for the treatment of gonococcal infections due to Systematic review: Noninvasive testing for
abdominal or pelvic pain have a broad differential increasing bacterial resistance: Chlamydia trachomatis and Neisseria gonorrhoeae.
including ovarian abscess or torsion, ectopic For patients who have severe penicillin allergies Ann Int Med. 2005;142(11):914925.
pregnancy, appendicitis, or renal calculi. and are unable to tolerate cephalosporins, r Fang J, Husman C, DeSilva L, et al. Evaluation of
r Other STIs treatment with a fluoroquinolone can be self-collected vaginal swab, first void urine, and
r Urinary tract infection considered; however, cultures rather than NAAT endocervical swab specimens for the detection of
r Vaginitis (yeast, bacterial vaginosis, other bacteria, techniques should be used in order to obtain Chlamydia trachomatis and Neisseria gonorrhoeae
contact) sensitivity data. in adolescent females. J Pediatr Adolesc Gynecol.
r For disseminated disease, consider bacterial arthritis, DISPOSITION 2008;21:355360.
r Tarr ME, Gilliam ML. Sexually transmitted infections
acute rheumatic fever, connective tissue diseases, or Admission Criteria
infective endocarditis. r Patients with disseminated disease or who are ill in adolescent women. Clin Obstetr Gynecol.
2008;51(2):306318.
appearing should be admitted for treatment.
r Neonates with GC ophthalmia need to be See Also (Topic, Algorithm, Electronic
TREATMENT
hospitalized, and clinicians should have a low Media Element)
MEDICATION threshold for obtaining blood and CSF cultures. r Pelvic Inflammatory Disease
r Urethritis
First Line Discharge Criteria
r Uncomplicated urogenital and anorectal infections: Most patients with uncomplicated GC infection can be
Ceftriaxone 250 mg IM or IV as a single dose, or discharged from the emergency department after
cefixime 400 mg PO as a single dose receiving antibiotic treatment. CODES
r Pharyngeal infections: Ceftriaxone 125 mg IM or IV
as a single dose ICD9
r Epididymitis: Ceftriaxone 250 mg IM in a single dose FOLLOW-UP r 098.0 Gonococcal infection (acute) of lower
r Neonatal conjunctivitis: Ceftriaxone 2550 mg/kg genitourinary tract
FOLLOW-UP RECOMMENDATIONS r 098.10 Gonococcal infection (acute) of upper
IV or IM in a single dose, not to exceed 125 mg, plus r In most areas, GC is reportable to health authorities.
irrigation with normal saline r Patients treated for uncomplicated GC do not genitourinary tract, site unspecified
r Disseminated GC: Ceftriaxone 1 g IV q8h r 098.11 Gonococcal cystitis (acute)
require a test of cure.
r Meningitis or bacteremia: Ceftriaxone 12 g IV q12h r Sexual partners who had contact with the patient
r Disseminated GC in neonates: Ceftriaxone 2550
mg/kg/day IV or IM in a single daily dose for 7 days,
within 60 days of the onset of symptoms should be
PEARLS AND PITFALLS G
treated empirically for C. trachomatis and N.
with a duration of 1014 days, if meningitis is gonorrhoeae. r Many cases of GC are asymptomatic.
documented; or cefotaxime 25 mg/kg IV or IM q12h r Patients should refrain from sexual activity until all r GC can present with a wide array of manifestations
for 7 days, with a duration of 1014 days, if treatment is complete. and has a low threshold for screening.
meningitis is documented. r Coinfection with other STIs is common.
r In addition, for uncomplicated documented GC
r NAAT tests are as sensitive as GC cultures.
infections of the cervix, urethra, epididymis, and ADDITIONAL READING
pharynx, the most recent CDC guidelines r CDC. Screening to detect Chlamydia trachomatis
recommend the addition of azithromycin 1 g PO
once or doxycycline 100 mg PO b.i.d. for 7 days and Neisseria gonorrhoeae infections2002.
even if Chlamydia is documented as negative. MMWR Recomm Rep. 2002;51(RR-15):138.
r CDC. Sexually Transmitted Disease Surveillance,
Second Line 2009. Atlanta, GA: U.S. Department of Health and
r For penicillin-allergic patients, azithromycin 2 g PO
Human Services; 2010.
as a single dose can be used as treatment for r CDC. Sexually transmitted diseases treatment
uncomplicated GC infection. Due to expense, a high
guidelines, 2010. MMWR Recomm Rep. 2010;
rate of side effects, and increasing bacterial
59(RR-12):1110.
resistance, azithromycin is not routinely
recommended for the treatment of GC.
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GROIN MASS
Marie Waterhouse
Deborah R. Liu
446
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GROIN MASS
Imaging
r Abdominal radiographs:
DISPOSITION REFERENCES
Admission Criteria
For most common causes of groin mass with a r Incarcerated hernias, if successfully reduced in the 1. Benjamin K. Scrotal and inguinal masses in the
benign abdominal exam, radiographs are emergency department, will require admission newborn period. Adv Neonatal Care. 2002;2:
generally not helpful. pending surgical repair. 140148.
May reveal loops of intestine within hernia sac r Strangulated or nonreducible incarcerated hernia 2. Brandt ML. Pediatric hernias. Surg Clin North Am.
Multiple air-fluid levels indicate small bowel will require emergent surgery. 2008;88:2743.
obstruction with incarcerated hernia. r Inguinal abscess may require IV antibiotics and 3. Kapur P, Caty MG, Glick PL. Pediatric hernias and
Free air indicates bowel perforation from surgical drainage. hydroceles. Pediatr Clin North Am. 1998;45:
strangulation. 773789.
r US: Discharge Criteria 4. Szelc CS, Kelly R. Lymphadenopathy in children.
r Well appearing with pain adequately controlled
May distinguish between hernia and hydrocele Pediatr Clin North Am. 1998;45:876888.
r Patients with hernia may be discharged from the
Poorly sensitive for locating undescended testis
emergency department if the mass is reducible and
DIFFERENTIAL DIAGNOSIS does not show signs of incarceration or bowel ADDITIONAL READING
See Etiology. obstruction.
r Klein BL, Ochsenschlager DW. Groin masses. In
Issues for Referral Fleisher GR, Ludwig S, eds. Textbook of Pediatric
TREATMENT r Referral to a pediatric surgeon for timely repair of all
Emergency Medicine. 6th ed. Philadelphia, PA:
reducible inguinal hernias. Lippincott Williams & Wilkins; 2010.
PRE HOSPITAL r Some hydrocele repairs may be postponed until after r Smith SR. Inguinal hernia reduction. In King C,
Ice or a cold pack may be applied to incarcerated age 2 yr depending on risk factors.
r Consider referral for biopsy for diagnosis of Henretig FM, King BR, et al., eds. Textbook of
inguinal hernia to decrease edema.
Pediatric Emergency Procedures. 2nd ed.
INITIAL STABILIZATION/THERAPY persistent lymphadenopathy >8 wk (4). Philadelphia, PA: Lippincott Williams & Wilkins;
Treatment depends on the etiology of the groin mass. 2008.
Refer to appropriate topics. FOLLOW-UP See Also (Topic, Algorithm, Electronic
MEDICATION Media Element)
r Analgesic agents IV, IM, or PO: FOLLOW-UP RECOMMENDATIONS r Cryptorchidism
Procedural sedation may be necessary for Discharge instructions and medications: r Hernia
r Instruct parents of children with hernias on signs r Lymphadenopathy
incarcerated inguinal hernia.
r Antibiotics: and symptoms of incarceration. r Malignancy Topics
G
r Return to emergent medical care for any signs of
Inguinal abscess or cellulitis requires antibiotics to r Scrotal Pain
cover skin flora (including MRSA, following bowel obstruction or incarceration.
regional susceptibility patterns). PROGNOSIS
Broad-spectrum IV antibiotics for strangulated r Depends on the etiology of groin mass CODES
hernia to prevent sepsis from enteric organisms r Most congenital hydroceles will resolve by age 2 yr
Adenitis from Bartonella usually self-resolves in
without surgery. ICD9
the immunocompetent host: r Inguinal hernia repair generally is safe and effective: r 550.90 Unilateral or unspecified inguinal hernia,
Consider antibiotics only for complicated cases.
1020% incidence of developing hernia on without mention of obstruction or gangrene
SURGERY/OTHER PROCEDURES contralateral side (1) r 603.9 Hydrocele, unspecified
r Incision and drainage of inguinal abscess: r 789.30 Abdominal or pelvic swelling, mass, or lump,
Presence of connective tissue disorder may
Not routinely recommended due to possibility of predispose the patient to recurrence of hernia unspecified site
formation of a permanent fistula after surgical repair.
May be attempted if abscess is superficial and the
procedure is unlikely to damage nerves, vessels, or COMPLICATIONS
r Depends on etiology of the groin mass PEARLS AND PITFALLS
other structures
r Incarceration of the hernia sac can lead to ischemic r Groin masses in children are most commonly hernia,
Consider US imaging or surgical consult if abscess
is deeper or if diagnosis is uncertain (due to risk of necrosis of involved structures (bowel, testis, ovary), hydrocele, lymphadenopathy, or undescended testis.
associated hernia, bowel perforation, and damage bowel perforation, and sepsis. r Do not incise an inguinal abscess until fully certain
to vascular or other structures). r Undescended testis can be associated with
that the bowel or other structures are not involved.
r Manual reduction of hernia increased future risk of malignancy and infertility. r Emergency department manual reduction of an
r Inguinal hernia repair: r Complication rate for hernias requiring emergent
incarcerated inguinal hernia is often successful.
Emergent for nonreducible or strangulated hernias surgery is higher than for manually reduced hernias r Strangulated or nonreducible incarcerated hernias
Elective (within 1 mo of diagnosis) for reducible repaired electively. constitute a surgical emergency.
hernias in term infants (3) r Complications of hernia repair include (2):
Testicular atrophy (12%)
Injury to vas deferens (<1%)
Iatrogenic cryptorchidism (0.62.9%)
Case reports of female infertility secondary to
fallopian tube injury
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448
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449
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GUILLAIN-BARRE SYNDROME
Christopher J. Russo
450
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GUILLAIN-BARRE SYNDROME
451
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GYNECOMASTIA
Maria Carmen G. Diaz
452
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GYNECOMASTIA
453
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HAIR-THREAD TOURNIQUET
Mark R. Zonfrillo
454
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HAIR-THREAD TOURNIQUET
455
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HALLUCINOGEN POISONING
Robert J. Hoffman
456
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HALLUCINOGEN POISONING
457
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HAND-FOOT-AND-MOUTH DISEASE
Esther Maria Sampayo
r A primary or minor viremia results in spread to r Cutaneous lesions are present in 2/3 of patients:
BASICS distant parts of the reticuloendothelial system, The exanthem may be macular, maculopapular, or
including the liver, spleen, bone marrow, and distant papulovesicular and may be petechial.
DESCRIPTION lymph nodes. Typically, the dorsal, interdigital aspect of the
r Hand-foot-and-mouth disease (HFMD) is a viral r The host immune response may curtail replication at hands and feet are involved.
illness characterized by: this point, resulting in a subclinical infection with The lesions are usually elliptical in shape with the
Fever and malaise only fever, sore throat, and malaise. long axis of the lesion along the skin lines and
Vesiculoulcerative enanthem in the mouth r A secondary major viremia usually occurs to target start as a 210-mm erythematous macule on
Macular, papular, or vesicular exanthem on the organs such as the pharynx, the skin, the which a gray, oval vesicle develops.
distal extremities myocardium, and the meninges. It can also involve The exanthem may also occur on the proximal
r The most common causative agent is Enterovirus. extremities, buttocks, and genitalia.
the adrenal glands, pancreas, liver, pleura, and
lungs. r Some patients may also exhibit a mild
EPIDEMIOLOGY
r HFMD is seen in children <10 yr of age, but most r Tropism to target organs is determined by the lymphadenopathy of the cervical or submandibular
commonly is seen in children <5 yr. infecting Enterovirus serotype. glands.
r In temperate climates, most commonly summer and r The minor and major viremia may correlate with the
DIAGNOSTIC TESTS & INTERPRETATION
fall biphasic appearance of fever and symptoms Lab
r Highly contagious and afflicts up to 50% of those commonly seen with Enterovirus. r The diagnosis can be made clinically.
r Antibody production in response to enteroviral r Routine lab tests are not indicated.
exposed
r Infection results in immunity to the specific virus infections occurs within the 1st 710 days, and r Although most children will not require culturing to
that caused the illness; however, a 2nd illness may viremia ceases with antibody production.
establish the diagnosis, viral cultures from the
occur to a different strain of Enterovirus. ETIOLOGY lesions, throat, CSF, urine, or stool may be sent to
r Infected persons are most contagious during the 1st r Enterovirus is the causative agent, of which classify the virus.
2 wk of the illness with respiratory viral shedding coxsackievirus A16 and enterovirus 71 are the most r Polymerase chain reaction assay is more rapid and
but may be carriers for a month after the initial common. more sensitive than cell culture and can detect
infection with fecal viral shedding. r Sporadic cases of HFMD may also be caused by Enterovirus.
r It is not transmitted to or from pets or other animals. coxsackieviruses A5, A7, A9, A10, B2, and B5. Pathological Findings
RISK FACTORS r Classic histopathologic findings of HFMD include an
r Contact with oral and respiratory secretions, blister intradermal vesicle containing neutrophils and
DIAGNOSIS
fluid, fecal material or aerosolized droplets in a eosinophilic cellular debris.
fecaloral or oraloral route HISTORY r The adjacent epidermis is characterized by
r Risk factors for infection include diaper changing, r The disease usually begins with a low-grade fever, intracellular and intercellular edema called reticular
poor sanitation, crowded living conditions, and low poor feeding and appetite, malaise, and often a sore degeneration.
socioeconomic status. throat or mouth. r The dermis has a mixed infiltrate in which
r Children <5 yr of age are the most susceptible to r Occasionally, patients may have high fever, diarrhea, eosinophilic intranuclear inclusions can be visualized
infection due in part to a lack of prior immunity; cough, and arthralgias. with an electron microscope (1).
HFMD is extremely uncommon in adults. r The enanthem is composed of painful lesions in the r Neuropathology in fatal cases of enterovirus 71
mouth, on the tongue, and in gingival and buccal have demonstrated features of acute encephalitis
GENERAL PREVENTION
r Good hand hygiene mucosa that develop 1 or 2 days after the onset of involving the brain stem and spinal cord.
r Cleaning dirty surfaces and soiled items such as toys symptoms.
r The exanthem is composed of a nonpruritic rash DIFFERENTIAL DIAGNOSIS
with soap and water initially, then disinfecting them r The characteristic findings of HFMD are seldom seen
located on the hands and feet that also develops in other diseases. However, early in the disease,
with a dilute solution of chlorine-containing bleach.
r Avoiding close contact with persons with the disease over 12 days. when only the exanthem or enanthem occur, the
r A person may only have the rash or only the mouth
r Standard and contact precautions in the differential diagnosis includes:
lesions, but both may occur simultaneously. r Herpetic gingivostomatitis
hospitalized patient r Mucosal lesions heal in 57 days.
r Breast-feeding reduces risk of infection. r Herpangina
r Cutaneous lesions are usually present for 510 days. r Aphthous stomatitis
PATHOPHYSIOLOGY r Stevens-Johnson syndrome
r Enterovirus infection is acquired initially via the oral PHYSICAL EXAM
r Most patients with HFMD will be febrile. r Boston exanthem:
or respiratory route with viral implantation in the r Oral lesions begin as erythematous macules that
buccal and ileal mucosa. The causative organism is echovirus 16.
r The incubation period for most enteroviral infections evolve into 23-mm vesicles on an erythematous Mild febrile illness with macular rash on the face,
base, appearing as a halo: trunk, palms, and soles accruing at the time or
ranges from 310 days.
r Initial replication in the pharynx and intestine is Vesicles are rarely observed because they rapidly after defervescence
become ulcerated. Oral lesions absent
followed by invasion of the lymphatic system within Lesions are usually located on the palate, buccal r Varicella
24 hr. mucosa, gingival, and tongue.
The tongue is involved in 44% of cases and is
usually tender and edematous.
The total number of ulcers averages from 510.
458
P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
LWBK822-driver-H LWBK822-Hoffman ch228.xml April 15, 2011 17:38
HAND-FOOT-AND-MOUTH DISEASE
DIET
r Avoid spicy foods. CODES
TREATMENT r Avoid acidic foods such as orange juice.
INITIAL STABILIZATION/THERAPY r Encourage cool fluids such as popsicles in frequent, ICD9
r Assess and stabilize airway, breathing, and small aliquots. 074.3 Hand, foot, and mouth disease
circulation.
r Severe cases may require administration of IV fluid PROGNOSIS
HFMD is self-limited and generally has