Category: Pediatrics

Neonatal Conjunctivitis

The 3 Worst Causes of Neonatal Conjunctivitis

  • Gonorrhea
    • Causes corneal ulcers and sepsis
    • Red flags
      • 1st week of life
      • Copious purulent drainage
    • Diagnose with cultures
    • Treatment
      • Cefotaxime (3rd generation cephalosporin)
      • Admit
  • Chlamydia
    • Occurs in 1st month of life
    • Treat with PO erythromycin
  • HSV
    • Can disseminate to the brain
    • Red flags
      • Mother tested positive (or had active lesions)
      • Vesicles on baby
    • Treatment
      • IV acyclovir
      • Admit

Other Causes of Conjunctivitis

  • Viral/other bacterial
    • Treat with erythromycin ointment
  • Chemical conjunctivitis
    • Caused by eye drops given after birth
  • Dacryostenosis (closed eye ducts)
    • Watery eyes from tears not draining

Additional Reading

  • Neonatal Conjunctivitis (CDC)

Blood in the Diaper

The 4 Most Common Causes of Blood in Diaper

  • Urinary crystals
    • Will be guaiac negative
    • Common in first few weeks of life
  • Vaginal bleeding
    • Common in newborn females as they withdraw from maternal estrogen
  • Maternal blood
    • Swallowed during birthing process
    • Breastfeeding with cracked/bleeding nipples
  • Anal fissures
    • Common and will improve on its own

Basic Approach

  • Step 1: Check if guaiac positive
    • If negative, it’s not blood
    • Urinary crystals, food coloring, etc
  • Step 2: Consider vaginal bleeding
  • Step 3: Perform apt test
    • Diagnoses maternal blood
  • Step 4: Check for anal fissure
    • Self resolve
  • Step 5: Expand the differential diagnosis
    • Necrotizing enterocolitis
    • Intussusception
    • Cow’s milk allergy
    • Colitis
    • Red Food Dye

Additional Reading

Neonatal Jaundice

Physiology

  • RBC hemoglobin breakdown -> unconjugated (indirect) bilirubin
  • Unconjugated (indirect) bilirubin -> liver -> conjugated (direct) bilirubin
  • Conjugated (direct) bilirubin -> Eliminated in stool

Causes of Hyperbilirubinemia

  • Increased RBC turnover
    • Sepsis
    • Rh incompatibility
    • RBC disorders
    • Maternal diabetes
    • Scalp hematoma
  • Decreased/slow conjugation by the liver
    • Peaks around day 5 of life
    • Congenital liver disorders
      • Gilbert/Crigler Najjar Syndromes
    • Breast milk jaundice
      • Breast milk inhibits conjugation of bilirubin
  • Decreased excretion
    • Bowel obstruction
    • Breast feeding failure (dehydration)
      • Decreased stool output results in reabsorbed bilirubin

Kernicterus

  • Brain damage from severe hyperbilirubinemia (>25 mg/dL)
  • Compare measured bilirubin to established nomogram
  • Treatment is phototherapy
    • (Worst case scenarios require exchange transfusion)

Additional Reading

Peds T- Tummy and Non-Accidental Trauma

Non-Accidental Trauma

  • Estimated 10% of pediatric patients are victims of abuse
    • Sexual abuse
    • Physical abuse
    • Neglect
  • Common red flags
    • Changing story
    • Story that doesn’t make since
    • Delays in seeking care
    • Unusual bruising locations
      • Torso
      • Ears
      • Neck
  • Common tests if non-accidental trauma suspected
    • Skeletal survey x-rays
    • Head CT
      • Especially if altered mental status
    • Abdominal CT
      • Especially if abdominal trauma
  • Report to child protective services (CPS)

Tummy Ache

  • Necrotizing enterocolitis
    • Classic presentation
      • Premature baby
      • 1st month of life
      • Ill appearing
    • Classic finding on x-ray
      • “Pneumatosis intestinalis”
  • Volvulus
    • Classic presentation
      • 1st month of life but previously healthy
      • Distended abdomen
      • Bilious vomiting
    • Testing
      • Abdominal Xray
      • Upper GI Series (ideal test)
  • Toxic megacolon
    • Complication of Hirchsprung Disease
    • Seen on x-ray
  • Intussusception
    • Telescoping bowel resulting in ischemia
    • Classic presentation
      • 2 months – 2 years old
      • Intermittent abdominal pain followed by lethargy
    • Diagnose with abdominal ultrasound
  • Pyloric stenosis
    • Classic presentation
      • Projectile vomiting
      • Normal appetite/hungry
      • Palpable “olive” in epigastrium
    • Testing
      • Electrolyte panel
        • Hypokalemia
        • Hypochloremia
        • Alkalosis
      • Abdominal ultraound

Additional Reading

Peds I- Inborn Errors of Metabolism and Endocrinology

Don’t be overwhelmed knowing/memorizing each inborn error of metabolism. The basic approach is actually quite easy!!!

Inborn Errors of Metabolism (IEM)

  • Almost always result in one of the following three clinical abnormalities
    • Buildup of toxins
      • Ammonia
        • To test for this, obtain an ammonia level
    • Buildup of acids
      • Methylmalonic acidemia
        • To test for this, obtain electrolyte panel and look for decrease CO2
    • Shortage of glucose
      • Glycogen storage disorders
        • To test for this, obtain a blood glucose level

Congenital Adrenal Hyperplasia (CAH)

  • Decreased 21-hydroxylase enzyme
  • Physiologic abnormalities
    • Decreased aldosterone
      • Low sodium (hyponatremia)
      • High potassium (hyperkalemia)
    • Decreased cortisol
      • Low glucose level
      • Hyperpigmentation
    • INCREASED sex hormone (androgens)
      • Fused labia
      • Partial male genitalia

Additional Reading

Peds H- Heart Failure and Congenital Heart Disorders

Common Chief Complaints

  • Cyanosis
  • Difficulty feeding
  • Failure to thrive

Cyanotic Heart Lesions

  1. Truncus arteriosus
    • Aorta and pulmonary artery are fused
    • Single vessel comes from both ventricles
  2. Transposition of great vessels
    • Aorta comes off RIGHT ventricle
    • Pulmonary artery comes off LEFT ventricle
  3. Tricuspid atresia
    • Blood unable to get from right atrium to right ventricle
  4. Tetrology of fallot
    • Overriding aorta
    • Ventricular septal defect
    • Right ventricular outflow tract obstruction
    • Hypertrophy of right ventricle
  5. Total anomalous pulmonary venous return
    • Pulmonary vein empties into the right ventricle

Ductal Dependent Lesions

  • Classically presents in first 30 days of life
  • Treatment = Prostaglandins
  • Common lesions
    • Hypoplastic left heart
    • Aortic stenosis
    • Coarctation of the aorta

Congestive Heart Failure

  • Common Presentation
    • Difficulty feeding
    • Organomegaly
    • Cardiomegaly on CXR
  • Treatment
    • Furosemide
    • Vasopressors
  • Admit

Additional Reading

Peds S- Sepsis and Serious Bacterial Infections

Pediatric “Sepsis”

  • Consider in any toxic appearing child/neonate
    • Especially with fever (or hypothermia)
  • Treatment
    • Early antibiotics
    • Fluid bolus

“Serious Bacterial Infections” (SBI)

  • Consider in any baby with fever
  • Three classic categories
    • Age <30 days
      • Introduction
        • Weak immune system
        • No immunizations
        • Very high risk for serious bacterial infections
      • Require a significant amount of testing
        • Urinalysis with Urine Culture
        • Blood Cultures
        • Lumbar Puncture with CSF Cultures
        • Chest X-Ray
      • Require admission and antibiotics
    • Age 30-60 days
      • ILL appearing
        • Treat same as fever in <30 day patient
      • WELL appearing
        • Testing and treatment differ by institution
        • Multiple criteria established to help in this age range
          • Rochester criteria
          • Philadelphia criteria
          • PECARN criteria
        • Choose one and use consistently
    • Age >60 days
      • (Assumes immunizations are up to date)
      • Workup is more targeted
        • Blood cultures, Urine cultures, Chest X-Rays still common

Additional Reading

  • Rochester Criteria Febrile Infants (MDCalc)
  • PECARN Rule for Low Risk Febrile Infants (MDCalc)

Peds H- Hyperglycemia and Hypoglycemia

Introduction

  • In pediatric patients, have a low threshold to check blood sugar
  • Undiagnosed diabetics commonly identified in ED during first episode of DKA
  • HYPOglycemia is very common in multiple conditions, especially in ill children

Hyperglycemia

  • DKA is different in kids
    • They get cerebral edema
      • Increased intracranial pressure with rapid fluid administration
    • Common symptoms
      • Headache
      • Altered mental status
      • Neurologic deficits
      • Cushings triad
        • Hypertension
        • Bradycardia
        • Irregular breathing
    • Treatment = mannitol

Hypoglycemia

  • Multiple causes
    • Sepsis
    • Inborn errors of metabolism
    • Endocrine disorders
  • Replace glucose using “Rule of 50s”
    • Dextrose % x Volume = 50
      • Neonates: 5ml/kg of D10
      • Pediatrics: 2ml/kg of D25
      • Teens/Adults: 1ml/kg of D50
    • 1 “amp” of D50 = 25g of sugar = 50ml

Additional Reading

Peds O- Oxygen, Airway, and Respiratory Disorders

Applying oxygen is one of the first steps in treating any crashing child!!!

Airway Emergencies

  • Foreign body (FB)
    • Patient presentation
      • Stridor
      • Choking episode
    • Testing
      • CXR
        • May directly show foreign body
        • May show secondary effects of a foreign body
          • Hyperinflated/collapsed lobes of the lung
    • Patient needs bronchoscopy if suspicion is high
  • Peritonsillar abscess
    • Visible in the pharynx
  • Bacterial tracheitis
    • HIDDEN IN the airway
  • Epiglottitis
    • HIDDEN ABOVE the airway
  • Retropharyngeal abscess
    • HIDDEN BEHIND behind the airway
  • Common presentations of airway emergencies
    • Voice changes
    • Drooling
    • Stiff neck
  • Testing
    • Most are seen on neck X-Ray
    • Peritonsillar abscess is clinical diagnosis
  • Treatment
    • Manage the airway
    • IV Antibiotics
    • Peritonsillar abscess needs drainage

Breathing Emergencies

  • Bronchiolitis = Badly breathing booger babies
    • Upper respiratory infection caused by virus
    • Signs of severe illness requiring admission
      • Grunting
      • Nasal flaring
      • Retractions
      • Hypoxemia
      • Unable to tolerate PO
    • Treatment
      • Deep suctioning
      • Can consider albuterol trial
      • Oxygen supplementation as needed
    • Generally avoid
      • Chest X-rays
      • Steroids
      • Antibiotics
  • Asthma
    • Treatment
      • First line
        • Albuterol/ipratropium
        • Steroids
      • Additional options as needed
        • Magnesium
        • Ketamine
        • IV epinepherine
  • Croup
    • Presentation
      • Barky cough
      • Stridor
    • Treatment
      • Steroids
      • Consider racemic epinephrine
  • Pneumonia
    • Diagnosed by x-ray
    • Treat with antibiotics
  • Cystic fibrosis
    • Albuterol/ipratropium
    • Nebulized saline
    • Antibiotics

Additional Reading

How to Save a Dying Baby

When you have a critically ill child in front of you, always remember, OH SHIT, Grab the Broslow!!!

Oxygen- Apply Oxygen and Consider Airway/Respiratory Emergencies

  • Foreign body
  • Peritonsillar abscess
  • Bacterial tracheitis
  • Epiglottitis
  • Retropharyngeal Abscess
  • Bronchiolitis
  • Asthma
  • Croup
  • Pneumonia
  • Cystic Fibrosis

Hyper/Hypoglycemia- Check Blood Glucose

  • Hypoglycemia
  • DKA

Sepsis- Consider Sepsis and Serious Bacterial Infections

  • Pediatric sepsis
  • Fever <30 days of age
  • Fever 30-60 days of age
  • Fever >60 days of age

Heart- Consider Congenital Heart Abnormalities

  • Truncus arteriosis
  • Transposition of great vessels
  • Tricuspid atresia
  • Tetrology of fallot
  • Total anomalous pulmonary venous return
  • Ductal dependent lesions
  • Congestive heart failure

Inborn Errors of Metabolism/Endocrinology

  • Congenital adrenal hyperplasia

Tummy/Trauma- Consider Abdominal Processes and Non Accidental Trauma

  • Non-accidental trauma
  • Necrotizing enterocolitis
  • Volvulus
  • Toxic megacolon
  • Intussusception
  • Pyloric stenosis

And never forget… If you feel flustered… GRAB THE BROSLOW!!!

Additional Reading

Pediatrics Exam

Mnemonic: ABCDEF

Appearance

  • The ‘A’ in the pediatric assessment triangle
    • Interactive vs distant
    • Good tone vs floppy
    • Calm and happy vs inconsolable

Breathing

  • The ‘B’ in the pediatric assessment triangle
    • Signs of respiratory distress
      • Nasal flaring
      • Retractions
      • Abnormal respiratory sounds

Color/Circulation

  • The ‘C’ in the pediatric assessment triangle
  • Pink = good
  • Abnormalities
    • Pallor
    • Cyanosis
    • Mottling

Distraction

  • Almost impossible to do a good peds exam in a crying kid
    • Easiest ways to keep kids distracted
      • Let parents hold/play with them
      • Toys
      • Stethoscope
      • Funny sounds/noises

ENT

  • Many times the kids don’t localize the symptoms
  • May present with vomiting, fever, irritability, etc
  • If difficulty examining pharynx, consider triggering a gag reflex

Fully Undress

  • Look for bruising, rash, blisters
  • Signs of non-accidental trauma
  • GU exam (especially in boys, check the testes!)

Additional Reading

Pediatrics History

Always ask about pediatric patient’s ‘P-I-S-S’ status!!!

Core Function Questions (P-I-S-S Status)

  • Peeing
    • Evaluates for dehydration
      • Number of wet diapers per day?
      • Same number as usual?
  • Intake
    • Rule of 3s
      • Estimates how much milk/formula an average infant should be taking
      • 3oz of milk or formula every 3 hours
  • Sleeping
    • Is the patient sleeping MORE than usual?
    • LESS than usual?
  • Stooling
    • Normal stool
      • Changes from dark meconium to tans/yellows

Pediatric Medical History

  • Prebirth
    • Did the patient have prenatal care?
    • Any issues with the pregnancy?
    • Was mom GBS positive?
  • Peribirth
    • What gestational age was patient born at?
    • Vaginal delivery or c-section?
    • How long did baby have to stay in hospital after delivery?
  • Postbirth
    • Diagnosed medical/surgical problems
    • Immunization status

Additional Reading

BRUE (Pediatrics)

Brief. Resolved. Unexplained. Events.

A few months ago the American Academy of Pediatrics (AAP) released a set of guidelines on the management of a  common pediatric condition formally known as ALTE (now known as BRUE). These babies used to ALL be admitted to the hospital for extensive testing. However, this is no longer the case. Now, the AAP divides these babies into 3 categories, HIGH risk, LOW risk, and NOT BRUE. I’ll break down this huge pediatrics topic and the new guidelines in this episode.

Pediatric GI Complaints

Today we are moving on to a completely new topic, we are going to be discussing a simple approach to pediatric GI complaints. I hope you enjoy it. The majority of this episode will be covering the life-threatening, differential diagnosis for pediatric abdominal pain. It is 12 items long, and can be thought of in regions: Upper Abdomen, Lower Abdomen, Genitourinary, and Generalized.

Also, in this episode, we will discuss how to obtain a quick pediatric GI history, the 5 most common tests that get ordered on children, and a basic GI treatment plan.

Even if your department doesn’t accept children, I still highly encourage you to listen, as this is not only a topic on your shelf, but also a huge topic on Step 2.

Let me know if you have any feedback on the content, and please check out the new website emclerkship.com

© 2020 EM Clerkship

Theme by Anders NorenUp ↑