Toddlers Breath-holding attacks commonly accompany frustration. They may cause the toddler to turn blue, lose consciousness, and even have a brief \201 t. Re \202 ex anoxic episod es ( \200\230pallid syncope \200\231) are due to excess vagal stimulation in illness or aft er injury. Bradycardia, pallor and loss of consciousness is occasionally accompanied by a s hort \201 t. Older children Syncope on exertion should prompt consideration of aortic stenosis, SVT, coa rctation or hypertrophic cardiomyopathy. Vasovagal episodes and hyperventilation also cause \200\230collapse \200\231. Atypical or unheralded collapse or seizures may be a feature o f inherited long QT syndrome, and is associated with torsades de pointes. Obtain an ECG in any child who presents with collapse or \200\230 \201 rst \201 t \200\231. 690 CHAPTER 15 Pediatric emergencies Status epilepticus De \201 nition a \201 t (or consecutive \201 ts without complete re covery between) lasting > 30min. The duration of the seizures is often underestimated becau se the intensity of the jerking diminishes with time and small amplitude twitching may be e asily missed. Status epilepticus usually involves tonic-clonic \201 ts and as in adults, is associated with signi \201 cant mortality ( 8 4 % ) and morbidity (up to 30 % have long-term neurolog ical damage). Prompt treatment with termination of the \201 t is crucial to d these risks . Causes meningitis, head injury, altered drug therapy, or non-compliance in known epilepti c child, metabolic disturbances, encephalopathy (including Reye \200\231s syndrome), \200 \230febrile status \200\231, poisoning. Treatment algorithm for the \201 tting child 1 \200 Open and maintain airway and give O 2 . \200 Do not prise open clenched teeth \200 \224 consider nasopharyngeal airway. \200 Rapidly obtain venous access and check BMG. \200 Give lorazepam 0.1mg/kg IV over 30 \200\22360sec * (if no venous access: give 0.5mg/kg diazepam PR or buccal midazolam 0.5mg/kg). Treat hypoglycaemia with 0.5g/kg dextrose (5mL/kg of 10 % ) IV. \200 Apply pulse oximeter and send blood for investigations (see below). \200 Check T * : if > 38 * C give paracet amol 15mg/kg PR. If seizure continuing at 10min \200 Repeat lorazepam 0.1mg/kg IV over 30 \200\22360sec * (or if vascular access still not obtained, give paraldehyde 0.4mL/kg PR in the same volume of olive oil or 0.9 % saline). Get senior help and call for senior ED/anesthetic/PICU help. If seizure continuing after a further 10min \200 If not known to be taking phenytoin: start phenytoin infusion 18mg/kg IV * over 20min (monitor BP and ECG) or if already on phenytoin, give phenobarbital 20mg/kg IV * over 10min. If seizure continuing after a further 20min \200 Paralyze, intubate and ventilate using IV thiopental (induction dose 4mg/ kg) and consider a thiopental infusion. Transfer to ICU/PICU for ventilation and EEG monitoring. Investigations : BMG and blood glu cose, U&E, Ca 2 + , Mg 2 + , PO 4 3 \200\223 , LFTs, FBC, ABG/capillary gas, blood culture s, coagulation screen, CXR. If taking anti- convulsant(s): check serum level(s). Obtain CT scan of head if intracranial disease is suspected (unless clinically meningitis), in which case treat immediately \200\224 b Meningococcal disease, p.666). 1 See APLS Manual 4th edn, 2005 . * Intraosseous route is an alternative. 691 DIABETIC KETOACIDOSIS Diabetic ketoacidosis Diabetic ketoacidosis will usually present to the ED in a child who i s known to be diabetic, but occasionally it can be the \201 rst presentation of DKA. The child will present with features including altered conscious level, polyuria, polydipsia, n ausea, vomiting, and abdominal pain. Children with DKA can die from cerebral oedema (unpred ictable and has 25 % mortality), aspiration pneumonia, or hypokalaemia. All of these are av oidable with appropriate treatment. Be very careful not to misdiagnose the abdominal pain of DKA as a \200\230surgical abdomen \200\231 or to dismiss the child as \200\230hyperventilating \200\231 (the i respiratory rate is due to profound metabolic acidosis). Call senior ED and pediatric staff when DKA is suspected. Causes First episode of DKA in a previously well child. In a child with known diabetes, lac k of insulin, change of therapy, and intercurrent viral illness can cause DKA. Fever sugges ts sepsis (fever is not part of DKA). Treatment algorithm for the child with DKA 1 \200 O pen and maintain airway if not fully conscious and give high \202 ow O 2 . \200 Attach cardiac monitor (look for tall T-waves) and record CRT/BP. \200 Rapidly obtain venous acc ess and check BMG (remember BMG often underestimates blood glucose in DKA) and estimate weight. Take blood for glucose, U&E, FBC, VBG (and ketones if available). \200 If evidence of sho ck (tachycardia, prolonged CRT, hypotension), give 10mL/kg 0.9 % saline as a bolus; repeat as required up to 30mL/kg. Con \201 rm the diagnosis of DKA \200 Check history with child and parents: polyuria, po lydipsia; vomiting, abdominal pain, drowsiness, and i respiratory rate. Biochemical : high glucose ( > 11mmol/L; acidosis (pH<7.3, bicarbonate <15mmol/L); glycosuria and ketonuria. Involve senior pediatric PICU staff \200 Assess level of dehydration (mild <3 % ; mode rate 5 % (dry mucous membranes/ d skin turgor); severe 8 % (sunken eyes, i CRT, shocked and needed \202 uid bolus) and record in ED notes. Involve PICU if very young (<2 years), severe acidosis (pH<7.1), severe dehydration or d co nscious level (cerebral oedema, i risk of aspiration). Further care \200 Do not start insulin until IV \202 uids have been running for at leas t 1hr \200\224 earlier insulin therapy is associated with i cerebral oedema. \200 Do not administer bica rbonate except on specialist PICU advice. \200 Follow local protocols for continuing \202 uid replacement, but remember that over-infusion of \202 uid is associated with cerebral oedema. \200 Aim for replace ment of \202 uids and potassium over 48hr or longer. 1 See http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf for full detail s. 692 CHAPTER 15 Pediatric emergencies Urinary tract infection (UTI) UTI investigation, since progressive renal failure and hypert ension may occur insidiously. 35 % have proven vesico-ureteric re \202 ux: early treatment may help to prevent renal failure. UTI may present in a variable and non-speci \201 c fas hion. Consider and exclude UTI as part of the initial approach to any ill child presenting to the ED. in children requires prompt Presentations Older children typically present with lower abdominal pain, dysuria, frequenc y, offensive urine, haematuria or fever. However, dysuria and frequency do not always re \202 ect UTI. Children <3 years old often present unwell with fever and irritability, but n o speci \201 c signs. Infants may present with poor feeding, vomiting, and failure to thri ve. Examination Always check the BP and feel for loin tenderness (pyelonephritis) and abdominal masses (polycystic kidneys). Investigation Obtain a clean catch specimen of urine for urinalysis, microscopy, culture an d sensitivity. This can prove to be quite dif \201 cult, depending upon the age of the chi ld. Try one of the following approaches: Neonates and infants \200 Clean the perineum wit h sterile water, then tap with 2 \201 ngers just above the symphysis pubis (ideally 1hr p ost-feed) and catch the urine which is upcoming, trying to avoid the \201 rst few millili ters. Clean the perineum as above and use a urine collection pad according to the manufacturer \200\231s instructions. Suprapubic aspiration is useful if the baby is seriously ill. Clean the skin with antisepti c solution, then using sterile gloves and an aseptic technique, insert a 21G needle in the midline 2.5cm above the pubic crest and aspirate urine. Toddlers and older children \200 Co-operation will enable an MSU to be obtained (in the male, gently retract the foreskin (i f possible) and clean the glans \201 rst; in the female, separate the labia and clean the perineum front to back, \201 rst). \200 If the child is uncooperative, try a urine col lection pad or bag. Dipstick urinalysis at the bedside will reveal the presence of blood, p rotein, sugar, bilirubin, ketones or nitrite. A positive nitrite test is accepted as good e vidence of UTI. Urine pH is not usually helpful, for although pH <4.6 or > 8.0 may re \202 ect infection, it may also be due to various acid-base disorders. Urinalysis may be normal , despite bacteriuria. Urine microscopy allows a search for pyuria and bacteriuria (highly suggestive of UTI) and an accurate assessment of other constituents (see Table 15.7 ). Perf orm FBC, U&E, blood glucose, and blood cultures if septicaemic, loin pain or i T . 693 URINARY TRACT INFECTION (UTI) Treatment \200 Children with suspected pyelonephritis or who appear toxic : resuscitate a s necessary with IV \202 uids ( b p.663) and refer for admission and IV antibiotics (eg c efotaxime). Infection with beta lactamase producing E. coli is said to be increasing, and s ome recommend at least one dose of gentamicin, pending sensitivities. Give antibiotics for 10 days. Symptomatic children with abnormal urinalysis (proteinuria or haematuria) : start a 3-day c ourse of antibiotics PO (trimethoprim or cefalexin \200\224 dose according to age, refer t o BNFC ). Encourage plenty of oral \202 uids and complete voiding of urine. Offer advice to the child and parents (eg avoid tight underwear, use toilet paper wiping from front to b ack). \200 Organize pediatric follow-up to receive results of MSU and to arrange subseque nt investigations : this may include U&E, blood glucose, ultra- sound scan (USS) and a vari ety of other tests (eg isotope renography and micturating cysto-urethrography), according t o local policy. \200 Recurrent UTIs with anogenital signs may be due to sexual abuse. Table 15.7 Urine microscopy \201 ndings and their signi \201 cance Normally <3/mm 3 Red cells Normally <3/mm 3 White cells Epithelial cells Present normally: shed from urinary epithelium Bacteria or fungi Always abnormal, re \202 ecting infection or specimen contamination Casts Hyaline casts \200\224 comprise Tamm \200\223Horsfall protein: may be normal, but i in fev er, exercise, heart failure, after diuretics Fine granular casts \200\224 may be present n ormally, eg after exercise Coarse granular casts \200\224 abnormal, seen in various renal disorders Red cell casts \200\224 imply glomerular disease and glomerular bleeding White cell casts \200\223occur in glomerulonephritis and pyelonephritis Epithelial casts \200\224 usually re \202 ect tubular damage Crystals Phosphate, urate, and oxalate crystals may not be pathological, but are also seen in Proteu s UTI and hyperuricaemia. See the \200\230NICE Guidance on UTI in Children \200\231. Available at: http://www.nice.o rg.uk/nicemedia/ pdf/CG54quickrefguide.pdf 694 CHAPTER 15 Pediatric emergencies Renal failure Causes of acute renal failure Pre-renal Hypovolaemia (bleeding, dehydration, sepsis), heart failure, nephrotic syndrome. Renal Haemolytic uraemic syndrome, glomerulonep hritis, acute tubular necrosis, drugs. Post-renal Obstruction following trauma or calculi. Presentation and investigation Presentation varies according to the cause. Emergency invest igations include MSU for microscopy, culture and sensitivity, urine and plasma osmolality, U&E, blood glucose, FBC, albumin, LFTs, clotting screen, and ECG monitoring. Treatment Get expert help early. Pre-renal failure from hypovolaemia (urine: plasma osmolal ity ratio usually > 5) should respond to treatment of the underlying condition and an IV \202 uid challenge (20mL/kg of 0.9 % saline, colloid/blood products, depending on cause) . Urinary catheter and CVP monitoring may help to assess \202 uid status. Urgent ultrasou nd can assess for obstruction of the urinary tract, the presence of stones and vascular \201 lling status. ED treatment of renal failure focuses on hyperkalaemia and hypertension. Hyperkalaemia Children presenting with hyperkalaemia (K + > 7) in advanced renal failure m ay require emergency measures prior to dialysis. Obtain expert help. Give 0.5mL/kg of 10 % calcium gluconate over 5min to stabilize the myocardium if there are ECG changes (widened Q RS complexes or tall T waves). Give sodium bicarbonate 1mmol/kg IV and commence an IVI of g lucose (0.5g/kg/hr) with insulin (0.05U/kg/hr). Consider nebulized salbutamol (2.5mg if <3 years; 5mg if 3 \200\2237 years; 10mg if > 7years) or Calcium Resonium 1g/kg PO or PR. N ebulized salbutamol, IV sodium bicarbonate, glucose/insulin all temporarily d serum K + by shifting it into cells: de \201 nitive treatment (dialysis) will still be required. Hypert ension Hypertension related to volume overload in renal failure may require IV nitrate ther apy in the ED (as for pulmonary oedema), but otherwise seek expert help for further interve ntion. Nephrotic syndrome Most cases of oedema, heavy proteinuria and hypoalbuminaemia ( hypercholesterolaemia) are idiopathic ( \200\230minimal change nephropathy \200\231). Pres entation is diverse and includes: anorexia, lethargy, frothy urine, mild diarrhea, abdomina l pain, ascites, oliguria, peri-orbital, or genital oedema. The prognosis is generally good , but peritonitis, renal or cerebral venous thrombosis may occur. Check U&E, albumin, LFTs, FBC, complement, cholesterol and lipids. Refer for further investigation/treatment. Haemol ytic uraemic syndrome Micro-angiopathic haemolytic anemia, thrombocytopenia and renal failu re of haemolytic uraemic syndrome typically affect infants/toddlers following a diarrhoeal illness ( E. coli 0157 , verocytotoxin, or shigella). The disease is also associated with S LE, HIV and various tumors. The child may present oliguric or anuric with d conscious level due to encephalopathy. Mortality is > 5 % . FBC reveals anemia with visible RBC fragments, thrombocytopenia, and leucocytosis. Coombs test is \200\223ve. Urea and creatinine are us ually i and there may be electrolyte disturbances. Treat life-threatening hyperkalaemia as above and refer for possible dialysis and transfusion. 695 HAEMATURIA Haematuria Dark or discolored urine is frightening for both the child and parents. Although it may re \202 ect haematuria, it may re \202 ect other causes: very concentrated urine, beetroot, porphyria, conjugated hyperbilirubinaemia, free Hb or myoglobin (usually black, as seen in rhabdomyolysis and malaria), or drugs (Table 15.8 ). Table 15.8 Possible alternative causes of discolored urine Drug/food Color Rifampicin Orange/pink Desferrioxamine, senna, rhubarb Brown Methylene blue Green If haematuria is con \201 rmed by urinalysis, obtain a full history, remembering to ask ab out preceding illnesses and trauma, foreign travel, drug history, and family history of ren al or bleeding disorders. Full examination includes BP and a careful check for abdominal ma sses and oedema. Causes of macroscopic haematuria \200 UTI (including schistosomiasis). \200 Glomerulone phritis. \200 Trauma. \200 Wilm \200\231s tumor. \200 Bleeding disorder. \200 Urina ry tract stones. \200 Drugs (warfarin, cyclophosphamide). \200 Factitious. Microscopic haematuria may be associated with: exercise, hypercalciuria or be familial. Glomerulonephri tis is often an immune reaction following an URTI due to B-haemolytic Strep infection 2 \200\2233 weeks previously. It may present with haematuria, oliguria hypertension and ur aemia. A similar presentation can occur with Henloch \200\223Sch nlein purpura ( b Purpuri c rashes, p.664), SLE or Berger \200\231s disease (mesangial IgA nephropathy). Investigation Send MSU and obtain plain X-rays of the urinary tract if there is abdominal p ain suggesting stones (relatively rare). Check U&E, blood glucose, FBC, clotting screen, an d if signi \201 cant bleeding (or if haematuria follows trauma) X-match. Further tests may be required (throat swab, urine, and serum osmolalities, viral titres, antistreptolysin-O, antinuclear antibodies, complement levels), but do not assist emergency treatment. Management Severe haematuria with clots requires resuscitation with IV \202 uids ( blo od), but is uncommon in children, except after trauma. Treat associated severe hypertension or hyperkalaemia associated with renal failure as described opposite. Refer children with haematuria of non-traumatic origin to the pediatrician. 696 CHAPTER 15 Pediatric emergencies Poisoning in children Pediatric poisoning may take many forms: \200 Neonatal poisoning fr om drugs taken by mother prior to birth (eg opioids, benzodiazepines). \200\230Accidental \200\231 (unintentional) poisoning is the most common form of poisoning . It largely involves toddlers and pre-school children (boys > girls), who are at particula r risk because of their innate curiosity and considerable indiscretion in putting things in their mouths. Children may be poisoned by any drugs that they can get their hands on, but also mushrooms, berries, plants, household items (eg disinfectant) and other objects misint erpreted as drink, food or sweets (eg button batteries). Inadvertent self-poisoning with recreational drugs (including alcohol and volatile agents). Iatrogenic poisoning by administration of the wrong dose wrong drug can happen with frig htening ease. Pediatric dosage charts, calculators, obsessional checking, attention to deta il and restriction of junior doctors \200\231 hours should help to prevent this in the ED. Deliberate self-poisoning in an apparent suicide attempt occurs in older children. Intentional poisoning by a parent, guardian, or carer is a sinister aspect of child abuse, which includes fabricated or induced illness ( b p.772). The child may present in a bizarre fashion, with a non-speci \201 c illness, for which the diagnosis is not immediately appa rent. Approach Follow the general guidelines described in b pp.180 \200\2237 to treat poisoned pa tients, with initial attention to oxygenation (airway), ventilation (breathing) and circula tion. Links to the National Poisons Information Service ( www.toxbase.org Telephone 0844 89 2 0111) will provide advice for speci \201 c poisonings ( b p.180). With notable exception s (eg paracetamol, opioids, iron, and digoxin) there are few \200\230antidotes \200\231 av ailable: treatment is often largely supportive. Try to elicit the substance(s) ingested, the amount involved and the time since ingestion. The majority of ingestions are unintentional and the time to presentation is often short. G astric emptying procedures are rarely performed, and should be considered only if a life-th reatening amount of a drug has been ingested in the previous hour and the airway can be pro tected ( b p.184). Avoid ipecac (ipecacuanha), which is ineffective in d drug absorption an d can be dangerous. Never try to empty the stomach following ingestion of gasoline or corro sives ( b p.205). Charcoal The role of charcoal (dose 1g/kg PO in infants; 15 \200\22330g i n older children) in pediatric poisoning is limited by its lack of palatability. Attempts a re cur- rently being made to make charcoal more palatable, yet remain effective. 697 PREVENTION OF pediatric POISONING Prevention of pediatric poisoning Background Poisoning in children is very common. More tha n 40,000 children present to hospital in the UK each year, many of whom are admitted for ob servation. Thankfully, relatively few (10 \200\22315 per year) die. More than 75 % of pedia tric unintentional ingestions involve drugs and poisons in the home that are plainly visibl e to the child. Poisoning is particularly likely to occur at times of \200\230stress \200 \231 (eg arrival of new baby, disturbed parental relationships, moving house) when there ma y be d supervision and disruption of the usual routine. Perhaps partly for this reason, chi ldren who present with a \201 rst episode of poisoning are at i risk of further episodes. It is therefore important to advise the parents of ways of preventing poisoning in childre n (see list below). Of \201 cial measures: packaging of drugs Legislation has been introduced to try to tackle the problem of poisoning in children. Perhaps the most successful has been the widespread adoption of child-resistant drug containers. Unfortunately, it is not yet mandatory for the se containers to be used for liquid drugs or potentially dangerous household items, such as bleach. Some drugs are presented in \200\230strip packaging \200\231, in the hope that an impulsive child would lose interest before gaining access to a signi \201 cant quantity. Advice for parents (consider providing a lea \202 et) \200 Provide adequate supervision for toddlers and young children, particularly when visiting friends and relatives. Keep all medicines locked out of reach in a cupboard. \200 Only purchase those drugs pres ented in child-resistant containers. \200 Dispose of out-of-date drugs and those no longe r required. \200 Never refer to drugs as \200\230sweets \200\231 in an attempt to encour age the child to take them. Take medicines out of sight of the child to help prevent imitation. \200 Keep all alcohol , perfumes, cosmetics, detergents, and bleaches out of reach. Ensure that all turpentine, paints, and weed killers are securely locked and inaccessible. Give away all toxic plants. \200 Keep ashtrays and waste baskets empty. 698 CHAPTER 15 Pediatric emergencies Abdominal pain in children The approach to the initial assessment and management of childre n presenting with abdominal pain is similar in many ways to that in adults ( b p.504). Bewa re underlying \200\230medical \200\231 causes (eg DKA, pneumonia). Remember that disease p rocesses may progress with great rapidity in children, therefore adopt a low threshold for referring children with abdominal pain to the surgical team. Whilst many of the common caus es of abdominal pain are the same in children as in adults (eg b Acute appendicitis, p.507) , be aware of causes that are typically pediatric (eg intussusception). Likewise, certain c auses of intestinal obstruction are seen almost exclusively in children. Pediatric causes of intestinal obstruction \200 Congenital (eg oesophageal/duodenal atres ia, Hirschsprung \200\231s disease). \200 Meconium ileus. \200 Hypertrophic pyloric ste nosis. \200 Intussusception. \200 Hernia (inguinal, umbilical). Hypertrophic pyloric stenosis Features This condition is relatively common, typically prese nting with effortless vomiting at between 2 \200\22310 weeks. It occurs more frequently in boys than girls and in \201 rst-born children. Vomiting becomes projectile in nature, wit h progressive dehydration and constipation. The vomit is not bile-stained. After vomiting, the baby appears hungry and keen to feed again. In advanced cases, there may be a profound hypochloraemic alkalosis, with associated hypokalaemia. Diagnosis Look for visible peristalsis. Abdominal palpation con \201 rms the diagnosis if an olive-sized lump is felt in the epigastrium (most prominent during a test feed). If the diagnosis is suspected, but not proven clinically, resuscitate (as below) and arrange USS. Management Once diagnosed, keep the infant nil by mouth. Insert an IV cannula and send bloo d for U&E, glucose, and FBC. Commence \202 uid resuscitation under senior guidance and re fer to the surgeon \200\224 operative treatment needs to be delayed until dehydration and electrolyte abnormalities have been corrected (this may take > 24hr). Defer insertion of a NG tube for appropriately experienced staff. Volvulus This is associated with congenital malrotations, but may occur in other circumstan ces also (eg Meckel \200\231s diverticulum, adhesions from previous surgery). It can presen t with abdominal pain and other features of intestinal obstruction (vomiting, distension), sometimes with a palpable mass. Obtain an abdominal X-ray and refer promptly to the surgica l team in order to maximize the chance of intervening to preserve bowel. 699 ABDOMINAL PAIN IN CHILDREN Intussusception Telescoping of one segment of bowel into another may affect the small or la rge bowel, but most cases are ileocolic. Typically affects children aged between 6 months a nd 4 years. The child may suddenly become distressed, roll up into a ball, and appear unwel l. Vomiting may develop and the child may pass a \200\230redcurrant jelly \200\231 stool. These features, however, together with pyrexia and a palpable mass, are not invariably pres ent: sometimes the presentation is shock without obvious cause. X-rays may be normal or rev eal an absent caecal shadow. If intussusception is suspected, refer urgently to the surgical team. The diagnosis may be con \201 rmed by air or barium enema, which may also be curative, by reducing the intussus ception. A barium enema characteristically reveals a \200\230coiled spring \200\231 sign o r sudden termination of the barium, but is contra-indicated if there is evidence of perfora tion. Acute appendicitis (see b p.507) Consider this diagnosis in any child presenting with abdominal pain. Acute appendicitis can occur in children of all ages. It can be a dif \201 cult diag- nosis to make, especially in the very young. \200\230Atypical \200\231 cli nical presentation (eg diarrhoeal illness) is often associated with delayed diagnosis and a n i rate of perforation. Do not perform a rectal examination \200\224 in the unlikely even t of this being considered essential, leave it to the surgical team. Abdominal mass There are many causes of abdominal masses in children, many of which may be relatively benign and asymptomatic: \200 Full bladder. \200 Full colon. \200 Enlarged liver and/or spleen. \200 Pregnancy in older children. \200 Hydronephrosis. \200 Hyp ertrophic pyloric stenosis (see opposite). \200 Appendix mass. \200 Intussusception. \200 Volvulus. \200 Neuroblastoma. \200 Nephroblastoma (Wilm \200\231s tumor). Intra-abdominal malignancy Neuroblastoma and nephroblastoma may reach a large size before c ausing symptoms (eg hemorrhage into the tumor). Neuroblastomas arise most commonly from the adrenal glands, but may occur at any point alon g the sympathetic chain. Nephroblastomas (Wilm \200\231s tumors) arise from the kidneys and may present with haematu ria. All children with suspected malignant abdominal masses require CT scan and/or USS investiga tion \200\224 refer urgently to the surgical team. 700 CHAPTER 15 Pediatric emergencies Inguinal and scrotal swellings Painless groin and scrotal lumps The parents or child who di scovers a lump may become very concerned. The absence of pain is to some extent reassuring, in that an acute surgical problem is unlikely. Ascertain when the swelling appeared, wheth er it changes in size or disappears, or whether there are any other symptoms. Reducible inguinal hernia Inguinal herniae in childhood result from a persistent patent pro cessus vaginalis and are therefore indirect in nature. They are commoner in boys than girls and often bilateral. The history is typically of an intermittent swelling, which appears w ith coughing or straining. If the swelling can be demonstrated, it will be impossible to ge t above it. If it cannot be demon- strated, a thickened spermatic cord may be palpated (som etimes known as the \200\230silk sign \200\231). Refer neonatal herniae for admission and surgery, refer infants and older children to a surgical clinic for elective surgery. Painless irreducible inguinal hernia Refer all irreducible inguinal hernias for admission a nd surgery (preceded by gallows traction in the infant). Hydrocoele This transilluminable painless scrotal swelling has similar etiology to inguinal hernia. It appears gradually, rather than suddenly, and does not empty or reduce on palpat ion. Refer to a surgical clinic. An encysted hydrocoele of the cord may be impossible to di stinguish from an irreduc- ible inguinal hernia and therefore requires surgical exploration . Undescended, retractile, or ectopic testis Complete descent of the testis has yet to occur in 3 % of term infants and 30 % of premature infants. Arrange surgical follow-up if the tes tis cannot be brought down to the fundus of the scrotal sac: orchidopexy will be required i f the testis fails to descend by 4 years. Inguinal lymphadenopathy This is on the list of differential diagnoses of painless inguinal swellings. Look for a potential source of infection in the leg and for involvement of any other lymph node groups. Idiopathic scrotal oedema An obscure allergic condition of the scrotal skin is possibly a v ariant of angioneurotic oedema. Redness, mild tenderness and oedema are not limited to one hemiscrotum. The testis is normal. The condition settles spontaneously, a process helped by antihistamines (eg chlorphenamine PO, doses: child 1 \200\2232 years require 1mg bd; 2 \200\2235 years require 1mg qds; 6 \200\22312 years require 2mg qds). If in doubt \200\224 refer. 701 INGUINAL AND SCROTAL SWELLINGS Painful groin and scrotal lumps Painful irreducible inguinal hernia Likely to contain obstr ucted or strangulated small bowel. Con \201 rm clinical suspicion of intestinal obstructio n (pain, vomiting and abdominal distension) by X-ray. Resuscitate as necessary with IV \202 uids, give analgesia and refer for surgery. Testicular torsion Commonest in the neonatal period and around puberty. In the neonatal per iod the torsion is extravaginal in nature and often diagnosed late. Later in childhood, tor sion of a completely descended testis is intravaginal due to a high insertion of tunica vag inalis. Undescended testes are also at particular risk of torsion. Classical presentation i s with sudden onset severe pain and vomiting. Occasionally, the pain is entirely abdominal. Examination reveals a red, tender swollen testis. The opposite testis may be seen to lie h orizontally, rather than vertically (Angell \200\231s sign). Fast and refer all suspected t orsions for urgent surgery: exploration, untwisting and bilateral orchidopexy. Torsion of the hydatid of Morgagni This remnant of the paramesonephric duct on the superior aspect of the testis is prone to undergo torsion, causing pain and vomiting. A discrete te nder nodule may be palpable. Refer, as surgical exploration and excision of the hydatid pro vides more rapid relief than the alternative conservative treatment (analgesia and rest). Epididymo-orchitis Unusual in pediatric age group, but may be associated with UTI. A painfu l swollen red testis and epididymis usually develops over a longer period of time, but may be dif \201 cult to distinguish from testicular torsion. Refer for an urgent surgical opin ion. Mumps orchitis The diagnosis is usually apparent because of parotitis ( b Childhood infec- tious diseases, p.222). Refer if there is doubt or symptoms are severe. Henoch-Sch nlein purpura Occasionally, testicular pain may be one of the initial presentin g complaints of Henoch-Sch nlein purpura (see b p.664). 702 CHAPTER 15 Pediatric emergencies Foreskin problems and zip entrapment Phimosis The foreskin may normally remain non-retracti le up to age 5 years. Foreskin that remains non-retractile after this, which \200\230ballo ons \200\231 on micturition, or is associated with recurrent balanitis may bene \201 t fro m surgery (preputial stretch or circumcision). Advise the parents to see their GP to discus s referral to a pediatric surgeon. Balanitis Balanitis produces redness, swelling, and even pus. Take a swab, check for glucos e in urine and send an MSU. Treat with amoxicillin (10mg/kg PO qds) or erythromycin (10mg/k g PO qds). If redness and swelling involve the whole penis: refer for IV antibiotics. Paraphimosis Irreducible, retracted foreskin results in pain and swelling of the glans. As in the adult, cold compresses and lubricating jelly may allow reduction. If not, refer for reduction under GA. Penile zip entrapment Unfortunately, underpants do not completely protect boys (and sometim es men) from catching their foreskins in trouser zips. On many occasions the entrapment wil l be released quickly by the child or parent. On others, the child will present to the ED. The optimal method to achieve release depends upon the entrapment \200 15 % zip foreskin through the moveable part of the zip, so that it is simply caught between the teeth of the zip alone. In this case, achieve easy release by cutting transversely through the zip below the entrapment. \200 85 % of entrapments involve the foreskin being caught between the t eeth and the moveable part of the zip. Local anesthetic (either injection using plain lidoc aine or topical gel) may allow manipulation and release. If this fails, the least traumatic option is to divide the moveable part of the zip into 2 parts by dividing the central sect ion ( \200\230median bar \200\231 or \200\230bridge \200\231) using bone cutters or wire c utters (use gauze to protect against parts of the zip \202 ying off; Fig. 15.16 ). Older children and adults may tolerate this in the ED, but in younger boys referral for release u nder GA is sensible. Circumcision is rarely required. 703 FORESKIN PROBLEMS AND ZIP ENTRAPMENT Strong wire cutters Zip slider Zip bridge Zip bridge Zip bridge Top view Zip slider Zip slider Side view Fig. 15.16 Method to achieve release from zip entrapment. 704 CHAPTER 15 Pediatric emergencies The limping child This common problem can cause diagnostic dif \201 culty, particularly in the young child who cannot provide a history and is dif \201 cult to examine. It is impor tant to try to exclude some causes of a limp that will require urgent treatment. Consider the following \200 Trauma (fractures, soft tissue injury, FB in foot, NAI). \200 Speci \201 c hip problems (Perthes \200\231, slipped epiphysis, irritable hip \200 \224 b p.706). Infection (osteomyelitis, septic arthritis). \200 Arthritis (Still \200\231s disease, juv enile ankylosing spondylitis). \200 Osteochondritis ( b p.708). \200 Referred pain from in \202 ammatory process elsewhere. \200 Malignant disease (Ewing \200\231s sarcoma, le ukemia). \200 Sickle cell crisis ( b p.176). Adopt the following approach: History Ascertain whether the problem developed suddenly (eg after trauma) or gradually. En quire about recent illness and other symptoms, including joint pains elsewhere. Examination Check T * . If the child is walking, assess the gait. Carefully inspect all of the painful leg for erythema, swelling, deformity, and note the position adopted. Exclude a relatively simple problem, such as a FB embedded in the foot. Note any skin rashes. Palpat e the limb for tenderness, joint effusions, and range of movement (compare with the other s ide). If the child will not walk, but can crawl without any apparent discomfort, this local izes the problem to below the knee (thereby avoiding the need to request \200\230routine \200\231 X-rays of the hips). Investigation If the child can walk, looks well, and there is no abnormality apparent on ex amination, consider providing analgesia and arranging to review after a few days, rather th an undertaking all of the following investigations immediately. Ensure the parents are told that they should return earlier if the limp gets worse. X-ray the tender or swollen part, particularly if there is a history of injury. If there is no obvious tenderness, X-ray the pelvis to include both hips. If the X-rays do not reveal a fracture, check WCC and CRP (or plasma viscosity/ESR). If the hip is implicated, but X-ra ys are normal, request USS of the hip (some experts prefer to use USS as the initial invest igation). MRI is emerging as having a potentially useful role. Follow local ED protocols wh ere available. Management Treat according to the cause (see opposite and b pp.706 \200\2239). 705 THE LIMPING CHILD Trauma Treat according to cause, which may include a FB in the soft tissues. There may not always be a clear history of injury \200\224 this particularly applies to toddler \200\231 s fracture (see b Pediatric lower limb injuries, p.726). Osteomyelitis Acute osteomyelitis usually results from blood-borne spread of a distant path ogen (eg from the respiratory tract). Staph. aureus is usually responsible, with almost inv ariable involvement of the metaphysis of a long bone (most commonly proximal or distal femu r, or distal tibia). Features i T * , lethargy, localized tenderness (which may be misdiagn osed as trauma). Septic shock may occur (especially in infants). Investigations i WCC, i CR P, i ESR > 50mm/hr (but all may be normal initially). X-ray changes occur after 8 10days. T reatment If suspected, refer for admission, IV antibiotics 9 surgical drilling/drainage. Septic arthritis Most commonly, Staph. aureus infection in the hip or knee. Occasionally se condary to penetrating injury but usually haematogenous spread from a distant site. Constit utional symptoms, fever and joint pain occur. A joint effusion may be clinically evident. J oint movement is likely to be severely impaired. Investigations may reveal i WCC, i CRP and i ESR. Refer for urgent con \201 rmatory joint aspiration and treatment. Non-septic arthritis Multiple painful joints are more likely to be due to a juvenile arthri tic process (eg RA or ankylosing spondylitis) than septic arthritis. Pain felt in several j oints frequently accompanies a variety of infections and other diseases, eg rubella, rheuma tic fever, Henoch \200\223Sch nlein purpura. Refer to the pediatrician for further investi gation. 706 CHAPTER 15 Pediatric emergencies The painful hip The limping child may be able to localize pain to the hip, but hip pain may be referred to the knee. Hip problems causing a limp include trauma, infection and other d isorders as in b The limping child, p.704. Speci \201 c hip problems include: Perthes \200\231 disease (Legg \200\223Calv \200\223Perthes \200\231 disease) Aseptic nec rosis of the upper femoral (capital) epiphysis presents with a painful limp in children age d 3 \200\22310 years. Boys are affected more than girls (M:F = 4:1). 15 % are bilateral. Et iology is unclear, but Perthes \200\231 disease is often grouped with the osteochondritides ( b p.708). Often d range of hip movement due to pain. FBC, CRP, ESR, and blood cultures a re normal. X-ray changes re \202 ect stage of disease and are progressive (as opposite): 1 i joint space on medial aspect of capital epiphysis (compare sides) 2 i bone density in af fected epiphysis (appears sclerotic) 3 Fragmentation, distortion ( \202 attening) and late ral subluxation of upper femoral epiphysis (leaving part of the femoral head \200\230uncovered \200\231) 4 Rarefact ion of the adjacent metaphysis in which cysts may appear Treatment Refer for specialist ass essment and treatment. Most cases respond satisfactorily to conservative therapy.