675 pediatric ENT PROBLEMS Examining a child \200\231s ear In an infant pull the pinna back and down (rather than up) for the best view. Fig. 15.12 Examining a child \200\231s throat. 676 CHAPTER 15 Pediatric emergencies Stridor: upper respiratory infections The upper airway is a tube which may be blocked by: d istortion (eg tongue falling back in coma), extrinsic compression (eg haematoma), swelling of its wall (eg burns, croup, epiglottitis, diphtheria), or FB within. Signs of upper airwa y obstruction Stridor, marked dyspnoea, drowsiness, subcostal/suprasternal recession, drool ing of saliva, dif \201 culty speaking, and cyanosis. Any of these warn of impending obstr uction. Stridor is a high pitched inspiratory noise. It occurs in croup, acute epiglottitis , inhaled FB, laryngeal trauma, laryngomalacia ( \200\230congenital laryngeal stridor \200 \231), angioneurotic oedema. See Table 15.5 . Acute croup (laryngotracheobronchitis) Viral in origin (para-in \202 uenza virus in > 80 % ). Common between 6 months, and 5 years of age. Spring and autumn epidemics occur. Illness lasts 8 3 \200\2235 days. Coryzal symptoms usually precede harsh stridor, a barking cough ( \200\230seal \200\231s bark \200\231) with hoarseness i over several days. Temperature (T ) * is only mildly i . Leave the child in a comfortable position preferably in the arms of the parent, who can hold an O 2 mask near the child. Look for signs of signi \201 cant air way obstruction, but do not examine the pharynx as this may precipitate laryngospasm or obs truction. If any of these signs are present, or if SpO 2 <92 % in air refer urgently \200 \224 intubation may be required. Use the modi \201 ed Westley croup score by adding indivi dual values as follows: \200 Stridor : none = 0, only when upset or agitated = 1, at rest = 2. \200 Retractions : mild = 1, moderate = 2, severe = 3. \200 Air entry : normal = 0, mild decrease = 1, marked decrease = 2. \200 SpO 2 <92 % on air : none = 0, with agita tion = 4, at rest = 5. \200 Level of consciousness : normal = 0, altered conscious level = 5. Children with moderate (score 3 \200\2235) or severe croup (score 6 \200\22311) and im pending respiratory failure (score > 11) require admission to hospital. Give oral dexametha sone 0.15mg/kg or nebulized budesonide (1 \200\2232mg in 5mL 0.9 % saline) if vomiting or s evere respiratory distress and refer to the pediatric team. If severe (score > 5), consider nebulized adrenaline driven by O 2 at 8L/min (0.5mL/kg of 1:1000, max 5mL; repeat as requi red). Refer severe cases to PICU (<1 % of croup is severe). Many children with mild croup ( score 0 \200\2232) can be safely discharged from the ED after a brief period of observation . This decision should be taken by an experienced emergency physician or pediatrician. Disc harge in the evening may be inadvisable, since croup can worsen overnight. Diphtheria Although rare in the UK, the exotoxin of Corynebacterium diphtheriae may produce serious organ damage (especially myocarditis) and upper respiratory tract obstruction. The non-immunized child may present with pyrexia, sore throat, and dysphagia due to an adheren t pharyngeal exudate. Cervical lymphadenopathy causes a \200\230bull neck \200\231 appeara nce. (Note that infectious mononucleosis may present similarly \200\224 b p.241). Treat wi th O 2 , obtain ECG and venous access, send blood for FBC, blood culture, and obtain a thro at swab. Refer for antitoxin (20,000U IM after a test dose) and IV erythromycin. 677 STRIDOR: UPPER RESPIRATORY INFECTIONS Acute epiglottitis Increasingly uncommon, due to widespread Hib vaccination. Rapidly progre ssive airway obstruction may result. Children aged 2 \200\2237 years are most usually invol ved, although it does occur in older children and adults. Unlike croup, stridor is usually soft and may even be absent. Onset is typically acute. The child is systemically unwell wit h pyrexia > 38.5 * C, but little or no cough. In severe cases, the child may be ominously q uiet, unable to speak, sitting upright drooling saliva in a \200\230snif \201 ng position \200\231. Management Do not attempt to visualize the throat as this may precipitate total airway obstruction. Let the child adopt the most comfortable position, give humidi \201 ed O 2 and call urgently for anesthetic, ICU and ENT help. Nebulized adrenaline (0.5mL/kg of 1:1000, max 5mL) may \200\230buy time \200\231. Defer doing blood tests (FBC, blood cultur es) and treatment with IV cefotaxime until an anesthetist has assessed the child. Lateral n eck X-rays are unnecessary and potentially hazardous. Intubation, if required, may be very dif \201 cult to perform. A safe approach is for an experienced anesthetist to use a gaseo us induction in the presence of a surgeon who is prepared for a surgical airway. Airway swe lling may require a smaller than expected diameter (and thus uncut) ET tube. Let the anesth etist know the number of adrenaline nebulizers given, as halothane induction could precipit ate arrhythmias. If visualization of the tracheal ori \201 ce is dif \201 cult at laryngo scopy due to oedema, ask an assistant to squeeze the chest and look for an air bubble emerg ing from the trachea. Loss of the airway \200\224 if this happens, summon help and attempt to ventilate with O 2 using bag and mask. If ventilation proves impossible, obtain a surgical airway (needle cri cothyroidotomy if <12 years, surgical cricothyroidotomy if \211 12 years) \200\224 see b p.326. Bacterial tracheitis May be due to Staph. aureus, Strep. , or H. in \202 uenzae . The pres entation of \200\230croup \200\231, plus moderate/severe pyrexia, and production of copiou s secretions suggests the diagnosis. If suspected, refer and treat as for acute epiglottiti s (intubation is often required). Bacterial tracheitis can cause rapid onset of septic shoc k. Table 15.5 Clinical presentations of upper airway obstruction Croup Epiglottitis Bacterial tracheitis Foreign body Age 1 \200\2232 years 2 \200\2236 years Throughout childhood Throughout childhood Onset 1 \200\2232 days <24hr <24hr <24hr History Coryza, barking cough Sore throat, dysphagia Rattling cough, sore throat Afebrile, non-toxic T > 38.5 toxic, mucopurulent secretions, soft/ absent stridor T > 38.5 toxic, upright position Signs T <38.5 non-toxic, harsh stridor, hoarseness 678 CHAPTER 15 Pediatric emergencies Severe acute asthma in children Assess conscious level, degree of breathlessness, degree of agitation, use of accessory muscles, amount of wheezing, pulse rate and respiratory rate. Attempt to measure peak \202 ow if age > 5 years (See Fig. 15.13 for normal peak \202 o w). Follow the 2011 British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/S IGN) Guidelines based on age and severity ( http://www. sign.ac.uk/pdf/sign101.pdf ). Inves tigations, including blood gas estimations, rarely alter immediate management. Cautions Chi ldren with severe asthma attacks may not appear distressed. Wheeze and respiratory rate cor relate poorly with severity of airway obstruction. Increasing tachycardia denotes worsening asthma, a fall in heart rate in life-threatening asthma is pre-terminal. Assessment in the very young (<2 years) may be dif \201 cult \200\224 get expert help. Normal peak expiratory \202 ow in children aged 5 \200\22318 years. 600 2SD Boys and girls ) n m 500 i Mean / s e r t i l ( w o 400 l f y r o t a r i p x e \200\2232SD 300 k a e P 200 100 110 120 130 140 Height (cm) 150 160 170 Fig. 15.13 679 SEVERE ACUTE ASTHMA IN CHILDREN Management of acute asthma in children aged > 2 years (Figs 15.14 and 15.15 ) \200 Summon senior ED/PICU/pediatric help if asthma is severe. \200 Provide high \202 ow O 2 via f ace mask (or nasal cannulae). \200 Give an inhaled B-agonist. In mild or moderate asthma use a metered dose inhaler with a spacer, and 2 \200\2234 puffs of 100mcg salbutamol every 10 \200\22320min. In severe or life threatening asthma use an O 2 -powered nebulizer with salbutamol 2.5 \200\2235mg or terbutaline 5 \200\22310mg. Give oral prednisolone (20mg for children aged 2 \200\2235 years; 30 \200\22340mg if aged > 5 years). If already taking maintenance steroids, give 2mg/kg (max 60mg). In children who vomit, repeat the dose of prednisolone and consider IV hydrocortisone 4mg/kg. Add ipratropium bromide 0.25mg every 20 \200\22330 min if there is poor initial response to nebulized B-agonist. Consider salbutamol (15mcg/kg) given IV over 10min in severe cases with a poor response to initial nebulized salbutamol and ipratropium bromide. Refer to PICU urgently and check K + levels. Aminophylline is not recommended in children with mild to moderate asthma. In severe or lif e-threatening asthma unresponsive to maximal doses of bronchodilators and systemic steroids , take specialist advice and consider IV aminophylline (5mg/kg over 20min; maintenance IV i nfusion at 1mg/kg/hr; omit loading dose if already receiving oral theo- phyllines). Consider an IVI of magnesium sulfate 40mg/kg over 20min, but evidence of bene \201 t is limited. \200 Do not give \200\230routine \200\231 antibioti cs. Notes If possible, repeat and record peak \202 ow 15 \200\22330min after starting tre atment. If the patient is not improving, give further nebulized B-agonist. Pulse oximetry i s helpful in assessing response to treatment. An SpO 2 \211 92 % in air after initial bro nchodilator therapy usually indicates the need for more intensive in-patient care usually i n PICU. CXR is indicated for severe dyspnoea, focal chest signs, or signs of severe infecti on. Consider need for anesthesia/intubation/IPPV and PICU transfer \200 Deteriorating peak \202 ow or worsening or persistent hypoxia or normal/ increased pCO 2 levels on ABG. Exhaustion, feeble respiratory effort, confusion, or drowsiness. \200 Coma or respiratory arrest. Management of acute asthma in children aged <2 years Assessing acute asthma in early childh ood is dif \201 cult: get specialist help (see www.sign.ac.uk ). Intermittent wheezing att acks are usually due to viral infection. Differential diagnosis includes: aspiration and ot her pneumonias, bronchiolitis, tracheomalacia, complications of underlying conditions (eg c ongenital abnormalities, cystic \201 brosis). If there is no response to inhaled bronchod ilators, review the diagnosis: \200 Use a metered dose inhaler with spacer to give B-agon ist therapy. \200 Consider systemic steroids early in the management of moderate to severe asthma in infants (10mg of soluble prednisolone). Consider adding inhaled ipratropium bromide (0.25mg) to inhaled B-agonists for more severe symptoms. 680 CHAPTER 15 Pediatric emergencies Age 2 \200\2235 years ASSESS ASTHMA SEVERITY Moderate asthma (cid:2) SpO2 \211 92% (cid:2) No clinical features of severe asthma Severe asthma (cid:2) SpO2 <92% (cid:2) Too breathless to talk or eat (cid:2) Heart rate >1 40/min (cid:2) Respiratory rate >40/min (cid:2) Use of accessory neck muscles Life threatening asthma SpO2 <92% plus any of: (cid:2) Silent chest (cid:2) Poor respirator y effort (cid:2) Agitation (cid:2) Altered consciousness (cid:2) Cyanosis NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Oxygen via face mask/nasal prongs to achieve SpO2 94 \200\22398% (cid:2) 2 agonist 10 puffs via spacer facemask or nebulized salbutamol 2.5 mg or terb utaline 5 mg (cid:2) Soluble prednisolone 20 mg or IV hydrocortisone 4 mg/kg (cid:2) Repeat every 20 \200\22330 minutes according to response (cid:2) If poor response add 0.25 mg nebulized ipratropium bromide (cid:2) Nebulized 2 agonist: salbutamol 2.5 mg or terbutaline 5 mg plus ipratropium brom ide 0.25 mg nebulized (cid:2) Oral prednisolone 20 mg or IV hydrocortisone 4mg/kg if vomiti ng (cid:2) 2 agonist 2 \200\22310 puffs via spacer facemask [given one at a time single puffs, tidal breathing and inhaled separately] (cid:2) Increase by 2 puffs every 2 minut es up to 10 puffs according to response (cid:2) Consider soluble oral prednisolone 20 mg 2 agonist dose 2 agonist up to Discuss with senior clinician, PICU team or pediatrician (cid:2) Repeat bronchodilators every 20 \200\22330 minutes Reassess within 1 hour ASSESS RESPONSE TO TREATMENT Record respiratory rate, heart rate and oxygen saturation ever y 1 \200\2234 hours RESPONDING (cid:2) Continue bronchodilators 1 \200\2234 hours prn (cid:2) Discharge when st able on 4 hourly treatment (cid:2) Continue oral prednisolone for up to 3 days NOT RESPONDING (cid:2) Arrange HDU/PICU transfer Consider: (cid:2) Chest X-ray and blood ga sses (cid:2) IV salbutamol 15 mcg/kg bolus over 10 minutes followed by continuous infusion 1 \200\2235 mcg/kg/min (dilute to 200 mcg/ml) (cid:2) IV aminophylline 5 mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusi on 1 mg/kg/hour At discharge (cid:2) Ensure stable on 4 hourly inhaled treatment (cid:2) Review the need fo r regular treatment and the use of inhaled steroids (cid:2) Review inhaler technique (cid:2 ) Provide a written asthma action plan for treating future attacks (cid:2) Arrange follow u p according to local policy Fig. 15.14 Management of acute asthma in 2 \200\2235-year-olds. See: www.brit-thoracic.org. uk and www.sign.ac.uk 681 SEVERE ACUTE ASTHMA IN CHILDREN Age >5 years ASSESS ASTHMA SEVERITY Moderate asthma (cid:2) SpO2 \211 92% (cid:2) PEF >50% best or predicted (cid:2) No clinic al features of severe asthma Severe asthma (cid:2) SpO2 <92% (cid:2) PEF 33 \200\22350% best or predicted (cid:2) Heart rate >125/min (cid:2) Respiratory rate >30/min (cid:2) Use of accessory neck muscles Life threatening asthma SpO2 <92% plus any of: (cid:2) PEF <33% best or predicted (cid:2) S ilent chest (cid:2) Poor respiratory effort (cid:2) Altered consciousness (cid:2) Cyanosis NB: If a patient has signs and symptoms across categories, always treat according to their most severe features Oxygen via face mask/nasal prongs to achieve SpO2 94 \200\22398% (cid:2) spacer or nebulized salbutamol 2.5 \200\2235 mg or terbutaline 5 \200\22310 mg ( cid:2) Oral prednisolone 30 \200\22340 mg or IV hydrocortisone 4 mg/kg if vomiting (cid:2) If poor response nebulized ipratropium bromide 0.25 mg (cid:2) Repeat ipratropium up to every 20 \200\22330 minutes according to response (cid:2) Nebulized salbutamol 5 mg or terbutaline 10 mg plus ipratropium bromide 0.25 mg nebulized (cid:2) Oral prednisolone 30 \200\22340 mg or IV hydrocortisone 4mg/kg if vomitin g (cid:2) spacer (cid:2) Increase by 2 puffs every 2 minutes up to 10 puffs according t o response (cid:2) Oral prednisolone 30 \200\22340 mg 2 agonist 10 puffs via 2 agonist: 2 agonist 2 \200\22310 puffs via 2 agonist dose Discuss with senior clinician, PICU team or pediatrician 2 agonist and (cid:2) Repeat bronchodilators every 20 \200\22330 minutes Reassess within 1 hour ASSESS RESPONSE TO TREATMENT Record respiratory rate, heart rate, oxygen saturation and PEF /FEV every 1 \200\2234 hours RESPONDING (cid:2) Continue bronchodilators 1 \200\2234 hours prn (cid:2) Discharge when st able on 4 hourly treatment (cid:2) Continue oral prednisolone 30 \200\22340 mg for up to 3 days NOT RESPONDING (cid:2) Continue 20 \200\22330 minute nebulizers and arrange HDU/PICU transf er (cid:2) Consider: Chest X-ray and blood gasses (cid:2) Consider risks and benefits of: ( cid:2) Bolus IV salbutamol 15 mcg/kg if not already given (cid:2) Continuous IV salbutamol infusion At discharge (cid:2) Ensure stable on 4 hourly inhaled treatment (cid:2) Review the need fo r regular treatment and the use of inhaled steroids (cid:2) Review inhaler technique (cid:2 ) Provide a written asthma action plan for treating future attacks (cid:2) Arrange follow u p according to local policy 1 \200\2235 mcg/kg/min (200 mcg/ml solution) (cid:2) IV aminophylline 5 mg/kg loading dose over 20 minutes (omit in those receiving oral theophyllines) followed by continuous infusion 1 mg/kg/hour (cid:2) Bolus IV infusion of m agnesium sulfate 40 mg/kg (max 2 g) over 20 minutes Fig. 15.15 Management of acute asthma in children aged less than 2 years. See: www.brit-tho racic.org.uk and www.sign.ac.uk 682 CHAPTER 15 Pediatric emergencies Acute bronchiolitis 1 Viral infection of the small airways results in in \202 ammation, oe dema, and excessive secretions, presenting with signs of obstructive airways disease. Acute bronchiolitis is common, particularly in the winter months and pre- dominantly involves in fants (typically 3 \200\2236 months). Those at particular risk are the very young (aged <6 weeks), the premature (born <35 weeks) and those with chronic respiratory, congenital heart disease, immunode- \201 ciency, or neurological problems. Parental smoking increases the risk of bronchiolitis. Breast feeding for more than two months appears to have a protectiv e effect. Most infants recover completely within 2 weeks. Agents responsible 75 % are caused by respiratory syncytial virus (RSV). Other causes inclu de in \202 uenza, para-in \202 uenza, adeno-, and enteroviruses. Presentation Coryza, rhinorrhoea, and mild fever progress to respiratory distress with dysp noea, dry cough, feeding dif \201 culties, and wheeze (variable). Some children may presen t with apnoea. Inspection may reveal cyanosis, dehydration, tachypnoea ( > 50/min), nasal \202 aring, grunting, subcostal and intercostal recession. The chest is usually visibly hy perin \202 ated in bronchi- olitis. There may be tachycardia and prolonged expiration ( wheeze) with \201 ne end-inspiratory crepitations. Complications Feeding dif \201 culties, apnoeic spells, and respiratory failure (hence, ad opt a low threshold for admission). Secondary bacterial infection can occur, but is uncommo n. Long-term airway damage may occasionally occur (obliterative bronchiolitis). Investigations \200 Apply a pulse oximeter, and check the pulse and CRT. \200 Do not do routine blood tests unless the infant is febrile or an alternative diagnosis, such as pneumonia or sepsis is more likely. Consider CXR and ABG/capillary gas only for those with progressive, atypical or severe illness. Do not do CXR routinely. Fluorescent antibody tests on nasopharyngeal aspirate to demonstrate the presence of RSV ar e recommended; these help with cohorting and isolation arrangements on the wards (see oppos ite), particularly during the annual epidemic season in winter. Assess feeding dif \201 culties by offering a bottle feed. CXR shows hyperin \202 ation w ith downward displacement of the diaphragm due to small airway obstruction and gas trapping . There may also be collapse or consolidation (usually upper lobe) or perihilar in \201 lt rates hard to distinguish from pneumonia. Differential diagnoses for bronchiolitis include congenital heart disease, asthma, pneumoni a, cystic \201 brosis, inhaled foreign body and septicaemia. 683 ACUTE BRONCHIOLITIS Treatment Refer all infants with respiratory distress, feeding dif \201 culties (<50 % usu al \202 uid intake in previous 24 hr), SpO 2 <94 % on air, apnoeic episodes, or dehydrati on. Emergency treatment is largely supportive, comprising humidi \201 ed O 2 (aiming to ke ep SpO 2 > 92 % ), NG or IV \202 uids and some- times CPAP or IPPV. Dehydration may be se vere enough to warrant an IV \202 uid bolus of 20mL/kg. Treatment with inhaled bronchodil ators may achieve short-term (30 \200\22360min) clinical improvement in a minority, but the re is no convincing evidence of ef \201 cacy. Nasal suction may help those in respiratory distress. Ribavirin is of no value and should not be used. Do not give antibiotics for bron chiolitis, but consider for severe illness suggestive of co-existing pneumonia or septicaem ia. There is no bene \201 t from using ipratropium, oral or inhaled steroids, or nebulized adrenaline. Do not use these therapies in acute bronchiolitis. PICU referral and ventilato ry support is indicated for those with recurrent apnoea, persistent acidosis pH <7.25, infa nts with d conscious level, poor chest wall movement, and low SaO 2 (<92 % ) despite FiO 2 > 60 % , and those with hypercapnoea. Cross infection is a serious problem during epidemics. Ensure all persons entering a cubicl e containing a child with bronchiolitis clean their hands before and after seeing the patie nt, and use gloves and plastic aprons. Prevention Palivizumab is a humanized monoclonal RSV antibody, which is used as a prophylac tic agent to reduce the severity of RSV disease in at risk infants. It can be considered fo r use on a case-by-case basis in infants who: \200 Were born prematurely (<35 weeks gesta tion). \200 Have acyanotic congenital heart disease. \200 Have chronic lung disease. \200 Have severe congenital immunode \201 ciency. Infants should be selected for this tre atment by a local lead pediatric specialist. 1 See the SIGN Guideline on Bronchiolitis in Children . Available at: http://www.sign.ac.uk /pdf/ sign91.pdf 684 CHAPTER 15 Pediatric emergencies Whooping cough ND Caused by Bordetella pertussis , whooping cough is a noti \201 able dise ase with an incubation period of 5 \200\22314 days ( b p.220). It is common (particularly i n the autumn) in children not immunized against it. A similar disease may also occur with o ther viral infections ( Bordetella parapertussis and adenoviruses). Presentation Coryza is followed by increasing cough (typically worse at night, and tending to occur in bouts, often culminating in vomiting). Severe coughing bouts may result in conj unctival hemorrhages. The characteristic \200\230whoop \200\231 is an inspiratory noise pr oduced after a coughing bout. It is not present in all infants with whooping cough. The cou gh may persist for several weeks. Complications Illness is often prolonged. There is a risk of neurological damage and bron- chiectasis. Infants are at particular risk of death from apnoeic episodes. Investigations Send blood for viral titres, mycoplasma antibodies and FBC (usually reveals markedly i lymphocytes). CXR may be normal or show \200\230shaggy \200\231 right heart bor der. Treatment Refer infants aged <6 months (risk of apnoea) and any acutely unwell child. Disch arge others (having informed the Infectious Diseases consultant) with PO erythromycin (12.5 mg/kg qds) and advice to avoid contact with other children for 5 days. Arrange GP follow-up and give PO erythromycin (12.5mg/kg qds) as prophylaxis to unimmunized infant siblings. Prevention Encourage immunization. 685 TBND AND CYSTIC FIBROSIS TB ND and cystic \201 brosis Pulmonary TB TB is being seen increasingly again ( b p.232). It is more common in visitors from overseas or HIV + ve children. TB may present in a vari ety of ways in children: persistent cough and fever, growth retardation, meningitis, pleura l effusion, monoarticular arthritis, lymphadeno pathy, back pain, hepatosplenomegaly. Inves tigation CXR. Treatment Refer suspected cases for specialist evaluation, including Mantoux (0.1mL intrade rmal tuberculin) and treatment. Cystic \201 brosis Recurrent respiratory infections in neonates and infants raise the pos sibility of cystic \201 brosis, tracheo-oesophageal \201 stula, cleft palate, or a defe ct in immunity. Cystic \201 brosis is an autosomal recessive disorder affecting 1 in 2000 children. It may present neonatally with meconium ileus or later with respiratory infectio ns ( \201 nger clubbing), failure to thrive, rectal prolapse and steatorrhoea. Once di agnosed, a child will remain closely monitored and treated by both GP and a specialist CF r espiratory team. Involve this team at an early stage if a child with cystic \201 brosis p resents with respira- tory infection. 686 CHAPTER 15 Pediatric emergencies Pneumonia Pneumonia is relatively common at all ages, but the infective agents responsible vary (Table 15.6 ). Viruses are most commonly found as a cause in younger children. In olde r children, when a bacterial cause is found, it is most commonly Strep. pneumoniae. Table 15.6 Infective agents responsible for pneumonia Age Common causes E. coli , B -haemolytic Strep., Chlamydia trachomatis , Listeria monocytogenes , CMV Neonates Infants and toddlers RSV, para-in \202 uenza viruses, Strep pneumoniae , H. in \202 uenzae , Mycoplasma Older children Strep pneumoniae , H. in \202 uenzae , Mycoplasma Symptoms Often an URTI is followed by i fever, cough, dyspnoea, lethargy, feeding dif \201 culties, and dehydration. Pleuritic chest pain, abdominal pain, and neck stiffness may occ ur. The presence of headache, abdominal pain, maculopapular rash, and joint pains suggests Mycoplasma infection. Signs The child is usually dyspnoeic, pyrexial, and unwell. Classic signs of consolidation ( b p.114) are often absent, especially in infants and younger children. Look for evidence of infection elsewhere (ears, throat) and dehydration. If wheeze is present in a pre-school child, bacterial pneumonia is unlikely, although it does occur occasionally with mycobacte ria in older children. Investigations \200 Take throat swabs. \200 Obtain blood for FBC, cultures, viral titre s, and mycoplasma antibodies. \200 Check SpO 2 . \200 Obtain urine for culture. \200 CXR may demonstrate widespread bronchopneumonia or lobar consolidation. Cavitation suggests Staphyloccocal pneumonia or TB. Treatment If SpO 2 <92 % , give O 2 . Treat dehydration with IV \202 uids. Refer for admi ssion and antibiotics. IPPV is rarely required. The choice of antibiotic will depend upon t he likely infective agent and local/national protocols (see British Thoracic Society guidel ines: www. brit-thoracic.org.uk and see Box 15.2 ). Refer to ICU those unable to maintain SpO 2 > 92 % with 60 % O 2 , those with signs of shoc k, increasing respiratory rate/pulse rate with respiratory distress and exhaustion, those w ith slow irregular breathing or recurrent apnoea. 687 PNEUMONIA Box 15.2 Antibiotic treatment for suspected bacterial pneumonia Uncomplicated community acquired pneumonia \200 Neonate : benzylpenicillin and gentamicin . \200 Neonate and child under 6 months : cefuroxime or co-amoxiclav (or benzylpenicillin if lobar pneumonia or S. pneumoniae suspected). \200 Child 6 months to 5 years : oral am oxicillin or oral erythromycin. \200 Child 5 \200\22318 years : oral erythromycin (or ora l amoxicillin if S. pneumoniae suspected). Add \202 ucloxacillin if staph suspected eg in in \202 uenza or measles Use erythromycin if atypical pathogens suspected or penicillin allergic Severe community acquired pneumonia of unknown etiology \200 Neonate : benzylpenicillin a nd gentamicin. \200 1 month to 18 years : cefuroxime or co-amoxiclav (or benzylpenicillin if lobar pneumonia or S. pneumoniae suspected). Use erythromycin if atypical pathogens such as mycoplasma (more common in children over 5 y ears) or Chlamydia suspected or penicillin allergic. Add \202 ucloxacillin if Staphylococ cus suspected. 688 CHAPTER 15 Pediatric emergencies Fits, febrile convulsions, and funny turns A careful history is crucial. Epileptic \201 t s may take many forms: Grand mal (tonic/clonic) Loss of consciousness and shaking of all limbs. Petit mal ( \200\230absences \200\231) Child pauses in speech or other activity and is unaw are of episode. Focal \201 t Involves 1 part of body (progression to grand mal = Jacksonian march). Myoclonic \201 t May be violent and includes drop attacks. Infantile spasm (Salaam attack) May involve truncal \202 exion and cause a fall. Temporal lobe epilepsy Numerous bizarre presentations. The \201 tting patient The child who is still \201 tting on arrival to hospital is like ly to have had a prolonged seizure and needs urgent attention. \200 Give O 2 . \200 Sec ure the airway. If teeth are clenched, do not try to prise them open to insert an airway. I nstead, if the airway is obstructed, try a nasopharyngeal airway ( b p.325). Give IV lorazepam (0.1mg/kg) or if venous access is unsuccessful, per rectum (PR) diazepam (0.5mg/kg) or buccal midazolam (0.5mg/kg). \200 Check bedside strip measurement of venous /capillary blood glucose (BMG) and treat hypoglycaemia with IV 0.5g/kg dextrose (5mL/kg of 10 % ). Treat fever > 38 * C with rectal paracetamol. \200 If \201 ts continue, follow the algo rithm for status epilepticus ( b p.690). After the \201 t has \201 nished Reassess Airway, Breathing, Circulation. Continue O 2 and place in the recovery position. Check for injuries and perform regular observations. Fi rst \201 t Refer for investigation of possible causes. U&E, blood glucose, Ca 2 + , Mg 2 + , FBC, and urinalysis will be required. Subsequent \201 t If appropriate, check serum anticonvulsant level and arrange for GP/out patient clinic to receive the results and adjust dose appropriately. Allow home patients wi th known epilepsy who have fully recovered and have no obvious cause for the \201 t (eg m eningitis, hypoglycaemia). Febrile convulsions These are grand mal seizures lasting <5min and secondary to pyrexia of febrile illness. Commonest cause of \201 ts between 6 months and 5 years, affecting 3 % o f children. Although 30 % recur, only 1 % go on to develop epilepsy in adult life. By de \201 nition, children already diagnosed as epileptic, do not have febrile convulsions, but \200\230further \201 ts \200\231. Treat patients who arrive 689 FITS, FEBRILE CONVULSIONS, AND FUNNY TURNS \201 tting with O 2 , airway care and IV lorazepam, PR diazepam or buccal midazolam as de scribed opposite. Check BMG and T * . Give PR (or if conscious, oral) paracetamol (15mg/kg) . Examine thoroughly for a source of infection (particularly meningitis) and perform an inf ection screen: U&E, FBC, blood cultures, MSU, CXR and LP. Consider discharging children age d > 2 years with second or subsequent febrile convulsion, and obvious benign and treatable cause for pyrexia, with appropriate treatment. Liaise with GP to consider arranging for par ents to administer rectal diazepam or buccal midazolam to terminate future febrile \201 t s. Admit children aged <2 years, those with \201 rst febrile \201 ts, and those with se rious infections or an unknown cause of pyrexia. Approach to the febrile child aged <3 years Usually symptoms and signs of illness are non-s peci \201 c. General aspects of behavior and appearance provide the best guide as to wheth er a serious illness is likely. The degree of fever and response to antipyretics is not hel pful. Up to 5 % of those who present with fever will have bacteraemia. Admit any febrile ch ild <3 years who appears unwell/ miserable. Febrile infants ( > 38 * C) aged <3 months are especially dif \201 cult to assess and require admission for a \200\230septic screen \200 \231 (FBC, serology, blood cultures, urine culture CXR, lumbar puncture (LP). Discuss wi th a neonatologist the need for IV antibiotics in babies aged <28 days. Young children aged 3 months \200\2233 years who have a clear focus of infection and appear well should be treated as indicated. If there is no clear focus of infection, consider sho rt-term admission in a pediatric facility. Funny turns Only a minority of reported \200\230funny turns \200\231 are epileptic \201 ts. Most require referral and investigation. The history is crucial. Infants Irregular and varying depth of respiration during sleep is normal, but can cause pa rental alarm. Self-limiting apnoeic or cyanotic episodes may be due to: \201 ts, inhaled FBs, near-miss cot death, gastro-oesophageal re \202 ux and laryngeal spasm, or arrhythmia s (eg SVT). 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.