Post on 25-Dec-2015
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Facilitated by Partners In Healthcare and sponsored by Walgreens
Evidence Based Pediatric Treatment Guidelines 2014:
Clinical Practice Strategies for the Retail Clinician
Wendy L. Wright, MS, RN, APRN, FNP, FAANPOwner – Wright & Associates Family Healthcare
Partner – Partners in Healthcare Education
Wright, 2014
Another Great Resource for Pediatrics
Wright, 2014 2
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014
Development & Anticipatory Guidance
• Developmental Screening– 9 months– 18 months– 30 months
• Identify those infants and children with developmental disorders
3
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/645/F1 accessed 05-01-2014
Wright, 2014
Development & Anticipatory Guidance
• Anticipatory Guidance–Every visit from birth – age 21
–Specific guidance is based upon age
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http://brightfutures.aap.org accessed 05-01-2014
Wright, 2014
Eye Examinations and Vision
• AAP recommendations– Begin vision screening as a newborn– Formal screening at:
• Age 3 years• Age 4 years• Age 5 years• Age 6 years• Age 8, 10, and 12 years• Age 15 and 18 years
5Wright, 2014
AAP Updates
• Hearing Screening– Most common congenital developmental
abnormality affecting children in the United States
– Screen before 1 month– Repeat by 3 months if abnormal– If abnormal, referred to early intervention
before age 6 months for formal evaluation
Wright, 2014 6http://aapnews.aappublications.org/content/32/8/36.2.extract accessed 05-01-2013
AAP Recommendations
• Universal newborn hearing screening• Screenings for hearing impairment should be
performed periodically on all infants and children in accordance with the following schedule– Newborn– Age 4, 5, 6, and 8– Risk assessments performed at all other well-
child visits
Wright, 2014 7
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/2/436 accessed 05-01-2014
USPSTF Hearing Screening Recommendations
• The USPSTF recommends screening for hearing loss in all newborn infants
• All infants should have hearing screening before 1 month of age
• Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age for confirmatory testing– These children should undergo periodic monitoring
for 3 years
8Wright, 2014
http://www.guidelines.gov/content.aspx?id=12640&search=hearing accessed 05-01-2014
Dental Examination
• AAP recommendations– Begin at age 12 months– 18 months– 24 months– 30 months– 3 years of age– 6 years of age
9Wright, 2014
Autism Screening
• Universal screening– Formal ASD screening on all children at 18
and 24 months regardless of whether there are any concerns
– Guidelines stress that providers need to ask/discuss any concerns that parents may have at every well-child visit
10Wright, 2014
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
M-CHAT Screening Tool
• http://www.mchatscreen.com
• Conducted at 18 and 24 months
• Can learn to become certified autism screener
Wright, 2014 11
Look for the Presence of Red Flags
• No babbling or pointing or other gesture by 12 months
• No single words by 16 months
• No two-word spontaneous phrases by 24 months
• Loss of language or social skills at any age.
Wright, 2014 12
http://www.aap.org/advocacy/releases/oct07autism.htm accessed 03-31-2011
Lead Screening
• AAP recommendations– 12 months or…– 24 months
• Continued risk factor assessment throughout childhood
13Wright, 2014
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014
Anemia Screening
• AAP recommendations– Age 12 months– Hemoglobin or hematocrit
• Continued risk assessment throughout childhood
14Wright, 2014
http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf accessed 05-01-2014
Wright, 2014
Children and Screening• Begin at 10 years of age in children
at risk or at the onset of puberty, if earlier than 10 years–Repeat every 3 years, if normal
www.diabetes.orgwww.aace.com
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What Constitutes a Risk Factor in Children?
• Overweight (BMI>85th %tile for age and sex, weight for height >85th%tile, or weight >120% of ideal for height)
• In addition – presence of two or more of the following:– Family history of type 2 diabetes in first- or second-degree relative– Race/ethnicity (Native American, African American, Latino, Asian
American, Pacific Islander)– Signs of, or conditions associated with, insulin resistance including
acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, small for gestational age at birth history in the child
– Maternal history of DM or gestational DM
Wright, 2014 16
http://care.diabetesjournals.org/content/36/Supplement_1/S11.full accessed 05-20-2014
General Health Counseling
• Seatbelts
• Helmets
• Sunscreen
• Smoke Detectors
• Pool Safety
• Carbon Monoxide
• Guns
• Domestic Violence17Wright, 2014
General Health Counseling
• Drugs
• Alcohol
• Smoking
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Remember – School / sport physicals may be the only contact that the child has with a health
care professional in a yearWright, 2014
Immunization schedule: aged 0 through 18 years—United States, 2014
Wright, 2014 19
ACIP Recommendations for Use
of Meningococcal Vaccine• Routine vaccination of adolescents with MCV-4
– Individuals age 11 - 18
– Microbiologists who are routinely exposed to isolates of Neisseria meningitidis
– Military recruits
– Persons who travel to, or reside in, countries in which N meningitidis is hyperendemic or epidemic
– Complement-deficient and asplenic patients
CDC. MMWR. 2005;54(RR-7):13.
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Wright, 2014
ACIP Recommendations – October 2010
• ACIP recommends routine vaccination of adolescents with MCV4 beginning at age 11 through 12 years at the pre-adolescent vaccination visit, with a booster dose at age 16 years.
• For adolescents vaccinated at age 13 through 15 years, a one-time booster dose should be given 3 to 5 years after the first dose.
Wright, 2014 21
Updated ACIP Recommendations
Why Change the Program Now?
• Data indicates protection wanes within 5 years after vaccination
Wright, 2014 22
HPV4
• Protects against 4 strains of HPV– 16 and 18 – cause 70% of all cervical
cancer
– 6 and 11 – cause 90% of genital warts
– CDC just recommended administration as young as 9 but ideally to 11 – 12 year old girls
– Age limit: < 26 years of age23Wright, 2014
HPV Vaccine
• Series of 3 injections– Day 0, day - 2 months and day - 6 months
• .5 ml injection IM injection into deltoid
24Wright, 2014
Additional Indication for HPV4
• Indicated to reduce risk of genital warts in males
• Also: reduction in anal cancers
• Ages: 9 years - < 26 years of age
• Universal recommendation for boys:– 9 – 21 years
• Permissive recommendation for boys– 22 – 26 years (insurance may not cover)
Wright, 2014 25
Additional Approval
• HPV4– Prevention of anal cancer and associated
precancerous lesions due to human papillomavirus (HPV) types 6, 11, 16, and 18 in people ages 9 through 26 years
– 78 percent effective in the prevention of HPV 16- and 18-related AIN
Wright, 2014 26
Influenza
Wright, 2014 27
Important Influenza Messages
• Begin to vaccinate as soon as flu vaccines are received in clinics
• Immunity lasts throughout entire flu season, even if vaccines are given in August
• All healthcare professionals who care for patients in a protected environment (severely immunocompromised) should receive the Trivalent Inactivated Vaccine (TIV) rather than LAIV
Wright, 2014 28
Egg Allergy and TIV• 2011 - The recommendation is as follows:
– For patients with a history of egg allergy WITHOUT anaphylaxis, there is no need to divide doses or perform skin testing before vaccination
– There will be no need to confirm the levels of ovalbumin in the 2011-12 flu vaccine because all products will contain less than 0.6 micrograms per dose;
– Patients with egg allergy should be observed for 30 minutes after vaccination; and
– Vaccine providers should be equipped and trained to handle anaphylactic emergencies
– Do not use LAIV (Flumist)
Wright, 2014 29
New Information
• 2014-2015 strains for influenza vaccine announced
• Trivalent or Quadrivalent– A/California/7/2009 (H1N1)– A/Victoria/361/2011 (H3N2)– B/Massachusetts/2/2012– Quad: B/Brisbane/60/2008
• http://www.who.int/influenza/vaccines/virus/en/ accessed 05-01-2014
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MMR and Travel• Before departure, children aged 6–11
months should receive the first dose of MMR vaccine– Infants vaccinated before age 12 months must
be revaccinated on or after their first birthday with 2 doses of MMR vaccine, separated by at least 28 days
Wright, 2014 31http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/vaccine-recommendations-for-infants-and-children.html accessed 12-30-2012
Management of Fever• Definition
– Temperature > 37.2° C orally or > 98.9° F in am– OR….> 37.7° C orally or > 99.9° F in afternoon
– pm
• When child presents with a fever of 5 – 7 days or less, must consider:– Viral vs. Bacterial infections– Bacteremia– Sepsis
32Wright, 2014
Worrisome Findings:Consider Hospitalization
• Altered LOC• Abnormal breathing• Tachycardia in presence of significant findings• Significantly elevated temperature• Petechiae• Cyanosis• Pallor• Delayed capillary refill (> 2 seconds)• Poor muscle tone
33Wright, 2014
Management of Fever• Antipyretics
– May mask signs and symptoms of serious conditions– Side effects may occur from these medications– Do not alter course of illness
• Benefits– Good when fever is > 103– Always recommend in children with history of febrile
seizure– May make more comfortable
34Wright, 2014
Management of Fever• Options for treatment (weight/age dosing)
– Acetaminophen– Ibuprofen
• Caution regarding cool sponge baths
• Education:– Monitor closely– Reinforce when to call or return– Avoid aspirin and related products– Increase fluids
35Wright, 2014
Clinical Pearl:
Document visual acuity on all eye
complaints
36Wright, 2014
Hordeolum
• Etiology– Obstruction of the glands of Zeiss– Staphylococcal aureus is the most common
causative organism
• History– Swollen, red, painful lesion on the lid margin– Itchiness of the eyelid
37Wright, 2014
Hordeolum
• Physical examination– Erythematous, tender nodule on the margin of the
eyelid– Surrounding edema
• Treatment– Warm compresses-20 minutes qid– Antimicrobial ointment or drops– Good eye hygiene and handwashing
38Wright, 2014
Hordeolum
39Wright, 2014
Internal Hordeola
40Wright, 2014
Viral Conjunctivitis• Etiology
– Adenovirus is the most common cause• 40 strains identified
– Recent studies have shown that it can remain viable on plastic and metal surfaces for up to 1 month
• Symptoms– Watery discharge, foreign body sensation, redness– URI symptoms are common including sore throat
and fever– Often bilateral
41Wright, 2014
Viral Conjunctivitis
• Signs– Normal visual acuity, PERRLA, EOMI, Fund nl– Mucoid-slightly watery discharge– Mild, diffuse injection– Preauricular lymphadenopathy
• Treatment– Symptomatic only– Cool compresses– Strict eye hygiene
42Wright, 2014
Viral Conjunctivitis
43Wright, 2014
Bacterial Conjunctivitis
• Etiology– Staphylococcus aureus– Streptococcus pneumoniae/pyogenes– Haemophilus influenzae– Neisseria gonorrhea
• Symptoms– Redness, swelling, purulent discharge, itching– No symptoms until eye complaints began
44Wright, 2014
Bacterial Conjunctivitis• Signs
– Normal visual acuity, PERRLA, EOMI, Fund nl– Diffuse injection– No ciliary injection– Unilateral at onset
• Treatment– Topical antimicrobials x 5-7 days– Warm compresses qid x 10-20 minutes– Strict eye hygiene given contagion
45Wright, 2014
Bacterial Conjunctivitis
46Wright, 2014
Conjunctivitis
• Bacterial– Non-palpable nodes
• GC and Chlamydia +
– Purulent discharge• GC-Mucopurulent
– Moderate conjunctival injection
– Unilateral at onset
• Viral– Palpable preauricular
node– Watery discharge– Mild-moderate
conjuctival injection– URI symptoms– Bilateral
47Wright, 2014
Allergic Conjunctivitis• Two types of allergic conjunctivitis
– Seasonal and perennial
• Seasonal is most common and caused by the following triggers– Pollens– Grass– Ragweed
• Perennial persists all year and is caused by indoor allergens, such as dust mites
48Wright, 2014
Signs and Symptoms
• Symptoms– Itching– Watery– stringy-like clear discharge
• Signs– Injected conjunctiva– Other physical examination findings such as:
• Dennie’s lines• Allergic shiners• Allergic facies• Allergic crease
49Wright, 2014
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51Wright, 2014
Treatment
• Systemic and/or topical antihistamines relieve acute symptoms due to interaction of histamine at ocular H1 and H2 receptors
• Examples of topical antihistamines include: epinastine (Elestat) and azelastine (Optivar)
• Vasoconstrictors are available either alone or in conjunction with antihistamines to provide short-term relief of vascular injection and redness• Common vasoconstrictors include naphazoline,
phenylephrine, oxymetazoline, and tetrahydrozoline
52Wright, 2014
Treatment
• Mast cell stabilizers include cromolyn sodium and lodoxamide (Alomide), Olopatadine (Patanol), nedocromil (Alocril)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) act on the cyclooxygenase metabolic pathway and inhibit production of prostaglandins. One example is: ketorolac tromethamine (Acular)
53Wright, 2014
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis
in Children and AdultsClinical Infectious Diseases Advance
Access published March 20, 2012
Wright, 2014 54
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
Algorithm for the management of acute bacterial rhinosinusitis
Chow A W et al. Clin Infect Dis. 2012;cid.cir1043
© The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
Wright, 2014 55
What Constitutes at Risk for Resistance?
• Age < 2 years or > 65 years
• Daycare
• Antimicrobial within past 1 month
• Hospitalization within past 5 days
• Comorbidities
• Immunocompromised
Wright, 2014 56
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
Wright, 2014 57
Goals of Treatment
• Restore integrity and function of ostiomeatal complex– Reduce inflammation– Restore drainage– Eradicate bacterial infection
http://www.medscape.com/viewprogram/5621 accessed 01-22-07
Wright, 2014 58
Treatment of Acute Bacterial Rhinosinusitis
• Nonpharmacologic Therapies– Cold steam vaporizer– Increased water intake– Intranasal saline irrigations with either physiologic
or hypertonic saline are recommended as an adjunctive treatment in adults with ABRS1
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
Wright, 2014 59
Management Strategies in ABRS
• Antihistamines or decongestants– No longer recommended
• Topical corticosteroids– Intranasal corticosteroids are recommended as an adjunct to
antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis1
• Corticosteroids
1http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Accessed 12-29-2012
Antimicrobial Regimens in Children
Wright, 2014 60http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html accessed 12-29-2012
Important Changes
• Macrolides (clarithromycin and azithromycin) are not recommended due to high rates of resistance among S. pneumoniae (30%)
• TMP/SMX is not recommended due to high rates of resistance among both S. pneumoniae and H. influenzae (30%–40%)
• Second and third-generation cephalosporins are no longer recommended due to variable rates of resistance among S. pneumoniae.
Wright, 2014 61
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html accessed 12-29-2012
Length of treatment
• The recommended duration of therapy for uncomplicated ABRS in adults is 5–7 days
• In children with ABRS, the longer treatment duration of 10–14 days is still recommended
Wright, 2014 62
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
When to Change Treatments
• An alternative treatment should be considered if symptoms worsen after 48–72 hours of initial empiric antimicrobial therapy, or when the individual fails to improve despite 3–5 days of antimicrobial therapy
Wright, 2014 63
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
When to Refer
Wright, 2014 64http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+htmlAccessed 12-29-2012
Ear Conditions
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Wright, 2014 66
Variations of Tympanic Membrane
Normal TMNormal TM
Acute OMAcute OM
Otitis Media Otitis Media with Effusionwith Effusion
67Wright, 2014
AAP Updated Guidelines• Diagnosis of AOM:
– Evidence: 1A• Moderate - severe bulging of TM• OR…new otorrhea NOT due to otitis externa
– Evidence: 1B• Mild bulging of TM and….• Recent ( < 48 hours) onset of ear pain or….• Intense erythema of TM
Wright, 2014 68
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AAP Updated Guidelines (cont.)• Severe AOM:
– Prescribe antimicrobial for AOM in children 6 months or older with severe signs and symptoms
• Moderate or severe otalgia for at least 48 hours OR…• Temperature: 102.2 (39 degrees Celsius)
Wright, 2014 69
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere bilateral AOM in children < 24
months without signs or symptoms:– Antibiotics should be prescribed even in the
setting of mild symptoms• Mild otalgia < 48 hours• Temperature < 39 degrees Celsius
Wright, 2014 70
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere unilateral AOM in children age 6
month – 23 months:– Two options:
• Antimicrobial therapy• Observation as treatment option
– Nonsevere– Follow-up must be ensured– Start antimicrobials if worsen or no improvement with 48 – 72
hours
Wright, 2014 71
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AAP Updated Guidelines (cont.)• Nonsevere AOM in older children (24 months
or older):– Two options:
• Antimicrobial therapy• Observation as treatment option
– Nonsevere– Follow-up must be ensured– Start antimicrobials if worsen or no improvement with 48 – 72
hours
Wright, 2014 72
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
Summary: AAP Updated Guidelines (cont.)
Wright, 2014 73
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AGE Otorrhea with AOM
Unilateral or Bilateral AOM
with Severe Symptoms
Bilateral AOM without
Otorrhea
Unilateral AOM without
Otorrhea
6 months – 2 years Antibiotic Antibiotic Antibiotic Antibiotic therapy or
observation
> 2 years Antibiotic Antibiotic Antibiotic or observation
Antibiotic or observation
AAP Updated Guidelines (cont.)• Treatment options:
– Amoxicillin: first line• Provided that: no antibiotics in previous 30 days and• No purulent conjunctivitis and • Not allergic to PCN
Wright, 2014 74
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
AAP Updated Guidelines (cont.)• Treatment options:
– Amoxicillin/clavulanate• Child who has received antibiotics in previous 30 days
OR….• Has concurrent purulent conjunctivitis OR….• History of AOM which is unresponsive to amoxicillin
Wright, 2014 75
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
Initial Immediate or Delayed Antibiotic Treatment
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy)
Amoxicillin (80-90 mg/kg/day) in two divided doses OR
Cefdinir (14 mg/kg/day) in one – two divided doses
Cefuroxime (30 mg/kg/day) in two divided doses
Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses
Cefpodoxime (10mg/kg/day) in two divided doses
Ceftriaxone (50 mg IM or IV) daily for 1 or 3 days
Wright, 2014 76
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
Antibiotic Treatment After 48-72 hours of Failure of Initial Antibiotic
Recommended First line Treatment Alternative Treatment (if Penicillin Allergy)
Amoxicillin/clavulanate (90 mg/kg/day or amoxicillin) with 6.4 mg/kg/day of clavulanate) in two divided doses
Ceftriaxone 3 dayClindamycin (30 – 40 mg/kg/day) in three divided doses with or without concomitant
third generation cephalosporin
Ceftriaxone (50 mg IM or IV) for 3 days Clindamycin (30 – 40 mg/kg/day) in three divided doses with concomitant third
generation cephalosporinTympanocentesisConsult specialist
Wright, 2014 77
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
Remember…
• For children with OM and tympanostomy tubes:– You may also utilize topical medications– Ofloxacin (Floxin Otic) 0.3% solution
• Age 1 - 12 years: 5 drops into affected ear bid x 10 days
– Ciprofloxacin (Ciprodex): • 6 months and up: 4 drops into the affected ear bid x 7
days
78Wright, 2014
Duration of Treatment for AOM
• Results– 10 days: Patients <2 years old or those with
severe symptoms– 7 days: Age 2-5 years of age with mild – moderate
AOM– 5 – 7 days: 6 years and older with mild – moderate
symptoms
79Wright, 2014
http://www.google.com/#sclient=psyab&q=guidelines+on+AOM&oq=guidelines+on+AOM&gs_l=serp.3..0i22i30l2.1956.5384.0.5749.19.13.1.5.5.0.127.1021.11j2.13.0...0.0...1c.1.11.psy-ab.8e640vy70iU&pbx=1&bav=on.2,or.r_qf.&fp=a7cbcbf4ec25b454&biw=1240&bih=556 accessed 05-01-2013
Otitis Media with Effusion• Fluid in the middle ear
• No signs and symptoms of AOM– Air fluid levels– Dullness of TM– Decreased movement of TM
80
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2014
OME
81Wright, 2014
OME• Treatment:
– Observation as a treatment option– Majority – up to 90% will resolve within 3 months
without intervention– If still present at 12 weeks – may need hearing
evaluation, referral to ENT– High risk individuals may be candidates for
myringotomy
82
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412 accessed 02-01-2010Wright, 2014
Otitis Externa
83Wright, 2014
Otitis Externa• Pathophysiology
– Inflammation +/or infection of the external auditory canal
– Associated with prolonged water exposure, inserting objects into ear, scratching the ear
– 10-20x more common in the summer– Children with eczema, psoriasis, seborrhea
are at a greater risk– Most common cause: Pseudomonas
84Wright, 2014
Otitis Externa
• Symptoms– Unilateral ear pain– Discharge from the ear– Low grade fever– Recent history of swimming or placing
something in ear– Pain with tragal movement– Redness around ear– Decreased hearing
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Otitis Externa
• Signs–Erythematous, edematous canal
–Pain with tragal/pinna movement
–Yellow/green discharge
–Foreign body
–Pre or postauricular lymphadenopathy
86Wright, 2014
Otitis Externa
• Plan– Diagnostic
• None• Can check culture
– Therapeutic• Remove foreign body• Irrigate canal• Erythromycin (Cortisporin) Otic Ear Solution: 4 drops qid
into affected ear x 5 days• Ciprofloxacin (Ciprodex) 3 – 4 drops tid into affected ear x
7 days
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Otitis Externa
• Plan– Therapeutic
• Warm compresses• NSAIDS/Tylenol• Prednisone• Auralgam• Wick
88Wright, 2014
Otitis Externa
• Plan– Educational
• Avoid prolonged water exposure - ear plugs• Ear wax removal kits• Prevention: Oil into canal; Vaseline on cotton
ball• No Q tips in ear• Try to remove all water after bathing by
manipulating ear
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Pharyngitis
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Pharyngitis
• Epidemiology–Group A Beta Hemolytic Strep
• Most interest because of its association with severe complications
• Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications
91Wright, 2014
Pharyngitis
• Symptoms– Group A Beta Hemolytic Strep
• Rapid onset of sore throat• Fever 103-104• Swollen glands• Children often complain of abdominal pain• Usually-no URI symptoms• Headache• Decreased appetite• Dysphagia• Irritability
92Wright, 2014
Exudative pharyngitis
Exudative pharyngitis
Differentials include:
Strep pharyngitis
Peritonsillar abscess
Mononucleosis
Viral pharyngitis
93Wright, 2014
Pharyngitis
• Plan–Diagnostic
• Throat culture: 24 hour is the gold standard
• Quick strep: 85-100% sensitivity; 31-95% specificity
• Must swab both tonsils for best results• Consider mononucleosis
94Wright, 2014
Pharyngitis
Even with a best case scenario, 1/3 - 1/2 of cases of strep pharyngitis are
missed or overdiagnosed using history and physical examination
only!!!
MUST DO A THROAT CULTURE
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Remember…Children with mono
have strep pharyngitis 50% of
the time
96Wright, 2014
Pharyngitis
• Plan– Therapeutic: Strep Pharyngitis
• PCN VK-standard• Treatment is for 10 days• Warm water gargles• Tylenol/NSAID’s
– Educational• Contagion• Quick improvement• Discard toothbrush
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Peritonsillar Abscess
• Generally begins as an acute febrile URI or pharyngitis
• Condition suddenly worsens– Increased fever– Anorexia– Drooling– Dyspnea– Trismus
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Peritonsillar Abscess
• Physical examination– May appear restless– Irritable– May lie with head hyperextended to facilitate
respirations– Muffled voice– Stridor may be present– Respiratory distress
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Peritonsillar Abscess
• Physical examination findings–Fiery red asymmetric swelling of
one tonsil
–Uvula is often displaced contralaterally and often forward
–Large, tender lymphadenopathy
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Peritonsillar Abscess
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Peritonsillar Abscess
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Important Reminder
•If respiratory distress is severe,
do not examine the pharynx
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Treatment
• Aspiration of the abscess may be performed for accurate diagnosis and treatment
• CT scan of the head and neck– Monitor airway at all times
• ENT consult is essential
• Usual management– IV antibiotics– Inpatient management
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Viral Upper Respiratory Infection
• Caused by the rhinovirus, adenovirus or coronavirus
• Transmitted through respiratory droplets
• Most common ages: 4 – 7 years
• Begins with sore throat, low grade fever and progresses on to include nasal congestion and a cough
• Typically lasts 3 – 14 days
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Treatment• Mainly symptomatic
– Avoid cough and cold medications in individuals < 2 years of age
• Consider the following:– Decongestants– First generation antihistamines– Cough suppressants– Guaifenesin products– Chicken soup
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General Signs and Symptoms of Respiratory Distress
• Respiratory rate which is > 50% above upper limits of normal for age
• Intercostal retractions
• Nasal flaring
• Substernal retractions
• Grunting with breathing
• Cyanosis/pallor
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Asthma and Asthma
Exacerbation108Wright, 2014
Impact of Asthma
• Most frequent cause for hospitalization in children (470,000 each year)– Emergency room visits and hospitalizations are
increasing• Most frequent cause of childhood death,
particularly amongst certain groups (children, african americans)– 5,000 people die yearly from asthma
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Asthma is...
• A disease of:– Inflammation
• Primary Process
– Hyperresponsiveness– Airway bronchoconstriction– Excessive mucous production
110Wright, 2014
AsthmaticAsthmaticNormalNormalJeffery P. In: Asthma, Academic Press 1998.
Epithelial Damage in Asthma
111Wright, 2014
Diagnosis of Asthma
112Wright, 2014
What is Asthma
• “A common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation.”
113
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007.
Wright, 2014
Diagnosis of Asthma
• History and Physical Examination
• Pulmonary Function Tests
• Monitoring:– Peak Flow Meters
114Wright, 2014
Symptoms and Signs of Asthma in Children
• Coughing, particularly at night• Wheezing• Chest tightness• SOB• Cold that lingers x months with a
persistent cough
115Wright, 2014
Diagnosis
• Consider the diagnosis of asthma and perform spirometry if any of these indicators are present. These indicators are not diagnostic by themselves but the presence of multiple key indicators increases the probability of the diagnosis of asthma. Spirometry is needed to make the diagnosis of asthma.
116
National Heart, Lung and Blood Institute; National Asthma Education and Prevention Program; Expert Panel Report 3: Guidelines for Diagnosis and Management of Asthma, Full Report 2007.
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Figure 17-1 Classifying Asthma Severity and Initiating Treatment in Children 0 to 4 Years of Age
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Stepwise Approach for Managing Asthma in Children Age 0 to 4 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Step 1Step 1
Preferred:Preferred:
SABA
PRN
Step 3Step 3
Preferred: Preferred:
Medium-dose ICS
Step 5Step 5
Preferred:Preferred:
High-dose ICS + either LABA
or Montelukast
Step 4Step 4
Preferred:Preferred:
Medium-dose ICS + either
LABAor
Montelukast
IntermittentIntermittentAsthmaAsthma
Persistent Asthma: Daily MedicationPersistent Asthma: Daily Medication
Consult with asthma specialist if Step 3 care or higher is required. Consult with asthma specialist if Step 3 care or higher is required. Consider consultation at Step 2.Consider consultation at Step 2.
Patient Education and Environmental Control at Each Step
Step Up iStep Up if NeededNeeded
((first check first check adherence, adherence,
inhaler inhaler technique, & technique, &
environmental environmental control)control)
Step Down iStep Down if PossiblePossible
(& asthma is (& asthma is well controlled well controlled
at least 3 at least 3 months)months)
Assess Assess ControlControl
Quick-Relief Medication for All Patients• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms• With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult).• Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of
previous severe exacerbations• Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations
on initiating daily long-term-control therapy
Step 2Step 2Preferred:Preferred:Low-dose
ICS Alternative: Cromolyn
or Montelukast
Step 6Step 6Preferred:Preferred:
High-doseICS + either
LABA or Montelukast
and Oral Systemic
Corticosteroids
Classifying Asthma Severity and Initiating Treatment in Children 5 to 11 Years of Age
Stepwise Approach for Managing Asthmain Children Age 5 to 11 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
Assess Assess ControlControl
Stepwise Approach for Managing Asthma in Patients Aged≥12 Years
www.nhlbi.nih.gov/guidelines/asthma/asthgdlnWright, 2014 121
Major Focus in EPR-3
• Controlling asthma is a major focus of the EPR-3 guidelines
122Wright, 2014
Assessing Asthma Control (Youths 12 Years of Age and Adults)Follow-up Visits: Determine Level of Control and Treatment NeededComponents of Control Well-controlled
Not Well-controlled
Very Poorly Controlled
Impairment
Symptoms≤2 days/week >2 days/week Throughout the day
Nighttime awakenings
≤2 x/month 1-3x/week ≥4x/week
Interference with normal activity
None Some limitation Extremely limited
Short-acting beta2-agonist use for symptom control (not prevention of EIB)
≤2 days/week >2 days/week Several times per day
FEV1 or peak flow>80% predicted/personal best
60-80% predicted/personal best
<60% predicted/personal best
Validated QuestionnairesATAQACQACT
0≤0.75*≥20
1-2≥1.516-19
3-4N/A≤15
Exacerbations0-1/year ≥2/year (see note)Consider severity and interval since last exacerbation
Risk
Progressive loss of lung function
Evaluation requires long-term follow-up care
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma.Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second. See figure 3-8 for full name and source of ATAQ, ACQ, ACT.
123Wright, 2014
Monitoring Control in Clinical Practice: Asthma Control Test™ for Patients Aged ≥12 Years1
1. Asthma Control Test™ copyright, QualityMetric Incorporated 2002, 2004. All rights reserved.2. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/epr3/resource.pdf. Accessed February 5, 2007.
Level of Control Based on Composite
Score2
≥20 = Controlled
16-19 = Not Well
Controlled
≤15 = Very Poorly Controlled
Regardless of patient’s self
assessment of control in
Question 5
124Wright, 2014
Acute Asthma Exacerbation Management
125Wright, 2014
Case Study
• 6 year old who presents with a 2 day history of increasing sob and wheezing
• Began after developing a URI• + nasal discharge, wheezing, cough, fever
– 99.6– Denies ST, ear pain, sinus pain, pain with
inspiration• Meds: none• Allergies: NKDA• PMH: Bronchiolitis: age 6 months –
required hospitalization126Wright, 2014
Physical Examination
• 6 year old who is wheezing audibly and obviously uncomfortable– RR: 30 and labored– Pulse: 124 bpm– Lungs: + inspiratory and expiratory wheezes– No use of accessory muscles– Remainder of exam is unremarkable
127Wright, 2014
Acute Asthma Exacerbation
• Measure Spirometry vs. Peak Flow• FEV1 is most important number
– >80% predicted– 50% – 79% of predicted– < 50% of predicted
128Wright, 2014
Spirometry Results
• FEV1 = 62% of predicted
• FEV1/FVC = 90%
• What does this mean for our patient?
129Wright, 2014
Acute Asthma Exacerbation
• Inhaled short acting beta 2 agonist: – Up to three treatments of 2-4 puffs by
MDI at 20 minute intervals OR a single nebulizer
• Can repeat x 1 – 2 provided patient tolerates– Albuterol or similar via nebulizer– Reassess spirometry or peak flow after
130Wright, 2014
Prednisone
• Multiple products available
• Prelone, Orapred, Prednisone– 1 mg/kg daily (may split dosage)
• Example: Prednisone 10 mg bid x 3 - 10 days
• No taper necessary
131Wright, 2014
Home Nebulizer
• May be important to order the patient a nebulizer to be delivered to his/her home
• Will be set up by a respiratory company
• Patient and parent will be taught appropriate utilization
132Wright, 2014
Patient Education
• Have plan in place for next URI
• Preventative therapy?
• Environmental modification
• Daily peak flows
133Wright, 2014
Severity of Acute Exacerbations
Wright, 2014 134http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf accessed 05-01-2014
Bronchiolitis
135Wright, 2014
Bronchiolitis
• Bronchiolitis is the most common lower respiratory tract infection in infants and is usually caused by a viral infection
• Most common cause: respiratory syncytial virus
• RSV is responsible for > 50% of all cases• Other causes: adenovirus and influenza• Most commonly seen in the winter and
spring136Wright, 2014
Bronchiolitis
• Bronchiolitis–Affects infants and young children most often
because their small airways become blocked by mucous more easily than older children
–Usually occurs between birth and 2 years of age
–Peak occurrence: 3 – 6 months
137Wright, 2014
Burden of Illness
• Typically, bronchiolitis is a mild illness
• Risk factors for more severe illness include:– Prematurity
– Heart or lung disease
– Weakened immune system
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Complications of Bronchiolitis
• Hospitalization
• Respiratory distress
• Children with this condition are more likely to develop asthma later in life
139Wright, 2014
Signs and Symptoms
• Usually presents as the common cold initially – Nasal congestion– Runny nose– Cough
• These symptoms typically last for 1 -2 days and then symptoms begin to worsen– Fever– Vomiting after coughing
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Signs and Symptoms• Cough worsens• Wheezes frequently occur
– High pitched sounds indicating a difficulty with air movement
• Worsening respiratory distress may occur– Retractions– Flaring of the nostrils– Irritability– Tachycardia and tachypnea
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Incubation Period and Duration
• Incubation period is:– Days – 1 week
– This is dependent upon which virus is responsible for the infection
• Duration of symptoms– Typically 7 days but children with severe
cases may cough for weeks
142Wright, 2014
Treatment
• Symptomatic treatment is the most common treatment– Increased fluids
– Cool mist vaporizer to thin the secretions
– Tilting the child’s mattress up may be beneficial
• Antibiotics are not helpful143Wright, 2014
Pharmacotherapy
• Corticosteroids
• Inhaled corticosterioids
144Wright, 2014
Bronchitis
145Wright, 2014
Bronchitis• Definition: Inflammatory condition of
the tracheobronchial tree–Acute bronchitis
• Most cases of acute bronchitis are viral (90-95%)
• 5% are bacterial
–Most frequent cause of bacterial bronchitis – atypical pathogen (i.e. mycoplasma)
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Treatment for Bronchitis
• Symptomatic
• Increase fluids
• Steam
• Guiafenesin or similar
• First generation antihistamine
• Cough syrup – usually not helpful or effective
147Wright, 2014
Bronchitis
• Treatment–Antibiotics rarely needed
• If needed, atypical pathogen coverage
–Prednisone• Short, non-tapering burst is often very
effective
• i.e. 5 days
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Pertussis
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150
Pertussis:Preventable but Persistent
“There is a relative lack of awareness among health-care providers that pertussis immunity from natural infection or childhood vaccination wanes 5-8 years after the last booster dose. This leaves adolescents and adults vulnerable to pertussis infection, and those infected can transmit risk of life-threatening disease to young infants.”1
Reference: 1. Healy CM, et al. Vaccine. 2009;27(41):5599-5602.
Pertussis: Highly Communicable,Frequently Overlooked
• Acute respiratory tract infection causedby Bordetella pertussis (gram-negative aerobic bacillus)1
• Highly communicable (90%-100%secondary attack rate among susceptibles)2,3
• Morbidity in all ages, especially infants1,2
• The cause of 13%-17% of cases of prolonged cough in adolescents and adults4
• Adolescents, adults with unrecognized or untreated pertussis contribute to the reservoir of B pertussis in the community and pose a risk of transmission to others1
References: 1. Centers for Disease Control and Prevention (CDC). MMWR. 2005;55(RR-14):1-16. 2. CDC. MMWR. 2006;55(RR-17):1-37. 3. Long SS: Pertussis (Bordetella pertussis and Bordetella parapartussis.) In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds, Nelson Textbook of Pediatrics. 18th edition. Philadelphia, PA: Saunders Elsevier;2007:1178-1182. 4. Cherry JD. Pediatrics. 2005;115(5):1422-1427.
Eye of S
cience /Photo R
esearchers, Inc.
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Reported Cases of Pertussis Are Highestin Adolescents and Adults …
• ~10,000-25,000 cases of pertussisare reported in the US every year1
• ~60% of reported cases occuramong adolescents and adults2
• Reported cases are the tip ofthe iceberg
– Estimated actual cases amongadolescents and adults:800,000-3.3 million per year3
References: 1. CDC. (Published July 9, 2009 for 2007). MMWR. 2007;56(53):1-94. 2. CDC. Data on file (Pertussis Surveillance Reports), 2003-2008. MKT 17595 (2003-2006); MKT18596 (2007); MKT 18761 (2008). 3. Cherry JD. Pediatrics. 2005;115(5):1422-1427. 4. CDC. MMWR. 2005;55(RR-14):1-16.
“Despite increasing awareness and recognition of pertussis as a diseasethat affects adolescents and adults, pertussis is overlooked in thedifferential diagnosis of cough illness in this population.”4
Courtesy of the Centers for Disease Control and Prevention (CDC).
152Wright, 2014
The Very Young are Very Vulnerable to Complications of Pertussis
AgeNo. with
pertussisa Hospitalization Pneumonia Seizures Encephalopathy Death
<6 months 7203 4543 847 103 15 56
6-11 months 1073 301 92 7 1 1
1-4 years 3137 324 168 36 3 1
References: 1. CDC. MMWR. 2002;51(4):73-76. 2. CDC. MMWR. 2005;54(RR-14):1-16.
a Individuals with pertussis may have had 1 or more of the listed complications. Data are for 1997-2000.
“Unvaccinated or incompletely vaccinated infants aged <12 months have the highest risk for severe and life-threatening complications and death.”2
Pertussis complications, hospitalizations, and deaths1
153Wright, 2014
• Multicenter study in France, Germany, Canada, US
• Study population: 95 infants ≤6 months of age with lab-confirmed pertussis
• Household members were responsible for 76%-83% of transmission to infants in 44 cases where a source could be identified
Reference: 1. Wendelboe AM, et al. Pediatr Infect Dis J. 2007;26(4):293-299.
Part-timecaretaker2% Grandparent
6%
Friend/Cousin10%
Father18%
Sibling16%
Aunt/Uncle10%
Transmitting Pertussis to InfantsIs a Family Matter1
Mother37%
“Implementation of the ACIP recommendation for adult and adolescent [Tdap] vaccination could substantially reduce the burden of infant pertussis, if high coverage rates among those in contact with young infants can be achieved.”
154Wright, 2014
ACIPa Recommendations for Use of Tdapb in Adults and Adolescents
• All adults 19-64 years of age who have not already received Tdap:1
– Single dose to those who received their last tetanus and diphtheria toxoid (Td) vaccine ≥10 years ago
– Interval as short as 2 years since last Td may be used, especially in settings of higher risk (outbreaks, contact with infants) (CHANGED)
• All adolescents 11-18 years of age2
– Single dose of Tdap instead of Td
– Preferred timing is 11-12 years of agea ACIP = Advisory Committee on Immunization Practices. b Tdap = Tetanus, diphtheria, and acellular pertussis vaccine.
Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37. 2. CDC. MMWR. 2006;55(RR-3):1-43. 155Wright, 2014
October 2010 – ACIP Recommendations
• Tdap – for those over 65 years of age who have not received Tdap previously, those desiring Tdap, or those who to be in contact with infants– Ideally, 2 weeks before contact
• Interval has been removed for time between Td and Tdap
• Also – Tdap may now be given (off-label) to individuals 7 years of age (as a catch up) for children not immunized
156Wright, 2014
The ACIP Recommends:Build a Cocoon of Protection Around Infants1
• Tdap is recommended for all adultswho have or anticipate havingclose contact with infants <12 months of age
• Parents, grandparents (<65 years of age), child-care providers, health-care personnel
• All should receive Tdap at least 2 weeks before beginning contact with the infant
Reference: 1. CDC. MMWR. 2006;55(RR-17):1-37.
157Wright, 2014
ACIP Recommendations: Tdap for Mothers
• Women are encouraged to receive a single dose of Tdap before conception if they have not already received Tdap1
– Maternal antibody affords only limited (<2 months) protection for the infant2,3
• For mothers who have not already received Tdap, Tdap is recommended “as soon as feasible” in the immediate postpartum period1
– Vaccination should occur before discharge from the hospital or birthing center
References: 1. CDC. MMWR. 2008;57(RR-4):1-56. 2. Healy CM, et al. J Infect Dis. 2004;190(2):335-340. 3. Shakib JH, et al. J Perinatol. 2010;30(2):93-97. 158Wright, 2014
New 2013
• Tdap with each pregnancy
• Tdap may be administered any time during pregnancy, but vaccination during the third trimester would provide the highest concentration of maternal antibodies to be transferred closer to birth
• Regardless of interval and previous vaccination with Tdap
Wright, 2014 159
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a4.htm accessed 05-01-2013
Tdap Issue Remaining
• What to do with individuals who have received Tdap and are in need of another Td vs. Tdap
• Tdap revaccination (June 2013) – Meeting agenda for June 2013– Decided NOT to universally recommend for
all, other than pregnant women
Wright, 2014 160
Diagnostic Tests for Pertussis
NP culture on special media (Regan-Lowe, Bordet-Gengou)
PCR Serologic tests Increased WBC
with an absolute lymphocytosis
DFA—variable sensitivity/specificity
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161Wright, 2014
Treatment of Cases and Chemoprophylaxis of Close
Contacts Erythromycin estolate or erythromycin ethylsuccinate
(EES) 40-50 mg/kg/day (max 2 g/day) in 2-4 divided doses for 7-14 days1*
Azithromycin 10-12 mg/kg/day (max 500mg/day) 1 dose/day for 5 days†
Clarithromycin 15-20 mg/kg/day (max 1g/day) in 2 divided doses for 7 days
Reference:1. Halperin SA. Pertussis Control in Canada [letter]. CMAJ. 2003;168(11):1389-1390.
* Use caution when using macrolides, especially erythromycin, in infants less than 2 weeks old. † Azithromycin may be given as 10-12 mg/kg/day (max 500 mg/day) on day 1 and 5 mg/kg/day (max 250 mg/day) on days 2-5.
162Wright, 2014
Treatment of Cases and Chemoprophylaxis of Close Contacts (cont’d)
• For patients allergic to macrolides:
– Trimethoprim-sulfamethoxazole 8mg TMP/40mg SMX/kg/day (max 320mg TMP/1600mg/day) in 2 divided doses for 14 days1
• All of these agents reduce transmission of B pertussis and ameliorate early symptoms2
• No antibiotic lessens the severity or shortens the duration of cough in patients who are already experiencing paroxysmal episodes1
• Penicillins/cephalosporins are not effectiveReferences:1. Edwards KM, et al. In: Plotkin SA, et al, eds. Vaccines. 1999:293-344. 2. CDC. The Pink Book, 7th ed. 2002:75-88. Available at: www.cdc.gov/nip/publications/pink/pert.pdf. Accessed March 15, 2005. 163Wright, 2014
Websites with Vaccine Information
• www.pertussis.com• www.cdc.gov/nip/vacsafe• www.cispimmunize.org• www.vaccine.chop.edu• www.vaccineprotection.com
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Stridor
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Stridor
• Few conditions in pediatrics are as emergent and potentially life threatening as an upper airway obstruction
• Rapid identification and treatment is essential
166Wright, 2014
Differential Diagnosis for Stridor
• Differential– Laryngotracheobronchitis (croup)– Mechanical obstruction (birth)– Foreign body aspiration– Peritonsillar abscess– Epiglottitis– Angioedema
167Wright, 2014
Croup• Causes:
– Usually caused by a virus– RSV, Parainfluenza or Rhinovirus
• Characteristics: – Inflammation and edema of the pharynx and
upper airways– Narrowing of the subglottic region– + laryngospasm is frequently seen
168Wright, 2014
Croup
Subglottic narrowing169Wright, 2014
Croup• Presentation:
– Mild URI symptoms x 24 – 48 hours• Rhinorrhea, cough, low grade fever, sore
throat
– Followed by a sudden onset of:• Croupy cough, hoarseness of the voice and
stridor
– Stridor usually begins when the child awakens suddenly from a nap or during the night with a fever
170Wright, 2014
Croup• Presentation:
– May have wheezing on auscultation– Suprasternal and subcostal retractions are most
common– Tachycardia and tachypnea are frequently
present– Hypoxemia may occur– Severity and course varies significantly but
illness usually lasts about 3 days – 1 week
171Wright, 2014
Croup• Treatment:
– Exposure to a cool night; child often improves on the way to the ED
– Humidification or mist may be helpful– Aerosolized racemic epinephrine can be helpful
• Very short acting agent delivered via nebulizer
– Nebulizer with albuterol or beta 2 agonist may offer some benefit
– Inhaled corticosteroids/prednisone is frequently beneficial
172Wright, 2014
Treatment
• Symptomatic treatment is the most common treatment– Increased fluids
– Cool mist vaporizer to thin the secretions
– Tilting the child’s mattress up may be beneficial
• Antibiotics are not helpful173Wright, 2014
Severe Croup
• Airway management may be essential
• Possibilities includes tracheostomy vs. intubation depending upon severity– Rarely done any longer although may be
needed if child is severe
174Wright, 2014
Pneumonia• Definition: Acute infection of the lung
parenchyma• Can occur as a result of:
– Aspiration– Viruses– Bacteria
• Children < than 4 years– Consider: RSV and parainfluenza– Consider S. pneumoniae and H. influenzae
175Wright, 2014
Pneumonia
• Children > 5 years – Mycoplasma, S. pneumoniae, Chlamydia
pneumoniae
• Physical Examination– Vital signs– Respiratory distress– Auscultate lungs (egophony, bronchophony)– Palpate for tactile fremitus
176Wright, 2014
Pneumonia
• Diagnostic– Chest Xray is recommended for all
suspected cases of pneumonia
177Wright, 2014
Treatment of CAP• < 5 years of age
– Presumed bacterial pneumonia• Amoxicillin (90 mg/kg/day) in two divided doses OR
• Amoxicillin/clavulanate (90mg/kg/day) in two divided doses
– Presumed atypical pneumonia• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on
days 2-5)
• Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR
• Erythromycin (40 mg/kg/day) in four divided doses
Wright, 2014 178http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 05-01-2013
Treatment of CAP• > 5 years of age
– Presumed bacterial pneumonia• Amoxicillin (90 mg/kg/day) in two divided doses OR• Amoxicillin/clavulanate (90mg/kg/day) in two divided doses • Consider adding macrolide is unclear etiology
– Presumed atypical pneumonia• Azithromycin (10 mg/kg on day followed by 5 mg/kg/day on days 2-5)• Clarithromycin (15mg/kg/day) in two divided doses x 7-14 days OR• Doxycycline for children > 7 – 8 years of age
Wright, 2014 179http://cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full.pdf accessed 05-01-2013
Chest Pain
• Chest pain in children and adolescents rarely has a cardiac etiology
• Most frequent causes– Musculoskeletal injury vs. overuse– Gastrointestinal (i.e. reflux)– Lung/pleural etiology– Psychogenic causes
180Wright, 2014
Cause of Chest Pain in Children• Precordial Catch – (Texidor’s twinge)
– Most common cause of chest pain– An innocent cause of chest pain
• Very typical history:– Sporadic (entirely random)– LSB (always same place)– Quality – sharp– Radiation: fingerpoint– Mild – severe– Lasts < 2 minutes– Respirations make it worse!!
181Wright, 2014
Cardiac Causes of Chest Pain
• Congenital heart conditions i.e. cardiomyopathies
• Arrhythmias must also be considered
• Pericarditis vs. myocarditis must also be considered
• Important:– Comprehensive history and physical
examination
182Wright, 2014
Murmurs
• Innocent murmurs will be heard in up to 50% of school aged children
• Goal to make sure that you do not miss a serious cardiac anomaly
• Important questions:– Any sob with exercise?– Any dizziness or syncope with exercise?– Any family history of sudden cardiac death?
183Wright, 2014
Characteristics of Benign Murmurs
• No radiation
• Systolic
• Grade < III
• Does not interfere with S1 and S2
• Decreases with sitting or standing
• Equal femoral and radial pulses
• Normal PMI
• Normal history and physical examination184Wright, 2014
Characteristics of Pathologic Murmurs
• Radiation
• Diastolic
• Grade > IV
• Interferes with S1 and/or S2
• Increases with sitting or standing
• Unequal femoral and/or radial pulses
• Displaced PMI
• Abnormal history185Wright, 2014
Work – up for Pathologic Murmur
• Cardiac consultation
• Echocardiogram
• If HCM is suspected, must deny sports participation pending additional work-up– Increases with standing– Systolic in nature– Often accompanied by shortness of breath
with exercise
186Wright, 2014
GI/GU
187Wright, 2014
Acute vs. Chronic Abdominal Pain
• Acute gastroenteritis – number one cause of acute abdominal pain in children
• Other causes of acute pain:– RLL and LLL pneumonia, constipation,
UTI, appendicitis, mittelschmerz, ectopic pregnancy and ovarian cysts
188Wright, 2014
Causes of Chronic or Recurrent Pain
• Constipation
• Musculoskeletal pain
• Lactose intolerance vs. celiac disease
• Colitis vs. Crohn’s
• IBS
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Diarrhea
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Statistics
• Common complaint worldwide– Millions of individuals develop diarrhea every year
• Young and old individuals at increased risk from this condition– Increased risk of dehydration– Increased risk of death
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Pathophysiology
• 4 basic mechanisms causing diarrhea– Retention of water within the intestine
• Malabsorptive syndrome; lactose intolerance• Maalox can produce diarrhea through this mechanism
– Excessive secretion of water and electrolytes into the intestinal lumen
• Cholera; E. Coli, Crohn’s disease, laxatives
– Release of protein and fluid into the intestinal mucosa• Ulcerative colitis, Crohn’s disease, Infections
– Altered intestinal motility resulting in rapid transport through the colon
• IBS, Scleroderma
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193
Acute Diarrhea
• Cause: most likely to be an infectious agent– Most will resolve on own– If diarrhea persists for 72 hours or more, is
associated with gross blood in stool, evaluation is essential
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194
History
• Any other family/friends ill?
• Any recent trips/camping?
• Food intake?– Any nonpasturized ciders?– Any beef?– Uncooked meats?– Mayonnaise?
• Medications?
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Symptoms• Sudden onset• Frequent bowel movements• Loose, watery stools• Bloody stools• Abdominal cramping• Thirst• Decreased urination• Dizziness• Fatigue
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Physical Examination
• Generally unremarkable• Tachycardia• Poor turgor• Orthostatic signs• Hyperactive bowel sounds (borborygmi)• Tender abdomen• Heme positive stool, possibly (E. Coli)• Fecal impaction
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Acute Gastroenteritis
• Symptoms– Abdominal pain described as colicky, diffuse,
crampy– May have vomiting– Headache– Fever and chills– Profuse diarrhea often helps to differentiate it from
appendicitis• Please remember that 15% of children with an
appendicitis will have significant diarrheaWright, 2014
198
Gastroenteritis
• Signs– Temperature
– Diffuse tenderness
– No obturator, psoas or markle’s sign
– Dehydration• No urination or tears in 8 hours constitutes
dehydration in children
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Gastroenteritis
• Diagnosis– History and physical examination– Fecal leukocytes
• Salmonella, Shigella, Amoeba and Campylobacter all invade the intestinal mucosa and therefore cause leukocytes
• Inflammatory bowel disease (Colitis, Crohn’s)• E. coli, viral etiologies do not generally produce
these cells
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200
Gastroenteritis
• Stools for O&P– Entamoeba histolytica– Giardia lamblia
• Stools for C&S– Salmonella or Shigella– Need to request specific tests for E. Coli, Yersinia,
and Campylobacter
• C. difficile– Previous antibiotic therapy
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Gastroenteritis
• Treatment– Fluids– BRATT diet
• Avoid lactose
– Antibiotics• Depending upon the pathology-antibiotic regimen varies
– IV rehydration– Hospitalization– Anti-motility agents (controversial)
Wright, 2014
Constipation
• Normal frequency of BM’s: 3 / day – 3 per week
• Focus is shifting more toward comfort with BM’s rather than number
• Most common GI complaint in the US
• Always ask regarding following:– Weight loss, blood in stool, abdominal pain,
anorexia, vomiting, anemia
202Wright, 2014
Constipation
• Options for treatment–Fiber intake
–Polyethylene glycol (Miralax)
–Lactulose
–Milk of Magnesia
–Behavioral modification
203Wright, 2014
Don...
Don is a 17yowm who presents with an 2 day history of worsening abdominal pain. Woke him from sleep today. Epigastric at onset. Now seems lower in right side of abdomen. Associated with nausea and vomiting for the past 2 hours and a temp of 100. Denies bowel changes, urinary symptoms.
Meds: none; Allergies: NKDA
What is going on with Don?204Wright, 2014
Appendicitis
• Inflammation/Infection of the Appendix– Can lead to ischemia and perforation of the
appendix
• Etiology– Most common age: 10-19 years– Incidence: 1.1/1000 Persons each year– Males>females– Whites>Nonwhites– Summer-most common time of year– Midwest-highest incidence 205Wright, 2014
Appendicitis
• Mortality and morbidity rates remain high
• Perforation rates: 17-40%– Perforation has been known to occur within
1st 24-48 hours of the infection
206Wright, 2014
History of a patient with appendicitis
• Careful history is the most important aspect– Individual is usually a teen or young adult
• Classic presentation: awakens in the night with vague periumbilical pain
• Worsens over the period of 4 hours• Subsides as it migrates to the RLQ• Worsened with movement, deep respirations,
coughing207Wright, 2014
Clinical Pearl
The presence of pain before vomiting is highly suggestive of
appendicitis.
Diarrhea before pain is more likely to be gastroenteritis.
208Wright, 2014
Physical Examination
• Abdominal Examination– Tenderness at McBurney’s point
• 1/3 the distance between the anterior iliac spine and the umbilicus
– Guarding• Contraction of the abdominal walls• Frequently present
209Wright, 2014
Physical Examination
• Rigidity– Important predictor of appendicitis
– Involuntary spasm of the abdominal musculature
– Caused by peritoneal inflammation
• Markle’s sign– Heel-drop jarring test
210Wright, 2014
Physical Examination• Rebound tenderness
– Press on area above the pain– Suddenly withdraw fingers
• Rovsing’s Sign– Pain felt in RLQ when examiner presses firmly in
the LLQ and suddenly withdraws
• Psoas Sign– Patient is placed in a supine position– Ask patient to life thigh against your hand that you
have placed above the knee 211Wright, 2014
Physical Examination
• Obturator Sign– May be or may not be positive– Patient is positioned in supine position with the
right hip and knee flexed– Internally rotate the right leg
• Internal Examination– Consideration to an ovarian cyst
• Rectal Examination– May be considered
212Wright, 2014
Laboratory/Radiologic Testing
• CBC with differential– Normal wbc count doesn’t rule-out the diagnosis– White blood cell count may actually decrease– Look for wbc left shift
• Elevated wbc• Elevated neutrophils• Elevated bands
213Wright, 2014
Laboratory/Radiologic Testing
• Urinalysis
• CT Scan vs. Ultrasound – Emerging evidence that US may be as effective
as CT scan for individuals with appendicitis– Many hospitals are moving to US first approach
to reduce radiation exposure
214Wright, 2014
http://www.sciencedaily.com/releases/2013/12/131202171811.htm accessed 05-01-2014
UTI
• Gram negative bacilli are the most common pathogens (Escherichia coli)
• Staphylococcus saprophyticus – more likely in young, sexually active women
• Preschoolers and young children will likely present with symptoms similar to an adult– Dysuria, urgency, frequency
• Must r/o or consider pyelonephritis
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UTI• Urinary dipstick findings
– Leukocytes– Nitrites– RBC’s
• Treatment– Trimethoprim/sulfamethoxazole (8 – 10 mg/day of
trimethoprim – Cefixime (Suprax) in children > 6 years– Cefpodixime (Vantin)– Treatment: 7 days – 10 days
216Wright, 2014
Enuresis• Definition: involuntary urination at night after 5
years of age in girls and 6 years of age in boys– Small percentage have diurnal enuresis
• Differentials (particularly if dry in past)– Urinary tract infection– Emotional issues (divorce, new baby)– Type 1 diabetes– Neurologic abnormalities– Constipation
217Wright, 2014
Enuresis
• Treatment Options– Desmopressin (DDAVP )(Nasal spray no
longer approved for this indication)– Tricyclic antidepressants (caution advised)– Bed wetting alarm– Bladder training– Constipation treatments
218Wright, 2014
School Physical Examination
• Help to maintain the health and safety of the young athlete by...– Detecting conditions that may predispose to
injury (obesity, recurrent ankle sprains)– Detect conditions that may be life threatening
(hypertrophic cardiomyopathy)
• Goal to not to exclude an individual from sport’s participation– But…to find any problems that might worsen
with particular activities
219Wright, 2014
Millions of Young Athletes
• Millions of young athletes are involved in a variety of activities
220Wright, 2014
Goals of the Preparticipation Physical Examination
• Pre-participation physical is also not a substitute for routine primary care
–However, the preparticipation physical examination is the only contact with a health care provider for 78% of all athletes
221Wright, 2014
Kids Just Want to Have Some Fun!!
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223
Frequency
• AAP recommends examinations every 2 years
• Many schools have different recommendations
http://www.emedicine.com/sports/TOPIC156.HTM#section~TimingFrequencyandTypesofEvaluations accessed 02-10-2010 Wright, 2014
Preparticipation Physical Examination
• Guidelines issued by AHA, AAFP and AAP
• Standardized forms recommended to include history and physical examination
• Biggest concern– Cardiac pathology
• Most common abnormality– Orthopedic abnormality
224
http://pedsinreview.aappublications.org/cgi/content/extract/22/6/199 accessed 02-10-2010
Wright, 2014
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Sprains/strains• Most frequently encountered in children:
– Ankles – number 1– Fingers– Knees
• Differentiation between various grades – First degree: minimal pain, joint stable– Second degree: severe pain, minimal joint
instability– Third degree: severe pain and complete instability
226
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.Wright, 2014
Treatment of Ankle Sprains
• Grade I: ice, elevation, NSAIDs, ankle brace, weight bearing may begin immediately. D/C brace in 1 month.
• Grade II: ice, elevation, NSAIDs, ankle brace, no weight bearing x 7 days
• Grade III: walking cast x 3 – 4 weeks, PT, ankle brace
227
Skinner, H.B. 3rd ed. Current Diagnosis & Treatment in Orthopedics. 2003. NY, NY: The McGraw-Hill Companies.
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Fractures
• Most common in children:– Fingers, toes, distal radius, clavicle, ankle
• Assessment– Capillary refill– Surrounding skin– Sensation
• Treatment– Stabilization, elevation, ice– Casting
228Wright, 2014
Chondromalacia Patella
• Occurs mainly in adults but can occur in adolescents
• Pain occurs when climbing stairs or going from a squatting position to standing
• Diagnosis:
– Consider knee films to r/o subluxation of the patella
229Wright, 2014
Treatment of Chondromalacia Patella
• Decrease activities which require full flexion of the knee and stress on the patellofemoral joint
• RICE
• Quad muscle strengthening
• Physical therapy may be helpful
• Consider orthotics if needed
• NSAIDs as needed230Wright, 2014
Osgood Schlatter Disease• Most common in later childhood and early
adolescence
• Painful swelling and tenderness of the tibial tuberosity
• Treatment:– Decrease quad loading and bending– RICE treatment protocol– Quad and hamstring stretching– NSAID as needed
231Wright, 2014
Neurologic Conditions
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Headache
• Headaches are common in childhood and adolescence
• Primary headaches account for 90+% of all headaches:– Migraine– Tension– Cluster
233Wright, 2014
Headache• Indications for Headache Work-up
–Systemic symptoms–Neurologic signs and symptoms–Onset–Older (< 5 or > 50)–Previous headache
Dodick DW. Adv Stud Med. 2003;3:87-92.
234Wright, 2014
Treatment for Headaches
• Tension:– NSAID or acetaminophen– Rest and heat
• Migraine– NSAID or acetaminophen– Trigger Avoidance– Triptan (rizatriptan and almotriptan approved
in children)– Preventative therapies, as indicated
235Wright, 2014
Syncope
• Syncope: sudden loss of consciousness with spontaneous recovery
• Majority of syncopal episodes in children are benign however, must consider the following– Seizure activity– Cardiac malformations/pathology
236http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2014
Syncope
237http://www.aafp.org/afp/20050601/tips/13.html accessed 08-22-2008Wright, 2014
Concussion Guidelines
Wright, 2014 238
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
What Is A Concussion?• A concussion is a disturbance in brain function caused by a
direct or indirect force to the head• Results in a variety of non-specific signs and / or symptoms
and most often does not involve loss of consciousness• Should be suspected in the presence of any one or more
of the following:– Symptoms (e.g., headache), or– Physical signs (e.g., unsteadiness), or– Impaired brain function (e.g. confusion) or– Abnormal behavior (e.g., change in personality)
Wright, 2014 239
http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
Concussions
• Confusion and amnesia will occur immediately after event
• Often accompanied by headache, dizziness, nausea and/or vomiting
• Symptoms following a concussion may last up to 3 months or longer
• Concussions are more likely to occur within 10 days of a previous concussion
240Wright, 2014
http://www.aan.com/globals/axon/assets/10722.pdf access 05-18-2013
241
Concussion
Wright, 2014
http://knowconcussion.org/wp-content/uploads/2011/06/graded_symptom_checklist.pdf accessed 05-19-2013
Administer prior to season; administer immediately after injury.Return to play when symptoms are consistent with baseline score
Return to Play
Wright, 2014 242
http://bjsm.bmj.com/content/47/5/259.full.pdf accessed 05-18-2013
This tool is not used alone but provides guidance for return to playShould NOT be returned to play on day of concussion
Dermatologic Conditions
243Wright, 2014
Abscess
• Definition: –Collection of pus in the cutaneous tissue
which results in a painful, erythematous, fluctuant mass
• Most common locations–Inguinal region, neck or back, axillary
region, vaginal
244Wright, 2014
Cutaneous Abscesses• Pathogens
– Methicillin sensitive staphylococcus aureus– Methicillin resistant staphylococcus aureus
• Treatment– Incision and drainage is the treatment of choice– Many recommend wound culture– Antibiotics may be utilized but are not as
effective as I&D– Warm soaks/compresses
245Wright, 2014
Verruca Vulgaris
• Common warts
• Benign lesions of the epidermis caused by a virus
• Transmitted by touch and commonly appear at sites of trauma, on the hands, around the periungual regions from nail biting and on the plantar surfaces of the feet
246Wright, 2014
Verruca Vulgaris
• Appearance– Smooth, flesh colored papules which
evolve into a dome-shaped growth with black dots on the surface
– Black dots are thrombosed capillaries and can be visualized with a 15 blade
247Wright, 2014
Verruca Vulgaris
248Wright, 2014
Verruca Vulgaris• Treatment
– OTC product: salicylic acid topical (Compound W) or similar– OTC cryosurgery kit– Liquid nitrogen– Duct tape– Cryosurgery in office– Cimetidine
• Immunomodulatory effects at high dosages; effects varied– Imiquimod– Tretinoin type products– Electrocautery– Blunt dissection (plantar lesions)
249Wright, 2014
Urticaria
• Etiology– Referred to as wheals or hives– Causes: Foods, soaps, inhaled substances– 20% of the population will have at least one
episode– 2 types: Acute and Chronic
• Acute is most common - lasting days to weeks (Cause is most often identified)
• Chronic: Lasts more than 6 weeks (Cause is rarely identified)
250Wright, 2014
Urticaria• Symptoms
– Hives itch!!!!!
– Red plaques
• Signs– Red lesions which vary in size from 2 - 4 mm
– Blanche with palpation
• Diagnosis– History and physical examination
251Wright, 2014
Urticaria
252Wright, 2014
Urticaria
• Plan–Therapeutic
• Stop medications if possible
• Stop suspected foods or drinks
• Cool compresses
• Antihistamines/H2RA
• Prednisone
253Wright, 2014
Urticaria
• Plan–Educational
• Avoid causes
• Educate regarding possible etiology
• Discuss side effects of antihistamines (sedation)
254Wright, 2014
Impetigo
• Contagious, superficial skin infection• Caused by staphylococci or streptococci
– Staph is the most common cause– Makes entrance through small cut or abrasion– Resides frequently in the nasopharynx
• Spread by contact• More common in children, particularly on the nose,
mouth, limbs– Self-limiting but if untreated may last weeks to months
255Wright, 2014
Impetigo
• Symptoms:– Rash that will not go away
– Begins as a small area and then increases in size
– Yellow, crusted draining lesions
• Physical Examination Findings– Small vesicle that erupts and becomes yellow-brown
– Initially, looks like an inner tube
– Crust appears and if removed, is bright red and inflamed
256Wright, 2014
Impetigo
257Wright, 2014
Impetigo• Physical Examination Findings
– 2-8 cm in size
• Diagnosis– Diagnostic:
• Culture – Today, must absolutely consider MRSA
– Therapeutic:• Mupirocin topical (Bactroban) or retapamulin topical
(Altabax)• 1st generation cephalopsporin vs. TMP/SMX
258Wright, 2014
Impetigo
• Educational–Good handwashing and hygiene
–No school/daycare for 24 - 48 hours
–Wash sheets and pillowcases
–Monitor for serious sequelae
259Wright, 2014
Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of
Methicillin –Resistant Staphylococcus aureus Staphylococcus aureus
Infections in Adults and Children: Executive Summary
Wright, 2014 260
Liu, Catherine et. al. MRSA Treatment Guidelines CID 2011:52 (1 February) 285-292
Treatment for Uncomplicated CA-MRSA
• No significant risk factors for adverse outcomes
• I&D is the treatment of choice
• Antibiotics are not necessary
Wright, 2014 261
Antibiotics Indicated
• Abscesses associated with the following:– Severe or extensive disease– Rapid progression in presence of cellulitis– Signs and symptoms of systemic illness– Associated comorbidities or
immunosuppression– Extremes of age– Abscess in area unable to be drained– Lack of response to I&D alone
Wright, 2014 262
Statistics/Treatment in My Community
• 37% of staph infection at DHMC – MRSA
• Nationally, approximately 31% are MRSA
• CA-MRSA antibiotic susceptibility– 50% will be resistant to clindamycin
• Trimethoprim/sulfamethoxazole (Bactrim) has best coverage/sensitivity: 96-98%– Important for clinicians to obtain own antibiogram
for communities in which you service
Wright, 2014 263
Treatment of CA-MRSA
• Obtain culture
• Should consider local antibiograms in selection of antimicrobials
• Skin infections:– Consider beta-lactam (PCN or Cephalo) in an
individual with mild infection and low rates of CA-MRSA in your community (generally thought of as < 10 – 15%)
Wright, 2014
Guilbeau, J.R. and Fordham, P.N. Evidence-Based management and Treatment of Outpatient Community-Associated MRSA. The Journal for Nurse Practitioners. 2010; Vol 6(2):140-145
264
Treatment of CA - MRSA
• TMP/SMX• Tetracycline (doxycycline or minocycline)• Clindamycin• Linezolid• When CA-MRSA and streptococcus coverage is
needed:– Clindamycin alone or….– TMP/SMX with amoxicillin (or similar)
Wright, 2014 265
Rifampin
• No longer recommended as a single agent or for adjunctive therapy for the treatment of skin and soft tissue infections
Wright, 2014 266
Children
• Simple, uncomplicated impetigo:– Mupirocin 2% topical ointment
• Avoid TCN or similar in children < 8 years of age
Wright, 2014 267
Treatment and Eradication Strategies: Recurrent infections
• GOOD handwashing
• Treatment with TMP/SMX,clinda, TCN, Linezolid
• Bathe with disinfectants– Hibiclens, phisodex, clorox bleach
• Utilize topical disinfectants– Purell– Mupirocin – seeing resistanceWright, 2014 268
Carriage of CA-MRSA• Treatment recommended for individuals with
recurrent infection– Consider ID consult before treatment– Mupirocin 2% each nostril two times daily x 5 – 10 days
along with daily chlorhexidine 4% bath for 5-14 days– Alternative: 1 teaspoon of bleach per gallon of water
(1/4 cup per ¼ tub); 15 minutes two times weekly for 3 months
– Oral antibiotics are not indicated for decolonization
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Bites and Stings• Insect Sting
– Reaction to wasp or yellow-jacket sting can begin within minutes – up to 60 minutes
– Anaphylaxis can occur within minutes in the individual with allergy
• Treatment:– Remove stinger, if present– Oral antihistamine– Ice pack and elevate– Anaphylaxis history: Epi Pen with instructions
270Wright, 2014
Erythema Chronicum Migrans
• Etiology– Caused by a spirochete called Borrelia Borgdorferi– Transmitted by the bite of certain ticks (deer,
white-footed mouse)– 1st cases were in 1975 in Lyme, Connecticut– Occurs in stages and affects many systems– Children more often affected than adults
271Wright, 2014
This is NOT a Lyme Bearing Tick
272Wright, 2014
Lyme Bearing Tick
273Wright, 2014
Erythema Chronicum Migrans• Symptoms
– 3-21 days after bite– Stage 1
• Rash (present in 72-80% of cases)-slightly itchy• Lasts 3-4 weeks• Mild flu like symptoms (50% of time)• Migratory joint pain
– Stage 2• Neurological and cardiac symptoms
– Stage 3• Arthritis, chronic neurological symptoms• Make take years to get to this stage 274Wright, 2014
Erythema Chronicum Migrans• Signs
– Rash: Stage 1 • Begins as a papule at the site of the bite• Flat, blanches with pressure• Expands to form a ring of central clearing• No scaling• Slightly tender
– Arthralgias: Stage 2• Asymmetric joint erythema, warmth, edema• Knee is most common location
275Wright, 2014
Summer 2009
Wright, 2014 276
Erythema Migrans
277Wright, 2014
Erythema Migrans
278Wright, 2014
Erythema Chronicum Migrans
• Signs– Systemic symptoms: Stage 3
• Facial palsy• Meningitis• Carditis
• Diagnosis– R/O Ringworm (Tinea Corporis)
279Wright, 2014
Erythema Chronicum Migrans
• Plan– Diagnostic:
• Sed rate: normal until stage 2• Lyme Titer
– IGM: Appears first: 3-6 weeks after infection begins– IGG: Positive in blood for 16 months– High rate of false negatives early in the disease– Lyme Western Blot
280Wright, 2014
Erythema Chronicum Migrans• Plan
–Therapeutic• Amoxicillin 500mg tid x 21 days• Doxycycline 100 mg 1 po bid x 21 days• If in endemic area and tick is partially engorged, may treat with doxycycline 200 mg x 1 dose with food
281Wright, 2014
Pityriasis Rosea
• Etiology– Common, benign skin eruption– Etiology unknown but believed to be viral– Small epidemics occur at frat houses and military
bases– Females more frequently affected– 75% occur in individuals between 10 and 35; higheset
incidence: adolescents– 2% have a recurrence– Most common during winter months
282Wright, 2014
Pityriasis Rosea
• Symptoms– Rash initially begins as a herald patch– Often mistaken for ringworm– 29% have a recent history of a viral infection– Asymptomatic, salmon colored, slightly itchy rash
• Signs– Prodrome of malaise, sore throat, and fever may precede– Herald patch: 2-10cm oval-round lesion appears first– Most common location is the trunk or proximal extremities
283Wright, 2014
Pityriasis Rosea
284Wright, 2014
Pityriasis Rosea• Signs
– Eruptive phase• Small lesions appear over a period of 1-2 weeks
–Fine, wrinkled scale–Symmetric–Along skin lines–Looks like a drooping pine tree–Few lesions-hundreds–Lesions are longest in horizontal dimension
285Wright, 2014
Pityriasis Rosea
• Signs (continued)
– 7-14 days after the herald patch
– Lesions are on the trunk and proximal extremities
– Can also be on the face
286Wright, 2014
Pityriasis Rosea
• Diagnosis– History and physical examination
• Plan– Diagnostic
• Can do a punch biopsy if etiology uncertain–Pathology is often nondiagnostic–Report: spongiosis and perivascular round cell
infiltrate
• Consider an RPR to rule-out syphilis
287Wright, 2014
Pityriasis Rosea• Plan
– Therapeutic• Antihistamine• Topical steroids• Short course of steroids although, may not respond• Sun exposure• Moisturize
– Educational• Benign condition that will resolve on own
– May take 3 months to completely resolve• No known effects on the pregnant woman• Reassurance
288Wright, 2014
Molluscum Contagiosum
• Infection caused by the pox-virus
• Most commonly seen on the face, trunk and axillae
• Self-limiting
• Spread by auto-inoculation
• Incubation period: 2-7 weeks after exposure
• Contagious until gone
289Wright, 2014
Molluscum Contagiosum• Asymptomatic lumps
• May have 1 - hundreds
• Physical Examination– 2-5mm papule with an umbilicated center– Flesh toned - white in color– Most often around the eye in children– Scaling and erythema around the periphery of
the lesion is not unusual– If in the genital area of a child-should consider
sexual abuse290Wright, 2014
Molluscum Contagiosum
291Wright, 2014
Molluscum Contagiosum• Plan
– Diagnostic: None or KOH prep looking for inclusion bodies
– Therapeutic: Conservative treatment is the best for children• Curettage• Cryosurgery• Tretinoin• Salicylic Acid (Occlusal)• Laser• TCA 292Wright, 2014
Molluscum Contagiosum
• Plan– Educational
• May resolve on own in 6 - 9 months• Contagious until lesions are gone• Benign• Recurrence very common
293Wright, 2014
Scabies• Etiology
–Contagious disease caused by a mite
–Common among school children
–Adult mite is 1/3 mm long
–Front two pairs of legs bear claw-shaped suckers
294Wright, 2014
Scabies• Etiology
– Infestation begins when a female mite arrives on the skin surface
– Within an hour, it burrows into the stratum corneum
• Lives for 30 days• Eggs are laid at the rate of 2-3 each day• Fecal pellets are deposited in the burrow behind the
advancing female mite• (Scybala)-feces are dark oval masses that are irritating
and often responsible for itching295Wright, 2014
Scabies
• Etiology– Transmitted by direct skin contact with
infested person either through clothing or bed linen
– Eruption generally begins within 4 – 6 weeks after initial contact
– Can live for days in home after leaving skin
296Wright, 2014
Scabies• Symptoms
– Minor itching at first which progresses– Itching is worse at night (this is characteristic of
scabies)
• Signs– Erythematous papules and vesicles– Often on the hands, wrists, extensor surfaces of
the elbows and knees, buttocks– Burrows are often present; May see a black dot
at the end of the burrow– Infants: wide spread involvement
297Wright, 2014
Scabies
298Wright, 2014
Scabies
•
299Wright, 2014
Scabies
• Diagnosis–Scraping to look for mite, eggs or
feces
• Plan–Diagnostic: Scraping–Therapeutic
• Permethrin 5% cream
300Wright, 2014
Scabies• Plan
– Therapeutic• Sulfur (6% in petroleum or cold cream qd x 3 days)• Antihistamine
– Educational• Cut nails short• Scratching spreads the mites• Itching can last for weeks• Treat all family members
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Scabies
• Plan–Educational
• Wash all clothing, towels and bed linen
• Do not need to wash carpeting
• Consider animal bathing
• Bag stuffed animals x 1-2 weeks302Wright, 2014
Lice/Pediculosis
• Caused by parasites that are found on the heads of individuals – most often children
• Very common in 3 – 10 year old individuals
• 1 out of 10 children will contract while in school
• Lice/eggs are most commonly located on the scalp behind the ears and near the neckline at the back of the neck
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Treatment
• Treat hair with pediculicide and comb nits daily
• Machine wash all in hot water cycle (130 degrees F or dry clean items
• Put items which can’t be cleaned into a plastic bag and seal it for two weeks
• Soak combs and brushes for one hour in rubbing alcohol or Lysol
• Vacuum the floor and furniture304Wright, 2014
Prescription Lice ProductsBenzyl
alcohol, 5% (Ulesfia)1
Malathion, 0.5%(Ovide)2
Spinosad, 0.9%
(Natroba)3
Ivermectin, 0.5%
(Sklice Lotion)4
Lindane, 1%5
Age indication
≥6 mo Safety not shown <6 y
≥4 y ≥6 mo Use w/caution in those <110
lb
Dosage 4-48 oz(varies with hair length)
2-oz bottles; apply enough to
wet hair and scalp
Up to 120 mL (1 bottle)
depending on hair length
Up to 120 mL ( 4-oz tube)
1-2 oz depending on
hair length and density
Time of application
10 min; repeat
treatmentafter 7 d
8–12 hrs; repeattreatment in 7-9 d if lice
present
10 minutes; repeat
treatment in 7 d if lice present
10 minutes; tube is intended for
single use only; consult HCP
prior to re-treatment
4 min; do not re-treat
References: 1. Ulesfia Prescribing Information. Atlanta, GA: Shionogi Pharma, 2010. 2. Ovide Prescribing Information. Hawthorne, NY: Taro Pharmaceuticals, 2011. 3. Natroba Prescribing Information. Carmel, IN, ParaPRO, 2011. 4. Sklice Lotion Prescribing Information. Swiftwater, PA: Sanofi Pasteur Inc., 2012. 5. Lindane Prescribing Information. Morton Grove, IL: Morton Grove Pharmaceuticals, 2005.
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Keeping Kids in School
• The AAP and National Association of School Nurses state: No healthy child should be allowed to miss school timebecause of head lice1,2
• “No-nit” policies for return to school should be abandoned1,2
• School-based head lice screening programs have not had a significant effect on incidence of head lice in schools and are not cost-effective2
• School nurses in concert with other health-care providers should become involved in helping school districts develop evidence-based policies1
References: 1. Pontius D, Teskey C. Pediculosis management in the school setting, position statement, National Association of School Nurses, 2011. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/40/Pediculosis-Management-in-the-School-Setting-Revised-2011. Accessed July 16, 2012. 2. Frankowski BL, et al. Pediatrics. 2010;126(2):392-403.
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Candidiasis/Tinea Infection
• Infection frequently caused by Candida albicans which invades the epidermis when there is a break in the skin and there is excessive moisture and heat
• Candida always involves the skin folds
• Orally: thrush (Oral candidiasis)– Treatment: Mycelex troches, Nystatin
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Candidiasis/Tinea
• Diaper: satellite lesions with well-defined beefy red rash– Treatment: Nystatin cream
• Tinea Cruris (male inguinal region)– Clotrimazole– Miconazole– Keep clean and dry– Consider treating the tinea pedis
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Atopic Dermatitis
• Etiology
– Most common inflammatory skin disease if childhood– Affects 10-12% of all children– Caused by an inflammation in response to an
allergen, chemical or an unidentified etiology– Often occurs in an individual with a family history of
allergies– 50% of eczematous children will develop allergic
rhinitis, asthma
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Etiology
• High levels of serum IgE are common– Higher the levels of IgE-more severe the case
• Proliferation of T-helper 2 cells; Th-2 cells produce cytokines
• Cytokines cause an inflammatory response in the skin
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Atopic Dermatitis
• Signs– Pruritic, erythematous dry patches
– Cracking and fissuring
– Lichenification (Thickening of the skin)
– Excoriations (Caused by scratching)
– Diffuse borders (different than psoriasis)
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Diagnosis?
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Common Locations
• Infants: scalp, face, and extensors
• Children: neck, flexor folds, feet
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Atopic Dermatitis
• Plan–Diagnostic
• None
–Therapeutic• Lubrication: Most important part
• Perform multiple times daily; particularly after a bath
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Atopic Dermatitis• Therapeutic
• Limit number of baths or showers– Avoid harsh soaps
• Antihistamines: OTC or prescription
• Low potency topical corticosteroids
• Immunomodulator (Elidel or Protopic)
• Avoids soaps, bath gels, bubble baths, shower gels
• Intralesional injections of corticosteroids
• Oral corticosteroidsWright, 2014
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Atopic Dermatitis• Educational
– Explain the chronic nature of this condition– Review medications and why they are utilized– Avoid harsh soaps– Monitor for yellow discharge-often results in
impetigo
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Acne Vulgaris
• Etiology– Disease involving the pilosebaceous unit– Most frequent and intense where sebaceous
glands are the largest– Acne begins when sebum production increases– Propionibacterium acnes proliferates in the sebum– P. acnes is a normal skin resident but can cause
significant inflammatory lesions when trapped in skin
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Diagnosis?
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Acne Vulgaris• Diagnosis
– History and physical examination
• Plan– Diagnostic: None– Therapeutic
• Benzoyl Peroxide• Topical Antibiotics• Oral Antibiotics• Tretinoin• OCPs• Isotretinoin (Accutane)
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Chickenpox (Varicella)
• Highly contagious viral infection• Varicella-zoster virus• Affects most children before puberty• Peak incidence is March-May• Spread via airborne droplets or vesicular fluid• Contagious for 1 - 2 days before rash until lesions
crust• Incubation period-up to 21 days
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Chickenpox (Varicella)
• No prodrome or very mild
• Rash usually begins on the trunk and scalp and then spreads peripherally
• Moderate to intense itching
• Fever: 101-105
• Lesions erupt for 4 days
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Chickenpox (Varicella)
• Physical Examination Findings– Lesions 2-4 mm papule (rose petal)– Thin walled clear vesicle (dew drop)– Vesicle becomes umbilicated within 8-12 hours– Followed by crusts– Lesions are in all stages – hallmark of this
disease
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Chicken Pox
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Chickenpox (Varicella)
• Plan– Diagnosis: None– Therapeutic: Symptomatic Treatment
• NO ASPIRIN• Clip Nails• Caladryl or Benadryl• Antiviral
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Chickenpox (Varicella)
• Plan– Education:
• Call immediately for worsening of symptoms• Contagious until all lesions crust• Caution of pregnant women and others
without immunity• Monitor for secondary complications• Prevention: Varicella vaccine
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Ringworm
• Tinea Corporis– Caused by a fungus / dermatophytes
which lives on the dead layer of the outer skin
– Can also be transmitted to an individual from an animal
– Increased sweating can promote fungal growth
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Tinea Corporis
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Tinea Corporis
• Produces characteristic rash– Pink– Scaly– Round– May be 3 – 5 cm in
size
• Treatment– Antifungal – topical
• Miconazole• Clotrimazole
– Avoid touching as it is very contagious
– No contact sports x 48 hours into treatment
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Herpes Simplex Virus
• HSV 1 and 2
• Spread in 3 manners– Respiratory droplets– Contact with an active lesion– Contact with fluid such as saliva
• 90% of primary infections are asymptomatic
• Symptoms usually occur 3 - 7 days after contact
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Herpes Simplex Virus
• Symptoms
–Tenderness, pain, paresthesia, burning, swollen glands, headache, fever, irritability, decreased appetite, drooling
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Herpes Simplex Virus
• Physical Examination Findings– Grouped vesicles on an erythematous base– Gingivostomatitis: Erythematous, edematous
gingiva that bleed easily with small, yellow ulcerations
• Yellowish-white debris develops on mucosa• Halitosis• Lymphadenopathy
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Herpes Simplex Virus
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Herpetic Gingivostomatitis
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Herpes Simplex Virus• Plan
– Diagnostic• Viral Culture• HSV IgG & IgM serum antibodies• Most accurate: HerpeSelect
– Therapeutic• Antiviral• Pain reliever• Cool rinses• Oragel 334Wright, 2014
Herpes Simplex Virus• Plan
– Educational: • Prevent contact with infected individuals• Discussion regarding asymptomatic shedding• Prevent recurrences• Call for worsening of symptoms (I.e. inability to
drink, no urination x 8 hours)
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Roseola
• Viral infection caused by HHV6 (human herpes virus – 6)
• Most common ages: 3 months – 4 years
• Incubation period: 5 – 15 days
• Fever up to 105 will precede the rash
336http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2014
Roseola
• Fever - up to 3 – 5 days
• The fever falls quickly – usually between day 2 - 4
• Rash will first appear on the trunk and then spreads to the limbs, neck, and face
• Rash lasts from hours to 2 days
• May be associated with a febrile seizure
337http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2014
Roseola
• Treatment–Ibuprofen
–Acetaminophen
–Tepid baths• Cautiously with
fever
338http://www.nlm.nih.gov/medlineplus/ency/article/000968.htm accessed 03-01-2010Wright, 2014
Fifth’s Disease (Erythema Infectiosum)
• Human Parvovirus B19– Occurs in epidemics– Occurs year round: Peak incidence is late winter and early
spring
• Most common in individuals between 5-15years of age– Period of communicability believed to be from exposure to
outbreak of rash– Incubation period: 5-10 days– Can cause harm to pregnant women and individuals who are
immunocompromised
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Fifth’s Disease (Erythema Infectiosum)
• Low grade temp, malaise, sore throat– May occur but are less common
• 3 distinct phases– Facial redness for up to 4 days– Fishnet like rash within 2 days after facial redness– Fever, itching, and petecchiae
• Petecchiae stop abruptly at the wrists and ankles– Hands and feet only
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Fifth’s Disease (Erythema Infectiosum)
• Physical Examination Findings– Low grade temperature– Erythematous cheeks
• Nontender and well-defined borders
– Netlike rash• Erythematous lesions with peripheral white rims• Rash-remits and recurs over 2 week period
– Petecchiae on hands and feet341Wright, 2014
• Fifth’s Disease
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Fifth’s Disease
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Fifth’s Disease (Erythema Infectiosum)
• Diagnosis/Plan– Parvovirus IgM and IgG
– IgM=Miserable and is present in the blood from the onset up to 6 months
– IgG=Gone and is present beginning at day 8 of infection and lasts for a lifetime
– CBC-May show a decreased wbc count
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Fifth’s Disease (Erythema Infectiosum)
• Diagnosis/Plan– Was contagious before rash appeared therefore, no
isolation needed• Spread via respiratory droplets
– Symptomatic treatment– Patient education-I.e. contagion, handwashing– Can cause aplastic crisis in individuals with hemolytic
anemias– Concern regarding: miscarriage, fetal hydrops– Adults: arthralgias
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Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Caused by the coxsackie virus A16 and now…A6• Most common in children• 2-6 day incubation period• Occurs most often in late summer-early fall• Symptoms
– Low grade fever, sore throat, and generalized malaise– Last for 1-2 days and precede the skin lesions– 20% of children will experience lymphadenopathy
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cdc.gov• From November 7, 2011, to February 29, 2012, CDC received reports of 63 persons
with signs and symptoms of HFMD or with fever and atypical rash in Alabama (38 cases), California (seven), Connecticut (one), and Nevada (17).
• Coxsackievirus A6 (CVA6) was detected in 25 (74%) of those 34 patients
• Rash and fever were more severe, and hospitalization was more common than with typical HFMD.
• Signs of HFMD included fever (48 patients [76%]); rash on the hands or feet, or in the mouth (42 [67%]); and rash on the arms or legs (29 [46%]), face (26 [41%]), buttocks (22 [35%]), and trunk (12 [19%])
• Of 46 patients with rash variables reported, the rash typically was maculopapular; vesicles were reported in 32 (70%) patients
• Of the 63 patients, 51 (81%) sought care from a clinician, and 12 (19%) were hospitalized. Reasons for hospitalization varied and included dehydration and/or severe pain
• No deaths were reported
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Hand, Foot, and Mouth Disease – A6
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Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Physical Examination Findings– Oral lesions are usually the first to appear
• 90% will have
– Look like canker sores; yellow ulcers with red halos– Small and not too painful– Within 24 hours, lesions appear on the hands and
feet• 3-7 mm, red, flat, macular lesions that rapidly become
pale, white and oval with a surrounding red halo• Resolve within 7 days 349Wright, 2014
Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Physical Examination Findings–Hand/feet lesions
• As they evolve – may evolve to form small thick gray vesicles on a red base
• May feel like slivers or be itchy
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Hand Foot and Mouth Disease
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Hand Foot and Mouth Disease
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Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Plan–Diagnostic: None–Therapeutic
• Tylenol• Warm baths• Oragel or diphenhydramine/Maalox• Magic mouthwash
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Hand, Foot, and Mouth Disease(Coxsackie Virus)
• Plan– Educational
• Very contagious (2d before -2 days after eruption begins)
• Entire illness usually lasts from 2 days – 1 week• Reassurance• No scarring
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Kawasaki Disease• Characterized by an systemic vasculitis
throughout the body• Seventy five percent of patients are under
five years old• It is more common in boys than girls• Majority of cases occur in the winter and
early spring• Believed to be viral in etiology and is not
contagious355
http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014
Kawasaki Disease• Diagnosis is based on clinical criteria by the
American Heart Association: – fever for 5 or more days (102 – 104)– a polymorphous exanthem – nonpurulent conjunctivitis– changes in the mucosa of the lips / oral cavity– redness or edema with later desquamation of the
extremities– at least one cervical lymph node > 1.5 cm in
diameter356
http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014
Kawasaki Disease
• Coronary artery aneurysms develop in 15% to 25% of untreated children
• May lead to ischemic heart disease or
sudden death
• Treatment– IV immunoglobulin– Aspirin– Echocardiography and cardiac consult
357http://circ.ahajournals.org/cgi/content/full/110/17/2747 accessed 03-01-2010Wright, 2014
358
Thank you for your time and attention!
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www.4healtheducation.com
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