Pedi̇atri̇k vakalar(fazlası için )

Pediyatrik Vakalar

My stomach hurts

5 year old with vomiting and diarrhea– Arrives because of persistent fever– In general pain actually improved a couple of days ago– Looks very good. Watching TV (the advantage of

having a new ED). In no distress– Abdominal diffusely and nonfocally tender– Ultrasound done to exclude appendicitis because

pediatrician wanted one.– WBC normal

Ultrasound negative– Patient discharged with diagnosis of gastroenteritis

Pediatric Appendicitis

• Lifetime risk 7%• Misdiagnosis is common

in young children– 100% around age 2– 70% ages 3-5– 40% ages 6-10

• Post-op complication from perforation increase from 8% to 39%

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Why is appendicitis missed

Most common misdiagnosis is

GASTROENTERITIS

Up to 33% of kids under age 3 have “diarrhea”

• 40% of missed appy is called gastroenteritis

• Pay CLOSE attention to exam. Gastro tenderness is diffuse, not localized.

• BEWARE: Kids under 5 are less likely to wall off their appendix and more likely to present with diffuse peritonitis

• CAREFUL physicians should not miss these

Diagnosis

• Clinical judgment• Labs• Plain Xray• Ultrasound• CT scan

Even in the best of hands the rate of normal appendix on operation in “classic” cases is over 10%. It is higher in more equivocal cases

Up to 20% in pregnancy

Diagnosis

• Clinical judgment• Labs• Plain Xray• Ultrasound• CT scan

The peripheral WBC is of extremely limited use– Children with VERY

common viral gastroenteritis or bacterial gastro often have high WBC counts

– Children with early appendicitis are OFTEN normal

Diagnosis

• Clinical judgment• Labs• Plain X-ray• Ultrasound• CT scan

• Plain abdominal Xrays are useless– Obtained because often

other diagnostic tests are unavailable

– This does not make them any better

• Not sensitive or specific

• Do not discriminate• Fecalith is unreliable

Diagnosis

Ultrasound

• Limited radiation• Relatively sensitive

– VERY dependent on the skills of radiologist

– Up to 80% helpful with good reader

• Does NOT exclude appendicitis

CT Scan

• More radiation• Expensive• Often unavailable• Extremely sensitive

– Less operator dependent

– Up to 95% sensitive• Excludes appendicitis if

normal appendix seen– Avoids operation

What about our girlCame back 3 days later with perforated

appendicitis

• She was likely perforated on initial evaluation

• She felt better when appendix ruptured a couple days earlier

• Illustrates several pitfalls

• Often misdiagnosed as gastroenteritis

• Often has diarrhea• Often has normal WBC• Often has nonfocal exam• Ultrasound limited in

EXCLUDING appendicitis

Pediatric hip pain• Septic arthritis• Toxic synovitis• Legg-Calve-Perthes• Aseptic necrosis• SCFE (Slipped

Subcapital Femoral Epiphysis)



Septic hip vs toxic synovitisThis is the REAL question

Septic Arthritis

• Average age 3-5 years• Time to presentation

– 4+ days• May be afebrile

– But most have low grade temperature

• May not look clinically ill if early

Toxic Synovitis

• Average age 3-4 years• Time to presentation

– 5+ days• May be very febrile

– But most do not have a temperature

• May be extremely uncomfortable and refuse any range of motion

Septic hip vs toxic synovitisGoal to identify EARLY before extensive

damage

Temperature and ESR are helpful in excluding septic hip– Most kids (66%) with septic

arthritis with temperature over 37.5 °C

– Most kids (80%) with septic arthritis with ESR over 20

– Combination picks up over 90% of sepsis

Septic hip vs toxic synovitis

Problem with using temp and ESR– Up to 50% of kids with

toxic synovitis have temperature OR a high ESR

Step two: Imaging– Plain films– Ultrasound



Septic hip vs toxic synovitisLooking for fluid

Plain films• Insensitive & will only

show advanced cases with a lot of fluid

Ultrasound• Sensitive and will find

show small amounts of fluid seen in synovitis

Septic hip vs toxic synovitisTapping the hip

Up to now the evaluation has been working towards EXCLUDING cases of toxic synovitis.

If there is a temperature or high ESR and fluid in the hip, you must do a diagnostic arthrocentesis– In the US this is an orthopedic procedure– There is some time urgency here– Diagnosis of septic hip should be washing out in the

operating room– Antibiotics for staph and strep should be considered

if ANY delays in operation or arthrocentesis are possible

Toxic synovitisAfter discharge

Toxic synovitis is a viral reactive arthritis and is managed with ibuprofen or aspirin

BUT…all cases require MANDATORY 12-24 hour follow to make SURE you are not missing septic arthritis

Other causes hip painLegg-Calve-Perthes

Idiopathic avascular necrosis of the femoral head– Other cases related to

chronic steroid use or sickle cell disease

School age children

Early cases with normal Xray– Need MRI or bone scan

Slipped Capital Femoral Epiphysis

Slipped growth plate at end of femoral head

Adolescents

Generally (not always) obese

Early cases with normal Xray– Need MRI or bone scan


Slipped growth plate at end of femoral head

Adolescents

Generally (not always) obese

Early cases with nothing on Xray– Need MRI or bone scan

Klein’s line ?


Price of a missed case– Complete slip– Disrupted growth plate– Lost growth potential– Avascular necrosis of

femoral hip– Chronic arthritis and DJD or

hip

Early pickups allow placement of a pin and potential recovery

The toxic neonateThat kid looks BAD!

Some illnesses present in the first two weeks of life with an abrupt deterioration

A good clinician will understand that this is NOT always sepsis



The toxic neonateThat kid looks BAD!

Important possibilities

• Sepsis• Congenital Cardiac

– Ductal dependent

• Inborn error of metabolism

• Congential adrenal hyperplasia– Boys



The toxic neonateCritical issues

• Stabilization– Rapid IV access– Adequate fluid

resuscitation– ETT and pressors?

• Ampicillin/Gentamicin– Listeria– E coli– Group B strep



– Ductal dependent

• Inborn error of metabolism

• Congential adrenal hyperplasia– Boys


• Recognition• Stabilization

– Rapid IV access– Adequate fluid resuscitation

• Prostaglandin E1– Antibiotics?– Pressors

• Intubation? Yes but BEWARE


• Sepsis

• Congenital Cardiac– Ductal dependent

• Inborn error of metabolism• Congential adrenal

hyperplasia– Boys


• Consideration - get a– Bicarb– Ammonia– Glucose

• Stabilization– Rapid IV access– Adequate fluid– Glucose– Sodium Bicarb

• Possible intubation



– Ductal dependent• Inborn error of metabolism• Congential adrenal

hyperplasia– Boys


• Recognition– Low sodium– High Potassium

• Stabilization– Rapid IV access– Adequate fluids

• Hydrocortisone– Pressor-resistant shock



– Ductal dependent• Inborn error of metabolism• Congenital adrenal

hyperplasia– Boys

Neonatal Vomiting

• Gastroesophageal Reflux

• Pyloric Stenosis• Volvulus

Typical features– Gradual onset– Usually with each feed– Quantity can be large– Consists only of milk

Do we really care?– Only if this is your

misdiagnosis

Neonatal Vomiting

• Gastroesophogeal Reflux


• Onset in first 2-6 weeks– Boys !

• Early -- looks like reflux• Can have abrupt onset

over 1-2 days• Late -- Vomits everything

each feed

Neonatal Vomiting



• Diagnosis– Ultrasound– The proverbial Olive– Classically projectile– Typical HUNGRY !

• Stabilization– Adequate fluids– Electrolyte correction

• Over 1-2 DAYS

• Then surgery



Neonatal Vomiting



– The AAA of pediatrics– You miss this, they die– A true emergency

• Onset usually acute• Onset at birth -- or anytime

in first couple of weeks• Bilious emesis

– Yellow or green

• Exam– Toxic appearing infant– Shocky– Distended, tight abdomen

Neonatal Vomiting



– The AAA of pediatrics– You miss this, they die– A true emergency

• TIME IS BOWEL• Diagnosis

– Immediate upper GI

• TIME IS BOWEL• Stabilitization

– Rapid IV access– Aggressive fluids

• TIME IS BOWEL• IMMEDIATE surgery

One more time A missed volvulus is a

death sentence





Pearl of Neonatal Wisdom

• 6 week old infant• Fussy and not feeding quite as

well– Decent urinary output

• Well appearing on exam– Nonfocal, normal exam– Well hydrated– Normal vital signs

• Discharged




A Bad Physician

Does not “hear” or listen to the parents

Paternalistic

Believes the parents are young, ignorant, uneducated



Pearl of Wisdom

A Good Physician

Listens carefullySOMETHING is

different or they wouldn’t be there

Be very careful ASSUMING nothing is wrong with an infant

Parents know BEST !




Just before discharge, the next shift physician asked -- what about the feeding?

Listening carefully, child really was changing.

Subtle decreased sodium and increased potassium suggested CAH so admitted.

Two days later, ruptured kidney unrecognized urethral obstruction

Take home message:

Always LISTEN to the parents

Pediatric FeverWell appearing 0-36 months of age

The game we play -- Where is it hiding

– Blood– Urine– CNS– Chest

Risk is affected by– Age– Temperature– Appearance– Sex– Circumcision status– Immunization Status

•This discussion is more germane to an urban population not at risk for zoonotic, typhoid, malaria, etc.

AppearanceWhat should you do?

Ill appearingNormal exam

• CBC/Blood Culture• UA/Urine Culture• Lumbar puncture?• Chest Radiograph?

Well appearing

Normal exam

It depends

The neonate0-30 days

Incidence of Serious Bacterial illness is high– Limited ability to localize or resist bacterial infection– Limited ability to express this illness

• Cry more, eat less, less active• Fever tends to be LOW (38.0°C)• Delay in recognition

– Rapid deterioration possible– This is true EVEN in the well appearing febrile infant– Don’t be cavalier with neonates

The neonate 0-30 days

Judgment is limited: evaluation is empiric– Bacteremia: CBC/Blood culture

• Prognostic value of CBC for bacteremia very limited

– Urinary Tract Infection: Urinalysis and culture• 20% of bacterial UTI with normal urinalysis

– Lumbar puncture: Meningitis• Social repertoire of young infants is so limited that clinical

judgment useless• All children need a spinal tap

– CXR: Pneumonia• Good thought but yield low without symptoms

The neonate0-30 days

Judgment is limited: evaluation is empiric– All children get antibiotics after cultures are drawn– Cover for typical organisms: from mother’s vaginal

tract• Group B streptococcus• E coli• Listeria (extremely uncommon in US)

– Empiric treatment with• Ampicillin• Gentamicin

– Admit (if possible)

The young infant0-30 days

While judgment is extremely limited:

– Children in first two weeks of life may be at greatest risk

– Children with changes in behavior such as lethargy and poor feeding are very worrisome

– Children with abnormal peripheral WBC (over 15,000 or under 5,000)

– Positive urinalysis– Abnormal CXR


Judgment remains limited– This is a transitional age between newborns and

older infants– They remain at risk for vaginal organisms from the

mother but also to typical encapsulated organisms of older children

– Social repertoire remains limited and difficult to assess

– These children can also deteriorate quickly


Judgment remains limited: evaluation is empiric– Bacteremia: CBC/Blood culture– Urinary Tract Infection: Urinalysis and culture

• 20% of bacterial UTI with normal urinalysis

– Lumbar puncture: Meningitis• Social repertoire of young infants remains limited• A low threshold for empiric lumbar puncture

– Many people empirically LP up to 6-8 weeks

• Missing meningitis is the most devastating infection possible– CXR: Pneumonia

• Again, yield low in absence of respiratory symptoms


Management

Children at higher risk:

– Children with changes in behavior such as lethargy and poor feeding are very worrisome

– Children with abnormal peripheral WBC (over 15,000 or under 5,000)

– Positive urinalysis (5-10 WBC)– Abnormal CXR


Children at higher risk should received empiric therapy until cultures back– The majority of pathogenic cultures will be positive within 24

hours

• Typical organisms– Group B strep, E coli (neonatal organisms)– Pneumococcus, Haemophilus type B, meningococcus

• Typical therapy– Third generation cephalosporin (ceftriaxone)– Lumbar puncture in the younger ages (6-8weeks)

• Admission– If ill-appearing or if unreliable followup

Older Infants3 months to 36 months

Risk is affected by– Age– Temperature– Sex– Circumcision status– Immunization Status

Children at highest risk of occult bacteremia are 12-24 months of age– 3-6 months are at less

risk– But they deteriorate

faster

• This risk is due to a development immunodeficiency

Older infants3 months to 36 months


Risk and Temperature thresholds vary by age– 38°C represents real risk under

3 months– Very young children rarely

have high temperatures– 39°C represents real risk over

3 months of age– Risk increases 2-3 fold as

temperatures increase to 39.5°C and 40°C



Boys are WEAK !

The main difference is found in risk of UTI

Highest risk of UTI is in uncircumcised boys under 6 months of age

Lowest risk is in circumcised boys over 12 months of age

Girls are intermediate



The risk of occult bacteremia in well appearing infants in the U.S. in a fully immunized population (against pneumococcus and Haemophilus) is probably less than

0.5%

3 months to 36 months

Risk are affected by– Age– Temperature– Sex– Circumcision status– Immunization Status

The risk of occult bacteremia in well appearing infants in the U.S. BEFORE universal immunization was on the order of

2-3%And this risk is modified by higher

temperatures, ill appearance, etc.

The real question to is: what is the risk of progression of occult bacteremia to

to meningitis?

A recent meta-analysis showed that– 25/257 (9.7%) of untreated patients with

pneumococcal bacteremia had persistent bacteremia or focal invasive infections at followup

– The same study showed a 2.7% risk of progression to meningitis

Pediatrics 1997;99:438Pediatrics 2000;106:505


Risk are affected by– Age– Temperature– Sex– Circumcision status– Immunization Status

The risk of UTI in this age group is unaffected by immunization status and is on the order of

5%

Loose recommendations for 3-24 (or 36) months

Well-appearing fever without a source

• UA/ Urine culture– All girls– Circumcised boys less

than 6-12 months– Uncircumcised boys less

than 12-24 months• Lumbar Puncture

– If ill appearing

• CBC/Blood culture– Consider strongly in

the unimmunized– Address WBC count

over 15-20,000 or less than 5,000 with empiric therapy

– May defer in the fully immunized

Note on treatment

Never administer parenteral (or oral) antibiotics without a reason– “Ear” infections are overdiagnosed. Do NOT use as

an excuse to administer antibiotics– Always obtain cultures (blood or urine) prior to

administering antibiotics (if possible)– NEVER administer antibiotics to a febrile infant

(without an identified source of fever) less than 6-8 weeks without first performing an LP

• Partially treated, unrecognized meningitis is a disaster

“Early” Pediatric meningitis

Classic signs of meningitis– Kernig’s sign– Brudzinski’s sign– Stiff neck– Irritability– Lethargy

These may NOT be present in early meningitis

Of course one can simply wait until the diagnosis becomes obvious…

Pediatric meningitisSymptoms can be subtle

Neonates– Well appearing with low grade

fever– Poor feeding– “Not acting right”

Infants 1-3 months– Fever and “a little fussy– Not feeding quite as well– Vomiting without diarrhea and

looking more ill than typical gastroenteritis

Older children– Consider meningitis in

ALL children with a fever who complain of a bad headache

– May be present in children with a bad headache, neck discomfort, or vomiting and NO fever

Febrile Seizures

• Frequency 1:20-50 children• SIMPLE febrile seizures need NO special evaluation or

treatment– Meaning no empiric spinal tap– Except for evaluating fever

• “Simple” means:– Nonfocal - generalized– Short - less than 15 minutes– Single - only 1 in 24 hours– Return to NORMAL mental status

• Beware the child already on antibiotics for partially treated meningitis

Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings

• Fever for 5 days– Irritability

• Skin changes– Rash– Peeling digits/perineum

• Mucosal changes– Conjunctivitis– Red lips, tongue

• Lymphadenopathy• Greater than 1.5 cm nodes

• Edema of hands and feet

Kawasaki DiseaseTypical Kawasaki Disease with five cardinal findings

• Fever for more than 5 days• Skin changes

– Rash– Peeling digits/perineum

• Mucosal changes– Conjunctivitis– Red lips, tongue

• Lymphadenopathy• Greater than 1.5 cm nodes

• Edema of hands and feet

Kawasaki DiseaseWhy this diagnosis is important

Nobody every died of Kawasaki disease. Or did they?– Kawasaki’s is a vasculitis and

myocarditis is present– Untreated, 13-40% develop

coronary aneurysms– These giant aneurysms (8mm)

thrombose, resulting in acute MI and death

– This risk is greatest in the first year after the illness

Kawasaki DiseaseWhy this diagnosis is important

KD and prevention of coronary aneurysms are very responsive to treatment– But the correct diagnosis

must be made– Treatment consists of

• Aspirin• IVIG (Immunoglobulin)• Possibly corticosteroids

Vomiting and lethargyWhat do these 2 cases have in common?

A 9 month old presents with 6 episodes of emesis for one day– No diarrhea– No fever– Last one bilious– No abdominal pain

On exam, awake in no distress– Glassy-eyed and lethargic– Very soft abdomen

You perform the LP but the results are negative

A 5 year old presents with intermittent, severe abdominal pain – No fever– Emesis once– No diarrhea– History of a vasculitic rash

for one week

On exam, comfortable and well appearing– Abdominal exam benign– Petechiae, purpura on

legs and buttocks

Intussusception

Classic, text book presentation– Colicky severe abdominal

pain– Acting normal between

episodes– Vomiting– Current jelly stools

• In reality, this presentation may be the exception



IntussusceptionA tale of two presentations

Classic, text book presentation– Colicky severe

abdominal pain– Acting normal between

episodes– Vomiting– Current jelly stools

• LATE finding!• Represents bowel

ischemia

Altered mental status– Lethargic, appears

almost sedated with drugs

– Meningitis often the primary misdiagnosis

– Vomiting invariable– Abdomen general

soft but may feel the mass

Diagnosis & Treatment

• Barium or air contrast enema diagnoses AND reduces the intussusceptum

• Refractory cases need surgery

• Do not do enema until surgeon called– Risk of perforation by less

experienced radiologist– Historically (1890s) up to

50% of children perforated and died



Diagnosis & Treatment

If a barium enema seems invasive, consider CT or ultrasound for diagnosis and then enema if intussusception present

Diagnosis & TreatmentIn context of Henoch-Schonlein Purpura

With HSP the intussusception – is NOT the typical ilio-colic

intussusception– It is ILIO-ILIAL– Diagnosis will NOT be made

with barium enema– Diagnosis is made on CT

scan– Usual treatment is medical

observation

Intussusception and HSPHenoch-Schonlein Pupura

IgA mediated vasculitis similar to TTP in adults

Diagnosis is clinical– Typical purpuric rash in

dependent areas• Lower ext in children• Buttocks in infants

– Arthralgias– Renal disease

• May result in renal failure

– Intussusception in some



Vomiting and tachypneaWhat do these two cases have in common?

8 year old with two days of vomiting– No fever– No diarrhea– Now bilious– Generalized abdominal

pain– Recent history of weight

loss

On exam– Thin and ill appearing– Nonfocal abd tenderness– Candidal perineal rash

2 year old with two days of fast breathing– No cough– No fever– No feeding well– Spits up feeds

On exam– Ill appearing– Dehydrated– Tachypneic– Clear lungs– Tachycardic

Diabetic ketoacidosisDiagnosed on a routine chemistry

• Diagnosis DKA easy with history of diabetes• Classic presentation polydipsia, polyuria,

weight loss -- but only if you ask• Atypical features

– Altered mental status– Respiratory “distress”– Thrush / Perineal ‘diaper’ rash– Abdominal pain and vomiting

DKAThree problems in order of importance

• Dehydration• Electrolyte

disturbances• Insulin deficiency

– While this is the underlying cause, it is NOT the immediate problem





DKADehydration

They are dry, why not give them lots of fluids?– Give only a SINGLE bolus of 10-

20cc/kg UNLESS hemodynamically unstable

– Theoretical risk of inducing cerebral edema– Correct dehydration over 12-24 hours– NEVER bolus with anything except

NORMAL SALINE

DKAElectrolytes

Potassium is the critical problem– They are profoundly depleted – Hypokalemia from both urinary loss and acid

base shifts in the serum– Never give potassium until you prove there is

no renal failure (urinate once)– If the starting serum potassium is low --

BEWARE -- it will drop quickly with fluids and insulin

• Be prepared to aggressively replace (and monitor -- every 2 hours) potassium once therapy starts

DKASerum glucose and insulin

No one NEEDS insulin in first hours– Address fluid deficit and potassium– Glucose will drop significantly with simple fluid

administration

Principles of insulin administration– Do NOT bolus insulin

• It does not act faster and simply results in overshoot hypoglycemia

– Start with 0.1 unit/kg/hour– When serum glucose below 250mg/dl do NOT

reduce insulin --- increase dextrose in IVFs

DKACerebral edema

This is what kills kids with DKA

• Occurs only in kids• Onset can be SUDDEN

– Blown pupil– Apnea– Profound mental status

change

• Be prepared to administer Mannitol IMMEDIATELY– Intubate if necessary

Stiff neck and StridorWhat do these two cases have in common?

23 month old leaving for Germany tomorrow with a stiff neck and fever– Fever 38.9°C– Holds neck stiffly– Decreased oral intake– Not particularly sick

appearing

19 month old transferred for asthma attack– No wheezing but has

stridor– Low grade fever– Poor response to

racemic epinephrine– Progressive respiratory

distress – Episodic apnea– Diagnosis made

Retropharyngeal abscess

• Occurs in younger children– Adenoids involute with age

• Multiple potential spaces in the neck

• Clinical presentation resembles meningitis with stiff neck

• Clues are there– Without altered mental status– Subtle swelling of face– Dysphagia/drooling



Retropharyngeal abscessDiagnosis and treatment

• Textbook diagnosis is a lateral neck film– Not particularly sensitive and

may miss early cases– Not particularly specific if

poor technique

• Money is on the CT scan for diagnosis– Delineates extent of disease– Helps decide whether

therapy is medical or surgical



Look-a-likes

A 9 month old presents with 6 episodes of emesis for one day– No diarrhea– No fever– Last one bilious– No abdominal pain

On exam, awake in no distress– Glassy-eyed and

lethargic– Very soft abdomen

You perform the LP but the results are negative

A 7 month old presents with 4 episodes of emesis for one day– No diarrhea– No fever– No abdominal pain– Lethargic all day

On exam– Lethargic– Ill-appearing– Non-focal exam

You perform the LP but the results are bloody

6 month old with one day lethargy

– Tactile fever– Sleeping– Little oral intake– Decreased urination– Vomited twice

On exam– Tachypneic– Lethargic– Dry– Low grade

temperature

Look-a-likes

Intussusception ?Meningitis

Child abuseShaken baby syndrome

Presents as altered mental status– In younger infants as

lethargy and poor feeding

– Vague story– Nonfocal exam

Same fractureTwo stories

My 1 year old was playing with a toy my 4 year old wanted

The older one tackled the younger one

His leg got twisted under his leg

He screamed and won’t walk on his leg and we rush him down here as fast as we could

My 1 year old was fine yesterday

Now he won’t walk

He fell off the couch yesterday. That might be it.

Child abuse



Conscious sedation in kids

Agents

– Midazolam– Midazolam/Opioid– Pentobarbital– Propofol– Etomidate– Ketamine

Problems

– Paradoxical reaction– Respiratory – Respiratory/hypotension– Hypotension – Respiratory– Laryngospasms (rare)

Ketamine

• Useful in all ages– Concern about use in older kids

misplaced

• Inexpensive• Reliable

– Does not provide analgesia per se– DISSOCIATIVE agent and therefore

unaware of pain– Also amnestic to procedure

Ketamine

• Useful in all ages• Inexpensive• Reliable• Risks are low

– Protects airway– No respiratory depression– No hypotension– Rare cases of laryngospasm

• Adverse effects– Vomiting (up to 20%)– Emergence reaction (uncommon)



KetamineAdministration practicalities

• Dosing– 2mg/kg IV– 4mg/kg IM

• Side effects NOT dose related

• Duration IS dose related– 0.5 - 1.0 mg/kg for short

procedures– May repeat multiple doses

if procedure prolonged

• Pretreat with ATROPINE

– Reduces secretions and laryngeal irritation

• No need to pretreat with midazolam– Does not prevent

emergence reaction– Can treat afterwards if

needed

• Laryngospasm– Almost all kids can be

bagged through the event

Pedi̇atri̇k vakalar(fazlası için )

Health & Medicine

Transcript of Pedi̇atri̇k vakalar(fazlası için )