Berkowitz’s – Section III: Acute & Emergent Problems

Nov 30, 2019 admin NHI KHOA 0

Berkowitz’s – Section III: Acute & Emergent Problems

Fever and Bacteremia

Eric R. Schmitt, MD, MPH
CASE STUDY
An 8-month-old girl is brought to the emergency department with a 2-day history of fever and increased fussiness. She is irritable but consolable by parents. Her parents believe that her immunizations are up-to-date, but they do not have the immunization record with them. On examination, she has a rectal temperature of 39.5°C (103.1°F). The rest of the physical examination is within normal limits, and no source for the fever is apparent.
Questions
1. What are the serious bacterial infections in febrile newborns and infants?
2. What has been the effect of conjugated vaccines against Haemophilus influenzae and Streptococcus pneumoniae on the incidence of bacteremia and meningitis in febrile newborns and infants?
3. What are the challenges in differentiating between serious and benign febrile illnesses in young children?
4. What diagnostic studies are recommended in the evaluation of febrile newborns, infants, and children?
5. When are empiric antibiotics indicated and when should febrile newborns and infants be hospitalized?

My note

Lab tests for newborn and <90-days:

  • Due to unreliable presentation, all febrile > 38 require CBC with dif, U/A with micro, cultures (blood, urine). CSF should be for all < 60-d. From 60 – 90-d “strongly considered” CSF and cultures
  • Rapid viral test positive but should be routine for urine cultures if suspected UTI
  • Nếu cần empiric antibiotics, phải làm lumbar pucture trước
  • Stool analysis and culture nếu có tiêu chảy
  • Routine X-ray không cần, chỉ nếu có triệu chứng hô hấp
  • Từ 3-36 months:
  • Trước đây, ANC (absolute neutrophil count) > 10,000 là best predictor cho occult bacteremia. Sau này thì ESR, CRP, procalcitonin (acute phase reactants) có tăng nhưng không reliably better. Tóm lại chưa có single test để xác định occult bacteremia
  • Sự ngoạn mục của vaccine viêm phổi khiến giảm giá trị cũa routine screening (culture, empiric antibiotics) cho occult bacteremia. WBC không còn screening vì giảm tỉ lệ bệnh nặng, trong khi dễ có dương tính giả do contamination. Nếu đã được vaccine 2 doses thì cứ an toàn không cần blood tests. Nếu chưa immunized hoặc không rõ tình trạng vaccine, hoặc chỉ mới 1 dose thì cần screening với CBC, blood and urine cultures và antibiotics nếu tăng WBC hoặc ANC.
  • > 39 cần urine test nếu girl < 2-y, uncircumcised boy < 12-m, circumcised boys <6-m
  • CXR nếu respiratory symptoms hoặc nghe thấy viêm phổi
  • > 39.5 và WBC >20,000 thì cần CXR cho dù không triệu chứng (vì 25% có occult pneumonia)

Lab tests for> 3 years

  • Tùy nhưng đa số không cần testing. No high risk for occult bacteremia, và presentation more reliable, dễ communicating. Testing nếu nhìn toxic hoặc comorbid

Management

  • tepid water = lukewarm water = 2 phần nước lạnh + 1 phần nước sôi, T=40
  • Tránh dùng ice water or alcohol baths
  • Nếu thấy toxic appearance, phải nhập viện cho KS. Most common là IV Ampi + Genta.
  • Do phòng chống GBS và KS intrapartum, nên giờ trổi lên G(-), kéo theo kháng thuốc Genta. Nên cần dùng cephalo 3rd (cefotaxime) làm empiric. Không nên ceftriaxone lứa tuổi này, nhất là có vàng da newborn, để tránh risk of kernicterus.
  • Well-appearing 29-90 days thì outpatient abx (ceftri 50mg/kg IV IM) hoặc chỉ để theo sát, miễn là không có SBI criteria. Nhưng phải communication tốt và good transportation nếu cấy ra dương tính.
  • Trẻ 29-90 ngày cần theo dõi sát 24 giờ. Đa số cấy dương tính trong 24 giờ đầu. Cần thêm vancomycin nếu nghi pneumo kháng thuốc.
  • Well-appearing dù UTI hay pneumonia mà no hypoxia/distress thì outpatient bằng ceftria trong 24-h đầu rồi chuyển dạng uống. Nếu mới tiêm 1 liều vaccine pneumo, thì cho 1 liều ceftri lúc đang chờ cấy máu, nếu WBC >15,000 kkhoặc ANC >10,000
  • Nghi ngờ menigo thì nhập viện

Prognosis

  • Occult bacteremia không chữa thì tự lành nhưng có thể thành meningitis (5-10%) hoặc septic arthritis hoặc persistent bacteremia (20%). Hib và S. pneumococcus chiếm 25% vs 5%

Emerging Infectious Diseases

Christian B. Ramers, MD, MPH, and Thomas R. Hawn, MD, PhD
CASE STUDY
A previously healthy 8-year-old boy is brought to his pediatrician’s office in late August with 2 days of fever, fatigue, headache, myalgia, nausea, and gingival bleeding. On the morning of the visit his mother noted a rash on his legs. He lives with his family in the Northeastern United States but recently returned from a 1-week vacation in Key West, FL. He engaged in extensive outdoor activities, including snorkeling, hiking, and several evening boat trips, and sustained multiple mosquito bites during the trip. He received all routine childhood immunizations, denies any allergies, and takes no medications. No other family members are ill. On physical examination, his temperature is 101.7°F (38.7°C) and he is generally ill-appearing. He has photophobia and mild meningism, and a petechial rash is noted on his trunk and lower extremities. Laboratory studies sent from the office reveal microscopic hematuria, leukopenia (white blood cell count 2.8), and thrombocytopenia (platelets 85,000).
Questions
1. What is an emerging or reemerging infection?
2. What pathogens are associated with emerging infections?
3. What are some common or emerging infectious diseases that may cause the clinical syndrome in the case scenario?
4. What types of exposures should be considered when assessing acute febrile illnesses such as that described in the case scenario?
5. How does recent travel influence the differential diagnosis?
6. What are appropriate steps in initial management?
7. What resources can a primary care physician access to help in making a diagnosis?
8. When do isolation and reporting procedures need to be considered?

My Note

“emerging/reemerging” là incidence tăng in past 2 decades, quan trọng nhất là do “human migration”, environmental và economic changes, changes in host susceptibility and immunity, and overuse of antibiotics

 

Febrile Seizures

Kenneth R. Huff, MD
CASE STUDY
A 12-month-old girl is brought to the emergency department by paramedics because she is having a seizure. She is unresponsive and hypertonic, with arched trunk and extended arms and legs that are jerking rhythmically. Her eyes are open, but her gaze is directed upward. She has bubbles of saliva around her lips as well as circumoral cyanosis. Her vital signs are a respiratory rate of 60 breaths/ min, heart rate of 125 beats/min, blood pressure of 130/78 mm Hg, and temperature of 105.8°F (41.0°C). An assessment of her respiratory status discloses that she is moving air in all lung fields, and there is no evidence of upper airway obstruction. The paramedics inform you that the girl has been convulsing with varying intensity of tone and movements but remaining unresponsive for approximately 6 minutes. Glucometer testing reveals a normal serum glucose. Blood samples for other tests are sent to the laboratory, and urine is collected. An intravenous (IV) line is started, and the girl is given lorazepam by IV push. Within 2 minutes, the movements cease, and her respirations become slow and even. Her physical examination shows no signs of trauma. Her only abnormality other than her unresponsive mental status is an inflamed and bulging right tympanic membrane. The girl’s parents tell you that she has had a mildly stuffy nose for 2 days but has been afebrile and has seemed to be her usual self. While she was playing, she became cranky, and her parents put her in her crib for her nap. Thirty minutes later they heard grunting noises, found her in the midst of a seizure, and called the paramedics. The girl has never had a seizure before. Her father recalls that his mother once told him that he had several “fever seizures” as an infant.
Questions
1. What are the characteristics of simple febrile seizures?
2. What is the appropriate evaluation of children with febrile seizures, whether it is the first one or a recurrence?
3. What is the recurrence risk for febrile seizures and the risk of developing unprovoked seizures following a febrile seizure?
4. What are the treatment options for children with febrile seizures?

My note

6-m to 5-y, more common <3-y

5% trẻ từng bị 1 lần

recurrence 30-50% ở trẻ < 1-y, 25% trong 1-3-y, only 12% after 3-y

thường chẩn đoán cuối là URI hoặc influenza hoặc sau immunization

DDx:

meningitis, encephalitis, brain abscess. Nhớ dấu kích thích màng não (meningeal irritation) không reliable ở trẻ < 12-m. Chú ý các trường hợp: history of lethargy, persistent vomiting, focal seizure, prolonged postictal depression; chưa chích ngừa Hib or pneumo, hoặc trước đó đã điều trị antibiotic (che dấu màng não) –> cần làm CSF (pleocytosis)

phân biệt simple vs complex febrile seizures, true febrile seizure vs seizure with fever

febrile seizure < 90 seconds vs complex febrile seizure may > 15-min

> 1 febrile seizure in one illness or in 24-hour: more likely complex febrile seizure

focal or partial onset, postictal focal neurologic signs –> febrile seizure complex

History questions for febrile seizures

• What were the child’s symptoms for the few days before the seizure?
• Where was the child and what was he or she doing immediately before the seizure?
• Were there any pregnancy-related or perinatal complications?
• Has the child’s development been normal or similar to that of siblings?
• Have any other family members had seizures of any kind, including during infancy?

Physical exam: chú ý bruises, fractures, retinal hemorrhages, signs of trauma. Dysmorphic features, enlarged organ, bony changes. Skin: pigmented, textured spots. Lateralized signs of tone or strength

Lab Testings

cultures, metabolic profiles, toxicology (blood and urine)

CSF examination, nếu không có tăng áp nôi sọ hoặc lateralized neurologic examination (trường hợp này cần dùng KS sớm và imaging trước khi lumbar puncture)

 

Respiratory Distress

David B. Burbulys, MD
CASE STUDY
A 6-month-old boy has been coughing and breathing fast for the past day. This morning he refused feeding and has been irritable. On examination, the infant is fussy. He has an oxygen saturation of 92%, a respiratory rate of 60 breaths/min, a pulse of 140 beats/min, and a normal blood pressure and temperature. In addition, he has nasal flaring, intercostal and supraclavicular retractions, and occasional grunting.
Questions
1. What are the causes of respiratory distress in infants and children?
2. What are the signs and symptoms of respiratory distress in infants and children?
3. What are the signs and symptoms of impending respiratory failure in infants and children?
4. What are the critical interventions for infants and children in respiratory distress?

Stridor and Croup

David B. Burbulys, MD
CASE STUDY
A 2-year-old boy has been breathing noisily for 1 day. For the past 3 days he has had a “cold,” with a runny nose, fever (temperature up to 100.4°F [38°C]), and slight cough. The cough has gradually become worse and now has a barking quality. On examination, the child is sitting up and has a respiratory rate of 48 breaths/min with marked inspiratory stridor and an occasional barking cough. His other vital signs include an oxygen saturation of 95%, heart rate of 100 beats/min, and temperature of 101.2°F (38.4°C). He has intercostal retractions, his breath sounds
are slightly decreased bilaterally, and his skin is pale. The remainder of the examination is normal.
Questions
1. What is stridor?
2. What are the common causes of stridor?
3. What is the pathophysiology of viral croup?
4. How are children with stridor managed?

Sudden Infant Death Syndrome and Apparent Life-Threatening Events

Lynne M. Smith, MD
CASE STUDY
A 4-month-old boy is brought to the emergency department by paramedics after being found blue and not breathing by his mother. He had previously been well except for a mild upper respiratory infection. His mother fed him at 2:00 am, and when she checked on him at 6:00 am she found him blue and lifeless. Although the mother smoked cigarettes during pregnancy, the pregnancy and
delivery were otherwise normal. The infant received the appropriate immunizations at 2 months of age.
Questions
1. What factors are associated with sudden infant death syndrome (SIDS)?
2. How are SIDS and apparent life-threatening events (ALTEs) related?
3. How are SIDS and sudden unexpected infant deaths (SUIDs) related?
4. What is the appropriate evaluation of infants who present with an ALTE?
5. What services are available to families who have lost infants to SIDS?
6. What should parents be advised to help prevent SUIDs?

Syncope

David Atkinson, MD
CASE STUDY
A 15-year-old girl comes to your office a week after her quinceañera because she fainted after the ceremony. The celebration was on a hot summer’s day, and she was so nervous that she had nothing to eat or drink the entire day. Though the girl thinks she has never fainted before but has gotten dizzy momentarily after standing up “too fast and sometimes in the shower,” her mother reports that she fainted about a year ago while having blood drawn. In addition, at age 18 months, she fell off her parents’ bed. She cried, gasped, stopped breathing, became pale, and passed out for about 30 seconds. She was diagnosed with a breath-holding spell. There is no family history of sudden death or seizures. Prior to fainting, she had completed the quinceañera mass and entry into the celebration hall with her family and was standing while her godfather began his toast. She remembers feeling “light-headed”; the next thing she recalls is awaking on the ground with her family and friends around her. Her mother states that she had passed out for about 10 to 15 seconds. She denies taking any medications or using any illicit drugs and denies sexual activity. The mother wants to know if it is safe for her daughter to go to the local amusement park with her friends next week. She has read about sudden death in high school athletes and asks if it is safe for her daughter to continue to play for the high school soccer team. The girl’s physical examination is unrevealing, and her vital signs are all normal. Electrocardiogram shows normal sinus rhythm with normal voltages and intervals for her age.
Questions
1. What are the causes of syncope?
2. What type of workup is done primarily to evaluate for syncope?
3. When should patients who experience syncope be referred to a subspecialist?
4. Which pediatric subspecialists assist in the evaluation of a patient with syncope?
5. Which patients presenting with syncope are at the greatest risk for sudden death?

Shock

Kelly D. Young, MD, MS
CASE STUDY
A 7-month-old boy is brought in by his parents with a history of vomiting and diarrhea for 2 days. He also has had a low-grade fever and, according to his parents, has become progressively more listless. Vital signs show a heart rate of 200 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 72/35 mm Hg. The infant is lethargic and mottled. Capillary refill time is 3 seconds. His anterior fontanelle is sunken, and his mucous membranes are dry. The abdomen is flat and non-tender and displays hyperactive bowel sounds.
Questions
1. What is shock, and what clinical signs can help in the recognition and assessment of shock?
2. What are the stages of shock?
3. What different types of shock are there, and what are the possible causes for each type?
4. What are the management priorities in treating shock?

Approach to the Traumatized Child

David B. Burbulys, MD
CASE STUDY
A 6-year-old boy is brought to the emergency department after being struck by an automobile while crossing the street. He was found unconscious at the scene. Initial evaluation shows that he has an altered level of consciousness, shallow respirations, ecchymosis across the upper abdomen, and a deformed, swollen left thigh. The pediatric emergency physician is called in to discuss an
initial assessment and management plan for the injured child with the trauma surgeon.
Questions
1. What are the most common mechanisms of injury responsible for trauma in children?
2. What are some of the physiological differences between adults and children that make children more susceptible to certain types of injuries?
3. Which areas of the body are most likely to be injured in a typical automobile versus pedestrian collision?
4. What are the components of a primary survey in pediatric trauma patients?
5. What radiographic and laboratory studies should be performed in children with multiple injuries?

Abdominal Trauma

David B. Burbulys, MD
CASE STUDY
An 8-year-old boy who was riding quickly on a bicycle unintentionally crashed into a tree and is transported to the pediatric emergency department by emergency medical services. On arrival at the trauma center, the paramedics report that the bike handlebars struck the child’s stomach, “knocking the wind out of him.” The boy complains of dizziness and vomits several times. Initial vital signs show a heart rate of 135 beats/min, blood pressure of 105/60, oxygen saturation of 98% on room air, and a respiratory rate of 24 breaths/min. The abdomen is flat but tender to palpation
in the mid-epigastric region and left upper quadrant.
Questions
1. What are the most frequent types of intra-abdominal trauma in children?
2. What are the diagnostic studies used to evaluate abdominal trauma?
3. What are the basic components of the treatment of shock that occurs following abdominal trauma?
4. What is a simple rule for establishing the lower limit of normal blood pressure in children?

Acute Abdomen (Appendicitis)

Steve L. Lee, MD
CASE STUDY
A 10-year-old girl presents with abdominal pain for 24 hours. The pain began in the periumbilical area and is now located in the right lower quadrant (RLQ). She had one bout of emesis but no diarrhea. She has no fevers or chills. She also has some pain with voiding. On physical examination, she has a low-grade fever and tachycardia. She is lying still in bed. Her abdomen is non-distended, but she is tender to palpation in the RLQ. She also has rebound tenderness and guarding in this area.
Questions
1. What is the differential diagnosis for patients with acute abdominal pain?
2. What is the appropriate workup for children with suspected appendicitis?
3. What is the current management for children with appendicitis?
4. What is the expected postoperative course and possible complications following appendectomy?

Head Trauma

Joseph Ravera, MD
CASE STUDY
A 2-year-old girl is playing on a window ledge unsupervised. She pushes the screen out and falls onto the concrete sidewalk below, striking her head. A neighbor reports that she is unconscious for 10 minutes. When paramedics arrive, the girl is awake but lethargic. She is transported to the emergency department. Her vital signs are normal. A scalp hematoma is present, and a depressed
area of cranial bone is palpated.
Questions
1. What are the priorities in the initial stabilization and management of pediatric head trauma?
2. What is the difference between primary and secondary brain injury?
3. What are the common structural injuries sustained by children with head trauma?
4. What are the various modalities available for treatment of increased intracranial pressure?
5. What are the scoring systems used in the evaluation  of mental status in children with head trauma?

Increased Intracranial Pressure

Kenneth R. Huff, MD
CASE STUDY
A 7-year-old boy has a 2-week history of recurrent vomiting. No fever, abdominal pain, or diarrhea has accompanied the vomiting; the vomiting has no particular relationship to meals; and the boy’s appetite has decreased only slightly. The vomiting has gradually increased in frequency and is occurring every night. Yesterday there were 4 episodes. The boy’s parents have noticed that their son is generally less active; he spends more time playing on the floor of his room and does not want to ride his bicycle or play with neighborhood friends. Some unsteadiness in the boy’s gait has developed in the last few days. His parents attribute this to weakness from the vomiting. The child’s vital signs are normal except for a blood pressure of 130/80 mm Hg. Although the boy is somewhat pale and uncomfortable, he does not appear to be in acute distress. His abdominal examination is unremarkable. His speech is grammatically correct but sparse and hesitant, and he seems inattentive. On lateral and upward gaze the boy has coarse nystagmus, and upward gaze is somewhat limited. Dysconjugate left gaze is apparent, with slight failure of left eye abduction. The left eye does not blink as much as the right eye. Fundal examination discloses elevated disks with indistinct margins. No upper extremity weakness is evident. The right foot is slightly weaker than the left, ankle tone is bilaterally increased, and 3 to 4 beats of clonus on the right and bilateral positive Babinski reflexes are present. Some tremor occurs in both arms with finger-to-nose testing. The boy walks with shuffling, small steps; his gait has a slight lurching character; and he veers to the right.
Questions
1. What clinical situations are associated with increased intracranial pressure (ICP)?
2. What is the pathophysiological process leading to ICP?
3. What studies are used to evaluate children with ICP?
4. What measures are used to treat children with ICP?

Management of Dehydration in Children: Fluid and Electrolyte Therapy

Sudhir K. Anand, MD
CASE STUDY
A 2-year-old boy presents to your office after 2 days of vomiting and diarrhea. His siblings were both ill a few days ago with similar symptoms. Two weeks ago his weight was 12 kg at a well-child visit. Today his weight is 10.8 kg. He has a pulse of 130 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 85/55. He is alert and responsive but appears tired. He has dry mucous membranes, no tears with crying, and slightly sunkenappearing eyeballs. His capillary refill is 2 seconds. He urinated a small amount about 6 hours ago. Despite his mother’s best efforts in your office, the patient has vomited all of the oral rehydration therapy given to him. You draw serum electrolytes, blood urea nitrogen, and creatinine and initiate intravenous rehydration and give 2 boluses of 240-mL normal saline (0.9% sodium chloride solution) each.
Questions
1. How does one assess the magnitude of dehydration in children?
2. What are the different types of dehydration?
3. How does one determine the type and amount of fluid that a dehydrated child requires?
4. How does one assess renal status in a dehydrated child?
5. What is the role of electrolyte and acid-base laboratory studies in the evaluation of the dehydrated child?

Acute Kidney Injury

Gangadarshni Chandramohan, MD, MS, and Sudhir K. Anand, MD
CASE STUDY
A 10-month-old girl has a 2-day history of fever, vomiting, and watery diarrhea. The child has previously been healthy. Her diet has consisted of infant formula with iron, baby food, and some table food. Since the onset of her illness, she has not been drinking or eating well, and she has thrown up most of what she has eaten. Her mother has tried to give her Pedialyte and apple juice on
several occasions but has had limited success. The child has had 8 to 10 watery stools without blood or mucus each day. Her temperature has varied between 98.6°F and 101.8°F (37.0°C and 38.8°C); the mother has given her daughter acetaminophen, which she has vomited. The girl’s 4-year-old brother and her parents are doing well and have no vomiting or diarrhea. The physical examination reveals a severely dehydrated (15%), listless infant. Her weight is 9.4 kg, her height is 74 cm, her temperature is 101.1°F (38.4°C), her heart rate is 168 beats/min, her respiratory rate is 30 breaths/min, and her blood pressure is 72/40 with an appropriately sized cuff. Capillary refill is 2 to 3 seconds. The skin appears dry, but no rash is present. Head and neck, chest, heart, and abdominal examinations are normal. Pending the results of her blood studies, an intravenous fluid bolus of 180 mL normal saline (20 mL/kg) over 20 to 30 minutes is administered. This is followed by 2 more boluses of 180 mL normal saline each. The girl is catheterized to obtain urine and determine the urine flow rate over the next several hours. A urinalysis is performed.
Questions
1. What are the 3 categories of acute kidney injury (AKI)?
2. What is the etiology of AKI?
3. How would one make an assessment of a patient with AKI?
4. What is the appropriate management for children with AKI?
5. What are the indications for renal replacement therapy?

Ingestions: Diagnosis and Management

Kelly D. Young, MD, MS
CASE STUDY
A 2-year-old girl is found by her mother with an open bottle of pills and pill fragments in her hands and mouth. She is rushed into the emergency department. She is sleepy but able to be aroused. The vital signs are temperature of 98.8°F (37.1°C), heart rate of 120 beats/min, respiratory rate of 12 breaths/min, and blood pressure of 85/42 mm Hg. Pupils are 2 mm and reactive. Skin color, temperature, and moisture are normal. She has no other medical problems.
Questions
1. What history questions should be asked to help identify the substance ingested?
2. What physical examination findings can give clues to the substance ingested and the seriousness of the ingestion?
3. What other diagnostic tests might be helpful in managing ingestion patients?
4. What are the management priorities?

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