{"id":5342,"date":"2011-07-14T20:25:39","date_gmt":"2011-07-14T20:25:39","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5342.htm\/"},"modified":"2011-09-26T22:48:53","modified_gmt":"2011-09-26T22:48:53","slug":"peds-emergencies","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/","title":{"rendered":"General Approach to Pediatric Emergencies"},"content":{"rendered":"

<\/span>Assessment Triangle:<\/span><\/h3>\n

Appearance (Alert, Anxious), Work of Breathing (tachypnea, retractions), Circulation (normal perfusion)<\/p>\n

 <\/p>\n

APAP dose in kiddies <100 kg add a 0 to weight in pounds for the dose<\/p>\n

 <\/p>\n

Infared ear temp is no good (INFRARED EAR THERMOMETRY COMPARED WITH RECTAL THERMOMETRY IN CHILDREN: A SYSTEMATIC REVIEW Craig, J.V., et al, Lancet 360:603 August 24, 2002)<\/p>\n

<\/span>Normal Resp Rates<\/span><\/h3>\n

Newborn<\/p>\n

30-60<\/p>\n

1-6 mo<\/p>\n

30-50<\/p>\n

6-12 mo<\/p>\n

24-46<\/p>\n

1-4 yr<\/p>\n

20-30<\/p>\n

4-6 yr<\/p>\n

20-25<\/p>\n

6-12 yr<\/p>\n

16-20<\/p>\n

>12 yr<\/p>\n

12-16<\/p>\n

 <\/p>\n

<\/span>NGT Depth<\/span><\/h3>\n

\"\"<\/a>(Annals Em 39:3)<\/p>\n

 <\/p>\n

Heliox improves moderate to severe RSV (Pediatrics 2002:109)<\/p>\n

 <\/p>\n

Head injury can cause hypotension in peds patients (AM J Surg 184, p.555, 2002)<\/p>\n

 <\/p>\n

<\/span>Resuscitation<\/span><\/h2>\n

Age\/4 +4=tube size, 3 x size=depth<\/p>\n

Shock<\/p>\n

I-up to 15%<\/p>\n

II-15-30% will have tachycardia, increased RR, but will maintain urine output<\/p>\n

III-30-40% compensated but decreased UO, may have mental status changes<\/p>\n

IV->40% decreased BP<\/p>\n

 <\/p>\n

\"\"<\/a><\/p>\n

 <\/p>\n

<\/span>Ophthalmologic Emergencies<\/span><\/h2>\n

conjunctivitis in newborns if >48 hrs after birth=gonorrhea, chlamydia, strep, staph or herpes.\u00a0 If patient was in hospital, also consider pseudomonas<\/p>\n

Pre\/Orbital Cellulitis<\/p>\n

Test EOM, should be pain free in preorbital.\u00a0 Vision must be normal.\u00a0 Can differentiate with CT with axial and coronal thin cuts.<\/p>\n

 <\/p>\n

<\/span>ABD X-RAY<\/span><\/h2>\n

Bones<\/p>\n

Stones<\/p>\n

Mass<\/p>\n

Gas<\/p>\n

<\/span>Consent<\/span><\/h2>\n

If an emergency, always treat.<\/p>\n

All states allow minors to consent to diagnosis and treatment for STDs or drug abuse without parenteral consent\u00a0 Most states also allow minors to consent for pregnancy related care.<\/p>\n

Emancipated minor definitions vary by state<\/p>\n

<\/span>Hypertension<\/span><\/h2>\n

H<\/strong>yperthyroid<\/p>\n

Y<\/strong><\/p>\n

P<\/strong>heochromocytoma<\/p>\n

E<\/strong>ats too much (obesity)<\/p>\n

R<\/strong>enal Disease<\/p>\n

T<\/strong>hrombosis of renal arteries<\/p>\n

E<\/strong>ndocrine (CAH or Hyperaldosteronism)<\/p>\n

N<\/strong>eurologic<\/p>\n

S<\/strong>tenosis of renal artery or coarctation of aorta<\/p>\n

I<\/strong>ngestion of toxin<\/p>\n

O<\/strong>B (eclampsia)<\/p>\n

N<\/strong>euroblastoma<\/p>\n

 <\/p>\n

<\/span>Dental Emergencies<\/span><\/h2>\n

Full bevy of primary teeth by age 2<\/p>\n

Secondary teeth are often heralded by the 1st molars (6 yr molars)<\/p>\n

Eruption cysts-blue black, sometimes blood filled cyst over new tooth, bengin.<\/p>\n

Teething can cause fever.<\/p>\n

Ellis Class<\/p>\n

I-only enamel<\/p>\n

II-through enamel and dentin, will see yellow dentin in enamel<\/p>\n

III-to pulp of tooth, will see bleeding<\/p>\n

IV-involve the root, need x-ray to dx<\/p>\n

Treat class I with filing, II and III should be covered with dental foil or commercial coating and sent to see a dentist within 24 hours (12 hours for <12 y\/o)<\/p>\n

Luxation Injuries<\/p>\n

Intrusion-tooth impacted into alveolar socket<\/p>\n

Extrusion-vertically dislodged from the socket<\/p>\n

Lingual Luxation-displacement of the tooth towards the tongue<\/p>\n

Labial Luxation-towards the lips<\/p>\n

Lateral Luxation-occurs within the plane of the tooth.<\/p>\n

Avulsion is a tooth knocked completely out of the socket.\u00a0 Put in mouth of parent or child, or hanks solution, or milk or saline.\u00a0 Never reimplant a avulsed primary tooth as ankylosis, a bony fusing of tooth to the ridge may occur<\/p>\n

 <\/p>\n

Permanent tooth luxations need immediate treatment.<\/p>\n

 <\/p>\n

<\/span>ENT Emergencies<\/span><\/h2>\n

ask child which finger he picks his nose with<\/p>\n

<\/span>Retropharyngeal Abscess<\/span><\/h3>\n

uncommon after five years old<\/p>\n

can track to mediastinum or carotid or jugular vein<\/p>\n

<\/span>Peritonsillar Abscess<\/span><\/h3>\n

quinsy<\/em><\/strong>, abscess pushes uvula to other side of mouth.\u00a0 red, bulging soft palette.<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>The Crying Infant:<\/span><\/h2>\n

A Checklist to Consider<\/p>\n

The crying infant represents a challenge to the emergency physician<\/p>\n

to evaluate a disruptive, noncommunicative patient in obvious<\/p>\n

distress.\u00a0 In addition to more serious etiologies, many common minor<\/p>\n

illnesses need to be excluded by a careful history and physical<\/p>\n

exam.<\/p>\n

 <\/p>\n

Areas to consider in the PE:<\/p>\n

Vitals\/Fever<\/p>\n

Tachypnea<\/p>\n

 <\/p>\n

Fundi Retinal hemorrhages<\/p>\n

Cornea Fluroscein dye for corneal abrasion<\/p>\n

Inspect for foreign body<\/p>\n

Ears Otitis<\/p>\n

Foreign body<\/p>\n

Abdomen\/Rectal Inspect for anal fissure<\/p>\n

Test stool for blood (e.g. intussusception)<\/p>\n

Genitalia Inguinal hernia<\/p>\n

Hair tourniquet<\/p>\n

Digits Hair tourniquet<\/p>\n

Urine Tox screen for cocaine metabolites<\/p>\n

 <\/p>\n

 <\/p>\n

<\/span>UTIs<\/span><\/h2>\n

CAN URINE CLARITY EXCLUDE THE DIAGNOSIS OF URINARY TRACT INFECTION?<\/p>\n

Bulloch, B., et al, Pediatrics 106(5, Part 1): November 2000<\/p>\n

METHODS:<\/strong> This study, from the Children’s HospitalMedicalCenter in Cincinnati, examined the utility of urine clarity as an indicator of urinary tract infection (UTI) in a convenience sample of 159 previously healthy patients aged 4 weeks to 19 years for whom urine cultures were ordered during emergency department evaluation. An aliquot of urine was placed in a red-topped blood tube and held 1cm from a white background containing text printed in an 11-point black font. Ability to read the text through the urine sample, under fluorescent lighting, with the same clarity as through a tube containing water was considered consistent with clear urine and, consequently, absence of a UTI. Samples were tested by two independent observers.<\/p>\n

RESULTS:<\/strong> Urine cultures were positive in 18% of the patients, while just under one-third of the specimens were judged to be cloudy. The sensitivity and specificity of urine clarity for UTI were 90% and 82 respectively, and the positive and negative likelihood ratios (LRs were 5.1 and 0.1. The sensitivity and specificity of other urine screening tests were 83% and 95%, respectively, for dipstick testing for leukocyte esterase, 28% and 98% for urinary nitrites 86% and 79% for pyuria (defined as at least 5 WBC\/HPF) on urine microscopy, and 93% and 40% for microscopy positive for bacteria UTI was confirmed by culture in three patients with clear urine<\/p>\n

CONCLUSIONS:<\/strong> Although the presence of clear urine on visual inspection does not definitively exclude UTI, it appears to be a rapid, inexpensive and relatively reliable bedside screening test I\/Q R 4\/4 – J 3\/4<\/p>\n

<\/span>Top Ten Peds Issues<\/span><\/h2>\n

<\/span>1. Fever<\/span><\/h3>\n

 <\/p>\n

0-28 Days c a fever >38<\/p>\n

Listeria, enterococcus, Group-B Strep, Staph<\/p>\n

CBC, Blood Cx, Urine, Spinal Tap, Admit<\/p>\n

Start Antibiotics:<\/p>\n

Ampicillin to hit listeria and enterococcus<\/p>\n

Cefotaxime for everything else<\/p>\n

 <\/p>\n

28-90 Days c a fever >38<\/p>\n

Sepsis W\/U<\/p>\n

Rochester Criteria<\/strong><\/p>\n

(Peds 94; 390-396, 1994)<\/p>\n

<60 days<\/p>\n

Temp >38<\/p>\n

Term infant, no perinatal abx, no disease, not in hospital longer than mom, well appearing s source<\/p>\n

WBC not <5 nor >15<\/p>\n

Ab Bands <1500<\/p>\n

UA <10 WBC per HPF<\/p>\n

Stool (if sx) <5 WBC per field<\/p>\n

Can send home if no high risk criteria<\/p>\n

Sensitivity 92%, Spec 50%, NPV 98.9%<\/p>\n

 <\/p>\n

Boston<\/strong> (J Peds 120, 22-27, 1992)<\/p>\n

28-89 days<\/p>\n

>38<\/p>\n

No immunizations in past 48 hours, no antibiotics in past 48 hours, not dehydrated, well appearing, no signs of infection.<\/p>\n

CSF <10 wbcs\/cc<\/p>\n

UA <10WBC\/hpf<\/p>\n

Chest film:\u00a0 no infiltrate<\/p>\n

WBC <20000<\/p>\n

Spec 94.6%, no sensitivity or NPV????<\/p>\n

 <\/p>\n

90 Days to 36 Months c >39 (102.2)<\/p>\n

<\/span>Occult Bacteremia (3-5%)<\/span><\/h3>\n

Urine:\u00a0 Boys <6 months old if circed<\/p>\n

<1 yr old if uncirced<\/p>\n

Girls\u00a0 <2 yrs old<\/p>\n

(Pediatrics 1993;92(1):1-12)<\/p>\n

1 Rochester Ceftriaxone, send home, with follow-up<\/p>\n

 <\/p>\n

36 months-death<\/p>\n

>105.8, even then, if they look good do nothing<\/p>\n

 <\/p>\n

<\/span>2. Resp Disease<\/span><\/h3>\n

Asthma, Bronchiolitis, Croup, Pneumonia<\/p>\n

To get a good exhalation, squeeze an infants chest between your hands<\/p>\n

<\/span>3. Trauma<\/span><\/h3>\n

Head Trauma<\/p>\n

Get CT:<\/p>\n

Falls >4 feet if <1 y\/o<\/p>\n

Falls >10 feet if >1 y\/o<\/p>\n

LOC<\/p>\n

Change in Mental Status persistent to ED<\/p>\n

Focal Neurological Signs<\/p>\n

Anisocoria<\/p>\n

Persistent Vomiting-> 5 episodes or an episode >6 hrs post-injury<\/p>\n

Headache<\/p>\n

Irritability or behavior change<\/p>\n

Seizure-(three types contact seizure, immediate, early, late)<\/p>\n

<3 months of age<\/p>\n

+- Scan<\/p>\n

>2 episodes vomiting<\/p>\n

Hematoma > 2cm<\/p>\n

Suspect Child Abuse<\/p>\n

LOC < 1min<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

Scalp Hematomas<\/p>\n

Subgaleal<\/p>\n

Caput<\/p>\n

Cephalohematoma<\/p>\n

Skull Fxs<\/p>\n

Diastatic separation of sutures, most commonly lamdoid<\/p>\n

Linear-get CT<\/p>\n

Depressed-getCT and admit<\/p>\n

Basilar-Get CT scan<\/p>\n

Infants can have skull fractures even in falls less than 3 feet.\u00a0 The parietal bone is the most often fractured with the linear type being the most common.\u00a0 (Annals 37:1, 2001)\u00a0 15-30% of linear skull fractures will have underlying injury.\u00a0 If there is a tear through the dura underlying the skull fracture, a growing skull fracture can result<\/p>\n

Bleeds<\/p>\n

Subdural-most common 8-10%, 75% venous<\/p>\n

Epidural-2-3%, 75% middle meningeal<\/p>\n

Abdominal Trauma<\/p>\n

Extremity Trauma<\/p>\n

Salter Classification<\/p>\n

 <\/p>\n

Plastic Fractures<\/p>\n

Buckle or Torus<\/p>\n

Greenstick<\/p>\n

Bowing or Bending<\/p>\n

 <\/p>\n

Toddler Fractures<\/p>\n

hairline fractures of distal third of tibia.\u00a0 May not show up on x-ray.\u00a0 Hold knee and twist ankle in opposite direction, may need bone scan<\/p>\n

Abrasion, Fx, Lacs<\/p>\n

<\/span>4. Rash<\/span><\/h3>\n

Contact Dermatitis<\/p>\n

Allergic Dermatitis<\/p>\n

Miliaria (heat rash)<\/p>\n

Milia (sebaceous gland occlusion)<\/p>\n

Transient Neonatal Pustular Milanosis-present at birth<\/p>\n

Erythema Toxicum-not born c it, 1st day of life, looks like flea bites, disappears by 1 week<\/p>\n

Varicella<\/h4>\n

Usually seen in the winter and the spring in 1-14 y\/o.<\/p>\n

1-3 week incubation period, infectious 2 days before and 5 days after rash 1.\u00a0 Skin Superinfection 2.\u00a0 Pneumonia 3.\u00a0 Hepatitis 4.\u00a0 Pancreatitis 5.\u00a0 Encephalitis<\/p>\n

One of the few rashes present in the scalp, meningococcemia should not be in the scalp.\u00a0 Kids with varicella before 1 year may have a second outbreak and are higher risk of shingles.\u00a0 Usually leukopenia.\u00a0 May see subclinical hepatitis.<\/p>\n

 <\/p>\n

Complications of varicella:<\/strong> death<\/em> (data prior to 1995)\u0097approximately 100 per year, 84% immunocompetent patients; typically due to encephalitis or Reye\u0092s syndrome; bacterial superinfection<\/em>\u0097most common complication; may present with adenitis; most often due to Staphylococcus aureus<\/em> or Streptococcus pyogenes<\/em>; necrotizing fasciitis rare sequela; herpes zoster\u0097 <\/em>9% of children with shingles had varicella in first year; central nervous system (CNS) dysfunction<\/em>\u0097acute cerebellar ataxia most common neurologic complication; elevated protein in cerebrospinal fluid (CSF); admit to hospital for 1 to 2 days of observation; resolves spontaneously; encephalitis and cerebritis also reported (viral antigen in CSF); varicella<\/em> pneumonia\u0097<\/em>admit child and treat with acyclovir; Reye\u0092s syndrome<\/em>\u0097rare since vaccines available; hemorrhagic complications<\/em>\u0097very rare; patient cannot terminate viremia; unable to make interferon; changes in T cell subsets; 70% mortality; hemorrhage in all organs; thrombocytopenia rash looks like purpura fulminans (Audiodigest)<\/p>\n

 <\/p>\n

Motrin can give necrotizing fasciitis, aspirin can give Reye, use Tylenol and benadryl.\u00a0 In 1st trimester, \u00bc of fetuses will get limb deformations,\u00a0 2nd trimester is no problem, 3rd trimester 5 days prior and 2 days post delivery can get Varicella encephalitis<\/p>\n

 <\/p>\n

 <\/p>\n

Erythema Multiforme Minor and Major<\/p>\n

Measles (Rubeola)<\/p>\n

Seen in 0-20 y\/o, usually in winter\/spring.\u00a0 Prodrome of high fever and URI sx.\u00a0 Erythematous macules and papules which become confluent and turn coppery-colored.\u00a0 Begins in hairline and moves down the body.\u00a0 Koplik spots, conjunctivitis, photophobia, cough, and pneumonia<\/p>\n

German Measles (Rubella)<\/p>\n

5-25 y\/o, usually in spring.\u00a0 Prodrome is mild URI sx.\u00a0 Maculopapular rash which becomes pinpoint.\u00a0 Begins on face and migrates to the trunk.\u00a0 Tender retroauricular, posterior cervical, and occipital lymphadenopathy.<\/p>\n

Erythema Infectiosum (Fifth Disease)<\/p>\n

From parvo B-19, 3-12 y\/o or nonimmune adults.\u00a0 Seen in winter\/spring. Prodrome of fever and malaise.\u00a0 Macular erythema on face, followed by erythematous macular eruption, then lacy erythema.\u00a0 Rash progresses from face to extremities.\u00a0 Associated with aplastic crisis, hydrops fetalis, popular-purpuric socks syndrome.<\/p>\n

Exanthem Subitum (Sixth Disease, Roseola)<\/p>\n

0-3 y\/o, usually in Spring or Fall.\u00a0 Prodrome of high fever for 3-5 days.\u00a0 Rash of erythematous to pink macules and papules arranged in rosettes on trunk, neck, and proximal extremities.\u00a0 Rash appears as fever resolves.<\/p>\n

Scabies<\/p>\n

Scarlet Fever<\/p>\n

Disease\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Day of Fever which Rash Develops<\/p>\n

Very \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Varicella \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 1st day of Fever, rash develops<\/p>\n

Sick\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Scarlet Fever\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 2nd<\/p>\n

Pts\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Small Pox\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 3rd<\/p>\n

Must\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Measles\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 4th<\/p>\n

Take\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Typhus\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 5th<\/p>\n

Double\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Dengue\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 6th<\/p>\n

Eggs\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Enteric Fever\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 7th<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

Jill M. Baren, MD, FACEP, FAAP<\/p>\n

Maculopapular Eruption<\/strong><\/p>\n

 <\/p>\n

 <\/p>\n

Differential Diagnosis<\/p>\n

a.<\/p>\n

Kawasaki’s disease<\/p>\n

b.<\/p>\n

Erythema multiforme<\/p>\n

c.<\/p>\n

Pityriasis Rosea<\/p>\n

d.<\/p>\n

Measles (Rubeola)<\/p>\n

e.<\/p>\n

Erythema Infectiosum (Fifth’s disease)<\/p>\n

f.<\/p>\n

Scarlet Fever<\/p>\n

g.<\/p>\n

Roseola Infantum<\/p>\n

h.<\/p>\n

Other viral exanthems<\/p>\n

 <\/p>\n

3. Disease Presentation and Management<\/p>\n

 <\/p>\n

a.<\/p>\n

Kawasaki’s disease (mucocutaneous lymph node syndrome)<\/p>\n

 <\/p>\n

Multisystem vasculitis of unknown etiology. Consider in all children who present with rash and fever but most common under age 4 years. Diagnostic criteria: Fever > 5 days plus (1) bilateral conjunctival injection, (2) Red or fissured lips, red pharynx, or strawberry tongue, (3) Erythema of palms or soles, edema, or desquamation (especially in diaper area), (4) Erythematous rash, nonscaling, possibly morbilliform(5) Cervical lymphadenopathy (>1.5 cm). Other clinical findings: arthralgias, cough, uveitis, sterile pyuria, aseptic meningitis, hepatitis, diarrhea, vomiting, myocarditis, pericarditis, coronary artery aneurysms. Lab findings: thrombocytosis, leukocytosis, elevated ESR. Complication: coronary artery aneurysms. Rx: Aspirin 100 mg\/kg\/day in 4 divided doses for 14 days, IV gamma globulin 2 gm\/kg once over 12 hours or 400 mg\/kg once daily for 4 days, hospitalization for diagnoses and management of possible complications.<\/p>\n

 <\/p>\n

b. Erythema multiforme<\/p>\n

 <\/p>\n

Common, inflammatory disease with many etiologies including drugs, infections, physical agents, pregnancy, malignancy, and connective tissue disease but in 50% of cases, no etiology found. More common precipitants are HSV (recurrent), EBV, Streptococcal, Mycoplasma, fungal infections; sulfa, penicillin, anticonvulsant drugs. Prodrome \u0096 malaise, itching, burning, but also asymptomatic. Lesions are polymorphous – red, round maculopapules on hands, feet, extensor surfaces and trunk that appear abruptly. Hallmark is target lesions that evolve over 24 hours. May heal in 1-2 weeks but may last up to a month and there may be changes in pigmentation. Rx \u0096 eliminate the precipitant if identifiable. No therapy in mild cases, otherwise prednisone and antipruritics. Acyclovir if HSV is the etiology. Can be very severe with blistering forms (Stevens-Johnson syndrome, Toxic Epidermal Necrolysis) and even life threatening.<\/p>\n

 <\/p>\n

c.<\/p>\n

Pityriasis rosea<\/p>\n

 <\/p>\n

Common benign skin eruption of unknown etiology (possibly viral) often seen in older children and adolescents and more often in the winter. Herald patch appears first (single oval or round lesion on trunk or extremities that resembles tinea corporis). Followed by eruption of salmon colored papular lesions on trunk and proximal extremities, concentrated in lower abdomen. Surrounded by scaly ring (collarette scale). Numerous lesions on the back appear like “Christmas tree” pattern. Mostly asymptomatic but may be pruritic. Rx- Topical steroids and antihistamines for itching. Sunlight hastens resolution of lesions.<\/p>\n

 <\/p>\n

d.<\/p>\n

Measles<\/p>\n

 <\/p>\n

Highly contagious disease spread by respiratory droplets most commonly seen in preschoolers or unvaccinated individuals. Prodrome characterized by harsh cough, coryza, conjunctivitis, photophobia and fever 10-12 days after exposure. Koplik spots are bluish-white spots with a red halo found on the buccal mucosa opposite the premolar teeth. Rash begins on face and spreads to trunk and extremities and is confluent and dark red to purplish (morbilliform). Complications: pneumonia, encephalitis. Rx \u0096 supportive.<\/p>\n

 <\/p>\n

e. Erythema Infectiosum (Fifth’s Disease)<\/p>\n

 <\/p>\n

Mild disease that is contagious; caused by parvovirus B19. Seen most often in children ages 5-14 years. Mild prodrome of fever, malaise, sore throat. Facial erythema (slapped cheek) is bright red, bilateral and spares the nasolabial fold and perioral region. There is also a fine fishnet like pattern on the extremities and trunk and a petechial “glove and sock” syndrome as well. Not contagious after rash appears. There may be accompanying arthritis most commonly in the knee. Complications include spontaneous abortion and aplastic anemia. Rx- reassurance, supportive.<\/p>\n

 <\/p>\n

f.<\/p>\n

Scarlet fever<\/p>\n

 <\/p>\n

Contagious disease produced by streptococcal erythrogenic toxin (Group A beta-hemolytic strain) originating in the pharynx or skin. Most common between the ages of 2-10 years. Sudden onset of fever and pharyngitis with nausea, vomiting, headache and abdominal pain. Oropharynx is bright red with palatal petechiae. Rash begins 1-2 days after other symptoms of illness on neck and face and spreads to trunk and extremities, spares palms and soles. Rash is red and sandpapery. May see Pastia’s lines (linear petechiae) in skin folds and strawberry tongue. Desquamation occurs on palms and soles and may last for several weeks. Can be confirmed with Rapid Strep test (high false negative rate). Rx \u0096 Benzathine penicillin IM (600,000 units for patients < 60 lbs. and 1.2 million units for > 60 lbs.) or oral 10 day course (125 mg or 250 mg QID). Alternatives are erythromycin or cephalosporins. May also be caused by Staph aureus infection.<\/p>\n

 <\/p>\n

g.<\/p>\n

Roseola Infantum<\/p>\n

 <\/p>\n

Caused by human herpes virus 6 usually in children aged 6 months to 4 years. Sudden onset of high fever (103-106\\F) for several days, decreased appetite, mild URI symptoms, febrile seizures, lymphadenopathy. Rash develops as fever subsides and is pale pink, confluent slightly raised papules on trunk and neck. Complications: Associated with febrile seizures. Rx \u0096 fever control and reassurance.<\/p>\n

 <\/p>\n

5. Case conclusion<\/p>\n

 <\/p>\n

C.<\/p>\n

Petechial\/Purpuric eruptions<\/p>\n

 <\/p>\n

1.<\/p>\n

Case presentation<\/p>\n

2.<\/p>\n

Differential Diagnosis<\/p>\n

a.<\/p>\n

Idiopathic Throbocytopenic Purpura<\/p>\n

b.<\/p>\n

Henoch-Sch\u00d6nlein Purpura<\/p>\n

c.<\/p>\n

Rickettsial disease<\/p>\n

d.<\/p>\n

Sepsis\/DIC<\/p>\n

e.<\/p>\n

Other viral exanthems (infectious mononucleosis)<\/p>\n

 <\/p>\n

3.<\/p>\n

Disease Presentation and Management<\/p>\n

 <\/p>\n

a.<\/p>\n

Idiopathic Thromocytopenic Purpura<\/p>\n

 <\/p>\n

The most common thrombocytopenic purpura of childhood characterized by a profound deficiency of circulating platelets. 70% of cases have antecedent viral infections 1-4 weeks prior. Acute onset of generalized petechiae, prominent over the legs with mucous membrane hemorrhage in a well appearing patient. Platelet count < 20K, normal hemoglobin and WBCs. Complications: intracranial hemorrhage. Rx \u0096 excellent prognosis even without therapy. Platelet transfusion only for life threatening hemorrhage. IV gamma globulin may induce remission, corticosteroids shorten the acute phase. Chronic form is uncommon.<\/p>\n

 <\/p>\n

b.<\/p>\n

Henoch-Schonlein Purpura<\/p>\n

 <\/p>\n

Vasculitis seen in children ages 2-10 years characterized by palpable purpura on legs and buttocks, abdominal pain, GI bleeding, arthralgias, and hematuria. Lesions can begin as erythematous maculopapules. Often occurs in the spring with clustering of cases, often preceded by a viral prodrome. May be recurrent. Lesions usually spare the trunk, fade in several days and are worsened with ambulation. GI symptoms in 40-60%, joint symptoms in 60-80%, nephritis in 20-50% with proteinuria and hematuria. Angioedema of the scalp, eyelids, lips, ears, hands, feet, back, scrotum, and perineum may be seen. RX \u0096 supportive, referral for long term follow. Complications: GI bleed, intussuception, chronic renal failure, CNS involvement, hepatosplenomegaly.<\/p>\n

 <\/p>\n

c.<\/p>\n

Rickettsial disease (RMSF)<\/p>\n

 <\/p>\n

Febrile illness caused by Rickettsia rickettsii (tick bite) seen in spring to early fall in south Atlantic states and Oklahoma. Multisystem manifestations including fever, headache, myalgias and vomiting. Rash erupts on wrists and ankles and involves palms and soles and then the trunk. Starts as pink, blanching macules, then becomes petechial. 15% of cases do not develop the rash. Mortality is > 30% without treatment. Skin biopsy for confirmation of diagnosis. Rx-supportive care, broad-spectrum antibiotics and tetracycline, doxycycline, or chloramphenicol for definitive therapy.<\/p>\n

 <\/p>\n

d.<\/p>\n

Sepsis\/DIC<\/p>\n

 <\/p>\n

Purpura fulminans is a nonspecific sign of sepsis that appears rapidly and occurs in association with several infections (Group A Strep, Strep pneumo, Staph, RMSF, Meningococcus. Patients are ill appearing and should receive a full sepsis work-up and broad-spectrum antibiotic coverage (ampicillin and gentamycin for infants, ampicillin and ceftriaxone or cefotaxime for older children plus chloramphenicol for very ill patients in whom RMSF is suspected.<\/p>\n

 <\/p>\n

 <\/p>\n

e.<\/p>\n

Other viral exanthems<\/p>\n

 <\/p>\n

Other viruses with associated petechial rash include Herpes Simplex, Epstein-Barr, CMV, Hepatitis, and enteroviruses.<\/p>\n

 <\/p>\n

5. Case conclusion<\/p>\n

 <\/p>\n

D.<\/p>\n

Vesicobullous eruptions<\/p>\n

 <\/p>\n

1. Case presentation (Varicella, Impetigo, SSSS)<\/p>\n

2.<\/p>\n

Differential Diagnosis<\/p>\n

a.<\/p>\n

Varicella Zoster (chicken pox)<\/p>\n

b.<\/p>\n

Staphylococcal Scalded Skin Syndrome<\/p>\n

c.<\/p>\n

Impetigo<\/p>\n

d.<\/p>\n

Hand, foot and mouth disease (Coxsackie infection)<\/p>\n

e.<\/p>\n

Herpes Zoster<\/p>\n

 <\/p>\n

3.<\/p>\n

Disease Presentation and Management<\/p>\n

 <\/p>\n

a.<\/p>\n

Varicella Zoster<\/p>\n

 <\/p>\n

Highly contagious viral illness seen in late winter to spring. Patients contagious from 2 days before onset of rash until complete crusting of lesions. Prodrome of fever, headache, malaise. Rash starts on trunk and spreads to face and extremities and is very pruritic. Lesions are in different stages of eruption. Begins as a red papule and becomes a thin walled clear vesicle (dewdrop on rose petal). Then becomes umbilicated and cloudy and ruptures to crust over. Oral and genital mucosa can be involved. Complications: skin infection, encephalitis, Reyes syndrome, pneumonia. Rx: supportive, antipruritics (diphenhydramine or hydroxyzine), cool baths (Aveeno), keep fingernails short to prevent scratching and superinfection, oral Acyclovir if seen within first 24 hours or for siblings, adolescents, immunocompromised individuals.<\/p>\n

 <\/p>\n

b. Staphylococcal scalded skin syndrome<\/p>\n

 <\/p>\n

A Staph toxin syndrome seen in children under age 5 years where the epidermis is cleaved. Follows a localized S. aureas infection. Rash is diffuse, erythematous with a sandpapery texture and tender with accentuation in the flexural areas. With fever, bullae form and peel off in large sheets. Look for radial fissuring and crusting around the mouth. Children ,may be irritable but not seriously ill. Minor pressure (Nikolsky’s signs) induces peeling. Can be associated with dehydration. Rx- hospitalization and IV antibiotics for extensive cases, otherwise oral antibiotics (dicloxicillin or cephalexin), skin lubrication after skin has started to exfoliate, avoidance of tape. Must differentiate from Toxic Epidermal Necrolysis (TEN).<\/p>\n

 <\/p>\n

c. Impetigo<\/p>\n

 <\/p>\n

Common contagious skin infection produced by Group A, alpha hemolytic streptococci or staphylococci or both. Bullous (mainly Staph) and nonbullous forms. Typically found on the face and around the nares. Starts as a bulla, pustule or vesicle that collapses and becomes a flat, honey crusted lesion. Commonly confused with Herpes Simplex virus which may precede it. Rx- application of 2% mupirocin ointment TID until lesions have cleared if disease is localized, otherwise 5-10 day course of dicloxicillin or cephalexin.<\/p>\n

 <\/p>\n

f.<\/p>\n

Hand, foot, and mouth disease<\/p>\n

 <\/p>\n

Common contagious viral illness from infection with Coxsackie viruses, strain A16 most common, or enterovirus 71. Associated with fever, malaise, soreness of the oral mucosa. Vesicles are found in the mouth first and easily rupture to become erosions. Skin vesicles erupt 1-2 days later on hands, feet, genitals, buttocks, and skin folds. Rx \u0096 reassurance, supportive, topical, oral analgesics (magic mouthwash).<\/p>\n

 <\/p>\n

e. Herpes Zoster<\/p>\n

 <\/p>\n

Can occur in any age patient with a prior Varicella infection. Tingling, itching or pain precedes the eruption of a red papule which evolves into a vesicle. Vesicles coalesce in a dermatomal distribution. Lesions can appear red, purple or gray. Common areas are face, scalp, and torso. Can be disseminated in immunocompromised individuals. Rx \u0096 pain control, antivirals may shorten course if given early.<\/p>\n

 <\/p>\n

4. Case conclusion<\/p>\n

 <\/p>\n

E.<\/p>\n

Urticarial eruptions<\/p>\n

 <\/p>\n

1. Case presentation<\/p>\n

2. Differential Diagnosis<\/p>\n

a.<\/p>\n

Allergic<\/p>\n

b.<\/p>\n

Infections<\/p>\n

c.<\/p>\n

Physical agents<\/p>\n

 <\/p>\n

3.Disease Presentation and Management<\/p>\n

 <\/p>\n

Urticaria (hives)<\/p>\n

 <\/p>\n

Skin manifestation of a Type 1 hypersensitivity reaction which produces significant itching. Significant number of causes: penicillin, sulfa, food allergies, insect bites, viral infections, analgesics, physical factors, chemicals. Lesions are edematous papules and plaques with pink color (wheals). They come and go rapidly. Rx \u0096 avoidance or withdrawal of precipitant, oral antihistamines (sedating and non-sedating), prednisone or H2 blockers for refractory cases.<\/p>\n

 <\/p>\n

4. Case conclusion<\/p>\n

 <\/p>\n

 <\/p>\n

V.<\/p>\n

References:<\/p>\n

 <\/p>\n

1.<\/p>\n

Edwards L. Dermatology in Emergency Care. Churchill Livingstone Inc., New York. 1997.<\/p>\n

 <\/p>\n

2.<\/p>\n

Fleisher GR and Ludwig S (eds.) Textbook of Pediatric Emergency Medicine, fourth edition. Lippincott Williams and Wilkins, Philadelphia. 2000.<\/p>\n

 <\/p>\n

3.<\/p>\n

Feigin RD and Cherry JD (eds.) Pediatric Infectious Diseases, third edition. W.B. Saunders Company, Philadelphia. 1992.<\/p>\n

 <\/p>\n

4.<\/p>\n

Barkin RM (ed.). Pediatric Emergency Medicine Concepts and Clinical Practice, second edition. Mosby, St. Louis, 1997.<\/p>\n

 <\/p>\n

5.<\/p>\n

Nelson WE (ed.). Textbook of Pediatrics, 15th edition. W.B. Saunders Company, 1996.<\/p>\n

 <\/p>\n

6.<\/p>\n

Habif, TP (ed.) Clincal Dermatology A Color Guide to Diagnosis and Therapy, third edition. Mosby, ST. Louis, 1996.<\/p>\n

<\/span>5.\u00a0 Vomiting and Diarrhea<\/span><\/h3>\n

Treat Diarrhea if salmonella <3 months old or bacteremic and <1 y\/o or or asplenic<\/p>\n

Always treat Shigella or campylobacter<\/p>\n

Can Rx E. Coli, but not if O157:H7 as it will make HUS worse<\/p>\n

<\/span>6.\u00a0 Pregnancy<\/span><\/h3>\n

<\/h3>\n

<\/span>7.\u00a0 Eye and Ear<\/span><\/h3>\n

To examine the relucatant child’s eye, roll them open with Q-Tips<\/p>\n

Conjunctivitis<\/p>\n

Corneal Abrasion<\/p>\n

Foreign Body<\/p>\n

Eye Trauma-don\u0092t patch, sub-conjunctival hemorrhage 360\u00b0, abnormal pupil shape<\/p>\n

Nasal Lacrimal Duct Stenosis<\/p>\n

Glaucoma->12mm pupil diameter, >20 on tonometry, 1 eye bigger, epiphora, photophobia, blephorospasm<\/p>\n

 <\/p>\n

Otitis Media<\/h4>\n

(everything above the clavicles is Pneumo, H. Flu or B. Catarrhalis<\/p>\n

)<\/p>\n

to look in the ears of an infant, put them in a prone position.<\/p>\n

 <\/p>\n

<6 months old, give full course of antibiotics<\/p>\n

6 months-2 years with certain dx of AOM, give antibiotics<\/p>\n

6 months-2 years with uncertain diagnosis, give antibiotics if severe illness otherwise observe, return in 72 hours<\/p>\n

>2 years treat only with certain diagnosis and severe illness.<\/p>\n

Have patient return in 72 hours if no improvement (Br Med J 322:336, 2001)<\/p>\n

 <\/p>\n

ANTIBIOTIC TREATMENT IN ACUTE OTITIS MEDIA PROMOTES SUPERINFECTION WITH RESISTANT STREPTOCOCCUS PNEUMONIAE CARRIED BEFORE INITIATION OF TREATMENT (Dagan, R., et al, J Infect Dis 183(6):880, March 15 2001 )<\/p>\n

Otitis Externa<\/h4>\n

coricosporin<\/p>\n

Foreign Body<\/p>\n

Laceration<\/p>\n

Perfed Tympanic Membrane-corticosporin or floxin<\/p>\n

Labrynthitis<\/p>\n

Endolymphatic Fistula<\/p>\n

<\/span>8.\u00a0 Urogenital<\/span><\/h3>\n

Boys<\/p>\n

Posthitis-inflammation of foreskin, soak in water, poor hygiene<\/p>\n

Belanitis-inflammation of glans only.\u00a0 Give bactrim, can be STD<\/p>\n

Phimosis-can\u0092t retract foreskin, send for circumcision<\/p>\n

Paraphimosis-can\u0092t reduce foreskin, must treat<\/p>\n

Testicular Torsion-Prehn\u0092s sign:\u00a0 if when you raise testicle, it feels better then it is not torsion.\u00a0 Loss of cremasteric reflex is the best test.\u00a0 Affected testicle will be higher.\u00a0 Reduce like opening a book<\/p>\n

Torsion of Appendix Testes-blue dot sign, only 1 point of the testicle is painful;<\/p>\n

Inguinoscrotal hernia\/hydrocele<\/p>\n

Variocele-bag of worms in scrotum, if it disappears when supine, no big deal<\/p>\n

Orchitis\/Epididymitis-can be from chlamydia<\/p>\n

Girls<\/p>\n

Vaginitis-can be chemical, Vag discharge is estrogen dependant so normal at less than 1 month from mom or after menarche.\u00a0 Infectious would be strep A or STDs (Chlamydia, candidiasis, gardinella, trichinosis)<\/p>\n

Foreign Body<\/p>\n

UTI<\/p>\n

<\/span>9.\u00a0 Surgical Emergencies<\/span><\/h3>\n

Get fingerstick, UA, Icon (if appropriate age and sex). drop the diaper to examine testicles, and look in the throat to avoid missing diagnoses.\u00a0 If patient is a virgin female, can assess adnexa by bimanual rectal exam.<\/p>\n

Malrotation with volvulus (One to Two Weeks)<\/h4>\n

Surgical emergency<\/p>\n

Any infant with bilious vomiting, especially \u00a0in 1st week of life<\/p>\n

double bubble sign on upright x-ray.\u00a0 Absence of ligament of treitz.\u00a0 Bloody stool.<\/p>\n

Pyloric Stenosis (One to Two Months)<\/h4>\n

projectile bilious vomiting from 2-6 months<\/p>\n

firstborn males.<\/p>\n

Examine with the infant on their back, flex their hips 90\u00b0 to relax abd.\u00a0 May palpate the olive by gently starting palpation with rocking motion below the liver, usually found on the right, just below the Xiphoid.\u00a0 Ultrasound is the test of choice.\u00a0 Will get hypochloremic, hypokalemic metabolic alkalosis.\u00a0 Must correct pH and electrolytes before the OR.<\/p>\n

Intusseseption (One to Two Years)<\/h4>\n

Classic triad:\u00a0 colicky intermittent abd pain, vomiting,\u00a0 guiac + stools<\/p>\n

usually will have lead point such as peyer\u0092s patches, polyps, or meckel\u0092s<\/p>\n

May have RUQ mass as ileocecal junction is the most common location<\/p>\n

Neuro symptoms are associated with this disease and can include weakness, lethargy, and seizures.<\/p>\n

Air enema or obstructive series as first test. \u00a0Can also be seen on UTS.<\/p>\n

Appendicitis (Any Age)<\/p>\n

can present with diarrhea.\u00a0 Get CBC and UA<\/p>\n

Compression graded UTS can be used, but CT is the better test.<\/p>\n

In children less than 2 yrs old, symptoms may include cough, grunting, or walking with a limp. (Annals EM 36:39-51, 2000).\u00a0 Diarrhea is present in up to 1\/3 of children under 3 y\/o with appendicitis (Am J Surg 173:80-82, 1997)<\/p>\n

Ask the child how high they can jump, then let them show you to test rebound.<\/p>\n

Can have white cells in urine, sometimes even bacteria (J Urol 129:1015, 1988 and Am J Surg 155(2), 1988)<\/p>\n

Hernias<\/p>\n

strangulated needs immediate op, incarcerated needs intervention.\u00a0 Umbilical hernias are common, especially in African Americans.\u00a0 Rarely become incarcerated.<\/p>\n

Meckel\u0092s<\/h4>\n

Rules of 2.\u00a0 2% of population.\u00a0 2 feet proximal to terminal ileum.\u00a0 2% of people with meckel\u0092s will have problems.\u00a0 Usually has ectopic gastric mucosal.<\/p>\n

 <\/p>\n

DKA<\/p>\n

Non-Accidental Trauma (NAT)<\/p>\n

UTIs<\/p>\n

infants with UTIs may have vomiting and diarrhea<\/p>\n

Strep Pharyngitis<\/p>\n

most common cause of abdominal pain in school age kids<\/p>\n

Pneumonia<\/p>\n

Testicular Torsion<\/p>\n

<\/span>10. Child Abuse\/Psych Illness<\/span><\/h3>\n

<\/span>Child Abuse<\/span><\/h3>\n

FRACTURES MORE LIKELY TO BE ABUSIVE \u00b7 Metaphyseal-epiphyseal fractures (i.e., corner, bucket handle, and metaphyseal lucency) \u00b7 Rib fractures-especially posterior \u00b7 Fractures in different stages of healing \u00b7 Fractures inconsistent with history or developmental age of the child \u00b7 Avulsion fractures of the clavicle or acromion process \u00b7 Skull-multiple, depressed, bilateral, or across suture lines \u00b7 Pelvic and spinal fractures without a history of significant force \u00b7 Femur fractures in a child less than 1 year of age \u00b7 Fractures with delayed onset of seeking care FRACTURES LESS LIKELY TO BE ABUSIVE \u00b7 Clavicle fractures \u00b7 Toddler’s fracture of the tibia \u00b7 Supracondylar fractures of the humerus \u00b7 Fractures of the hands and feet \u00b7 Torus fractures of the long bones \u00b7 Pelvic or spinal fractures with a history of significant force<\/p>\n

 <\/p>\n

<\/span>Tips on Examination<\/span><\/h2>\n

ask the child what his\/her favorite food is, then ask if they would eat some now.<\/p>\n

look for smurfs in the ears<\/p>\n

have the child jump up and down to test for peritoneal pain.<\/p>\n

have kids huff and puff and blow the house down to get good resp effort<\/p>\n

or if kid is tiny, push in on their chest to get good exhalation<\/p>\n

put baby on belly and elevate their head to stop crying, loud shush mimics sound of uterine arteries<\/p>\n

Have child inhale during throat exam to prevent gagging<\/p>\n

pant like a dog<\/p>\n

<\/span>Peanut Allergies<\/span><\/h2>\n

Unlike other food allergies, you do not grow out of this one.<\/p>\n

Most common food allergy<\/p>\n

Need 4 hour observation period secondary to severe recurrence after initial improvement.<\/p>\n

<\/span>Ibuprofen<\/span><\/h2>\n

(Pediatrics 2002; 109 e20)<\/p>\n

can safely use motrin in peds asthmatics and more had exacerbation with APAP<\/p>\n

<\/span>Epistaxis<\/span><\/h2>\n

1\/3 of children referred for recurrent epistaxis had a diagnosable coagulopathy.\u00a0 Get CBC, PT\/PTT, ristocetin cofactor activity.\u00a0 Most common cause of coagulopathy is VWD. (J Pediatr Hematol Oncol 2002;24:47-49)<\/p>\n

 <\/p>\n

Lancet 360:603 August 24, 2002<\/p>\n

 <\/p>\n

BACKGROUND<\/strong>: Accurate temperature measurement is important for clinical decision- making, but can be difficult in children Infrared ear thermometers are currently being used by about two-third of pediatricians and family practice physicians, but their correlation with rectal temperature measurement has not been clearly established.<\/p>\n

METHODS<\/strong>: The authors of this British study performed a systematic review of the literature to identify studies that compared rectal temperatures with temperatures measured by infrared ear thermometers. Their meta-analysis included 31 comparisons involving 4,441 children.<\/p>\n

RESULTS<\/strong>: Using the rectal temperature as a reference standard, the pooled mean difference (rectal minus infrared ear thermometry) was 0.29C, with 95 confidence intervals that ranged between (-)0.74C to 1.32C. As such, for a measured rectal temperature of 38C temperatures measured by infrared ear thermometry could range between 37.04C and 39.2C. The 95% confidence intervals were wide in comparisons in which the ear device was used in various modes (e.g., rectal actual, core, oral or tympanic). There appeared to be no relationship between the child’s age and differences between rectal and ear temperatures. There was insufficient information to determine the effects of otitis media on this parameter<\/p>\n

CONCLUSIONS<\/strong>: In view of the wide range of the 95% confidence intervals in comparisons between rectal temperatures and those measured with infrared ear thermometry in children, the authors conclude that agreement between the two techniques is insufficient to rely upon infrared ear thermometry when precision in the measurement of body temperature is important.<\/p>\n

 <\/p>\n

<\/span>Toxicology<\/span><\/h2>\n

One Tsp or One Tablet can kill a kid:<\/p>\n

    \n
  1. Chloroquine<\/li>\n
  2. Hydroxychloroquine<\/li>\n
  3. Imipramine<\/li>\n
  4. Theophylline<\/li>\n
  5. Thioridazine<\/li>\n
  6. Quinine<\/li>\n
  7. Chlorpromazine<\/li>\n
  8. Desipramine<\/li>\n
  9. Camphor<\/li>\n
  10. Methylsalicylate<\/li>\n
  11. 3 Tabs of Codeine<\/li>\n
  12. 5 Tabs of Lomotil<\/li>\n
  13. 5 Tabs of Benadryl<\/li>\n<\/ol>\n

     <\/p>\n

     <\/p>\n

    <\/span>INFANT COLIC: EMPIRICAL EVIDENCE OF THE ABSENCE OF AN ASSOCIATION WITH SOURCE OF EARLY INFANT NUTRITION<\/span><\/h3>\n

     <\/p>\n

    Clifford, T.J., et al, Arch Ped Adol Med 156:1123, November 2002<\/p>\n

     <\/p>\n

    BACKGROUND<\/strong>: It has been estimated that from 5% to 40% of infants develop colic, generally between the second and sixth weeks of life. Infantile colic can be the source of significant parental stress, possibly leading to abusive behavior. Some studies have implicated early infant nutrition as playing a role in the development of colic, but methodologic shortcomings limit the confidence with which these conclusions can be accepted.<\/p>\n

    METHODS<\/strong> This study, from the University of Western Ontario, examined relationships between early infant feeding (exclusively or partially breast-fed or exclusively formula-fed) and the development of colic during the first six weeks of life. The study included 856 mother-infant pairs. In addition to nutritional source, information was collected regarding maternal anxiety postnatal depression and social support. A diagnosis of colic was based on prospectively completed diary charts and\/or retrospectively completed questionnaires.<\/p>\n

    RESULTS<\/strong>: Colic developed in 23% of exclusively breast-fed infants, 21% of exclusively formula-fed infants, and 29% of breast-fed infants with formula supplementation. On multivariate analysis that adjusted for confounders, there was no apparent relationship between infant nutrition and the development of colic. Development of colic appeared to be possibly related to factors such as the mother’s employment status two months before delivery, maternal anxiety marital status and use of alcohol.<\/p>\n

    CONCLUSIONS<\/strong>: In this study the development of infantile colic was not related to the source of early infant nutrition.<\/p>\n

     <\/p>\n

    <\/span>Lymphadenopathy<\/span><\/h2>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

    Must first know patterns of drainage:<\/p>\n

    Anterior Cervical=mouth, pharynx, upper respiratory tract<\/p>\n

    Occipital and Posterior Cervical=scalp<\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

    –\"\"<\/a><\/p>\n

     <\/p>\n

    <\/span>Duration of Viral Illnesses<\/span><\/h2>\n

    CLINICAL COURSE OF ACUTE INFECTION OF THE UPPER RESPIRATORY TRACT IN CHILDREN: COHORT STUDY<\/p>\n

    (Br Med J 327:1088, November 8, 2003)<\/p>\n

     <\/p>\n

    Clinicians should advise caregivers that more than half of children with an acute viral infection of the upper respiratory tract will be unwell for at least one week, and about one-fourth will be unwell for approximately two weeks. More realistic predictions regarding the course of the illness might promote greater confidence in caregivers and reduce unnecessary repeat visits.<\/p>\n

     <\/p>\n

    IS THIS CHILD DEHYDRATED? Click here to hear the Reviewer’s comments via MP3. Steiner, M.J., et al, JAMA 291(22):2746, June 9, 2004 BACKGROUND: Several organizations have developed treatment guidelines for pediatric dehydration that are dependent upon clinical classification of dehydration as mild, moderate or severe, but under- or overestimation of the degree of dehydration is common. METHODS: The authors, from the University of North Carolina at Chapel Hill, conducted a systematic review of 13 studies (1,246 patients) of the utility of the history, physical exam and laboratory testing for the assessment of dehydration in children aged one month to five years. RESULTS: None of the studies fulfilled criteria for high methodologic quality. Parental reporting of symptoms was not found to be useful. Of eleven clinical findings, the three most useful predictors of 5% dehydration were prolonged capillary refill time (positive likelihood ratio [LR] 4.1), abnormal skin turgor (LR 2.5) and abnormal respiratory pattern (LR 2.0). Low positive LRs and\/or wide 95% confidence intervals limited the predictive ability of other clinical findings (sunken eyes, dry mucous membranes, cool extremities, weak pulse, absence of tears, increased heart rate, sunken fontanelle and poor overall appearance). Diagnostic accuracy appears to be improved by the use of combinations of clinical findings or clinical scales. The ability of clinical signs to predict the degree of dehydration is problematic, and agreement between examiners is only fair to moderate. BUN or bicarbonate levels should not be considered definitive evidence of dehydration and are most useful when markedly abnormal, although a normal bicarbonate level reduces the likelihood of dehydration. CONCLUSIONS: These findings highlight the pitfalls of relying on clinical evaluation for the assessment of dehydration in children. The authors favor the WHO approach which advocates use of the physical examination to classify dehydration as “none,” “some” or “severe” as a guide to clinical management. 45 references (dewaltd@med.unc.edu)<\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n

    |\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"

    Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[11],"tags":[],"yoast_head":"\nGeneral Approach to Pediatric Emergencies - Crashing Patient<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"CrashMaster\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"28 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/\",\"url\":\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/\",\"name\":\"General Approach to Pediatric Emergencies - Crashing Patient\",\"isPartOf\":{\"@id\":\"https:\/\/crashingpatient.com\/#website\"},\"datePublished\":\"2011-07-14T20:25:39+00:00\",\"dateModified\":\"2011-09-26T22:48:53+00:00\",\"author\":{\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d\"},\"breadcrumb\":{\"@id\":\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/crashingpatient.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"General Approach to Pediatric Emergencies\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/crashingpatient.com\/#website\",\"url\":\"https:\/\/crashingpatient.com\/\",\"name\":\"Crashing Patient\",\"description\":\"\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/crashingpatient.com\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d\",\"name\":\"CrashMaster\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/crashingpatient.com\/#\/schema\/person\/image\/\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g\",\"caption\":\"CrashMaster\"},\"url\":\"https:\/\/crashingpatient.com\/author\/emcrit\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"General Approach to Pediatric Emergencies - Crashing Patient","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/","twitter_misc":{"Written by":"CrashMaster","Est. reading time":"28 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/","url":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/","name":"General Approach to Pediatric Emergencies - Crashing Patient","isPartOf":{"@id":"https:\/\/crashingpatient.com\/#website"},"datePublished":"2011-07-14T20:25:39+00:00","dateModified":"2011-09-26T22:48:53+00:00","author":{"@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d"},"breadcrumb":{"@id":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/crashingpatient.com\/pediatrics\/peds-emergencies.htm\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/crashingpatient.com\/"},{"@type":"ListItem","position":2,"name":"General Approach to Pediatric Emergencies"}]},{"@type":"WebSite","@id":"https:\/\/crashingpatient.com\/#website","url":"https:\/\/crashingpatient.com\/","name":"Crashing Patient","description":"","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/crashingpatient.com\/?s={search_term_string}"},"query-input":"required name=search_term_string"}],"inLanguage":"en-US"},{"@type":"Person","@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/68373c312014141023ba30948675be1d","name":"CrashMaster","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/crashingpatient.com\/#\/schema\/person\/image\/","url":"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/df72275d57de87ddb0cfafc82b66d544?s=96&d=mm&r=g","caption":"CrashMaster"},"url":"https:\/\/crashingpatient.com\/author\/emcrit\/"}]}},"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts\/5342"}],"collection":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/comments?post=5342"}],"version-history":[{"count":0,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/posts\/5342\/revisions"}],"wp:attachment":[{"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/media?parent=5342"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/categories?post=5342"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/crashingpatient.com\/wp-json\/wp\/v2\/tags?post=5342"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}