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Jen Avegno, MD LSU – New Orleans Emergency Medicine Resident Conference 2010

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Jen Avegno, MD LSU – New Orleans Emergency Medicine Resident Conference 2010
Jen Avegno, MD
LSU – New Orleans Emergency Medicine
Resident Conference 2010

2006 National Hospital Ambulatory Medical Care
Survey showed:

most common ED diagnosis for
 kids <1 = upper respiratory infection
 kids 2-12 = otitis media/ear disorders

In all, fever is the most common chief complaint of
kids presenting to the ED (about 20-30% all peds
visits)
this lecture is about
NOT



Review high-yield, commonly encountered,
infections of childhood
Discuss pathophysiology, common organisms,
presentations, management and treatment of each
See LOTS of pictures of my children

Mom brings in a 3-week-old baby girl with a fever
for 4 hours. The child was a normal vaginal delivery
with no complications and has been feeding and
growing well at home. This morning, she began to
“spit up” her bottle and had several loose stools.
She has been somewhat sleepy but does respond
to her parents. Physical exam reveals a child in no
distress with a rectal temperature of 100.8 and a
normal exam for age.

what is the risk of serious bacterial illness (SBI) in
kids less than 3 months with fever?
SBI = UTI, bacteremia, meningitis, osteo, pneumonia,
gastroenteritis, cellulitis, septic arthritis
 risk is about 6-10% in these kids, with those younger than
1 month having the highest chance of SBI


kids under 3 months may present looking like “viral
syndrome” but still have SBI … in one study, kids
less than 60 days with temp>38:


22% had RSV
7% with RSV also had concomitant SBI



immature immune system
exposure to pathogens during delivery (esp. GBS)
cannot mount immune response to prevent
localized infection from disseminating


fever = “a pyrogen-mediated rise in body
temperature above normal range”
what is a NORMAL temp?



the magical 98.6 was set as “normal” by a German guy in
the 19th century using a 22cm long mercury glass
thermometer … we now think that his instruments may
have been OFF by 1.5-2 degrees!!
normal temps can vary by age in kids from 99.5
(neonates) to 98 (older kids)
temps are influenced by age, sex, race, time of day,
activity level, ambient temp, site of measurement, type
of device


NO REAL EVIDENCE to support the hardand-fast cutoff of 100.4 (38°C) –
evidence suggests that oral temps 37.237.8 may be considered febrile
depending on situation
BEST SITE to measure temperature …


the hypothalamic artery. (yeah, right)
take-home point: fever is an ARBITRARY
number – base your workup on overall
clinical impression, not a particular
cutoff

oh, yeah, the “mom hands” … don’t blow them off!


60% of parents use their hands instead of a thermometer
to assess fever
is this method accurate? studies show:
 74-90% sensitive
 76-86% specific
 85-94% NPV

the exact number or method doesn’t matter …
BELIEVING the parents is!
AGE
BACTERIAL
VIRAL
OTHER
0-28 days
Group B Strep
Listeria
E. Coli
C. trachomatis
N. gonorrhoeae
Herpes simplex
Varicella
Enterovirus
RSV
Flu
Bundling
environment
1-3 months
H. flu
S. pneumo
N. meningiditis
E. coli
Varicella
Enterovirus
RSV
flu
Bundling
environment






length of illness
localized symptoms?
pertinent PMH, birth hx of both mom & baby
sick contacts
vaccination status
any meds/ABx


VITAL SIGNS (yes, ALL of them!!)
ABCs – respiratory/airway distress? signs of shock?
tachycardia?



for infants less than 1 year, HR should increase 10 beats
for every 1°C
TAKE THOSE CLOTHES OFF!!
just remember … in non-immunocompetent kids
(neonates) … fever may be the ONLY presenting
sign of SBI – do not be reassured by a “normal”
exam!!



again, ABCs … consider intubation for respiratory
distress, hypoxia, altered MS
fluid resuscitation: 20 ml/kg IV/IO fluids to total of
60-100 ml/kg (if hypovolemia persists)
cultures prior to Abx, if possible


sterilization of CSF can occur as quickly as 15 min – 2 hrs
after receiving Abx, so watch results!
BROAD SPECTRUM TREATMENT:


Ampicillin + (Gentamycin or Cefotaxime) – avoid Rocephin
in kids <28 days
Vanc? Acyclovir?
PHILADELPHIA
ROCHESTER
BOSTON
AGE
29-60 d
<60 d
28-89 d
TEMP
>38.1
>37.9
>37.9
EXAM
well, no focus
well, no focus
well, no focus
LAB VALUES (lowrisk)
WBC <15
Band<0.2
UA < 10 wbc
CSF < 8 wbc
neg CXR
WBC 5-15
band <1500
UA <10 wbc
WBC <20
HIGH-RISK dispo
admit, IV Abx
admit, IV Abx
admit, IV Abx
LOW-RISK dispo
home, no Abx
home, no Abx
home, empiric Abx
How good is it??
sens/spec
PPV/NPV
98%/42%
14%/99.7%
92%/50%
12%/98.9%
NPV 94.6%
** these rules miss very few kids with SBI **
UA <10 wbc
CSF <10 wbc
neg CXR



cancer
toxic shock
autoimmune and/or congenital disorders (cardiac,
pulmonary)

Dad comes to the ED with little Maria, age 2, and
reports that she has had a fever for the last 2 days
(up to 103.4 at home). The parents have tried
Tylenol and Motrin to no avail. Maria has not eaten
much but is still drinking water and juice. She had a
“runny nose” a few days ago, but is not sneezing,
coughing, or vomiting. In the ED, Maria has a
temperature of 102.8. She looks droopy, but
interacts well with her parents.


fever is the most common complaint in this age
group!!
unlike neonates, of young children who present
with viral illness (RSV, croup, bronchiolitis etc) and
fever (>39), less than 0.5% will also be bacteremic

concern here is for OCCULT BACTEREMIA


before HiB and Prevnar, the rate of occult bacteremia in
the non-focal febrile child was 5%
currently … it is less than 1% with other pathogens more
prevalent
 N. meningiditis
 urinary pathogens

WHY do we treat a fever?




feel better/decrease anxiety
lower morbidity/mortality
prevent febrile seizures
HOW do we treat a fever?






ambient temp control
light clothing/bedding
fluids
sponge bath
warm feet/potatoes or onions in socks (REALLY!)
antipyretics



Acetaminophen 15 mg/kg every 4-6 hours
Ibuprofen 10 mg/kg every 6 hours
alternate??



evidence shows some minor benefits in reducing fever
faster and lasting longer BUT …
potential for dosage/scheduling errors; synergistic renal
toxicity; difficult to understand and comply
detailed information/handout at appropriate
reading level on administration of antipyretics
should be given to caregivers!!
AGE
BACTERIAL
VIRAL
OTHER
3-36 months
S. pneumo
N. meningiditis
E. coli
Varicella
Enterovirus
RSV
Flu
Mono
Roseola
Adenovirus
Norwalk
Coxsackie
Leukemia
Lumphoma
Neuroblastoma
Wilms’ tumor


length of illness
localized symptoms?






headache – neck pain – sore throat – pulling @ ears –
cough (describe!!) – wheeze – vomiting – RASH – mental
status
use of antipyretics (**defervesence after use does
NOT exclude bacteremia!)
sick contacts
po intake/output
vaccination status
any meds/ABx


VITAL SIGNS (yes, ALL of
them!!)
ABCs – respiratory/airway
distress? signs of shock?
tachycardia?


capillary refill is an easy and
reliable indicator of perfusion
TAKE THOSE CLOTHES OFF!!

thorough search for focal
findings


most guidelines argue for getting the WBC first,
then CXR if WBC > 20k … but who does this?
study showed that rate of pneumococcal
bacteremia increased to 0.5% with WBC 10-15k;
3.5% with WBC 15-20k; 18% with WBC>20k

ANC >10k (include all immature forms) increases risk of
bacteremia by 10-fold over those with ANC<10k

the post-immunization world has resulted in much
lower rates of bacteremia for this age group:



where bacteremia rates in febrile kids >1.5%, the most
cost-effective strategy is a WBC, blood CX, and empiric
Abx (Rocephin)
when rates <0.5%, clinical judgment alone for treatment
& management is most useful to select out high-risk
groups
kids 3-6 mo are still relatively nonimmunocompetent … recommendations are for all
kids in this age group with temp >39 to have WBC &
BCx; treat all WBC > 15k with empiric ABx



CANCER
autoimmune disease: JRA, Kawasaki’s
brain tumors

Mom brings in a 6 year-old boy with “pink eye.”
She got a call from school today that the child’s
right eye was red and draining yellow gunk, and
that she needed to pick him up. The boy is afebrile
and non toxic, with no recent illnesses or PMH.
Immunizations are up to date. He has mildly
injected right conjunctiva with some seropurulent
drainage from the eye, as well as mild nasal mucoid
rhinorrhea. What now?


conjunctivitis = “inflammation of bulbar & palpebral
conjunctiva caused by various viral, bacterial,
mechanical, allergic & toxic agents”
most frequent pediatric eye complaint in the ED

viral: adeno, coxsackie, entero, rhino, flu
**MOST COMMON**

bacterial:
S. pneumo
 H. flu
 S. aureus
 M. catarrhalis
 N. gonorrhoeae (yuck)
 less common: other Gram negatives (Pseudomonas)


viral – generally itchy, red, irritated with watery or
purulent discharge, preauricular LAN
associated with other URI sc
 may start in one eye & spread to other
 may last longer than bacterial


bacterial – “pinkeye,” redness, FB sensation, lid
swelling, drainage, “eye boogers”


usually no photophobia or vision impairment
allergic – very itchy, usually bilateral
FINDING
BACTERIAL
VIRAL
Bilateral at onset
50-74%
35%
Conjunctival discharge
mucopurulent
watery
Preauricular adenopathy
late
early
Concurrent OM
20-73%
10%


viral – artificial tears, cool compresses,
antihistamine drops if necessary
bacterial – warm compresses & topical Abx:
sulfa, floxin (ok in kids!), erythromycin, neomycin
 ointment vs. drops??

 ointment – soothing, prolonged contact with conjunctiva
 drops – do not blur vision, ?easier to get in?

tx for 7 days




no established guidelines for ED management/care
of conjunctivitis (darn.)
bacterial conjunctivitis – most common standard is
return to school 24 hours after beginning Abx
treatment
viral conjunctivitis – ??
If you don’t think it’s pinkeye … SAY SO &
DOCUMENT for parents!

ophthalmia neonatorum – conjunctivitis within 1st
month of life


within 1st 2 weeks – gram stain & culture of drainage
N. gonorrhoeae – usually from birth canal, within 1st 1-7
days of life – must carefully evaluate for disseminated GC
 tx = Rocephin

Chlamydia – usually sx between 5-19 days old
 tx = topical Erythromycin


chemical – from ointment given at birth; dx of exclusion
HSV & VZV can affect the eyes and lead to scarring,
dry eye

Mom brings in a 15-month old girl who woke up
last night screaming and with fever to 101.2. She
has not eaten much today but is drinking liquids
with normal urine output. All of her immunizations
are up to date and she is otherwise healthy. On
exam, you note a mildly ill appearing, non-toxic
child who responds well to mom. The left TM is red
and bulging with loss of landmarks.



Most commonly diagnosed disease in kids <15
By age 3 – estimated that more than 80% of kids
have had one episode; 40% have had >3
Risk factors:
Male
 Smoking
 Day care
 Family history
 Anatomic abnormalities
 Winter
 Bottle feeding


ACUTE: s/s of acute infxn WITH effusion


OME: effusion WITHOUT s/s of acute infxn



aka “acute suppurative” or “prurulent” OM
aka “serous,” “mucoid,” “secretory,” “nonsuppurative”
CHRONIC: chronic ear discharge from perforated
membrane
RECURRENT: >3 episodes in 6 mo or >4 episodes
in 1 year

It’s all about the tube – functions of
the eustachian tube:




Ventilates middle ear for pressure
equilibration
Drains middle ear
Protects ear from NP secretions
Only open when
yawning/chewing/swallowing
CHILD
When the eustachian tube
becomes obstructed …
Middle ear ventilation
Negative middle ear cavity
pressure causes fluid to
move into middle ear
(transudate)and combine
with NP secretions &
bacteria
•S. Pneumoniae
•H. flu –higher % in OME
•M. catarrhalis
•S. aureus
•S. pyogenes
•gram-negative bacteria
•VIRUSES:






“Pulling at ears”
Cough
Vomiting & diarrhea
Decreased po intake
Fever – may be present in only ¼ of cases, with less
than 10% having temp >40
URI sx
pars flaccida
malleus
pars tensa
umbo
eustachian tube
opening
light reflex

What does the TM look like?
bulging
erythematous
hemorrhagic
normal
Middle ear effusions
other indicators of AOM:
lack of TM mobility *** (MOST RELIABLE SIGN)
cloudy, retracted, dull TM
1/3 of cases may NOT have symptoms!
AAP/AAFP guidelines state that the following should be
present to dx AOM:
1.
2.
3.
Recent, usually abrupt onset of s/s
Presence of middle ear effusion
(bulging, limited TM mobility, air-fluid level,
otorrhea)
S/s of middle ear inflammation
(erythema or otalgia)

AAP guidelines on management of AOM in
kids:





Dx by hx of acute onset + signs of effusion + signs of
middle ear inflammation
Assess for pain – if present, treat
Limited role for observation in select patients > 2
years (must have “a ready means of communication
with clinician”)
If treat with ABx – start with amox 80-90
mg/kg/day
If treatment failure by 48-72 hours – reconsider dx
or change ABx
Temp <39.1 or
severe otalgia or
BOTH
Initial Tx
Clinical failure
after 48-72 hrs
with initial tx
NO
Amox 80-90 mg/kg/day
PCN all: cefdinir,
cefuroxime, cefpodoxime,
azith, clarith
Augmentin 90 mg/kg/day
(of amox)
PCN all: Rocephin (3 day
tx), clinda
YES
Augmentin 90 mg/kg/day
(of amox)
PCN all: Rocephin (1-time
or 3 day tx)
Rocephin (3 days)
PCN all: clinda +
tympanocentesis

Important points:







“treatment failure” = lack of clinical improvement and/or persistent
signs of AOM
Bactrim & macrolides often considered 2nd line, but resistance rates
approach 30-40%
Courses are generally 10 days in patients < 2 yrs , perf TM, and
recurrent OM, recommended in patients <6 years
NO INDICATION for antihistamines, decongestants, steroids, or tubes
in single episode AOM
Auralgan may be useful for pain relief
Tx of OME (either alone or following episode of OM) is
controversial – ABx? Antihistamines?
Tubes for patients with OME for 4-6 months, failed tmt, and
hearing loss


otitis externa
mastoiditis

Parents bring an 8 year old boy to the ED with fever
of 102.3, and complaints of headache and
abdominal pain. He was otherwise healthy until
this morning, and his shots are all up to date. The
patient is febrile and tachycardic to 120 with
normal blood pressure. He is ill-appearing but nontoxic, speaks normally, and is not drooling. His
oropharynx is red with bilateral white exudates and
tender, palpable cervical lymphadenopathy.



dx of tonsillitis/acute pharyngitis is made more
than 7 million times/year
MCC is viral in kids
MCC bacterial pharyngitis is GABHS (15-30%)




kids 5-15 y/o predominantly
Group C & G Strep are likely much more common than
typically thought & may be missed by routine testing
about 1 in 4 kids with acute sore throat has serologically
confirmed GABHS
MC in winter when respiratory viruses predominate

BACTERIAL:

Strep
 Group A
 Groups C & G





mixed anaerobic (“Vincent’s angina”)
N. gonorrhoeae
C. diphtheriae
Arcanobacterium haemolyticum; Yersinia; tularemia
atypicals

VIRAL: rhino, corona, adeno, paraflu, flu, CMV;
HSV 1 & 2 – oral gingivostomatitis
 Coxsackie – aka herpangina – fever & painful, white-gray
papulovesicular lesions/ulcers in posterior OP
 EBV - **mono**

 severe pharyngitis with GENERALIZED LAD (posterior
cervical), hepatosplenomegaly, periorbital edema, palatal
petechiae
 Amoxil rash!!

HIV** may be most common presenting sx!
herpangina
diphtheria
HSV
stomatitis
weird
looking
throats
Vincent’s
angina


sick contacts – common in both bacterial & viral
causes
how to differentiate viral vs. bacterial sore throat?
BACTERIAL (GABHS)
VIRAL
Sudden onset
More gradual
+ fever
+/- fever
headache
conjunctivitis
N/V/abd pain
diarrhea
Tender anterior LAD
Cough, hoarseness, coryza
Patchy discrete exudates
myalgias
Scarlatiniform rash


single throat swab & culture is 90-95% sensitive;
rapid kits are 90-99%
Modified Centor criteria for dx of GABHS in kids:
tonsillar exudates
 tender anterior cervical LAD or lymphadenitis
 absence of cough
SCORE RISK OF MGT
GABHS
 hx of fever
0
1-2.5%
No testing or Abx
 age < 15 add 1 point

1
5-10%
2
11-17%
3
28-35%
Culture; Abx for +
results
4-5
51-53%
Tx without test


most common viral causes are self-limited and
resolve with supportive tx
GABHS is generally self-limited and resolves
without tx … but … why do we treat with Abx?


symptom relief; decrease spread; shorten duration of
illness (16 hrs)
prevent complications (1 in 1000)
 suppurative – bacteremia, endocarditis, mastoiditis,
meningitis, OM, PTA, RPA, pneumonia
 nonsuppurative – PSGN, RF

Abx options:




Pen V K po or Pen G IM
Amox
PCN allergy – Keflex, Azithromycin (resistance rates near
10% thanks to us!)
supportive measures – antipyretics, warm salt
water gargles, cool soothing fluids, etc.





mono
retropharyngeal abscess
peritonsillar abscess (older adolescents)
epiglottitis (more common in adults now)
scarlet fever – caused by pyrogenic exotoxinproducing form of GABHS in non-immune
individuals


outbreaks are cyclical
rash 24-48 hours after onset of symptoms (may be longer)

Two worried parents rush their 1 year old baby to
the ER at 2 am because of “breathing problems”
and fever. She was a normal healthy infant until
she woke up at midnight with a high fever,
breathing fast, and wheezing. There is no prior
history of asthma and no sick contacts. The baby is
febrile to 101.3, breathing 40 times a minute with
some retractions and audible wheezes but has a
vigorous cry.



worldwide phenomenon, usually winter – spring
transmitted through secretions
may manifest as



bronchiolitis – may result in bronchial obstruction
pneumonia – severe inflammation in alveoli & interstitial
tissue – greatest in kids < 1 yr
greatest % of hospitalizations for respiratory
reasons in infants (2-5% of those hospitalized will
need intubation)

increased risk in preemies, congenital conditions, boys,
lower socioeconomics



most likely (75%) caused by parainfluenza virus
peak incidence 3 mo – 3 years
MCC infectious airway obstruction in kids
(subglottic … at narrowest diameter)

3-5 day incubation period, followed by:
cough
 WHEEZE
 prolonged expiratory phase
 apnea (up to 20% infants with RSV)



may have RAPID decompensation (kids have less
pulmonary reserve)
CXR may be normal, show lobar pneumonia or
peribronchial inflammation
steeple sign




1-4 day incubation period
barking, “seal-like” cough with
“whistling” (stridor) on inspiration,
sneezing, nausea/vomiting, fever,
hoarseness
often worse at night … then gets
better when the kid is taken outside
to drive to ER …
90% of cases are mild! (whew)

treatment is largely SUPPORTIVE
supplemental oxygen
 secretion management
 admitted kids – consider ribavirin, NO, heliox
 high-risk kids get preventative antibody/immunoglobulin
 nebulized B-agonists – short-term improvement in
oxygenation, unclear if there is a real benefit (same for
racemic epi)
 NO significant benefit for steroids


Westley croup score
SIGN/SX
0
1
2
3
Retractions
None
Mild
Moderate
Severe
Stridor
None
With
agitation
At rest
Cyanosis
None
LOC
Normal
Air entry
Normal
≤2 = mild croup
3-7 = moderate
≥8 = severe croup
4
5
With
agitation
At rest
Disoriented
Decreased
Markedly
decreased

about 6% kids with croup are hospitalized, only 1%
of these are intubated



mist inhalers, steam showers
nebulized racemic epi?



moderate – severe croup despite tmt usually means
admission
short-lived benefit; sx may recur within 2 hours
may give q1 hr – but >1 dose often means admission
steroids

IM or po dexamethasone (0.6 mg/kg) may decrease need
for hospitalization and/or return visits



aspirated FBs
underlying lung pathology (CF)
other causes of pneumonia/bronchitis


kids will be kids and get SICK
fortunately, most of the time they are not TOO SICK


(let us all say a prayer of thanks to the guy(s) who
invented vaccines)
when you hear hoofbeats … it’s OK to consider a
zebra, as long as the herd of horses doesn’t trample
you while you’re thinking …
Fly UP