health

1. Andrew Hashikawa, MD, MS, FAAP
Assistant Professor
Children’s Emergency Services
University of Michigan Medical School

2.  No Conflicts of Interest to Report

3. Undergraduate:
University of Michigan-Flint
(Chemistry and History)
Medical School and Pediatric Training:
Mayo Clinic
Pediatric Emergency Medicine Fellowship:
Children’s Hospital of Wisconsin

4. 1. Review case-based treatment and management pearls of
common infectious and injury complaints in urgent care
settings.
2. Learn procedures for common complaints in primary care
and urgent care settings
3. Understand urgent issues that should be referred to the ED.

5.  6-year-old male
 Fell at playground
 Wrist pain
 No snuff box tenderness
 No deformity, open wound, or swelling
 Some tenderness at wrist with palpation

6.  Small buckle
fracture distal radius

7.  Data support - removable
splint in 6+ year old children
who will keep splint on
 No difference vs. casting
 Healing
 Pain
 Better function and parent
satisfaction
Plint,AC et al. A RandomizedControlTrial of Removable SplintingVs. Casting for Wrist
Buckle Fracture in Children. Pediatrics 2006.

8.  4 year-old-female
 Hx of URI & wheezing and
one prior ER visit with no
hospitalization
 Clears after one Duoneb
 Parents says nebulizer
worked best and wants Rx
for nebulizer

9.  Meta-analyses show nebulizer and MDI clinically equivalent
 Nebulized albuterol (0.15 mg/kg per dose max 5mg) higher doses than MDI
 But . . . MDI delivers particles more effectively to lungs, cheaper, faster, and
portable, and shorter ED stays = so tie goes to MDI.
 Must use higher doses of MDI
 2-4 puffs young children
 4-6 puffs older children
 4-8 puffs adolescents
Cates CJ et al. Holding chambers versus nebulizers for beta-agonist treatment of acute asthma. Cochrane Database
of Systematic Reviews. 2003.

10.  If fails initial treatment in the clinic or urgent care (moderate
exacerbation) . . .
 Give steroids as soon as possible before sending to ED to
treat inflammatory process.

11.  15 year old male – seen by
urgent care for asthma 2
days ago
 Using albuterol MDI every
2 hours (2 puffs)
 On day 2 of steroids
 Patient says albuterol “not
working.”
 Mild, scattered diffuse
wheezing
 Looks well and no distress
 One neb treatment later he
looks well and is completely
clear

12.  Steroid dosing?
 MDI # of puffs?
 Technique?

13.  Consider single or 2-dose regimens of dexamethasone as a
alternative to a 5-day course of prednisone/prednisolone.
 Prednisone 60 mg or Dexamethasone (0.6 mg/kg) 12-16 mg max for
adults ( 1 or 2 dose regimen)
 MDI # of puffs? 6-8 puffs
 Technique: Lack of spacer (Rx cost) – little medication in lungs.

14.  24 month old Female (13 kg)
 Barky cough this morning
 Hoarse voice
 Noisy breathing last night
 Currently no stridor
 Child looks well, no cough

15.  Low threshold to give – sx likely to get worse tonight, day 2 or 3
 Dexamethasone liquid
 0.5 mg/5 mL (majority of outpatient pharmacies)
 13 kg at 0.6 mg/kg = 8 mg
 One dose = 80 mL = over 2 ½ ounces of dexamethasone liquid.
 Taste is terrible!
 Dexamethasone tablets
 Small (2 small tablets)
 Easily crushed and mixed with applesauce or chocolate syrup

16.  20 month old infant
 An in-home child care setting
 Ate yogurt for the 2nd time
 Developed hives and vomited once
 Crying and inconsolable
 No tongue swelling, diarrhea,
hypotension, wheezing or stridor.

17.  True food allergies affect 6-8% of children < 4 years of age
 Among Peanut Allergy Registry, 16% with allergic reaction to peanut/tree nut
in school or child care, with 64% of reactions occurring in preschool or child
care.
 25% of allergic reactions occurring in preschool or child care centers
represent the first reaction.
 Majority of reactions begin with GI symptoms.
 NEISS data base – 13% of all food allergies had anaphylaxis, but 50% pediatric
patients.

18.  Younger children that are
inconsolable - worrisome for
abdominal pain (gut edema)
 Many providers do not recognize GI
symptoms/fussiness as symptom of
anaphylaxis
 Very low threshold for Epipen Jr.

19. 0%
0%
0%
0% A. Yes
B. No
C. Practice only
D. Don’t know how to give

20.  Blue to the sky
 Orange to the thigh
 Count 10 to 1 (hold)
 Then call 911.

21.  2 year old infant
 Pulled up by arms and
swung around
 Now not using the right
arm
 Exam reveals no swelling

22.  Hyperpronation:
 Required fewer attempts than supination
 more often successful than supination,
 and was often successful when supination failed.
Macias et. Al. A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations
Pediatrics. 1988

23.  11 month old M with 2 days of
fever eating less.
 Looks nontoxic and TM’s are
fine
 Patient is teething (drooling
more) and fussy, but
consolable

24. Case 7: Pearl
- Don’t forget to look in posterior
pharynx (need to use tongue
depressor)
- Will often miss source of fever
- Herpangina
- Clues are decreased eating, more
drooling, fever, “teething”

25.  Cause?
 Coxsackievirus A16 and Enterovirus 71
 Spread?
 Virus shed several weeks; respiratory, direct, fecal-
oral
 Exclude from School/Child Care?
 No, unless fever, behavior change, unable to
participate
 Return?
 When exclusion criteria end. Ibuprofen!

26. MALES
 < 1 year old
 Uncircumcised
 Or history of UTI
 > 3% risk
FEMALES
 < 1 year
 Temperature >39C
 White Race
 Fever > 2 days
 Absence of another source of
fever on hx or exam
 3 or more have best accuracy in
making diagnosis.
Gorelick, MH:Validation of a decision rule identifying febrile young girls at high risk for urinary tract
infection. Pediatr Emerg Care, 2003.

27. MALES
 < 1 year old
 Uncircumcised
 Or history of UTI
 > 3% risk
FEMALES
 < 1 year
 Temperature >39C
 White Race
 Fever > 2 days
 Absence of another source of
fever on hx or exam
 3 or more have best accuracy in
making diagnosis.
Gorelick, MH:Validation of a decision rule identifying febrile young girls at high risk for urinary tract
infection. Pediatr Emerg Care, 2003.

28. Case 8
1-year-old
Blisters, rash on
feet.
Fussy but
consolable.

29.  Often palms, soles, head, neck in children
 Treatment?
 Permethrin cream (1% or 5% cream?)
 Head to toes overnight (8 – 12 hr)
 Wash, repeat 2 weeks
 Close contacts
 Itching may persist – hypersensitivity
 Topical steroids, antihistamines

30. Case 9:
4 year old girl
Clinical findings of
strep.
Rapid strep is
positive.

31.  Treatment? – Amoxicillin (best tasting)
 50 mg/kg dose (max 1 g) daily x 10 days
 Penicillin G benzathine IM x 1
 Consider first dose in ED + Rx note

32. Case 9:
17-year-old female
Sore throat
What else to
consider besides
strep?

33. Case 10: Conjunctivitis
4 year old Male
Some clear drainage
from both eyes. His
temperature is
97.5° axillary.

34.  Viral
 Exclude from school/child care?
 Only if fever, behavior change
 Return? – AAP recs:
 Antibiotics – no longer required
 Consider Rescue Rx and Note
 May be child care issue

35. Case 10:
5 year old
Male
Honey
colored,
crusty
lesion.

36. Case: 10 Impetigo
 Exclude From School or Child Care?
 At end of day, not immediate
 Return?
 Treatment – “24 hours”
 Treatment:
 Single lesion: Topical mupirocin
 If multiple lesions or near mouth or outbreak,
systemic antibiotic*
 If strep - Concerns about acute rheumatic fever? - No

37. Case 11 :
3 year old Male
Yellow, crusted
area for several
weeks
Feels indurated,
boggy.

38.  Cause?
 Kerion – cell-mediated response to tinea capitis
 Often confused with bacterial skin infection
 Oral antibiotics and incision and drainage not recommended
 Treatment?
 Griseofulvin 10-20 mg/kg (max 1g) (microsize)
 4-6 weeks, 2 weeks past resolution symptoms
 Terbinafine (≥4yo) 6 weeks equivalent
 ±Selenium sulfide shampoo
 Return to school or child care?
 Treatment started

39. Case 12:
•2 year old Male
•Presents with intense
scratching of anus.
•Mild irritation around rectum
•4 yo sister with vaginal
itching
•What is the cause?

40.  Exclude?
 No.
 Treatment?
 Mebendazole 100 mg po x1
 Repeat 2 weeks
 Treat family
 Return to school?
 Immediately after 1st treatment

41.  5 y/o M
 Febrile
 Pain
 Has otitis media

42. Acute Otitis Media (AOM)
• Middle Ear Effusion (MEE) - demonstrated by pneumatic otoscopy,
tympanometry, air fluid level, or a bulging tympanic membrane plus
• Evidence of acute inflammation – opaque, white, yellow, or
erythematous tympanic membrane or purulent effusion plus
• Symptoms of otalgia, irritability, or fever

43.  If well, no severe pain, or fever – Rescue Rx (50%
will not fill)
 Azithromycin 30 mg/kg ( 1 dose)
 Cefdinir (10-15% cross over allergy) but 14 mg/kg
once daily dosing
 Side effect of Cefdinir?

44.  The management of AOM should include an assessment of pain. If pain is
present, the clinician should recommend treatment to reduce pain
regardless of the use of antibiotics.
 Pain associated with AOM can be substantial the first few days and often
persists longer in young children.
 Antibiotic tx does not provide symptomatic relief in the first 24 hours
 Even after 3 to 7 days, there may be persistent pain, fever, or both in 30% of
children < 2 years of age.
 Analgesics do relieve pain associated with AOM within 24 hours

45. 2 year old itching scalp.

46.  How long has it been there?
 Occur in all socioeconomic groups
 Exclude?
 Only at end of day.
 Treatment
 Over-the-counter
 None of old remedies (mayo) have been show n to work.
 No evidence that combing improves treatment success if using chemical tx
 Return?
 No nit policy? – nits farther than ¼ inch from scale do NOT have live lice in them
 1st treatment; may need 2nd; Vacuum effective; 5 minutes > 129 degrees and dried
hot setting;
 Itching persists: why?
 - reaction to saliva (may persist for weeks)

48. Case : Nasal Foreign Body
•3 year old Male

57.  6 year old brought by mom
 No wheezing
 History of bad asthma
 Looks tired
 Sats 87%
 Not better after couple Duonebs

58.  Call EMS
 Next step while waiting?

59. 0%
0%
0%
0%
0% A. Intubate
B. Start IV
C. Epipen
D. Inhaled steroids
E. Xray

60.  Blue to the sky
 Orange to the thigh
 Count 10 to 1
 Then call 911.

61. Case 9: Foreign Bodies
2 year old Male
“Swallowed a coin”.
No respiratory distress.

65.  Button Battery or Magnets – urgent removal
 Typically once in stomach – we let foreign bodies
pass (except magnets)

66. Dental Injury
•6 year old Male
•Playground (vs. pole)
30 min ago
•Dad kept tooth
•Unsure if permanent
or baby tooth

68.  Can store in
 Cold milk or Hank’s Balanced Salt Solution
 Saline (less preferred)
 ED (if avulsed permanent tooth)
 Can reimplant avulsed PERMANENT tooth
 Don’t scrub
 Rinse with saline
 Insert root of tooth into socket
 Send to ED for splint.
 90% survival (30 min);
 Declines 1% every minute beyond 30 min
 > 60 minutes (dry) almost never viable.