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Pedi̇atri̇k vakalar(fazlası için www.tipfakultesi.org)

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Pedi̇atri̇k vakalar(fazlası için www.tipfakultesi.org)

  1. 1. Pediyatrik Vakalar
  2. 2. My stomach hurts 5 year old with vomiting and diarrhea – Arrives because of persistent fever – In general pain actually improved a couple of days ago – Looks very good. Watching TV (the advantage of having a new ED). In no distress – Abdominal diffusely and nonfocally tender – Ultrasound done to exclude appendicitis because pediatrician wanted one. – WBC normal Ultrasound negative – Patient discharged with diagnosis of gastroenteritis
  3. 3. Pediatric Appendicitis • Lifetime risk 7% • Misdiagnosis is common in young children – 100% around age 2 – 70% ages 3-5 – 40% ages 6-10 • Post-op complication from perforation increase from 8% to 39% QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  4. 4. Why is appendicitis missed Most common misdiagnosis is GASTROENTERITIS Up to 33% of kids under age 3 have “diarrhea” • 40% of missed appy is called gastroenteritis • Pay CLOSE attention to exam. Gastro tenderness is diffuse, not localized. • BEWARE: Kids under 5 are less likely to wall off their appendix and more likely to present with diffuse peritonitis • CAREFUL physicians should not miss these
  5. 5. Diagnosis • Clinical judgment • Labs • Plain Xray • Ultrasound • CT scan Even in the best of hands the rate of normal appendix on operation in “classic” cases is over 10%. It is higher in more equivocal cases Up to 20% in pregnancy
  6. 6. Diagnosis • Clinical judgment • Labs • Plain Xray • Ultrasound • CT scan The peripheral WBC is of extremely limited use – Children with VERY common viral gastroenteritis or bacterial gastro often have high WBC counts – Children with early appendicitis are OFTEN normal
  7. 7. Diagnosis • Clinical judgment • Labs • Plain X-ray • Ultrasound • CT scan • Plain abdominal Xrays are useless – Obtained because often other diagnostic tests are unavailable – This does not make them any better • Not sensitive or specific • Do not discriminate • Fecalith is unreliable
  8. 8. Diagnosis Ultrasound • Limited radiation • Relatively sensitive – VERY dependent on the skills of radiologist – Up to 80% helpful with good reader • Does NOT exclude appendicitis CT Scan • More radiation • Expensive • Often unavailable • Extremely sensitive – Less operator dependent – Up to 95% sensitive • Excludes appendicitis if normal appendix seen – Avoids operation
  9. 9. What about our girl Came back 3 days later with perforated appendicitis • She was likely perforated on initial evaluation • She felt better when appendix ruptured a couple days earlier • Illustrates several pitfalls • Often misdiagnosed as gastroenteritis • Often has diarrhea • Often has normal WBC • Often has nonfocal exam • Ultrasound limited in EXCLUDING appendicitis
  10. 10. Pediatric hip pain • Septic arthritis • Toxic synovitis • Legg-Calve-Perthes • Aseptic necrosis • SCFE (Slipped Subcapital Femoral Epiphysis) QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  11. 11. Septic hip vs toxic synovitis This is the REAL question Septic Arthritis • Average age 3-5 years • Time to presentation – 4+ days • May be afebrile – But most have low grade temperature • May not look clinically ill if early Toxic Synovitis • Average age 3-4 years • Time to presentation – 5+ days • May be very febrile – But most do not have a temperature • May be extremely uncomfortable and refuse any range of motion
  12. 12. Septic hip vs toxic synovitis Goal to identify EARLY before extensive damage Temperature and ESR are helpful in excluding septic hip – Most kids (66%) with septic arthritis with temperature over 37.5 °C – Most kids (80%) with septic arthritis with ESR over 20 – Combination picks up over 90% of sepsis
  13. 13. Septic hip vs toxic synovitis Problem with using temp and ESR – Up to 50% of kids with toxic synovitis have temperature OR a high ESR Step two: Imaging – Plain films – Ultrasound QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  14. 14. Septic hip vs toxic synovitis Looking for fluid Plain films • Insensitive & will only show advanced cases with a lot of fluid Ultrasound • Sensitive and will find show small amounts of fluid seen in synovitis
  15. 15. Septic hip vs toxic synovitis Tapping the hip Up to now the evaluation has been working towards EXCLUDING cases of toxic synovitis. If there is a temperature or high ESR and fluid in the hip, you must do a diagnostic arthrocentesis – In the US this is an orthopedic procedure – There is some time urgency here – Diagnosis of septic hip should be washing out in the operating room – Antibiotics for staph and strep should be considered if ANY delays in operation or arthrocentesis are possible
  16. 16. Toxic synovitis After discharge Toxic synovitis is a viral reactive arthritis and is managed with ibuprofen or aspirin BUT…all cases require MANDATORY 12-24 hour follow to make SURE you are not missing septic arthritis
  17. 17. Other causes hip pain Legg-Calve-Perthes Idiopathic avascular necrosis of the femoral head – Other cases related to chronic steroid use or sickle cell disease School age children Early cases with normal Xray – Need MRI or bone scan
  18. 18. Slipped Capital Femoral Epiphysis Slipped growth plate at end of femoral head Adolescents Generally (not always) obese Early cases with normal Xray – Need MRI or bone scan
  19. 19. Slipped Capital Femoral Epiphysis Slipped growth plate at end of femoral head Adolescents Generally (not always) obese Early cases with nothing on Xray – Need MRI or bone scan K lein’s line ?
  20. 20. Slipped Capital Femoral Epiphysis Price of a missed case – Complete slip – Disrupted growth plate – Lost growth potential – Avascular necrosis of femoral hip – Chronic arthritis and DJD or hip Early pickups allow placement of a pin and potential recovery
  21. 21. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  22. 22. The toxic neonate That kid looks BAD! Some illnesses present in the first two weeks of life with an abrupt deterioration A good clinician will understand that this is NOT always sepsis QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  23. 23. The toxic neonate That kid looks BAD! Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  24. 24. The toxic neonate Critical issues • Stabilization – Rapid IV access – Adequate fluid resuscitation – ETT and pressors? • Ampicillin/Gentamicin – Listeria – E coli – Group B strep Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
  25. 25. The toxic neonate Critical issues • Recognition • Stabilization – Rapid IV access – Adequate fluid resuscitation • Prostaglandin E1 – Antibiotics? – Pressors • Intubation? Yes but BEWARE Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
  26. 26. The toxic neonate Critical issues • Consideration - get a – Bicarb – Ammonia – Glucose • Stabilization – Rapid IV access – Adequate fluid – Glucose – Sodium Bicarb • Possible intubation Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congential adrenal hyperplasia – Boys
  27. 27. The toxic neonate Critical issues • Recognition – Low sodium – High Potassium • Stabilization – Rapid IV access – Adequate fluids • Hydrocortisone – Pressor-resistant shock Important possibilities • Sepsis • Congenital Cardiac – Ductal dependent • Inborn error of metabolism • Congenital adrenal hyperplasia – Boys
  28. 28. Neonatal Vomiting • Gastroesophageal Reflux • Pyloric Stenosis • Volvulus Typical features – Gradual onset – Usually with each feed – Quantity can be large – Consists only of milk Do we really care? – Only if this is your misdiagnosis
  29. 29. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus • Onset in first 2-6 weeks – Boys ! • Early -- looks like reflux • Can have abrupt onset over 1-2 days • Late -- Vomits everything each feed
  30. 30. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus • Diagnosis – Ultrasound – The proverbial Olive – Classically projectile – Typical HUNGRY ! • Stabilization – Adequate fluids – Electrolyte correction • Over 1-2 DAYS • Then surgery QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  31. 31. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus – The AAA of pediatrics – You miss this, they die – A true emergency • Onset usually acute • Onset at birth -- or anytime in first couple of weeks • Bilious emesis – Yellow or green • Exam – Toxic appearing infant – Shocky – Distended, tight abdomen
  32. 32. Neonatal Vomiting • Gastroesophogeal Reflux • Pyloric Stenosis • Volvulus – The AAA of pediatrics – You miss this, they die – A true emergency • TIME IS BOWEL • Diagnosis – Immediate upper GI • TIME IS BOWEL • Stabilitization – Rapid IV access – Aggressive fluids • TIME IS BOWEL • IMMEDIATE surgery
  33. 33. One more time A missed volvulus is a death sentence QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  34. 34. Pearl of Neonatal Wisdom • 6 week old infant • Fussy and not feeding quite as well – Decent urinary output • Well appearing on exam – Nonfocal, normal exam – Well hydrated – Normal vital signs • Discharged QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  35. 35. Pearl of Neonatal Wisdom A Bad Physician Does not “hear” or listen to the parents Paternalistic Believes the parents are young, ignorant, uneducated QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  36. 36. Pearl of Wisdom A Good Physician Listens carefully SOMETHING is different or they wouldn’t be there Be very careful ASSUMING nothing is wrong with an infant Parents know BEST ! QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  37. 37. Pearl of Neonatal Wisdom Just before discharge, the next shift physician asked -- what about the feeding? Listening carefully, child really was changing. Subtle decreased sodium and increased potassium suggested CAH so admitted. Two days later, ruptured kidney unrecognized urethral obstruction Take home message: Always LISTEN to the parents
  38. 38. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  39. 39. Pediatric Fever Well appearing 0-36 months of age The game we play -- Where is it hiding – Blood – Urine – CNS – Chest Risk is affected by – Age – Temperature – Appearance – Sex – Circumcision status – Immunization Status •This discussion is more germane to an urban population not at risk for zoonotic, typhoid, malaria, etc.
  40. 40. Appearance What should you do? Ill appearing Normal exam • CBC/Blood Culture • UA/Urine Culture • Lumbar puncture? • Chest Radiograph? Well appearing Normal exam It depends
  41. 41. The neonate 0-30 days Incidence of Serious Bacterial illness is high – Limited ability to localize or resist bacterial infection – Limited ability to express this illness • Cry more, eat less, less active • Fever tends to be LOW (38.0°C) • Delay in recognition – Rapid deterioration possible – This is true EVEN in the well appearing febrile infant – Don’t be cavalier with neonates
  42. 42. The neonate 0-30 days Judgment is limited: evaluation is empiric – Bacteremia: CBC/Blood culture • Prognostic value of CBC for bacteremia very limited – Urinary Tract Infection: Urinalysis and culture • 20% of bacterial UTI with normal urinalysis – Lumbar puncture: Meningitis • Social repertoire of young infants is so limited that clinical judgment useless • All children need a spinal tap – CXR: Pneumonia • Good thought but yield low without symptoms
  43. 43. The neonate 0-30 days Judgment is limited: evaluation is empiric – All children get antibiotics after cultures are drawn – Cover for typical organisms: from mother’s vaginal tract • Group B streptococcus • E coli • Listeria (extremely uncommon in US) – Empiric treatment with • Ampicillin • Gentamicin – Admit (if possible)
  44. 44. The young infant 0-30 days While judgment is extremely limited: – Children in first two weeks of life may be at greatest risk – Children with changes in behavior such as lethargy and poor feeding are very worrisome – Children with abnormal peripheral WBC (over 15,000 or under 5,000) – Positive urinalysis – Abnormal CXR
  45. 45. The young infant 30-90 days Judgment remains limited – This is a transitional age between newborns and older infants – They remain at risk for vaginal organisms from the mother but also to typical encapsulated organisms of older children – Social repertoire remains limited and difficult to assess – These children can also deteriorate quickly
  46. 46. The young infant 30-90 days Judgment remains limited: evaluation is empiric – Bacteremia: CBC/Blood culture – Urinary Tract Infection: Urinalysis and culture • 20% of bacterial UTI with normal urinalysis – Lumbar puncture: Meningitis • Social repertoire of young infants remains limited • A low threshold for empiric lumbar puncture – Many people empirically LP up to 6-8 weeks • Missing meningitis is the most devastating infection possible – CXR: Pneumonia • Again, yield low in absence of respiratory symptoms
  47. 47. The young infant 30-90 days Management Children at higher risk: – Children with changes in behavior such as lethargy and poor feeding are very worrisome – Children with abnormal peripheral WBC (over 15,000 or under 5,000) – Positive urinalysis (5-10 WBC) – Abnormal CXR
  48. 48. The young infant 30-90 days Children at higher risk should received empiric therapy until cultures back – The majority of pathogenic cultures will be positive within 24 hours • Typical organisms – Group B strep, E coli (neonatal organisms) – Pneumococcus, Haemophilus type B, meningococcus • Typical therapy – Third generation cephalosporin (ceftriaxone) – Lumbar puncture in the younger ages (6-8weeks) • Admission – If ill-appearing or if unreliable followup
  49. 49. Older Infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Children at highest risk of occult bacteremia are 12-24 months of age – 3-6 months are at less risk – But they deteriorate faster • This risk is due to a development immunodeficiency
  50. 50. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Risk and Temperature thresholds vary by age – 38°C represents real risk under 3 months – Very young children rarely have high temperatures – 39°C represents real risk over 3 months of age – Risk increases 2-3 fold as temperatures increase to 39.5°C and 40°C
  51. 51. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status Boys are WEAK ! The main difference is found in risk of UTI Highest risk of UTI is in uncircumcised boys under 6 months of age Lowest risk is in circumcised boys over 12 months of age Girls are intermediate
  52. 52. Older infants 3 months to 36 months Risk is affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of occult bacteremia in well appearing infants in the U.S. in a fully immunized population (against pneumococcus and Haemophilus) is probably less than 0.5%
  53. 53. 3 months to 36 months Risk are affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of occult bacteremia in well appearing infants in the U.S. BEFORE universal immunization was on the order of 2-3% And this risk is modified by higher temperatures, ill appearance, etc.
  54. 54. The real question to is: what is the risk of progression of occult bacteremia to to meningitis? A recent meta-analysis showed that – 25/257 (9.7%) of untreated patients with pneumococcal bacteremia had persistent bacteremia or focal invasive infections at followup – The same study showed a 2.7% risk of progression to meningitis Pediatrics 1997;99:438 Pediatrics 2000;106:505
  55. 55. Older infants 3 months to 36 months Risk are affected by – Age – Temperature – Sex – Circumcision status – Immunization Status The risk of UTI in this age group is unaffected by immunization status and is on the order of 5%
  56. 56. Loose recommendations for 3- 24 (or 36) months Well-appearing fever without a source • UA/ Urine culture – All girls – Circumcised boys less than 6-12 months – Uncircumcised boys less than 12-24 months • Lumbar Puncture – If ill appearing • CBC/Blood culture – Consider strongly in the unimmunized – Address WBC count over 15-20,000 or less than 5,000 with empiric therapy – May defer in the fully immunized
  57. 57. Note on treatment Never administer parenteral (or oral) antibiotics without a reason – “Ear” infections are overdiagnosed. Do NOT use as an excuse to administer antibiotics – Always obtain cultures (blood or urine) prior to administering antibiotics (if possible) – NEVER administer antibiotics to a febrile infant (without an identified source of fever) less than 6-8 weeks without first performing an LP • Partially treated, unrecognized meningitis is a disaster
  58. 58. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  59. 59. “Early” Pediatric meningitis Classic signs of meningitis – Kernig’s sign – Brudzinski’s sign – Stiff neck – Irritability – Lethargy These may NOT be present in early meningitis Of course one can simply wait until the diagnosis becomes obvious…
  60. 60. Pediatric meningitis Symptoms can be subtle Neonates – Well appearing with low grade fever – Poor feeding – “Not acting right” Infants 1-3 months – Fever and “a little fussy – Not feeding quite as well – Vomiting without diarrhea and looking more ill than typical gastroenteritis Older children – Consider meningitis in ALL children with a fever who complain of a bad headache – May be present in children with a bad headache, neck discomfort, or vomiting and NO fever
  61. 61. Febrile Seizures • Frequency 1:20-50 children • SIMPLE febrile seizures need NO special evaluation or treatment – Meaning no empiric spinal tap – Except for evaluating fever • “Simple” means: – Nonfocal - generalized – Short - less than 15 minutes – Single - only 1 in 24 hours – Return to NORMAL mental status • Beware the child already on antibiotics for partially treated meningitis
  62. 62. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for 5 days – Irritability • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
  63. 63. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
  64. 64. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
  65. 65. Kawasaki Disease Typical Kawasaki Disease with five cardinal findings • Fever for more than 5 days • Skin changes – Rash – Peeling digits/perineum • Mucosal changes – Conjunctivitis – Red lips, tongue • Lymphadenopathy • Greater than 1.5 cm nodes • Edema of hands and feet
  66. 66. Kawasaki Disease Why this diagnosis is important Nobody every died of Kawasaki disease. Or did they? – Kawasaki’s is a vasculitis and myocarditis is present – Untreated, 13-40% develop coronary aneurysms – These giant aneurysms (8mm) thrombose, resulting in acute MI and death – This risk is greatest in the first year after the illness
  67. 67. Kawasaki Disease Why this diagnosis is important KD and prevention of coronary aneurysms are very responsive to treatment – But the correct diagnosis must be made – Treatment consists of • Aspirin • IVIG (Immunoglobulin) • Possibly corticosteroids
  68. 68. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  69. 69. Vomiting and lethargy What do these 2 cases have in common? A 9 month old presents with 6 episodes of emesis for one day – No diarrhea – No fever – Last one bilious – No abdominal pain On exam, awake in no distress – Glassy-eyed and lethargic – Very soft abdomen You perform the LP but the results are negative A 5 year old presents with intermittent, severe abdominal pain – No fever – Emesis once – No diarrhea – History of a vasculitic rash for one week On exam, comfortable and well appearing – Abdominal exam benign – Petechiae, purpura on legs and buttocks
  70. 70. Intussusception Classic, text book presentation – Colicky severe abdominal pain – Acting normal between episodes – Vomiting – Current jelly stools • In reality, this presentation may be the exception QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  71. 71. Intussusception A tale of two presentations Classic, text book presentation – Colicky severe abdominal pain – Acting normal between episodes – Vomiting – Current jelly stools • LATE finding! • Represents bowel ischemia Altered mental status – Lethargic, appears almost sedated with drugs – Meningitis often the primary misdiagnosis – Vomiting invariable – Abdomen general soft but may feel the mass
  72. 72. Diagnosis & Treatment • Barium or air contrast enema diagnoses AND reduces the intussusceptum • Refractory cases need surgery • Do not do enema until surgeon called – Risk of perforation by less experienced radiologist – Historically (1890s) up to 50% of children perforated and died QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  73. 73. Diagnosis & Treatment If a barium enema seems invasive, consider CT or ultrasound for diagnosis and then enema if intussusception present
  74. 74. Diagnosis & Treatment In context of Henoch-Schonlein Purpura With HSP the intussusception – is NOT the typical ilio-colic intussusception – It is ILIO-ILIAL – Diagnosis will NOT be made with barium enema – Diagnosis is made on CT scan – Usual treatment is medical observation
  75. 75. Intussusception and HSP Henoch-Schonlein Pupura IgA mediated vasculitis similar to TTP in adults Diagnosis is clinical – Typical purpuric rash in dependent areas • Lower ext in children • Buttocks in infants – Arthralgias – Renal disease • May result in renal failure – Intussusception in some QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  76. 76. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  77. 77. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  78. 78. Vomiting and tachypnea What do these two cases have in common? 8 year old with two days of vomiting – No fever – No diarrhea – Now bilious – Generalized abdominal pain – Recent history of weight loss On exam – Thin and ill appearing – Nonfocal abd tenderness – Candidal perineal rash 2 year old with two days of fast breathing – No cough – No fever – No feeding well – Spits up feeds On exam – Ill appearing – Dehydrated – Tachypneic – Clear lungs – Tachycardic
  79. 79. Diabetic ketoacidosis Diagnosed on a routine chemistry • Diagnosis DKA easy with history of diabetes • Classic presentation polydipsia, polyuria, weight loss -- but only if you ask • Atypical features – Altered mental status – Respiratory “distress” – Thrush / Perineal ‘diaper’ rash – Abdominal pain and vomiting
  80. 80. DKA Three problems in order of importance • Dehydration • Electrolyte disturbances • Insulin deficiency – While this is the underlying cause, it is NOT the immediate problem QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  81. 81. DKA Dehydration They are dry, why not give them lots of fluids? – Give only a SINGLE bolus of 10- 20cc/kg UNLESS hemodynamically unstable – Theoretical risk of inducing cerebral edema – Correct dehydration over 12-24 hours – NEVER bolus with anything except NORMAL SALINE
  82. 82. DKA Electrolytes Potassium is the critical problem – They are profoundly depleted – Hypokalemia from both urinary loss and acid base shifts in the serum – Never give potassium until you prove there is no renal failure (urinate once) – If the starting serum potassium is low -- BEWARE -- it will drop quickly with fluids and insulin • Be prepared to aggressively replace (and monitor -- every 2 hours) potassium once therapy starts
  83. 83. DKA Serum glucose and insulin No one NEEDS insulin in first hours – Address fluid deficit and potassium – Glucose will drop significantly with simple fluid administration Principles of insulin administration – Do NOT bolus insulin • It does not act faster and simply results in overshoot hypoglycemia – Start with 0.1 unit/kg/hour – When serum glucose below 250mg/dl do NOT reduce insulin --- increase dextrose in IVFs
  84. 84. DKA Cerebral edema This is what kills kids with DKA • Occurs only in kids • Onset can be SUDDEN – Blown pupil – Apnea – Profound mental status change • Be prepared to administer Mannitol IMMEDIATELY – Intubate if necessary
  85. 85. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  86. 86. Stiff neck and Stridor What do these two cases have in common? 23 month old leaving for Germany tomorrow with a stiff neck and fever – Fever 38.9°C – Holds neck stiffly – Decreased oral intake – Not particularly sick appearing 19 month old transferred for asthma attack – No wheezing but has stridor – Low grade fever – Poor response to racemic epinephrine – Progressive respiratory distress – Episodic apnea – Diagnosis made
  87. 87. Retropharyngeal abscess • Occurs in younger children – Adenoids involute with age • Multiple potential spaces in the neck • Clinical presentation resembles meningitis with stiff neck • Clues are there – Without altered mental status – Subtle swelling of face – Dysphagia/drooling QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  88. 88. Retropharyngeal abscess Diagnosis and treatment • Textbook diagnosis is a lateral neck film – Not particularly sensitive and may miss early cases – Not particularly specific if poor technique • Money is on the CT scan for diagnosis – Delineates extent of disease – Helps decide whether therapy is medical or surgical QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  89. 89. Look-a- likes A 9 month old presents with 6 episodes of emesis for one day – No diarrhea – No fever – Last one bilious – No abdominal pain On exam, awake in no distress – Glassy-eyed and lethargic – Very soft abdomen You perform the LP but the results are negative A 7 month old presents with 4 episodes of emesis for one day – No diarrhea – No fever – No abdominal pain – Lethargic all day On exam – Lethargic – Ill-appearing – Non-focal exam You perform the LP but the results are bloody 6 month old with one day lethargy – Tactile fever – Sleeping – Little oral intake – Decreased urination – Vomited twice On exam – Tachypneic – Lethargic – Dry – Low grade temperature
  90. 90. Look-a- likes Intussusception ? Meningitis
  91. 91. Child abuse Shaken baby syndrome Presents as altered mental status – In younger infants as lethargy and poor feeding – Vague story – Nonfocal exam
  92. 92. Same fracture Two stories My 1 year old was playing with a toy my 4 year old wanted The older one tackled the younger one His leg got twisted under his leg He screamed and won’t walk on his leg and we rush him down here as fast as we could My 1 year old was fine yesterday Now he won’t walk He fell off the couch yesterday. That might be it.
  93. 93. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  94. 94. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  95. 95. Child abuse QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  96. 96. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  97. 97. Conscious sedation in kids Agents – Midazolam – Midazolam/Opioid – Pentobarbital – Propofol – Etomidate – Ketamine Problems – Paradoxical reaction – Respiratory – Respiratory/hypotension – Hypotension – Respiratory – Laryngospasms (rare)
  98. 98. Ketamine • Useful in all ages – Concern about use in older kids misplaced • Inexpensive • Reliable – Does not provide analgesia per se – DISSOCIATIVE agent and therefore unaware of pain – Also amnestic to procedure
  99. 99. Ketamine • Useful in all ages • Inexpensive • Reliable • Risks are low – Protects airway – No respiratory depression – No hypotension – Rare cases of laryngospasm • Adverse effects – Vomiting (up to 20%) – Emergence reaction (uncommon) QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
  100. 100. Ketamine Administration practicalities • Dosing – 2mg/kg IV – 4mg/kg IM • Side effects NOT dose related • Duration IS dose related – 0.5 - 1.0 mg/kg for short procedures – May repeat multiple doses if procedure prolonged • Pretreat with ATROPINE – Reduces secretions and laryngeal irritation • No need to pretreat with midazolam – Does not prevent emergence reaction – Can treat afterwards if needed • Laryngospasm – Almost all kids can be bagged through the event

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