NorthEM Ep2 Pediatric Review 2/3

Pediatrics 2 of 3 Pediatric Respiratory Topics Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care. 1. Asthma Assessment Tool: PRAM (Pediatric Respiratory Assessment Measure) The scoring system ranges from 0 to 12 points. The mnemonic provided is WE SOS. W (Wheeze): 0 to 3 points E (Air Entry): 0 to 3 points S (Suprasternal In-drawing): 0 to 2 points O (Oxygen Saturation): 0 points (>94%), 1 point (92 to 94%), 2 points ( S (Scalene Retractions): 0 to 2 points Severity Scoring: Mild: 1 to 3 points. Moderate: 4 to 7 points. Severe: 8 to 12 points, or the presence of cyanosis or altered level of consciousness. Treatment and Dosing: Mild Asthma: Ventolin (SABA): Every 20 minutes. Dose: 4 puffs (8 puffs (>20 kg). Give three rounds. Dexamethasone (DEX): 0.6 mg/kg PO (give two doses: one now, and one dose to take tomorrow). Moderate Asthma: Ventolin and Ipratropium Bromide: Both given every 20 minutes for three rounds. Ipratropium Bromide Nebs: 250 micrograms (500 micrograms (>20 kg). Ventolin Nebs: 0.15/kg/dose (5mg) up to 3/hr for continuous DEX is also given. Severe Asthma: Continuous nebulized Ventolin and Ipratropium Bromide. DEX or Methylprednisolone. Methylprednisolone Dose: 1 mg/kg. Magnesium: 50 mg/kg (can be repeated every 20 minutes as needed). Other options: Epi, epi infusion, inhaled epinephrine, ketamine, or heliox. Admission and Discharge Criteria: Admission Criteria: Oxygen saturation less than 90%, respiratory distress, social concerns, comorbidities, or requiring a SABA more than every 4 hours. Discharge Criteria: The patient must be able to tolerate 4 hours without receiving a round of Ventolin. Take-Home Ventolin Dosing: Four puffs every 4 hours for 4 days.   2. Bronchiolitis Common Age: Less than one to less than three-year-olds. Scoring System Mnemonic: WE SOS for Real. W (Wheeze). E (Air Entry). S (Substernal In-drawing). O (Oxygen Saturation). S (Scalene or Abdominal Retractions). F (Feeding). R (Respiratory Rate): Less than 60 (normal), 60 to 70 (worse), greater than 70 (even worse). Treatment: Oxygen for saturations less than 94%. Nasal suctioning. Trial of Ventolin (if it works, keep doing Ventolin). If Ventolin works, give Steroids. Volume repletion (by feeding or IV fluids). May also try nebulized or IM epinephrine. Admission Criteria (CPS): 90 RASCAL. 90: Less than 90% oxygen saturation. R: Respiratory distress. A: Apnea. S: Social concerns. C: Comorbidities (especially cardiac or pulmonary conditions). A: Age less than 3 months or if premature. L: Lactation or not tolerating feeds.   3. Croup (Laryngotracheobronchitis) Common Age: 6 Month to 6 year olds. Scoring System: Wesley Croup Score. The mnemonic provided is CRIES. C (Cyanosis): 0 or 5 points R (Retractions): 0 to 3 points I (Impaired Consciousness): 0 or 5 points E (Air Entry): 0 to 2 points S (Stridor): 0 to 2 points Severity Scoring: Mild: 0 to 3 points (stridor only when upset). Moderate: 4 to 6 points (stridor at rest). Severe: 7 plus points (stridor at rest, severe respiratory distress). Treatment and Dosing: Mild Croup: Dexamethasone: 0.6 mg/kg (one dose now, and one dose to be taken in 24 hours). Moderate/Severe Croup (stridor at rest): Dexamethasone 0.6 mg/kg Racemic Epinephrine: 2.25% concentration. Dose: 0.1 mL per kilogram up to 0.5 mL (usually 0.5 mL). Can be repeated every 20 minutes as needed. Monitoring: Due to the dose lasting 2 to 3 hours, patients must be monitored for at least 3 hours after their last dose of racemic epinephrine. Severe Croup may also require intubation or IM/IV epinephrine. Admission Criteria: Uses the 90 RASCAL mnemonic (similar to bronchiolitis), but also specifically includes stridor despite treatment and does not include apnea. ENT & Head/Neck Infections Epiglottitis Age Group: 5–7 years old or older Common Bugs: H. flu (historically), Group A strep, S. aureus, S. pneumoniae Treatment Specifics: Airway management/ICU monitoring, Ceftriaxone and Vancomycin. Tracheitis Age Group: 3–5 years old Common Bugs: Often mixed, potentially predominantly S. aureus Treatment Specifics: Airway management/ICU monitoring, Ceftriaxone and Vancomycin. Retropharyngeal Abscess (RPA) Age Group: 6 months to 3 years old Common Bugs: Group A strep, S. pneumoniae, S. aureus, Fusobacterium Treatment Specifics: Ceftriaxone and Clindamycin (due to anaerobes). Requires surgical consult, especially if the abscess is greater than 2 cm in size. Peritonsillar Abscess (PTA) Age Group: 15–30 years old Common Bugs: Mixed, Group A strep, S. aureus, Fusobacterium Treatment Specifics: Ceftriaxone or Clindamycin. Needs drainage (needle aspiration or I&D). Maybe safe for discharge home on Amoxicillin/Clavulanate (amoxy clav) for 10 days. Lemierre's Syndrome Age Group: 15–24 years old Common Bugs: Group A strep, Fusobacterium (accounts for about a third of infections) Treatment Specifics: Ampicillin/Sulbactam, Piperacillin/Tazobactam, or Carbapenem. Diagnosis via CT neck with contrast. Lemierre's Syndrome Classic Triad: Pharyngitis, anterior neck tenderness and swelling, and non-cavitary pulmonary infiltrates (from septic emboli). 4. Acute Otitis Media (AOM) Watch and Wait Criteria (CPS): Must be met for observation to be acceptable. Healthy, immunized, and over 6 months. Well appearing. Temperature less than 39° C. Less than 2 days of symptoms. Able to sleep well with mild pain. Intact tympanic membrane (TM) with no discharge. Unilateral infection. Treatment (Moderate to Severe AOM): Pain control and antibiotics. Antibiotic Duration: 10 days (6 months to 2 years old); 5 days (over 2 years old). Amoxicillin Dosing (Most Common): 90 mg/kg per day divided into two doses. Other options include Cefuroxime or Amoxicillin/Clavulanate. Ear Tubes: Patients can go home with Ciprodex drops.   5. Pertussis (Bordetella pertussis) Incubation Period: 12 to 17 days. Three Phases: Catarrhal Phase: Dry cough, rhinorrhea, mild fever (looks like a mild viral infection). Paroxysmal Phase: Violent coughing paroxysms (8 to 10 coughs) followed by a whoop. This phase lasts 2 to 4 weeks. Convalescent Stage: Gradual improvement, though cough can linger up to 8 weeks. Treatment: Azithromycin for the patient as well as contacts. Admission Criteria: Less than 3 months old or premature, or less than a year old with significant symptoms.   Cardiovascular Topics 6. Congenital Heart Disease (General) Ductal Closure: The PFO closes at about 6 months. The PDA closes within 1 to 3 days. Prostaglandin E1 (PGE1) Dosing (for ductal-dependent lesions): 0.05 micrograms per kilogram per minute, titrated to effect. Side Effects: Apnea, hypotension, seizures, fever. Specific Diagnostic Testing: 4limb Blood Pressure Test: Upper extremity BP greater than lower extremity BP by 20 points is concerning (e.g., for coarctation). Pre and Post-ductal Sats: Measure at the right arm and left leg. Concerning if the right arm is less than 90% or if there is a 3% difference between the two limbs. Hyperoxia Test (100% O2): Poor Man's Test: Less than 10% increase in saturation is concerning. True Test: Less than 100 mmHg increase in PaO2 is concerning for a right-to-left shunt. Greater than 250 mmHg rules out a right-to-left shunt. Lesion Categories: Cyanotic Lesions: Tetralogy of Fallot (TOF), Truncus Arteriosus, Total Anomalous Pulmonary Vein Connection (TAPVC), Transposition of the Great Arteries (TGA), Tricuspid Atresia, Pulmonary Atresia or Stenosis. Obstructive Lesions (Lead to shock/gray baby, present in first few weeks): Severe Aortic Stenosis, Interrupted Aortic Arch, Coarctation of the Aorta, Hypoplastic Left Heart. CHF/Mixing Lesions (Present at 1 to 3 months): VSD, large ASD, PDA.   7. Tetralogy of Fallot (TOF) and Tet Spells The Four Lesions (TET): VSD, RV outflow obstruction, overriding aorta, and RV hypertrophy. Treatment for TET Spell (right-to-left shunting): Decrease Tachycardia: Anxiolysis or knee-to-chest position. Increase SVR (Systemic Vascular Resistance): Knee-to-chest position, fluid bolus, or possibly Phenylephrine. Decrease PVR (Pulmonary Vascular Resistance): Oxygen.   8. Kawasaki Disease Diagnosis Mnemonic: WARM CREAM. Diagnosis is clinical, based on fever for 5 or more days PLUS 4 out of 5 of the following criteria: C: Conjunctival injection. R: Rash (generalized, polymorphous). E: Erythematous palms and soles. A: Adenopathy (cervical, unilateral, more than 1.5 cm). M: Mucous membrane changes (dry cracked lips or strawberry tongue). Incomplete Kawasaki Disease: Fever for 5 days PLUS 2 or 3 criteria. Labs: Order CRP and ESR. Diagnostic Values: Elevated CRP (more than 30) or ESR (more than 40). If elevated and 3 criteria met: Treat as Kawasaki and order echo. If elevated and 2 criteria met: Admit, order echo, and draw supplemental labs (including WBC > 15, Platelets > 450, albumin Treatment and Dosing: IVIG: 2 grams per kilogram (single dose). Aspirin: 30 to 50 mg/kg daily orally in four divided doses.   9. SVT versus Sinus Tachycardia (Pediatrics) SVT Rate Thresholds (Faster than Sinus Tachycardia): Infants: Over 220 bpm. Older Children: Greater than 180 bpm. Other Differences: SVT is very regular (maintained R-R intervals), unlike sinus tachycardia, which varies with activity or respirations. SVT may lack P waves or have inverted P waves coming after the QRS. 10. Rheumatic Fever (Jones Criteria) Prerequisite: Documented diagnosis of a Group A Strep infection. Diagnostic Criteria: Two Major OR One Major and Two Minor criteria must be met. Major Criteria (Jones, where O is the heart): J: Joints (Arthritis with swelling). O (Heart): Carditis. N: Nodules (Subcutaneous nodules). E: Erythema Marginatum. S: Sydenham Chorea. Minor Criteria (FAPE): F: Fever. A: Arthralgia (without swelling). P: PR interval prolongation. E: ESR or CRP elevation.   Gastrointestinal Topics 11. Neonatal Jaundice (Hyperbilirubinemia) Bilirubin Thresholds: Bilirubin level over 85 can cause jaundice. Bilirubin level over 340 is a risk factor for kernicterus. Indications for Further Investigation: Jaundice within the first day of life. Jaundice beyond 3 weeks of life. Sick appearing infant. Elevated conjugated bilirubin (always pathological). Rapidly rising bilirubin level. Total serum bilirubin not responding to phototherapy and approaching the exchange transfusion threshold. Neurotoxicity Risk Factors (Lower Threshold for Phototherapy): Isoimmune hemolytic disease, G6PD deficiency, asphyxia, lethargy, temperature instability, sepsis, acidosis, and Albumin less than 30. Causes of Unconjugated (Indirect) Hyperbilirubinemia (Examples): Physiological jaundice, breast milk jaundice, hemolysis (e.g., ABO incompatibility, G6PD deficiency), GI obstruction (e.g., pyloric stenosis), and metabolic conditions (e.g., Gilbert syndrome). Causes of Conjugated (Direct) Hyperbilirubinemia (Always Pathological): Infections (e.g., sepsis, TORCH), biliary obstructions (e.g., biliary atresia), and metabolic causes (e.g., cystic fibrosis, alpha 1 antitrypsin deficiency). 12. GI Foreign Bodies Indications for Urgent Removal/Consultation (Patient Factors): Respiratory distress. Esophageal obstruction (inability to swallow). Intestinal obstruction or perforation. Esophageal impaction for more than 24 hours. Indications for Urgent Removal/Consultation (Object Factors): Esophageal button battery. Sharp object in the stomach. Long object in the stomach (longer than 5 cm). Wide object in the stomach (wider than 2 cm). Multiple magnets.   13. Specific Pediatric GI Conditions Meckel's Diverticulum Presentation: Painless bleeding (hematochezia). Can lead to intussusception. Rule of Twos: Affects 2% of the population, located 2 feet proximal from the ileocecal valve, typically 2 inches in length, common in less than two-year-olds, and has a 2:1 male to female ratio. Management: Meckel scan, transfusion, possible surgery. Midgut Volvulus with Malrotation Presentation: Presents in the first month of life with bilious vomiting in a sick infant. Diagnosis: Upper GI series with small bowel follow-through (may show corkscrew pattern or double bubble on X-ray). Management: Resuscitation, decompression, Antibiotics (Ampicillin, Gentamicin, Flagyl), and surgical consultation. Necrotizing Enterocolitis (NEC) Presentation: Presents in the first month of life, particularly in premature babies. Onset related to starting enteral feeding. X-ray findings: Pneumatosis intestinalis, perforation, and dilated loops. Management: Decompression, resuscitation, Antibiotics (Ampicillin, Gentamicin, Flagyl), and surgical consultation. Intussusception Common Age: 6 months to 2 years of age. Features: Colicky abdominal pain, current jelly stools, right-sided sausage-like mass, and lethargy between pain episodes. Diagnosis: Ultrasound shows a target sign. Management: Air or barium enema. Hirschsprung's Enterocolitis Pathophysiology: Congenital lack of innervation of the myenteric plexus. Suspicion: Delayed meconium passage beyond one day. X-ray findings: Cut off sign in the colon, pneumatosis intestinalis, or signs of perforation. Management: Biopsy to confirm diagnosis. Enterocolitis treatment requires Ampicillin, Gentamicin, Flagyl, and pediatric surgery consultation. Pyloric Stenosis Presentation: 3 weeks to 2 months of life. Features include projectile non-bilious emesis and a palpable olive-like mass. Labs: May show low potassium, low chloride, and alkalosis. Ultrasound Diagnostic Values (PI pneumonic): 3 mm by 14 mm by 19 mm (note: one source cites 4 mm instead of 3 mm). Management: Hydration, electrolyte correction, and surgical consultation (surgery is not urgent). Henoch-Schönlein Purpura (HSP) Age: 4 to 6 year olds. Symptoms Mnemonic: ARENA: Abdominal pain, Rash (palpable purpura), Edema (diffuse), Nephritis, Arthritis. Key Lab Finding: Normal platelets despite the purpura. Treatment: NSAIDs. Steroids if severe abdominal pain, GI bleeding, hematuria, or severe arthritis. These severe findings also serve as admission criteria. Disclaimer: Content is for educational exam preparation only and does not constitute medical advice. Medicine changes quickly; always verify with current, local guidelines before applying to patient care.