APPENDICITIS
Definition
• Inflammation of the appendix
History
• Diffuse/periumbilical pain → localizing to RLQ, anorexia, nausea, vomiting, irritability (may be the only sx in age <2), fever
Physical Findings
• RLQ tenderness, rebound/guarding, Rovsing sign (RLQ pain w/ palpation in LLQ), psoas sign (RLQ pain w/ hip extension), obturator sign (RLQ pain w/ leg flexion + internal hip rotation)
Evaluation
• Labs: CBC, UA (sterile pyuria/mild hematuria), hCG
• Imaging: U/S (90% sens: Much lower if perforated/large habitus/operator dependent), abdominal plain films (fecalith 10%), CT scan (95% sens/spec)
Treatment
• Surgical consult for operative management, abx (ampicillin 50 mg/kg, gentamicin 1 mg/kg + metronidazole 15 mg/kg or cefoxitin 20–40 mg/kg)
Disposition
• Admit
Pearls
• 90% of children <2 y/o have perforation at presentation (thinner walled/looser omentum → ↑ perforation)
• Young children may not have anorexia
INTUSSUSCEPTION
Definition
• Invagination of bowel into another, most commonly ileocolic (most frequent cause of SBO in <6 y/o)
History
• Age 3 mo–3 yr (peak 5–9 mo), lethargy, vomiting, intermittent fussiness/crying/inconsolability w/ drawing legs to chest, cramping abdominal pain
Physical Findings
• Not tender b/w episodes, abdominal tenderness, RUQ sausage-like mass, heme + stool, “currant jelly” stool (late finding in <1/3 of pts)
Evaluation
• Upright plain abdominal film to r/o free air: SBO/air outlining area/nl; U/S (definitive): Target, bull’s eye, doughnut, pseudokidney sign; barium/air/water enema: Diagnostic/therapeutic (90% successful)
Treatment
• Barium/air/water enema, NGT, surgical consult for operative management in case barium enema fails, hydration (severe dehydration is common), NPO
Disposition
• Admission for 24 h observation
Pearls
• <3 y/o likely idiopathic
• Barium enema is contraindicated if peritoneal signs
MALROTATION WITH MIDGUT VOLVULUS
Definition
• Malrotation & weak fixation of the duodenum & colon during embryologic development → twisting of the mesentery causing duodenal obstruction/SMA compression → necrosis
History
• Neonate (may be older), acute abdominal pain, bilious vomiting, ±distension, irritability/lethargy, FTT, mostly occur w/i 1st year of life
Physical Findings
• Ill appearing/dehydration, heme + stool/grossly bloody, abdominal tenderness, often peritoneal
Evaluation
• Upright plain films: “Double bubble” (dilated stomach & duodenum)/pneumatosis/SBO; U/S: “Whirlpool sign”; upper GI series (diagnostic): “Corkscrew sign”, coiled-spring appearance of jejunum
Treatment
• Immediate surgical consult for operative management, NGT, NPO, abx, fluids
Disposition
• Admission
INCARCERATED/STRANGULATED HERNIA
Definition
• Defects in the abdominal wall that allow protrusion of abdominal contents through the inguinal canal
History
• More commonly male, abdominal/groin/testicular pain, inguinal fullness w/ prolonged standing/coughing, vomiting, irritability in infants
Physical Findings
• Intestine/BS in scrotal sac
Evaluation
• Scrotal/abdominal U/S if physical exam is unclear, x-ray can be used to r/o free air
Treatment
• Reduction: Place in Trendelenburg → gentle pressure ± ice analgesic/benzodiazepines; >12 h concern for perforation/gangrene → surgical management
Disposition
• Admission if operative management required
MECKEL’S DIVERTICULUM
Definition
• Omphalomesenteric duct remnant w/ 60% containing heterotopic gastric (80%) or pancreatic tissue
History
• Any age (sxs usually begin <2 y/o), ±LLQ pain, melanotic stool (acid secretion → ulceration/erosion of mucosa), vomiting, sx of SOB, intussusception
Physical Findings
• LLQ mass, heme + stool/brisk bleeding, abdominal distension
Evaluation
• Technetium scan (Meckel’s scan): Identifies heterotopic gastric tissue (90% sens)
Treatment
• Type & cross/transfuse for brisk bleeding, surgical consult for Meckel’s diverticulectomy
Disposition
• Admit
NECROTIZING ENTEROCOLITIS (NEC)
Definition
• Inflammatory condition of intestinal wall
History
• Preterm neonate (10% full term), bilious vomiting, abdominal distension, bloody stool, feeding intolerance
Physical Findings
• Ill appearing, hypotension, lethargic, abdominal tenderness, heme + stools, diarrhea
Evaluation
• Abdominal x-ray: Pneumatosis intestinalis (75%); barium enema if x-ray is ambiguous
Treatment
• NPO, hydration/transfusion, NGT, abx (ampicillin/gentamicin/metronidazole), surgical consult
Disposition
• Admit
Pearls
• Bell stages: I. Vomiting/ileus, II. Intestinal dilation/pneumatosis on x-ray, III. Shock/perforation
• Cx: DIC, strictures, obstruction, fistulas, short gut syndrome
HIRSCHSPRUNG DISEASE
Definition
• Absence of ganglion cells in the myenteric plexus of the colon → constant contraction & proximal dilation → constipation (4:1 male predominance)
History
• Chronic constipation, delayed 1st meconium, FTT, abdominal distension, vomiting
Physical Findings
• Palpable stool in abdomen, tight sphincter, fecal mass in LLQ, no stool in rectal vault, “squirt” – explosive release of stool when finger is withdrawn
Evaluation
• Abdominal plain film: Dilated colon/fecal impaction/air fluid levels; barium enema; Dx → biopsy (aganglionosis) or anal manometry
Treatment
• Outpt surgical eval
Disposition
• D/c unless cx: Toxic mega colon, perforation, enterocolitis
CYANOSIS
Approach
• Differentiate cyanosis that is central (mucous membranes, tongue, trunk, 2/2 right-to-left shunt) vs. peripheral (feet, hands, lips, 2/2 peripheral vasoconstriction)
Definition
• Acrocyanosis: Blueness in hands/feet only seen in newborns 2° perfusion of the extremities → nl & resolves w/i 1st few days of life
• Breath-holding spell: Prolonged period w/o attempt to breathe a/w intense crying from pain, anger, fright → benign, but Dx of exclusion
History
• Age of onset, central or peripheral, med ingestion, recent illness
• Change w/ crying: Improvement → respiratory etiology (↑ alveolar recruitment); exacerbation → cardiac etiology (↑ cardiac output)
Findings
• Appearance (ill or well), VS, respiratory distress, heart murmur
Evaluation
• Provide O2, obtain CXR, ECG
• Hyperoxygenation test: Compare ABG on RA & on 100% O2 for 10 min, PO2 of >250 excludes hypoxia 2/2 congenital heart dz
• Improvement in O2 sat w/ O2, lack of murmur, nl ECG → pulmonary process
• No change in O2 sat w/ O2, murmur, abnl ECG → cardiac cause → obtain echo (see 14-19)
Treatment
• O2, identify then tx underlying condition
• Consider PGE1 for pts <2 wk of age in circulatory failure
Disposition
• Admit any pt who is ill appearing, low O2 sat or PaO2
• Consult cardiology for any pt w/ suspected congenital cardiac dz
PEDIATRIC FEVER
Approach
• Fever (38°C or 100.4°F) management is different in pediatric population than adults
• ABCs, check O2 saturation, rectal temperature
• Need for abx & hospitalization depends on age, tox, exposures, immune status, identified source, seriousness of source
• Introduction of H. influenzae & pneumococcal vaccines have changed the incidence & etiology of febrile illness in pediatric populations
FEBRILE INFANT 0–90 D OLD
History
• Difficult to obtain localizing hx; standardized w/u to Dx serious bacterial illnesses
• Exposures (travel, ill family members) & immunizations are helpful
Findings
• Fever >38°C or 100.4°F rectal considered standard; fussy, irritable, poor feeding
• Assess frequency & # of wet diapers, cap refill, fontanelles, tears, to estimate dehydration
• Ask about any rashes (viral exanthems, meningococcus)
Evaluation
• Sepsis w/u: See table
Treatment
• Less than 1 mo: Cefotaxime 50 mg/kg IV q12h + ampicillin 25–50 mg/kg IV q8h
• 1–3 mo: Ceftriaxone 50 mg/kg IV q24h or IM ceftriaxone 50 mg/kg if being discharged
• Higher doses for suspected meningitis, consider adding acyclovir 20 mg/kg IV (see 14-16)
• Treat other identified bacterial source appropriately
• If LP was not performed, consider withholding abx in well-appearing infant w/ nl WBC
Disposition
• If <30 d or <90 d & toxic appearing, admit and follow cx even if all labs nl
• Can d/c 30–90 d w/ negative sepsis w/u, well appearing/feeding after 1 dose ceftriaxone, f/u in 24 h
Pearl
• Due to inability to localize source of infection, relative immaturity of immune systems & prevalence of occult bacteremia, all pts receive extensive sepsis w/u
FEBRILE CHILD 3–36 MO
History
• Vulnerable immune system, esp to encapsulated organisms exposures
• Exposures (travel, ill family members) & immunizations helpful
Findings
• Irritable, poor feeding; elicit hydration status via # of wet diapers, tears, fontanelle, cap refill
• Ask about any rashes (viral exanthems, meningococcus)
Evaluation
• See table
Treatment
• If ill appearing w/ fever, 1 dose ceftriaxone (80 mg/kg IV & 24-h admission for cx)
• Treat identified bacterial source appropriately
Disposition
• If well appearing w/ negative w/u:
• WBC >15K (ANC >9000), give empiric abx (ceftriaxone IV or IM) & admit for 24-h observation
• WBC <15K (ANC <9000), d/c w/o abx, but close f/u in 24–48 h
Pearls
• Prevalence of occult bacteremia in well-appearing children <36 mo is now 0.25–0.4% (Acad Emerg Med 2009;16(3):220; Arch Dis Child 2009;94(2):144)
• Rapid influenza testing may reduce further testing & interventions in febrile infants & children in the ED (Pediatr Infect Dis J 2006;25(12):1153)
JAUNDICE
Definition
• Yellowish discoloration of the skin/tissue/body fluids caused by ↑ bilirubin production or ↓ excretion
Approach
• Bilirubin: Formed from degradation of hemoglobin → bound to albumin in blood (unconjugated/indirect) → conjugated in liver by glucuronyltransferase (conjugated/direct) → excreted in bile
History
• Differential depends on age (neonates ≤4 wk), gestational age, breast-feeding status
• Time of onset of sx: Yellowing of skin, dark urine
Physical Findings
• Scleral icterus, jaundice
Labs
• Total/fractionated bilirubin (visible >5 mg/dL in neonates), LFTs, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type), reticulocyte count, serum haptoglobin
• Neonates → unconjugated (can be physiologic, treat to prevent kernicterus)/conjugated (always pathologic)
PHYSIOLOGIC JAUNDICE
Definition
• Elevated unconjugated bilirubin in the 1st wk of life, 60% newborns will be jaundiced (peaks 2–5 d), due to low activity of glucuronyltransferase
Evaluation
• Total/fractionated bilirubin, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type), total bilirubin usually <6 mg/dL, up to 12 mg/dL in premature infants
Treatment
• No tx necessary
Disposition
• Home
Pearls
• Pathologic: In the 1st 24 h of life, peak >17 mg/dL in breast-fed/>15 mg/dL in formula-fed infants, persists beyond 1st wk of life, ↑ bilirubin >5 mg/dL/d
• Cx of severe hyperbilirubinemia: kernicterus (bilirubin deposition in basal ganglia → neurodevelopmental deficits)
• Sepsis can rarely present as jaundice
BREAST-FEEDING JAUNDICE
Definition
• ↑ unconjugated bilirubinemia in breast-fed infants possibly due to hormonal mediators or altered intestinal secretion/absorption of bile, early onset after birth
Evaluation
• Total/fractionated bilirubin, CBC
Treatment
• No tx necessary if bilirubin <17 mg/dL, continue breast feeding, phototherapy
Disposition
• Home
BREAST MILK JAUNDICE
Definition
• Due to substances in breast milk that prevent conjugation & excretion of bilirubin. Occurs after 3–5 d of life, persists for weeks.
Evaluation
• Total/fractionated bilirubin, CBC
Treatment
• If bilirubin <17 mg/dL, continue breast feeding, phototherapy
• If >17 mg/dL, stop breast feeding, will not recur when resumed
Disposition
• Home
ABO AND RH INCOMPATIBILITY/HEMOLYTIC DISEASE
Definition
• Hemolytic dz caused by maternal antibodies against fetal A or B type proteins or maternal Rh antibodies (sensitized from previous pregnancy) against Rh-positive fetus (Rh incompatibility)
History
• Yellowing of skin w/i 1st 24 h of life, dark urine, lethargy
Physical Findings
• Severe jaundice, scleral icterus, ill appearing
Evaluation
• Total/fractionated bilirubin, CBC (hemolysis/anemia → Coombs test, smear, ABO/Rh type)
Treatment
• Phototherapy, exchange transfusion (see table)
Disposition
• Admit
CONJUGATED HYPERBILIRUBINEMIA
Definition
• Pathologic increase in direct bilirubin leading to jaundice (conjugated bilirubin >20% of total, or >2 mg/dL)
History
• Yellowing of skin, dark urine, lethargy, ±genetic syndrome/metabolic syndromes/sepsis
Physical Findings
• Severe jaundice, scleral icterus, ill appearing
Evaluation
• Total/fractionated bilirubin, CBC, blood cultures, blood smear, LFTs, blood type, KUB if signs of obstruction, U/S: Biliary obstruction, UA, Ucx
Treatment
• Hydration, tx based on cause (see below)
Disposition
• Admit
LIMP
Approach
• Examine abdomen, genitalia, spine, hips, long bones, knees, ankle, feet; observe gait
• Careful hx from pt & care giver: Acute vs. chronic, fevers, skin Δ; trauma
• Obtain x-rays although pain is often referred (classically, knee pain referred from hip)
• Consider systemic sxs in conjunction w/ chief complaint of joint pain
INFECTIOUS
Septic Arthritis of the Hip
History
• Most commonly in children <3 y/o, but can occur at any age
• Limp or refuse to walk, h/o fever & irritability (sxs may be far more subtle in infants)
Findings
• Febrile & toxic appearing
• Flexed, externally rotated, abducted hip; antalgic gait (if walking)
• Significant pain w/ ROM but not necessarily warm, swollen or erythematous
Evaluation
• ↑ WBC, ↑ CRP, ↑ ESR; arthrocentesis shows ↑ WBC, +gram stain & culture
• X-rays & U/S may show effusion
Treatment
• Orthopedic consultation for drainage & washout in the OR
• Abx: β-lactamase–resistant PCN (IV nafcillin or oxacillin 50–100 mg/kg/d QID) & 3rd-generation cephalosporin (cefotaxime or ceftriaxone 50 mg/kg); consider vancomycin
• Pain control
Disposition
• Admit for surgical wash-out
Pearl
• Hip > knee > elbow likely to be septic in children
Toxic (Transient) Synovitis
History
• 3–6-y/o boy w/ acute or chronic unilateral hip, thigh, or knee pain
• May be mildly febrile, possibly recent URI
Findings
• Nontoxic appearing
• Limited hip ROM 2/2 pain; mild restriction of passive ROM to abduction & internal rotation; most sens to log roll
• Antalgic gait, painful to palpation
Evaluation
• X-ray of hip nl; may show effusion
• WBC & ESR nl or slightly ↑; afebrile children w/ nl labs can avoid arthrocentesis
• U/S can diagnose effusion, but cannot differentiate type
Treatment
• Pain control w/ NSAIDs, heat, & massage
Disposition
• Orthopedic f/u, crutches to keep weight off hip until pain resolves
Pearls
• Most common cause of acute hip pain in children from 3–10 yr; arthralgia & arthritis secondary to transient inflammation of the synovium of the hip
• Recurrence rate <20%, most develop w/i 6 mo, no ↑ risk for juvenile chronic arthritis
MUSCULOSKELETAL
Legg–Calvé–Perthes Disease (Avascular Necrosis of Femoral Head)
History
• Most commonly in 5–7 y/o w/ limp & pain in groin, thigh, or knee; worse w/ ↑ activity
• No fever or irritability, no h/o trauma
Findings
• Nontoxic appearing, antalgic gait
• ↓ Hip ROM secondary to pain w/ possible thigh atrophy, ↑ w/ internal rotation & abduction
Evaluation
• WBC & ESR nl
• X-rays of hip show progression; frog-leg views helpful
• Widening of cartilage space, diminished ossific nucleus
• Subchondral stress fx of femoral head; linear lucency in femoral head epiphysis
• Femoral head opacification & flattening known as coxa plana
• Subluxation & protrusion of femoral head from acetabulum
Treatment
• Goal is to avoid severe degenerative arthritis, maintain ROM, relieve weight bearing
• Orthopedic eval; bone scan & MRI more rapidly diagnostic than x-rays
Disposition
• Orthopedic f/u, crutches to keep weight off hip until pain resolves
Pearls
• Idiopathic osteonecrosis of capital epiphysis of femoral head; 15–20% bilateral
• Caused by interruption of blood supply to capital femoral head → bone infarction
• Better prognosis at younger onset; proportional to degree of radiologic involvement
Slipped Capital Femoral Epiphysis (SCFE)
History
• 12–15-y/o boy or 10–13-y/o girl, c/o limp & groin, thigh, or knee pain
• If sxs >3 wk, considered chronic
• If unable to bear weight, considered unstable (higher complication rate)
Findings
• Affected leg externally rotated, shortened w/ pain when flexing hip; antalgic gain
Evaluation
• nl temp, WBC, ESR
• X-ray: Femoral head is displaced posteriorly & inferiorly in relation to femoral neck w/i confines of acetabulum; AP & frog-leg views best
Treatment
• Orthopedic consult for operative internal fixation; goal to prevent AVN of femoral head
Disposition
• Admission for orthopedic surgery
Pearls
• Obesity is the RF; genetics plays role; bilaterality more common in younger pts who also tend to have metabolic/endocrine disorders
• If traumatic hip injury w/ obvious external rotation & shortening of the leg, do not force ROM as this can worsen epiphyseal displacement
Osgood–Schlatter Disease
Definition
• Microtrauma to the tibial tubercle tuberosity apophysis occurring during use
History
• Preteen boy w/ knee pain, worse w/ activity & better w/ rest
Findings
• Edema & pain of tibial tubercle; enlarged & indurated tibial tuberosity
• Tender over anterior knee, esp over thickened patellar tendon
• Pain reproduced by extending knee against resistance, stressing quads or squatting w/ knee in full flexion, running, jumping, kneeling, squatting, stairs
Evaluation
• Knee x-ray: Soft tissue swelling over tuberosity & patellar tendon; no effusion
Treatment
• Guided by severity: Range from decreasing activity in mild cases to rest in severe cases
• NSAIDs for pain control, ice, ±crutches
Disposition
• D/c home w/ pain control
Pearls
• One of the most common causes of knee pain in adolescent; benign & self-limited
• Bilateral in 25% of cases; 50% give h/o precipitating trauma
PEDIATRIC SEIZURE
Definition
• Abn, paroxysmal d/c of CNS neurons leading to abn neurologic fxn
Approach
• ABCs, check O2 saturation, temperature
• Immediate bedside glucose fingerstick & tx, consider administering empiric glucose
• If actively seizing, quickly administer suppression medications
• Careful hx: Description of events before & after sz, associated sxs (HA, photophobia, vomiting, visual changes, ocular pain), focal neurologic sxs
• Assess for head or neck trauma, meningismus, petechiae
• Thorough neurologic exam; Todd’s paralysis: Transient paralysis after a sz
• CBC, CMP, tox screen, UA, CXR: Tox screen, anticonvulsant levels, infectious w/u
• Consider CT if persistent AMS, neurologic deficit, or trauma
• Consider LP after head CT if persistently AMS, fever, & therapeutic med levels
• 1st-time sz w/u: Consider head CT, ECG, CBC, CMP, tox screen, LP
• EEG days to weeks after sz unless concern for nonconvulsant status epilepticus
• Status epilepticus is recurrent or continuous sz activity lasting >30 min w/o return to baseline MS
• Can result in cerebral hypoxia, lactic & respiratory acidosis, hypercarbia, hypoglycemia
• Disposition: Admission for abnl neuro exam, others w/ Neurology f/u
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