Pediatric Head Trauma

Brief H&P:

A young child, otherwise healthy, is brought to the pediatric emergency department after a fall. The parents report a fall from approximately 2 feet after which the patient cried immediately and without apparent loss of consciousness. Over the course of the day, the patient developed an enlarging area of swelling over the left head. The parents were concerned about a progressive decrease in activity and interest in oral intake by the child, and they were brought to the emergency department for evaluation. Examination demonstrated a well-appearing and interactive child – appropriate for age. Head examination was notable for a 5x5cm hematoma over the left temporoparietal skull with an underlying palpable skull irregularity not present on the contralateral side. Non-contrast head computed tomography was obtained.

Imaging

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CT Head

Fracture of the left temporal and parietal bone with overlying scalp hematoma.

Algorithm for the Evaluation of Pediatric Head Trauma (PECARN)1,2,3

Algorithm for the evaluation of pediatric head trauma

References

  1. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. doi:10.1016/S0140-6736(09)61558-0.
  2. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. American Journal of Roentgenology. 2001;176(2):289-296. doi:10.2214/ajr.176.2.1760289.
  3. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Archives of Disease in Childhood. 2014;99(5):427-431. doi:10.1136/archdischild-2013-305004.

Pediatric Emergencies

Diseases by Age

  • 1 week – 1 month: Ductal dependent cardiac lesions
  • 1st month: Malrotation with volvulus
  • 1 – 2 months: Pyloric Stenosis
  • 2 – 6 months: CHF
  • 3 months – 2 years: Intussusception
  • 6 months – 2 years: Croup
  • <2 years: Bronchiolitis
  • 2 years: Meckel’s
  • 2 years – 6 years: Epiglottitis

Cardiology

Ductal Dependent Lesions

  • Present 1st week to 1st month
  • Normal duct seals by 3 weeks
  • If dependent on shunt for pulmonary flow  cyanosis
  • If dependent on shunt for systemic flow cold shock (may be worse w/ fluids)
  • Prostaglandin E1
    • 1 mg/kg/min
    • Side effects include apnea, bradycardia, hypotension, seizure
      • Consider intubating prior to administration
    • IVF, cover for sepsis

Congestive Heart Failure

  • Present 2nd to 6th month
  • Presents with respiratory symptoms (wheezing, retractions, tachypnea)
  • Difficulty with feeding (the infant stress test)
  • Treatment: Supportive

 Tetrology of Fallot

  1. Calm the child, knee to chest
  2. O2 = reduction in PVR
  3. Analgesia: morphine 0.1mg/kg, fentanyl 1.5 mcg/kg, ketamine 0.25 mg/kg
  4. Establish Access: 10-20cc/kg bolus
  5. Phenylephrine 0.2 mg/kg IV (to increase SVR)
  6. +/- HCO3 1mmol/kg (if acidosis)
  7. +/- beta blocker (with cardiology consultation)
  8. PGE1 0.05mcg/kg/min titrating to 0.1mcg/kg/min

Dermatology

Slapped Cheek/5th Disease

  • Parvo B19
  • Slapped cheeks, lacy reticular pattern of rash on body
  • Complications:
    • Pregnancy hydrops
    • Sickle Cell Disease  aplastic crisis

Measles

  • Koplik spots, conjunctivitis, fever
  • Can cause blindness

VZV

  • Different stages of development
  • Treat with acyclovir if > 12 years old
  • Give VZIG in neonates and immunocompromised

Scarlet Fever

  • Erythematous rash, palatal petechiae, pastia’s lines
  • Strawberry tongue
  • Trunk to periphery
  • Treat with Pen VK: 50mg/kg BID x10d or Amox 20mg/kg BID x10d
  • Pen allergic: Azithro 10mg/kg day 1 then 5mg/kg 2-5

Staphylococcal Scalded Skin Syndrome

  • Toxin mediated, negative Nikolsky, good prognosis
  • Treatment: Anti-staphylococcal antibiotics
    • Nafcillin 25mg/kg/d IV
    • Augmentin 45mg/kg/d PO in 2 divdied doses 7-10d
    • Keflex 10mg/kg/d QID x7-10d

Henoch-Schonlein Purpura

  • Palpable purpura in dependent areas
  • Arthralgia/Arthritis (50-84%)
  • Abdominal pain (50%): vascular lesions in bowel, may be intussusception lead point
  • Renal Disease (20-50%) may develop within 2 months
  • Treatment: Supportive, NSAIDs

Kawasaki Disease

  • 5 days of fever + 4/5 of criteria
    • Diffuse polymorphous diffuse rash
    • Conjunctivitis
    • Mucous membrane change (strawberry tongue)
    • Cervical LAD (usually unilateral)
    • Extremity changes
  • Incomplete and atypical forms more common in infants
  • Treatment (drop complications from 25% to 4-5%)
    • Aspirin 20mg/kg/dose Q6H
    • IVIG 2gm/kg over 12H

Gastroenterology

Bilious Vomiting

  • Bilious vomiting malrotation with volvulus until proven otherwise  surgical emergency
  • 1st month of life “pre-verbal child’s disease”
  • Dx: Upper GI Series (10-15%) false positive rate

Necrotizing Enterocolitis

  • 10% of cases full term
  • XR w/ pneumatosis intestinalis

Hirschsprung’s

  • No meconium, slightly distended abdomen
  • Less severe  later presentation, p/w constipation

Pyloric Stenosis

  • Presents around 6 wks: vomiting but very hungry
  • Diagnosis
    • US pylorus > 4mm thick, >15mm long
    • NGT aspiration 5cc is abnormal
  • Treatment
    • Resuscitate
    • Correct metabolic abnormalities
    • Consult surgery

Intussusception

  • Most common infant emergency
    • 3 months – 2 years
  • Abdominal pain, currant jelly, palpable mass (30% only)
  • Typical presentation
    • Lethargy (may be only sign)
    • Vomiting
    • Paroxysms of pain
    • SBO
    • PO intolerance
  • Diagnosis: US
  • Treatment: Enema (80-95% successful), 10% recurrence

Meckel’s Diverticulum

  • Around 2 years of age, boys > girls
  • Obstruction, intussusception
  • Diagnose with technetium scan

Appendicitis

  • 1/3rd with vomiting and diarrhea (AGE-type syndrome)

Hemolytic Uremic Syndrome

  • Watery/bloody diarrhea
  • Three components
    • Acute renal failure
    • Thrombocytopenia
    • Microangiopathic hemolytic anemia (MAHA)
  • Signs
    • Pallor
    • Abdominal Pain
    • Decreased urine output
    • Low energy/AMS
    • Hypertension
    • Edema
    • Petechiae
    • Icterus
  • Treatment: Supportive vs. Dialysis (50%)

GI Bleed by Age

Age Well-Appearing Ill-Appearing
Neonate Allergic Proctocolitis Malrotation with Volvulus
Anal Fissure Necrotizing Enterocolitis
Swallowed Maternal Blood Coagulopathy
Infant/Young Child Allergic Proctocolitis Meckel’s
Gastritis Intussusception
Infectious Colitis Vascular Malformation
Older Child/Adolescent Gastritis IBD
Esophageal Bleeding Cryptic Liver Disease
Juvenile Polyps Intestinal Ulceration

Congenital Disorders

Congenital Adrenal Hyperplasia

  • Presents in first two weeks of life
  • Chief complaint may be vomiting
  • Lyte: HyperK, HypoNa, Hypoglycemia  dysrhythmias, seizures
  • Treatment
    • IVF (usual dose)
    • Glucose (usual dose)
    • Hydrocortisone: 25mg (neonate/infant), 50mg child, adolescent/adult 100mg

Inborn Errors of Metabolism

  • Possible CC: Vomiting, Lethargy, Seizures, Hepatomegaly, Metab Acidosis, Odor
  • May have normal labs and imaging
  • Life-threatening: Metabolic acidosis, Hypoglycemia, Hyperammonemia, Sepsis
  • Labs
    • VBG (acidosis),
    • CMP (liver, kidney, anion gap)
    • Ammonia, lactate, urine (ketones, reducing substance)
    • Bunch of extra tubes for labs later
  • Treatment
    • NPO
    • IVF bolus
    • D10 at 1.5x maintenance
    • Treat Sepsis
    • Control seizures PRN, correct hyperammonemia/acid/lyte (may need dialysis)

Pulmonary

Croup

  • Toddlers (6-24 months), 5% of all children, boys > girls
    • PIV #1
    • Rhinovirus, Metapneumovirus, PIV II-IV, RSV, Flu A/B
    • Frequent co-infections with one or more viruses
  • Sx: 1-3 days of URI Sx  Abrupt cough/stridor worse for one day, then better
  • Signs: Nontoxic, if wheezing likely RSV
  • Studies: XR to r/o FB (steeple sign if positive)
  • Treatment: Racemic Epi: 0.25-0.75 cc in 3 cc Q 20 minutes, lasts < 2 hours
  • Disposition: If stridor at rest then treat if no improvement, then admit
Stridor Steroids Racemic Epi Dispo
Mild 0.15 mg/kg No Home
At rest with WOB 0.30 mg/kg Yes Admit
Severe at rest 0.60 mg/kg Yes ICU

Bronchiolitis

  • Children < 2 years old, November through April (peak Jan/Feb)
    • Apnea in neonates and ex-premies < 2 months
    • Bacterial superinfection is very rare
  • Presentation: Desat, tachypnea, nasal flaring, intercostal retractions, secretions
  • Exam: Fine rales, diffuse/fine wheezing
  • Treatment: Suction, O2 (if < 90%), NPPV
  • Maybe albuterol, but no steroids/epi/abx

Epiglottitis

  • Bimodal (2-6, 20-40y), < 1% URI with stridor, boys = girls, al year
    • Non-typable H.flu, staph/strep, Moraxella
    • Candida, HSV, VZV, crack cocaine
  • Symptoms: Muffled voice, drooling rapid progression in hours
  • Signs: No pharyngeal findings with severely tender anterior neck
  • Studies: XR w/ thumb sign
  • Treatment: Laryngoscopy, airway management

Bacterial Tracheitis

  • Preschool (1-10y), boys = girls, Downs
  • Symptoms: Several days’ URI  toxic in hours, rapid progression
  • Signs: Subglottic diffuse inflammation, edema with exudates and pseudomembranes
  • Studies: CXR demonstrates narrow trachea
  • Treatment: Emergent intubation, 3rd generation cephalosporin

Rapid Pediatric Assessment

This post presents a tool for the rapid assessment of the cardiopulmonary status and cerebral/metabolic function of critically ill pediatric patients. The purpose is not to establish a diagnosis, rather to identify the particular physiological derangements to prioritize initial interventions. The tool was initially designed as a “triangle” – it has been adapted here (with permission) as a Venn diagram.1

Pediatric Assessment Diagram

Pediatric Assessment Diagram

Assessment of Appearance

  • Tone: Moves spontaneously, resists examination
  • Interactivity: Interacts with environment, reaches for items
  • Consolability: Comforted by caregiver
  • Gaze: Makes eye contact

Assessment of Work of Breathing

  • Airway Sounds: Stridor, grunting, wheezing
  • Position: Tripod
  • Retractions

Assessment of Circulation

  • Pallor
  • Mottling
  • Cyanosis

Management

Impression Interventions
Respiratory distress
  • Position of comfort
  • Oxygen, suction
  • Therapy as appropriate (albuterol, epinephrine, etc)
  • Labs/radiographs as indicated
Respiratory failure
  • Head/airway positioning
  • 100% oxygen
  • Ventilation support (BVM)
  • Advanced airway
Shock (compensated and decompensated)
  • Oxygen
  • Access
  • Fluid resuscitation
  • Specific therapy (antibiotics, surgery)
  • Labs/radiographs as indicated
CNS/Metabolic
  • Pulse oximetry
  • Rapid glucose
  • Labs/radiographs as indicated
Cardiopulmonary Failure
  • Head/airway positioning
  • 100% oxygen
  • Ventilation support (BVM)
  • Chest compressions as needed
  • Specific therapy (defibrillation, epinephrine, amiodarone)
  • Labs/radiographs as indicated

References:

  1. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312-315. doi:10.1097/PEC.0b013e3181d6db37.

Pediatric Sizes and Doses

Below is a rapid reference for essential information related to the care of pediatric patients including sizing estimates for endotracheal tubes and weight-based dosing for critical/common medications (rapid sequence intubation, pediatric advanced life support, seizure management), compiled by Dr. Kelly Young1.

Airway

ETT
4 + Age/4 = uncuffed
Subtract 0.5 for cuffed
Gestational age (weeks) / 10 if premature
Depth = ETTx3
Blade
Newborn: 0
<2yo: 1
2-8yo: 2
>8yo: 3
Other Tubes
NGT = ETT x 2
Chest tube = ETT x 4

Estimating Weight

Age (years) 1 3 5 7 9
Weight (kg) 10 15 20 25 30

Vital Signs

Blood Pressure

Age Measure
Neonate 60mmHg
<1yo 70mmHg
1-10yo 70 + (Age x2)
>10yo 90mmHg

Heart/Respiratory Rate

Age (yrs) HR RR
0-1 140 40
1-4 120 30
4-12 100 20
>12 80 15

Medications

Name Dose
RSI (Paralysis)
Succinylcholine 1mg/kg (x2 infant, x3 neonate)
Rocuronium 1-1.2mg/kg
RSI (Sedation)
Etomidate 0.3mg/kg
Ketamine 2mg/kg
Midazolam 0.1mg/kg
Fentantyl 1mcg/kg
PALS
Defibrillation 2, 4, 10J/kg
Cardioversion 0.5, 1J/kg
Epinephrine 0.01mg/kg (0.1mL/kg of 1:10,000)
Atropine 0.02mg/kg (minimum dose 0.1mg, maximum 0.5mg)
Adenosine 0.1mg/kg (max 6mg), 0.2 mg/kg (max 12mg)
Amiodarone 5mg/kg
Calcium gluconate (10%) 1mL/kg
Calcium chloride (10%) 0.2mL/kg
Magnesium sulfate 25mg/kg
Sodium bicarbonate 1mEq/kg
3% saline 5cc/kg
Mannitol 1g/kg
Fluids
Normal saline (0.9%) 20cc/kg
PRBC 10cc/kg
Maintenance 4cc/kg (first 10kg), 2cc/kg (second 10kg), 1cc/kg thereafter
Dextrose
<1yo D10, 5cc/kg
1-10yo D25, 2cc/kg
>10yo D50, 1cc/kg
Anti-epileptics
Lorazepam, Midazolam 0.1mg/kg x3
Fosphenytoin 20 PE/kg
Keppra 20-40mg/kg
Valproate 20mg/kg
Phenobarbital 20mg/kg
Midazolam infusion 0.1mg/kg/h
Midazolam IN 0.2mg/kg (max 10mg)
Antibiotics
Ceftriaxone 50mg/kg
Amoxicillin 90mg/kg divided BID
Azithromycin 10mg/kg day 1, 5mg/kg days 2-5
Common Medications
Acetaminophen 15mg/kg
Ibuprofen 10mg/kg
Diphenhydramine 1.25mg/kg
Ondansetron 0.15mg/kg

Reference:

  1. Young, K. D. (2016, April 18). Pediatric Doses and Sizes. Lecture presented at Harbor-UCLA Medical Center in CA, Torrance.

Failure to Thrive

Failure to ThriveID:

5mo female with a history of multiple food allergies, GERD and FTT admitted from clinic for persistent failure to gain weight.

HPI:

The patient’s mother states that the current diet is 3oz of Neocate 20cal/oz q3h, and that the baby sleeps through the night. The child has a history of reflux, but no emesis in the past few weeks since starting Reglan. There was a history of bloody diarrhea, however none since age 2mo after a change of formula. Mother reports known allergies to milk, soy, protein, and egg. No recent fevers/chills, emesis, diarrhea, fussiness.

The patient was born at 27wks via emergency Cesarean for non-reassuring fetal heart tracings, was intubated in the DR and remained in the NICU for one week.

PE:

  • VS: 98/65mmHg, 114bpm, 98.1°, 33/min, 100% RA
  • Gen: Small for age, smiling and interactive
  • HEENT: PERRL, MMM, no lesions
  • CV: RRR, no M/R/G, Lungs: CTAB
  • Abdomen: +BS, soft, NT/ND, no masses, no hepatosplenomegaly
  • Ext: Normal capillary refill

Assessment & Plan:

5mo female, ex-27wks with a history of multiple food allergies, GERD, FTT. Persistent failure to gain weight, admitted for evaluation of feeding habits and observed weight gain. The patient was determined to not be receiving adequate intake and was advanced to a high-calorie formula and parental education was provided. After two days of observed (and appropriate) weight gain, the patient was discharged with follow-up at multiple specialty clinics including GI, FTT, and A&I.

Differential Diagnosis for Failure to Thrive:

A System for Failure to Thrive

 

Sore Throat

Oropharynx AnatomyID:

17 year-old female presenting to the pediatric ED with sore throat for 2 days.

HPI:

The patient reports steadily worsening sore throat over the past 2 days, associated with a sensation of swelling. The pain is described as sharp, 4/10 in severity, located on the left side of her throat, and worsened with swallowing. She denies inability to swallow or difficulty breathing, she also denies fever, cough, new skin rashes or genital lesions.

She has no PMH/PSH, takes no medications, denies t/e/d use and is not currently sexually active.

PE:

  • VS: 111/65mmHg, 80bpm, 97.8°, 16/min, 100% RA
  • Gen: Well-appearing, NAD
  • HEENT: PERRL, no conjunctival injection, TM clear b/l, minimal pharyngeal erythema on left with 6mm white circular lesion on left tonsil, no tonsillar enlargement, no uvular deviation, no cervical LAD, neck supple no masses, normal neck ROM
  • CV: RRR, no M/R/G, Lungs: CTAB
  • Abdomen: +BS, soft, NT/ND
  • Ext: Warm, well-perfused, normal peripheral pulses

Assessment & Plan:

17yo female with no significant PMH with acute pharyngitis for 2 days. The most likely cause of the patient’s symptoms is viral pharyngitis, potentially herpangina (given the appearance of the tonsillar lesion). A more serious viral/bacterial pharyngitis is less likely given the absence of fever or significant erythema/exudate. There was no uvular deviation to suggest peritonsillar abscess and no evidence of airway obstruction to suggest other acute processes (epiglottitis, retropharyngeal abscess). The plan is to recommend supportive care and ibuprofen for symptomatic relief. The patient will be discharged home in good condition with precautions to return if symptoms worsen or she begins to have difficulty swallowing/breathing.

Differential Diagnosis of Acute Pharyngitis:

Acute Pharyngitis

 

Evaluation (history):

  • Respiratory distress: epiglottitis, retropharyngeal abscess, peritonsillar abscess, EBV (obstruction in or near pharynx)
  • Fatigue: infectious mononucleuosis
  • Abrupt onset: epiglottitis

Evaluation (physical examination):

  • Vesicles anterior: herpetic stomatitis, SJS, Behcet
  • Vesicles posterior: herpangina (± involvement of extremities)
  • Asymmetry: peritonsillar abscess
  • Stridor, drooling, respiratory distress: airway obstruction
  • Generalized inflammation: Kawasaki

Pediatric Fever

CXR with infiltrates

ID:

5yo girl brought to the pediatric emergency department by her mother due to 3 days of fever.

HPI:

The patient’s fever was first noted 3 days ago, measured at home to 103°F. It is associated with a moist cough, vomiting, and decreased PO intake. Her mother reports that she appears lethargic and has been urinating less frequently. The patient denies headache, changes in vision, burning with urination, or ear pain. No known sick contacts, attends day care.

PMH (Birth History):

No significant medical/surgical history. Ex-term born NSVD with no complications.

PE:

  • VS: 95/65mmHg, 100bpm, 102.6°, 22/min
  • General: Well-appearing, mildly irritated but consolable
  • HEENT: NC/AT, PERRL, oropharynx without erythema, no cervical LAD
  • CV: RRR, no M/G/R
  • Lungs: No evidence of respiratory distress (retractions, flaring), faint crackles over right inferior lung fields
  • Abd: +BS, soft, non-distended, TTP RLQ > LLQ, no rebound/guarding
  • Back: No CVAT

Labs/Imaging:

  • CXR PA/Lateral: RML/RLL infiltrate

Assessment:

5yo with 3 days persistent high fever and cough. These symptoms along with examination findings of crackles warranted further imaging (CXR) which revealed infiltrate in the right inferior lung field. The patient appeared clinically stable and was tolerating PO intake in the ED and was discharged home with azithromycin 5mg/kg/dose (with loading dose), clinic follow-up and strict return precautions.

Evaluation and Management of Pediatric Fever

Algorithm for the Evaluation of Pediatric Fever

A System for Pediatric Fever:

Pathophysiology:

Pathophysiology

Diagnosis:

  • <3mo: 38.0°C, 100.4°F
  • 3-36mo: 39.0°C, 102.2°F
  • Rectal > oral > axillary

Differential Diagnosis of Pediatric Fever:

Causes Of Fever

Serious Bacterial Illness (SBI):

1) UTI and pyelonephritis

  • Most common cause of SBI
  • Accounts for 3-8% of uncharacterized fevers
  • Female > male, uncircumcised > circumcised
  • Consider BCx, CSF evaluation as 5-10% bacteremic at presentation
  • Urinalysis: LE 75% specificity, Nitrites 97% specificity

2) Pneumonia and sinusitis

  • Sinusitis uncommon <3yo (sinuses unformed)
  • PNA diagnosed with CXR, obtain if findings of respiratory distress (grunting, tachypnea, hypoxemia) or rales on exam

3) Meningitis

  • Diagnose with LP
  • Meningitis suggested if:
    • ANC > 1,000
    • Protein > 80
    • Seizure (particularly complex febrile seizure)

Diagnosis by Age Group:

<3mo

  • Physical exam findings:
    • Tachypnea, hypoxemia → LRT infection
    • Irritability, inconsolability, bulging anterior fontanelle → meningitis
    • Vomiting/diarrhea → non-specific, GE, AOM, UTI, meningitis
  • History
    • Recent immunization: increased risk of SBI (usually UTI) 24-72h after immunization
    • Confirmed bronchiolitis (viral): enterovirus/parainfluenza associated with SBI

3-36mo

  • Physical exam findings:
    • Viral (URTI, GE) → vomiting, diarrhea, rhinorrhea, cough, rash; still playful and responsive
    • UTI → fever, foul-smelling urine, crying when urinating
    • Meningitis → irritability with handling, vomiting, bulging anterior fontanelle, complex febrile seizures

>36mo

  • Physical exam findings: presentation more adult-like
  • Watch for:
    • Group A Streptococcal pharyngitis
    • Infectious mononulceosis
    • Kawasaki: high fever (>5d), strawberry tongue, conjunctivitis, desquamating rash on palms/soles

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