Mistakes you don’t want to

make in pediatric patients

Richard M. Cantor, MD FAAP/FACEP

Professor of Emergency Medicine and Pediatrics

Section Chief, Pediatric Emergency Medicine

Director, Pediatric Emergency Medicine Fellowship

Golisano Children’s Hospital, Syracuse, NY

TALK LANDSCAPE

These are real life cases

Presented in real time

All diagnoses made in the ED

Classic mistakes made

Happy endings eventually

Lessons learned

COMING SOON

ALL PUFFED UP

History

A 3 year old girl awakens with a swollen face

Essentially no other complaints

No history of allergies

No inciting historical event

No fever

No pruritis

No SOB

Physical

Afebrile

HR 90

RR 16

BP 90/70

OSAT 98%

Physical

Periorbital edema

Clear lungs

No murmur

Abdomen “full”

Ankle edema

Some form of anaphylactic/allergic reaction

Working Diagnosis at the Time

Initial Interventions

IV access

IV Diphenhydramine

EPIPEN

IV Steroids

Clinical Progression (30 minutes later)

No change in findings whatsoever!

NOW WHAT??????

ARE THERE ARE OTHER ETIOLOGIES OF EDEMA?

Copyrights apply

Edema:

The Big Picture

Copyrights apply

Building A Workup For Edema

Therapeutic Trial:

EPIPEN

Antihistamines

Steroids

Building A Workup For Edema

CXR

ECG

BMP

Building A Workup For Edema

BMP

Albumin

Total Protein

LFT’s

Urinalysis

Further Work Up

CBC WNL

LFTs Normal

Serum Albumin/Total Protein LOW

Markedly elevated urine protein

Creatinine/BUN elevated

ECG/CXR normal

Case Progression

Nephrology Consult:

Renal Sono WNL

Complement studies ordered

Admitted

Steroids

Albumin

FINAL DIAGNOSIS:

NEPHROTIC SYNDROME

Take Home Message

Edema is a common complaint

Allergic etiologies are prevalent

Antihistamines, EPIPEN are reasonable interventions

Be prepared to broaden your diagnoses and workup

Everyone You Discharge Must Be Able

To Walk Out

History

At precisely 4:55 PM on a Friday afternoon, a 3 year old girl is referred to your ED by her for evaluation of a limp

Previously well, she awoke earlier that day with complaints that her right knee hurt and refused to bear weight

No antecedent trauma is described

History

She has had a cold for the past week, consisting of a mild cough and runny nose

No fever is described

She denies rash, sore throat or other systemic complaints with the exception of an upset stomach

Physical Examination

Vital Signs

• T 38.9C

• HR 72

• RR 16

• BP 90/70

General

• Well appearing young girl, very unhappy to be in the ED

HEENT

• PERRLA

• Pharynx normal

Physical Examination

Neck

• Supple

Chest

• PMI normal, no murmur

• Clear lungs

Abdomen

• Mild tenderness peri-umbilically

• No masses

Physical Examination

Extremities

• Right leg held flexed and abducted at the hip

• Decreased range of motion at the right hip

• No warmth or redness

• Rest of extremity normal

Skin

• No rash

Problem List At This Point

Fever

Abnormal hip exam

Mild abdominal tenderness

Case Progression

WBC 29,000 with 20% bands

ESR = 88, CRP = 7

Lyme titers normal

Hip and Knee films normal

Hip sono unremarkable

Tap of hip normal - ortho signs off case

The Retroperitoneal Space is Dangerous

S: suprarenal gland (adrenal)

A: aorta/IVC

D: duodenum

P: pancreas

U: ureters

C: colon

K: colon

E: esophagus

R: rectum

Psoas Anatomy

Psoas Abscess

Hernia

Gluteal Injury

The Ibuprophen Didn’t Work, Now What?

Broaden the workup

Imaging

Abdominal sonogram

Appendix not visualized

Abdominal CT?

CT demonstrates an iliopsoas abscess

Case Resolution

Pediatric surgery consulted

Taken to OR

Perforated walled off appendix with underlying psoas abscess

Recovered uneventfully

Take Home Message

Always consider non-orthopedic causes of limp

Psoas abscess

Appendicitis

Hernia

Gluteal tears

A TALE OF 2 TOXINS

History

A 23 month old male with no past medical history presented

to the emergency department with altered mental status

His mother reported that she found him rolling on the floor

of the kitchen 2 hours prior to ED presentation

She stated he felt very warm and dry and he was unable to

ambulate

History

She also mentioned he was very irritable could not focus on her as he was reaching out for things that weren’t there and trying to grab onto them

She mentions she found a cup of Fabuloso household cleaner near him alongside his older brother

She suspects the older brother may have given him what was in the cup

Physical Examination

Vital Signs

T 38C, HR 140, RR 20, BP 140/95

General

Irritable toddler

Staring “right past you”

HEENT

Dilated, reactive pupils

TM clear

Pharynx dry

Physical Examination

Neck

Supple

Chest

PMI normal, no murmur

Clear lungs

Abdomen

Absent bowel sounds

Physical Examination

Skin

Red and hot and dry

Pulses

Normal

Neurologic

Non focal agitation

Primary survey

ABC’S intact

Dextrostix 120

Encephalopathic

Pertinent Findings At This Point

Fever

Tachycardia, mild hypertension

Dilated Pupils

CNS Issues

Workup You Know You’ll Be Doing

Fever -------- CBC, Blood Cultures

Tachycardia, mild hypertension -------- Antipyretics (revaluate)

Dilated Pupils --------- Reevaluate, reconsider

CNS Issues ---------- CSF analysis, imaging

Labs Are Back (1 hour later)

CBC, Electrolytes normal

Spinal Tap unremarkable

CT brain normal

Child still encephalopathic, mydriatic

What Should We Consider When Multiorgan

Abnormalities Present Acutely (especially in a

toddler)?

The classic anticholinergic syndrome

Warm, dry, flushed skin (red as a beet)

Dry mouth (dry as a bone)

Mydriasis(blind as a bat)

Ileus

Delirium (mad as a hatter)

No Guts No Glory

Administer physostigmine at a dose of 0.02mg/kg?

It was administered over 5 minutes after which there

was no change in mental status, vital signs or

clinical presentation

A second dose (doubled) was given, with resolution

of pupillary dilitation, and encephalopathic behavior

Drugs with anticholinergic effects

Antihistamines (almost all)

Antipsychotics

Antispasmodics (Lomotil)

Muscle Relaxants (Flexeril)

Tricyclics

Antihistamine OD

Therapeutic as H1 receptor antagonists

In OD mimic anticholinergic poisoning

In general, toxicity occurs after ingestion of 3-5X usual daily dose

Children are more sensitive to the toxic effects of antihistamines than adults

More Labs

Salicylate and Ethyl Alcohol levels were negative

Acetaminophen level was 421.2 mg/L

Acetylcysteine loading dose was administered and the patient

was admitted to the pediatric intensive care unit for further

care of what we presumed to be an

acetaminophen/diphenhydramine overdose

The Additional Toxin

Take Home Message

ALWAYS obtain APAP and ASA levels in cases of

suspected accidental and intentional drug overdose

Oh No, Not Another Colicky Kid!

History

A 12 week old male is brought to the ED with a chief

complaint of “seeming to be in pain”

His parents state that over the past 8 weeks the infant had

frequent episodes of crying

The crying occurred more in the daytime and seemed to be

related to bottle feeding

At 3 weeks, after his pediatrician diagnosed colic, he was

switched to Soy formula

History

Over the next 6 weeks, after examination by another

pediatrician and a visit to the ED, a diagnosis of severe colic

was made

Donnatal drops were prescribed, as well as glycerin

suppositories

The child was switched to Nutramigen without success

Birth and family history were unremarkable

History

The current ED visit was prompted by the development of

what the parents describe as respiratory distress and

diaphoresis while feeding

No fever, cough, N,V,D were described

Physical

HEENT:

PERRLA Pharynx normal

General:

WDWN infant in mild distress

Vital Signs:

T 37C, HR 160, RR 44, BP 80/46 OSAT 90%

Physical

Pulses:

Equal

Abdomen:

Liver 3cm below RCM

Chest:

PMI normal, no murmur Grunting Rales

Labs

CBC WNL

Anion gap of 20

Bicarb 15

Radiograph

ECG

Case Progression

Given 20 cc/kg NS

Marked increase in work of breathing

Given a 3rd generation Cephalosporin

Cardiology consulted

ECHO performed………

Diagnosis: ALCAPA

ALCAPA

ALCAPA

Common cause of MI in infancy

Mortality 65-85%

Ischemia often produced by feeding (“steal” syndrome)

Common symptoms and signs for ALCAPA

Tachypnea (60%)

Diaphoresis (40%)

Murmur (45%)

FTT (55%)

Cardiomegaly (96%)

Abnormal EKG (90%)

Case Progression

Pediatric Cardiology confirmed the diagnosis

CP surgery performed emergent repair

Mild myocardial damage

Grunting: A Cautionary Tale

• Prospective study of 51 grunting patients

• Fell into 3 groups based upon mode of presentation

• 55% had respiratory signs and symptoms

• Each one had a respiratory or cardiac condition

• 25% presented with a high fever but without respiratory

signs

• ALL had an infectious cause (75% had an invasive

bacterial disease)

• 20% presented with neither fever or respiratory signs

• All had a variety of conditions that caused pain

Pediatric Emergency Care 1995; 11: 158

Grunting Summarized

Take Home Message

Grunting is OMINOUS

Always rule out

Respiratory causes

Cardiac causes

Bad infections

Abdominal crises

Feeding difficulties WITH diaphoresis may be due to underlying cardiac disease

Oh No, Not Another Headache!

Case

An 8 year old boy presents with a headache for 1

week

Headache is frontal and throbbing

Positionally sensitive

No fever

Case

Emesis x 2 today

No prior history of headaches, no trauma

Positive family hx of migraines

No medications

Case PE

Vitals normal

Normal body habitus

PERRLA

Disc margins not visualized

Case PE

Neck supple

Neurologically intact

Case Progression

Given “standard migraine therapy” (IV fluids, Compazine) without improvement

All lab work WNL

CT scanning unremarkable

What’s next?

Next?

Neurology consult?

More precise imaging?

More varietal anti headache meds?

Expand the differential?

Case Progression

Adequately prepared for a Spinal Tap

EMLA

Lidocaine

Morphine

Versed

All indices normal, except for a markedly elevated OP

A diagnosis of Idiopathic Intracranial Hypertension

was made

IIH: “Classic” Teaching

Obese females, usually adolescents

Exact mechanism unknown

Vomiting, blurred vision, papilledema, 6th nerve

palsies, ataxia, spasticity

CT: no mass, narrow ventricles

MRI: may see occlusion of the dural sinuses

LP: elevated pressure

Pediatr Emer Care 2015;31: 6–9

Conclusions

IIH should be considered in any child with new-

onset headache or visual disturbance,

irrespective of age, sex, weight, or the presence of

known predisposing factors

When IIH is suspected, neuroimaging should be

performed promptly to exclude secondary causes

of this condition because IIH in children remains

a diagnosis of exclusion

Take Home Message

The vast majority of headaches in children are febrile in origin

Standardized approach to the afebrile headache

Careful history (re: migraines in the family)

Visual acuity

Careful eye exam

Trial of migraine therapy

If successful, discharge

If unsuccessful

CT scanning

CSF tap WITH OP

Sadly, childhood obesity is on the rise

Just Another Cellulitis?

Case History

• A 14 year old boy with a swollen ankle for 2 days

• 2 days earlier, while playing hockey, he noted an

abrasion of the outer part of his ankle

• 1 day earlier the area became more red and swollen

• No significant PMH

Case PE

Vitals:

T 39C, HR 120, RR 16, BP 80/50

HEENT: Unremarkable

Chest: Hyperactive precordium

Abdomen: Generalized non focal tenderness

Case PE

Ortho: Obvious cellulitis, ankle with some pain on

mobility

Neuro: Irritable

Skin: Generalized warmth and erythema

The Ankle and The Rash

Initial Problem List

Fever

Obvious cellulitis

Generalized erythroderma

“Soft” blood pressure

Case Progression

Blood cultures drawn

Started on broad spectrum antibiotics

Arrangements made for admission

Initial Labs

CBC

WBC 21.5 with a marked left shift

H/H WNL

Platelets 80,000

BMP

BUN = 60

Creatinine = 2.8

New Problem List

Cellulitis

Erythroderma

Bacteremic profile

Renal insult

Soft blood pressure

One Hour Later

Blood pressure 70/50

HR 160

Given 60 cc/kg NS

Necessitated pressors for

5 days

Developed ARDS

Intubated for 3 days

Blood cultures negative

What Did I Miss?

Toxic Shock Syndrome

TSS: CDC Case Definition

Fever

T >38.9C (102.0F)

Hypotension

Systolic blood pressure 90 mmHg for adults or less than fifth

percentile by age for children <16 years of age

Orthostatic drop in diastolic blood pressure 15 mmHg

Rash

Diffuse macular erythroderma

Desquamation

1 - 2 weeks after onset of illness, particularly involving palms

and soles

CDC Case Definition

Multisystem involvement (3 or more of the following organ systems)

GI: Vomiting or diarrhea at onset of illness

Muscular: Severe myalgia / CPK elevation >2X

Mucous membranes: Vaginal, oropharyngeal, or conjunctival hyperemia

Renal: BUN or serum creatinine >2 X normal, or pyuria (>5 WBC/hpf)

Hepatic: Bilirubin or transaminases >2 X the normal

Hematologic: Platelets <100,000/L

CNS: Disorientation or alterations in consciousness without focal

neurologic signs

Take Home Message

Beware of impending TSS in ANY patient with ANY

Streptococcal or Staphylococcal disease

Careful attention to Vital Signs

Especially those patients with tachycardia “out of

proportion” to physical findings

Be liberal in laboratory evaluations

Always err on the side of early volume resuscitation

STICK YOUR NECK OUT

HISTORY

A 10 month old previously healthy male presents with 1

day of high fever and irritability

No URI or GI symptoms

Drinking well

Immunized

No one is ill at home

MOM IS AN ED DOC!

Physical Exam

T 40C

HR 140

RR16

BP 90/70

OSAT 99%

Irritable but calmable

Physical Exam

Fontanelle flat

Eyes clear

Throat unremarkable

No adenopathy

Lungs clear

Abdomen soft

Joints normal

No rash

Initial Work Up

CBC

WBC 43K

24% Bands

Toxic granulations

BMP normal

Urine normal

Further Work Up

CSF unremarkable

CXR WNL

Abdominal sono unremarkable

CRP 130!

ESR 80!

Initial Thoughts/Interventions

This infant has a bacterial process (somewhere)

Pretreatment cultures were obtained (Blood, Urine, CSF)

Given IV Ceftriaxone

Admitted

Rethinking The

Anatomy

CSF

CXR

SONO

URINE

JOINTS

Where Else Should

We Look?

Why The Neck Is Not Your Friend I

Why The Neck Is Not Your Friend II

Why The Neck Is Not Your Friend III

Why The Neck Is Not Your Friend IV

CT Neck

RETROPHARYNGEAL

ABSCESS

Back To Our Patient

Discharged after 3 days of IV antibiotics

8cc drained from abscess

ENT was consulted, taken to the OR

Take Home Message

Soft tissue neck infections in infants and children are on

the rise

There is often an element of torticollis

Routine PE may be unrewarding

Enhanced CT scanning will often diagnose

RPA

Parapharyngeal space infections

Lymphatic infections of the neck

Clinical Summary Points

Not all edema is allergy related

Consider abdominal disorders in the limping child

Grunting often heralds serious underlying conditions

Patients with Pseudotumor are getting younger, male, and

thinner

ANY Gram Positive infection can cause TSS

Enhanced imaging is indicated in the setting of fever and

torticollis

Thanks For Listening!