Author: Yenis Paez-Perez

Resident: Yenisleidy Paez Perez 

CC:“I”m bringing in my son. He has been having tooth pain since last night, and I gave him Tylenol but then he seemed to pass out and had white stuff at the mouth and his face and hands look blue”

HPI: 5-year-old male presents to ED brought by his mother today after she noticed his mouth, legs, arms, and legs started turning blue. Patient was brought immediately after mother noticed the symptoms. Prior to arrival, patient was given Tylenol which mom bought a local store for a toothache he’s been having for the past few days. Patient has appointment with the dentist tomorrow. Patient’s mother denies any change in behavior, HA, dizziness, or syncope episode. Denies fever, chills, recent illnesses, nausea, vomiting, diarrhea, generalized weakness, or lethargy, abdominal pain, limitations in his activities, difficulty breathing, cough or URI symptoms. Upon arrival, patient is hypoxic, saturating 77% on room air. Despite this, pt denies SOB or Chest pain.

Physical Exam:
T: 35.6 °C (Tympanic) HR: 126 (Monitored) RR: 14 BP: 102/73 SpO2: 82% (on Non-rebreathing Mask) WT: 18.60 kg

Constitutional: Awake, alert, comfortable but irritable, crying but consolable by the mother. Head: Normocephalic, atraumatic

Eyes: PERRL, EOMI

ENT: External ears are unremarkable. B/L external auditory canals are normal and clear, no cerumen impaction, non-erythematous. B/L TMs are normal, nonerythematous, no bulging or dullness or effusion. Posterior pharynx is grossly normal, non-erythematous, no tonsilar enlargement, or exudates. Multiple dental cavities with mild tenderness on palpation of right lower jaw.

Neck: Supple, full range of motion, no mass Chest: Normal appearance and motion, no deformity or crepitus.

Cardiovascular: Tachycardia. Rhythm is regular. Normal S1 and S2, No gallops, murmurs, or rubs., symmetric pulses bilaterally

Respiratory: Normal chest rise and fall, no respiratory distress or stridor despite hypoxia and cyanosis, equal breath sounds bilaterally, clear to auscultation bilaterally, no wheezing, rales or rhonchi. No stridor.

Abdomen/GI: Soft, non-tender, no rebound tenderness or guarding, nondistended, no organomegaly

Neuro: Alert and oriented, Mentation is appropriate for age, moves all fours, good tone. GCS 15. 5/5 strength in all extremities. Sensory intact

MS/extremity: ROM intact in all extremities. Pulses equal. Neurovascularly intact.

Skin: Acrocyanosis and periorbital cyanosis noted, no rashes, no erythema,

Laboratory Data:
Blood work was drawn and the blood was noticed to be chocolate brown

CMP: Na: 137    K+: 3.9    Cl: 104    CO: 21    BUN: 12    Cr: 48    Glucose: 116 Alk Phos: 279    AST: 25    ALT: 9

CBC: WBC: 8.4    Hg: 12.7    Hct: 38.1    Platelet: 312    PT: 13. 7    INR: 1    PTT: 32.6

D-dimer: 0.43      Troponin: < 0.010      VBG & MetHb: Pending!

 

Pertinent Images/EKG:
EKG: Sinus Tachycardia at 126 bpms. Normal PR- Interval and QRS- interval. No T waves changes.
Chest X ray: Normal chest X-ray, NO cardiomegaly, NO increased interstitial lung markings , no consolidation, no PTX.

Working Diagnosis at time of Disposition: Methemoglobinemia , CO Poisoning  and Anemia

ED & HOSPITAL COURSE:

VGB (Mixed Venous Gas) pH: 7.39   pCO2: 36   pO2: 265   HCO3: 21.8   Lactate 2.6   COHb: 0.2   MetHb: 30

5-year-old male presented to the ED with hypoxia, saturating 77% on room air. His saturations went up only to 85% – 87% while on a non-rebreather mask.. No evidence of anaphylaxis, no wheezing, rales or decreased breath sounds on exam. No rashes, no vomiting or abdominal pain. Chest x-ray did not reveal cardiomegaly or pulmonary infiltrate or pneumothorax. Blood work was drawn as well as Met hemoglobin levels, VBG and carboxyhemoglobin levels were obtained. Met hemoglobin level return at greater than 30%.

This is a case of methemoglobinemia, which was treated with Methylene blue (2mK/kg over 15 minutes). After it was administered, patient’s saturation increased to 97% while on non-rebreather mask.

On further questioning, patient’s mother asked the grandfather who had been taking care of him if he had given him any new medications. He admitted to administering Oragel to the patient’s teeth multiple times per day for the past couple of days.

In ED patient was given: methylene blue: 37 mg (2mg/kg over 15min) (02/24/19 12:02:00 EST) Sodium Chloride 0.9%: 372 mL (02/24/19 11:27:00 EST)

Hospital Course: ABG was repeated and MethB had normalized. Patient did not have return of cyanosis and never experience respiratory distress during his hospital stay. OMFS was also consulted for his toothache and patient started on IV Unasyn for right buccal swelling, which was fluctuant, erythematous and tender with palpation. He underwent drainage of dental abscess and tooth removal. He was transitioned Amoxicillin PO for 1 week, and discharged the next day

WHAT IS IN ORAGEL? 20% Benzocaine!

Pearls & Take Away: Methemoglobinemia!

BACKGROUND: 

• Definition: An abnormal elevation of Methemoglobin, which refers to, the ferric form of hemoglobin (Fe+3) that is unableto bind to O2.
• An abnormal MetHb level is any level > 1%
• Suspect in any patient with cyanosis not responsive to supplemental oxygen!!!
• Pulse Oximetry readings are inaccurate in the presence of MetHb

 PATHOPHYSIOLOGY

• Oxidized Fe+3 sites on MtHb are unable to bind to oxygen
• This results in a leftward shift in the oxyhemoglobin dissociate curve which leads to decreased oxygen delivery
• Methemoglobinemia occurs when there is a deficiency of the reducing enzyme (NADH MetHb reducatase) OR when there is increased oxidative stress to the body

CAUSES:

1. NADH reductase deficiency – unable to reduce ferric to ferrous iron (Fe³⁺→ Fe²⁺)
2. Exposure to oxidizing agent
3. Benzocaine and other local anesthetics
4. Contaminated well water
5. Nitrofurantoin, Nitroprusside
6. Sodium Nitrite, Amyl nitrite
7. Antimalarials: Quinolones
8. Dapsone (used to treat leprosy, PCP pneumonia, toxoplasmosis, dermatitis herpetiformis, brown recluse bite)
9. Aniline dyes
10. Phenazopyridine^[3]

 CLINICAL PRESENTATION:

• Patients with anemia or preexisting cardiopulmonary disease will show symptoms sooner (i.e. CHF, Pneumonia, COPD, anemia, etc)
• Important diagnosis feature (Saturation < 85% without response to 100% FiO2)
• Wavelength averaging by the pulse oximeter causes a falsely low O2 reading
• Symptoms depend on level of metHb:
• < 20%:Asymptomatic or very mild symptoms; gray-blue cyanosis, chocolate brown colored blood
• 20-50%:Anxiety, HA, weakness, lightheadedness, tachycardia, dyspnea, dizziness, syncope
• 50-60%:Myocardial ischemia, dysrhythmias, ischemia, tachypnea, depressed mental status due to CNS hypoxia, seizure
• >70%:Severe hypoxia, Death

DIFFERENTIAL DIAGNOSIS:

• Emergent: Anaphylaxis, Angioedema, Airway Obstruction, Aspiration, Asthma, Cor pulmonale, Non-cardiogenic or Cardiogenic pulmonary edema, Pneumonia, Pulmonary Embolism, Tension Pneumothorax, Tamponade, MI, Pericarditis, Myocarditis

• With normal/increased Respiratory effort—-Anemia, CO Poisoning, Salicylate toxicity, DKA, Sepsis, renal failure, metabolic acidosis

EVALUATION:

• ABCs
• Provide 100% Fio2, —-lack of response should raise concern for methemoglobinemia. If patient does response to supplemental oxygen then most likely it is from a cardiovascular or pulmonary etiology
• Venous blood gas (VBG)
• Arterial blood gas (ABG) would reveal a normal
• Co-Oximeter panel for MetHb level (Can use VBG or ABG) : Measures levels of oxyhemoglobin, Carboxyhemoglobin,methemoglobin, reduced hemoglobin

• “Chocolate brown” color of blood
• If no response to Oxygen —– Draw MetHb concentration

MetHB > 30% ——àSpO2 will fall to 80-85% and will not increased despite additional oxygen.  This occurs due to light absorption of both oxyHb and deoxyHb.

• Who gets treatment?

1. MetHb < 25% with symptoms, abnormal vital signs, metabolic acidosis or end organ dysfunction (AMS, seizure, etc)
2. MetHb > 25% regardless of symptoms

MANAGEMENT

• Initiate treatment if symptomatic OR asymptomatic with MetHB > 25%
• 1-2mg/kg Methylene Blue IV over 5-15 minutes, repeat if no effect with initial dose. Flush line after infusion completed
• Clinical improvement seen within 20 minutes
• Contraindicated in G6PD deficiency as it can induce acute hemolytic anemia
• Exchange transfusion for symptomatic patients with G6PD deficiency as well.
• Hyperbaric oxygen when methylene blue ineffective or contraindicated

 

 

Emergency Medicine Symposium – Seventh Annual St. Joseph�s Regional Medical Center

Resident: D’Amore/Clayton

CC: “My heart is racing.”

HPI: 26 year old male with no past medical history presents to the Emergency Room with complaints of palpitations. Patient states that while exercising at the gym just prior to arrival, he suddenly developed palpitations along with associated lightheadedness. He reported one similar episode in the past that self-remitted. He denies chest pain, shortness of breath, nausea or vomiting but was experiencing intermittent lightheadedness. He denies taking any medication prior to arrival. Patient states he drinks ETOH infrequently with his last drink several days ago. He denies tobacco or illicit drug use. Patient also denies any family history of heart disease or arrhythmias.

Physical Exam:
Vitals: HR: 221 BP: 117/74 RR: 20 T: 98.8 Pulse Ox 100% on Room Air
General: Patient is awake, appears uncomfortable
Respiratory: No respiratory distress. Lungs are clear to auscultation.
Cardiovascular: +S1/+S2, tachycardic, irregular. No murmurs, rubs or gallops.
Abdomen: Soft, non-tender, non-distended
Extremities: Palpable, rapid pulses. No cyanosis, clubbing, or edema.
Neurological: Alert and oriented to person, place, time, and situation, following all commands, strength and sensation intact and equal bilaterally.

Laboratory Data:
Lab work and radiography including troponins, complete blood count, complete metabolic panel, thyroid stimulating hormone, chest x-ray, and urine drug screen were all within normal limits. Image 1 is the EKG on presentation. The patient quickly became hypotensive 90/52 and complained of lightheadedness. The patient was quickly sedated and cardioverted with 150 joules. He returned to sinus rhythm at which time the underlying conduction was more apparent.

Questions

1. What EKG abnormalities do you notice?
2. EMS requests permission to administer 6mg of Adenosine to treat the arrhythmia.

What is your recommended treatment plan?

Answers:

1. This EKG demonstrates Wolff-Parkinson-White Syndrome with Atrial Fibrillation.
2. Advise EMS not to treat with Adenosine or other A-V nodal blocking agents as this may precipitate ventricular tachycardia or ventricular fibrillation.

Discussion:

Wolff-Parkinson-White Syndrome is a pre-excitation syndrome where myogenic bundles known as the Bundles of Kent directly link the atria to the ventricles, bypassing the atrioventricular (AV) node and the organized infranodal system [source: Tintinalli]. Atrial Fibrillation (AFib) in Wolff-Parkinson-White Syndrome (WPW) is a presentation of this syndrome in up to 20% of cases.

Features include an irregularly irregular rhythm, very rapid ventricular rates often in the range of 250 to 300, and widened QRS complexes that differ in duration and morphology from one to the next.The accessory pathway present in patients with WPW allow for the multitude of additional ectopic atrial impulses present in AFib to bypass the AV node and conduct to the ventricles, accounting for the unusually rapid ventricular rates. The variation in QRS duration and morphology can also be attributed to simultaneous conduction through the traditional AV node-His-Purkinje pathway as well as the Bundle of Kent-Ventricle route.

WPW with AFib is often misdiagnosed as a supraventricular tachycardia (SVT), ventricular tachycardia (VT) or atrial fibrillation with a bundle branch block, all of which can be safely treated with AV nodal blockers such as Adenosine, Diltiazem, and Amiodarone. WPW in the presence of atrial fibrillation makes degeneration into ventricular fibrillation more likely and thus synchronized cardioversion, delivering 0.5 – 2 Joules/kilogram, is the first-line treatment. Second-line treatments include Procainamide or Ibutilide whose mechanism prolongs the refractory period of the accessory pathway and whose dosing is weight-based. Stable WPW in the presence of narrow-complex SVT can be treated with the traditional vagal maneuvers, adenosine, and calcium channel- or betablockers [source: Tintinalli]. Patients with WPW should undergo ablation as this syndrome can lead to sudden cardiac death by means of ventricular fibrillation.

Take Home Pearls:

• Wolff-Parkinson-White with Atrial Fibrillation presents as an irregularly irregular tachycardia with widened QRS complexes that vary in morphology and result in ventricular rates often greater than 250.

• If the QRS complex is widened, avoid use of any AV nodal blockers as they can precipitated ventricular arrhythmias.

• Procainamide and synchronized Cardioversion are the treatment of choice for WPW with AFib.

CC: Hand Injury-Job Related

HPI: 35 yo otherwise healthy male presents to the Emergency Dept. (ED) with a laceration over the palmar surface of the left hand, proximal to the PIP joint and extending over the MCP joints of the 4^th and 5^th digit. He sustained this injury at work one hour ago. He is a firefighter and was responding to a house fire when he accidently tripped over an object in a smoke filled room while putting on his glove. He states his left hand went through a glass door. At the scene, patient washed it out with sterile saline and a dressing was applied. Pt also complaints of decreased sensation to the distal aspect of his left 5^th digit. He denies any other trauma, preceding symptoms of chest pain, dizziness, feeling lightheaded, palpitations, inhalation injury or difficulty breathing. Denies head injury, neck pain or LOC. Last tetanus is unknown.

Physical Exam:

Vitals: BP 155/97   Pulse 97   RR 15     T 98.6F   SpO2 100% on RA
MSK/extremities: 2.5cm complex “V” shaped laceration over the palmar MCP of the left 5th digit that is oozing blood; no arterial bleeding noted. Tissue flap noted. 1.5 cm laceration over the left palmar aspect of the 4th digit between the MCP and PIP joint. Hemostasis noted. Small tissue flap noted. Sensation intact over the distal left 4th digit; Sensation mildly decreased over the distal left 5th digit. Cap refill brisk both digits. Pt is able to flex and extend both digits.

Location of laceration

:

Pertinent Labs (if any): N/A
Pertinent Imaging/EKG: No displaced fracture or dislocation. No radiopaque foreign body is identified.

Working Diagnosis: Prior to x-rays: possible FB, dislocation/subluxation, fracture. Possible Partial flexor tendon laceration.

 ED/Hospital course: Pt received Toradol for pain and a tetanus shot

• Digital block was performed on the 4th and 5th digits of the left hand by injecting lidocaine into the web spaces as well as local was performed on the palm where the digital block was ineffective.
• Moderate bleeding/oozing noted of the 5th left finger laceration. Upon lifting the tissue flap of the 5th digit the flexor tendon was exposed but not lacerated. The 4th left digit wound more superficial. No tendon exposed. No FB found in either laceration.
• 4th finger closed w/ six 4-0 Ethilon sutures
• 5th finger closed w/ ten 4-0 Ethilon sutures
• Pt discharged w/ Rx for: Bacitracin Ibuprofen Keflex F/u w/ employee health F/u in 7-10 days for suture removal

 Pearls & Takeaways:

• For lacerations to the hand or other injuries that may or may not involve a tendon always ask:
  • Position of hand injury?
  • Crush, burn, injection, chemical injury?
  • Other trauma or preceding symptoms?
• Exam for hand/wrist lacerations
  • Check and compare Bilateral grip strength
  • Check sensation
    • Compare bilaterally with 2 point discrimination to the volar aspect of each fingertip
    • Normal 2 point discrimination on the hand is 5-6 mm
    • Review of nerve distribution :
    • 
  • Check Motor function
    • Ask them to make a clenched fist— The middle and distal phalanges should all be parallel to each other with the nails positioned in the same plane and pointing toward the Scaphoid when fist is clenched
    • Ulnar Nerve innervates the Lumbricals and Adductor Pollices Muscles
      • Lumbricals: Have patient abduct their fingers and have them resist the force of you pushing their fingers back to midline
      • Adductor Pollices Test: Have patient hold a piece of paper with the volar pulp of the thumb and PIP of index finger. If you pull away at the paper, and pt is able to maintain the key pinch of paper against resistance then adductor pollicis is strong.
        • Look for Froment’s Sign ( Flexes IP joint of thumb to compensate for weak Adductor Pollices)
        • https://www.youtube.com/watch?v=yJTIhm1VfSI

• Median Nerve
  • Make the “OK” Sign (Flexor Pollicus Longus)
  • Opposition (Thenar Muscles): As them to touch their pinky with their thumb
  • Ask pt to abduct their thumb with palm up and have the pt resist a force to redirect the thumb toward the palm (Abductor Pollicis longus)
• Radial Nerve
  • With palm on the table, hyperextend all fingers against resistance from can have them lay their palm flat on a table, and lift each digit straight up and extend up from the table while keeping the palm flat
• Vascular
  • Check for capillary refill and pulses
• Flexor Tendor Testing
  • 90% of the tendon can be severed/lacerated with preservation of ROM without RESISTANCE.
  • Apply resistance when testing for tendon function
  • Pain along course of tendon during resistance testing suggest partial laceration even if pt has FULL ROM
  • Test for Flexor Digitalis Profundus (FDP): Ask the to flex their DIP joint against resistance while holding their MCP and PIP joint in extension
  • Test for Flexor Digitalis Superficialis (FDS): Ask to flex their PIP joint against resistance while ALL the rest of the fingers are held in full extension (Hyperextension disengages FDP and the FDS function is isolated).
  • 
• Imaging
  • If isolated fingers involved, get a AP, oblique and lateral view of the designated finger as well as the hand
• Digital Blocks
  • Web Space– Inject 1-3 mL of Anesthetic
  • 
  • 
  • Transthecal
    • Inject into flexor Tendon sheath
    • ID distal palmar crease and tendon
    • Insert needle at 45 degrees just distal to crease
    • Inject
    • If resistance, withdraw slightly
    • Apply proximal pressure
    • Pros: Only 1 poke and numbs entire finger
    • Cons: It’s over most sensitive part of the hand
    • 
  • Method to get a bloodless field
    • Use tourniquet or Penrose drain at base of finger secured by hemostat
    • Use another tourniquet or gauze to wrap around distal end of finger and wrap w/ moderate compression down from most distal part to laceration milking out the blood in the distal finger
    • Do not leave tourniquet on for >20 minutes
  • What If there is a stellate laceration?
    • Great video on the corner stitch! Try it next time!
    • https://lacerationrepair.com/techniques/basic-suturing-techniques/the-corner-stitch/
  • When to refer tendon lacerations:
    • 
  • Splinting tendon Injuries:
    • General rule is to splint in the direction of function
      • Extensor tendons splinted in extension
      • Flexor tendons splinted in flexion
    • Flexor Tendon Injuries specifically:
      • Dorsal splint
      • Wrist flexed to 30 degrees
      • 70 degree MCP flexion
      • 30-45 degree PIP flexion
      • 
    • Antibiotics
      • NO Great guidelines
      • ACEP Clinical guidelines
        • Looks ok-à No ABX
        • Looks bad-à ABX
      • If simple laceration -à no ABX
      • If not simple (contaminated, infected, bone, tendon, joint involvement)-à ABX
        • 1^st line: Cephalosporin
        • Consider Context:
          • Human, Cat, Dog Bites: Amoxicilin/Clavulanic Acid (Augmentin)
          • Open fractures: Cefazolin (Ancef)
          • Visibly dirty and open wound: Ancef + Gentamycin

Case presented by Dr. Jessica Williams

Scavenger Hunt in Hoboken ! 

 

 

  

CC: Shortness of breath

HPI: 7 day old female presents to the Emergency Dept. (ED) after being seen earlier in clinic. Mother is rom Nigeria and arrived to the U.S a few weeks prior to delivery. Prenatal care is unclear. Patient was delivered via C-Section at 39 weeks at another nearby hospital. Both mother and baby spent one day in the hospital after delivery being discharged home. Mother states that since last night, the baby appears to “ not breathing right.” She also hasn’t’ been eating much and is crying more often than usual, during which her lips start to turn blue.

Physical Exam:
Obvious respiratory distress, hypoxic on RA, saturating in the middle to low 80’s on NC 3 L
HR 176,   RR 60.    Accuchek 96.
BP: (RA) 69/45    BP (LA) 91/64     BP (LL) 84/64     BP (RL) 71/58

Pertinent Imaging/ECG

ECG in the ED:

Working Diagnosis: Shock secondary to congenital cardiac pathology.

ED/Hospital course:  Patient was admitted to PICU, underwent Echocardiogram and further imaging and was diagnosed with Coarctation of the Aorta. The patient was transferred to Mt. Sinai for operative repair.

Pearls:

• 7 day olds are terrifying, especially if they are sick.
• Take a breath! Start with your ABCs.
• Coarctation of Aorta(CoA) is a congenital aortic narrowing which most commonly occurs at the level of ductus arteriosis. There are Pre-ductal and Post-ductal types. Pre-Ductal CoA is a Truncus dependent lesion and most patients present within 2 weeks of birth once duct closes. Aortic narrowing leads to increased LV function and dilation. Post-ductal are commonly identified in adulthood.
• Obtain a BP/pulse Ox in all 4 extremities
• Perform the Hyperoxia test
  • Obtain ABG on RA. Then, apply 100% supplemental oxygen with a NRB for 10-15 minutes. Repeat the ABG on the NRB.
    • On repeat ABG
      If PaO2 > 250mmHg = Lung problem
      If PaO2 < 100mmHg = Congenital Heart Disease
      If PaO2 100-250: Assume the worst situation first
• You may also apply supplemental oxygen and assess the infant’s response. If saturation increases to at least 5-10%, it’s most likely a Lung problem. If it remains the same, think about Congenital Heart Disease
• Prostaglandin (pt is less than 4 weeks old typically 1-2 weeks of life) start at 0.05 mcg/kg/min.
• Dr. Hochman rule #11, call consultants early “don’t be the captain of a sinking ship”
• Additional medications: Lasix 1 mg/kg if evidence of volume overload.Ductal dependent lesions, pulmonary presentation cyanosis/hypoxia use phenylephrine . If systemic SX, shock, pulmonary congestion on CXR Milrinone (decrease afterload + inotropic support).

The SICK NEONATE!

Case presented by Dr. Daniel Poor

 3-year-old boy presents to the ED with a 4-day history of cough and 1-day history of fever. Per family patient has been having rigors and chills with vomiting. He also reports chest pain with coughing. His immunizations are UTD. The child does not appear toxic,

VS: Temp 103.3F,  BP 90/65,  HR 100,  RR 30,  96% O2 Saturation on RA.
Patient has some intercostal retractions, with decreased air entry on the right side with audible crackles.

Questions for EM physician

• How do you make the diagnosis of pneumonia?
• Distinguishing patients with bacterial pneumonia, who would benefit from antibiotics, from those with nonbacterial pneumonia who would not.
• Who requires inpatient management vs. patients that can be safely discharged home on oral antibiotics.
• Pneumonia is the number 1 killer of children worldwide.
• Pneumonia occurs more often in early childhood than at any other age and causes significant morbidity and mortality.
• Identifying the cause of pneumonia in children is difficult due to a lack of rapid, accurate, commercially available laboratory tests for most pathogens. Empirical therapy based on patient’s age, clinical scenario and risk factor is the most common course in most cases.

Age-specific causes of pneumonia in otherwise healthy children. Pathogen listed in order of frequency
Neonates	GBS, E. Coli, Listeria Monocytogenes, Staphylococcus
1 month – 2 years	RSV, Parainfluenza virus, Metapneumovirus, Influenza virus, Adenovirus, S. Pneumoniae  **3 weeks to 3 months of age (Pneumonitis syndrome/Afebrile Pneumonia Syndrome (APS))*: Chlamydia trachomatis, RSV, Parainfluenza virus, Bordetella pertussis
2 – 5 years	RSV, S. Pneumoniae, Non-typeable H. Influenzae (NTHi), Group A Streptococcus, Mycoplasma pneumonia, Chlamydia pneumonia
6 – 18 years	Mycoplasma pneumonia, Chlamydophila pneumonia, Streptococcus pneumonia, NTHi, Influza virus A , other respiratory viruses
	*Infants (1 – 3 months of age) may present with a characteristic syndrome of cough, tachypnea, progressive respiratory distress, and radiographic evidence of bilateral diffuse pulmonary infiltrates with air trapping. Most are afebrile. This syndrome is also called APS. The most common pathogen included Chlamydia trachomatis and respiratory viruses. Infection of Bordetella pertussis should also be considered due to recent dec. in immunization. Acutely, APS is generally benign and self-limiting disease. In such cases, infants often have viral illness, which does not respond to antibiotic therapy, but differentiating bacterial from viral illness is often difficult. Consider empiric antibiotic therapy.

Diagnosis of pneumonia:

• • Definition: Essentially it is infection of lower respiratory tract in the presence of radiographic abnormalities on CXR.
  • WHO guidelines for pneumonia in children is cough and tachypnea
    • Age < 2 months: Tachypnea is >60 RR
    • Age 2 months to 5 months: Tachypnea is >50 RR
    • Age >12 months: Tachypnea is > 40 RR

• • Clinical features
    • Fever and tachypnea are sensitive but not specific
    • Cough
    • Productive cough is rarely seen before late childhood
    • Consider pneumonia in any child presenting with prolonged fever, prolonged cough, high fever, as well as focal respiratory findings not including wheezing, especially with the presence of multiple symptoms.

Evaluation
Absence of tachypnea, respiratory distress, and rales/decreased breath sound rules-out pneumonia with 100% sensitivity

• CXR: Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
  • • Consider for:
      • Age 0-3mo (as part of sepsis work up)
      • <5yr with temperature >102.2, WBC >20K and no clear source of infection
      • Ambiguous clinical findings
      • Pneumonia that is prolonged or not responsive to antibiotics
  • Consider RSV, Influenza 

Treatment

Empiric Antimicrobial Therapy For Children with Pneumonia by Age group
Age group	Outpatient	Inpatient
Neonates	NOT RECOMMENDED	Ampicillin 200 mg/kg/d IV divided Q6H + Gentamycin 7.5 mg/kg/d IV divided Q8H OR + Cefotaxime 150mg/kg/day IV divided Q8H Consider Cloxacillin and Nafcillin for patient with S. aureus infection or Vancomycin for MRSA
3 wk – 3 mo	NOT RECOMMENDED	Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days
3 mo – 5 yr*	Amoxicillin 80 – 100mg/kg/day in 2 divided doses	Ampicillin 200 mg/kg/d IV divided Q6H OR Ceftriaxone 50 mg/kg Q24hrs Consider Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days Consider Vancomycin for seriously ill patients
6yr – 18yr*	Azithromycin 10 mg/kg for first dose, then 5 mg/kg daily for 4 days	Azithromycin 10 mg/kg IV first dose, then 5 mg/kg IV QD for 4 days PLUS Ceftriaxone 50 mg/kg Q24hrs Consider Vancomycin for seriously ill patients
*Refer to AAP guideline on management of pediatric pneumonia below

Disposition

• Consider Admission For
  • Age: <2-3 months old (Consider up to 6 months)
  • History of severe or relevant congenital disorders (Cystic fibrosis)
  • Suspected complication (Empyema)
  • Vomiting, dehydration, unable to tolerate PO
  • Immune suppression (HIV, SCD, malignancy)
  • Toxic appearance/respiratory distress
  • SpO2 <90-93%
  • Social circumstances

Post by Dr. Michael Hong

Go to emsymposium.org for more information or click the images below to download the brochure! We hope to see you all there!