Pediatric Pearl: UTI (February)

FEBRUARY UTI – Hima Khamar

Pediatric Urinary Tract Infection
By: Hima Khamar, PGY3

In a previous pediatric pearl, we discussed how to treat febrile infants below 60 days. This pearl discussed management of pediatric urinary tract infection (UTI), but also discusses patients above the age of 60 days with a fever with no obvious source in whom UTI as a source.

History and Physical

History
Duration of fever
Symptoms that suggest an alternative source
Hydration status History of recurring fever without source
History of UTI
History of constipation
Dysfunctional voiding by history
FH of vesicoureteral reflux (VUR) or renal diseases

Physical
Vital signs
Suprapubic, flank tenderness
Abdominal mass, palpable bladder
Evidence of spinal lesion
Other GU abnormalities

Signs and Symptoms of UTI: Most common to least common*
Infants < 3 months Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine
Infants > 3 months – preverbal Fever Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Verbal – 18 years Frequency
Dysuria
Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

Risk factors for UTI
Infants >56 days who are not toilet trained

Female risk factors
–       Non-black
–       T ≥ 39°C
–       Fever ≥ 2 days
–       No source
–       < 12 months
>3 risk factors consider screening>4 risk factors recommend screening
Male risk factors
–       Non-black
–       T ≥ 39°C
–       Fever ≥ 2 days
–       No source
–       < 6 monthsCircumcised:
≥ 3 consider screening
≥ 4 recommend screening
Uncircumcised:
≥ 2 consider screening
≥ 3 recommend screening
Fully toilet trained – 18 yrs
–       Symptoms referable to urinary tract
–       Prior history of UTI, fever ≥ 2 days
–       Prolonged fever (≥ 5 days)Recommend screening for any of the above factors
 

TO CATH OR NOT TO CATH?

The AAP recommends obtaining a catheterized specimen for diagnosis of UTI, but this is a level C recommendation. Upon further reading, they basically state a bagged specimen is acceptable as well. SO BASICALLY, GET THE URINE IN WHATEVER WAY YOU CAN.

UTI Definition

DEFINITE UTI
Catheterization with >50,000 cfu/ml
Clean catch with >100,000 cfu/ml
Leukocyte esterase and nitrite positive
Nitrite positive, leukocyte esterase negative
Pyuria and bacteriuria positive
Bacteriuria positive and pyuria negative
POSSIBLE UTI
Catheterization with >10,000 cfu/ml
Clean catch with >50,000 cfu/ml
Leukocyte esterase positive, nitrite negative = only treat if good evidence for UTI
Leukocyte esterase and nitrite negative = no UTI
Pyuria positive and bacteriuria negative = only treat for UTI if have good evidence
Bacteriuria and pyuria negative = no UTI

Whom to culture?

– Infants and children who are suspected to have acute pyelonephritis/upper urinary tract infection
– Infants under 3 months
– Infants and children with a positive result for leukocyte esterase or nitrite – EVERY POSITIVE URINALYSIS SHOULD BE CULTURED
– Infants and children with recurrent UTI
– Infants and children with an infection that does not respond to treatment within 24–48 hours, if no sample has already been sent

Urine Pathogens
E. coli, Proteus sp.
Enterococcus sp.
Pseudomonas sp.
Serratia sp.
Corynebacterium Urealyticum
Klebsiella sp.
Enterobacter sp.
Group B streptococci
Staphylococcus aureus

Common Contaminants
Lactobacillus sp.
Corynebacterium sp.
Coagulase-negative staphylococci
Alpha-hemolytic streptococci

ANTIBIOTICS

Oral vs. Parenteral Antibiotics
– Most patients will tolerate oral antibiotics. Patients should receive parenteral antibiotics if patient is ill appearing, not able to tolerate PO, or has any other contraindication to oral antibiotics.

-Antibiotics are recommended for 7-14 days. Shorter courses result in spread of infection and renal scarring.

PARENTERAL ANTIBIOTICS ORAL ANTIBIOTICS
Ceftriaxone 75 mg/kg Q24h

Cefotaxime 150 mg/kg divided into Q6-8h

Ceftazidime 100-150 mg/kg divided into Q8h

Gentamicin 7.5 mg/kg divided into Q8h

Tobramycin 5 mg/kg divided into Q8h

Piperacillin 300 mg/kg divided into Q6-8h

Amox-clav 20-40 mg/kg divided into Q8h

TMP 6-12 mg/kg SMX 30-60 mg/kg divided into Q12h

Cefixime 8 mg/kg Q daily

Cefpodoxime 10 mg/kg divided into Q12h

Cefuroxime 20-30 mg/kg divided into Q12h

Cephalexin 50-100 mg/kg divided into Q6h

ADMISSION CRITERIA

– Toxic appearance
– Dehydration requiring IVF
– Failed outpatient therapy
– Febrile infants < 60 days
– Non-febrile infants 31-60 days can be considered for outpatient therapy if they have good follow up within 24 hours

IMAGING

ALL patients should have a renal bladder US (RBUS) after their first febrile UTI. RBUS should be obtained after the patient has recovered from the acute infection (4-6 weeks). Studies have shown that in the acute phase can have false positives due to structural changes that are transient caused by the infection, such as hydronephrosis. (THIS IS FOR THE OUTPATIENT PHYSICIAN)
-Obtain the RBUS during acute illness if: Hospitalized; Ill, concern for sepsis; Abdominal, pelvic mass; Inadequate response to 48 hours of therapy.
-Voiding cystourethrogram (VCUG) should not be obtained routinely after first febrile UTI.
-Obtain VCUG if RBUS is abnormal.

 

REFERENCES:
1. CHOP Clinical Pathways
2. Seattle Children’s Hospital Clinical Pathways
3. AAP Guidelines on UTI
4. NICE Guidelines on UTI

 

Pediatric Pearl – January

PAIN MANAGEMENT & VASO-OCCLUSIVE CRISIS IN SICKLE CELL DISEASE

By: Hima Khamar, PGY3  &  Dr. Patel, PGY16

Sickle cell disease (SCD) is a common disease process we encounter in the ED. There are multiple complaints related to SCD that patients present with such as: pain, fever, stroke like symptoms, anemia. In this pediatric pearl article, we will discuss pain management during vaso-occlusive crisis (VOC) in the pediatric sickle cell patient.
We as emergency medicine physicians often tend to undertreat pain in SCD patients, we tend to be even more cautious with pediatric patients. The goal of this pediatric pearl article is to emphasize trusting patient reported pain, treating pain adequately, realizing opioids are the main stay for VOC, discussing dosing of various pain medications along with routes, and hopefully making you more comfortable treating VOC in pediatric patients.

Primary Goal on Arrival (provided patient’s ABCs are stable and the patient is neurologically intact): PAIN ASSESSMENT

  • Assess, document pain – TRUST the PATIENT’S self-reported score
  • Recent pain medication, dose, time of last dose
  • Allergies to any medication (if they need Benadryl, ONLY PO, avoid use of IV or IM. DO NOT re-dose with every administration of pain medication. Dose every 4-6 hours as you normally do when using Benadryl.)
  • Order pain medication immediately (ideally should be administered within 30 mins of arrival)
History and Physical

Pain Assessment
–          Pain typical of previous VOE?
–          Location, quality, duration, intensity
 
Prior Hx of Complications of SCD
–          Acute chest syndrome
–          Aplastic crisis (Parvovirus Infection)
–          Documented bacteremia
–          Stroke, TIA
–          Splenic sequestration
–          Gall bladder disease
–          Osteomyelitis, septic arthritis

Past Medical History
–          Baseline pulse oximetry reading
–          Previous admissions, ICU admissions
–          Transfusion history
–          Vaccination history

Medications
–          Penicillin prophylaxis
–          Hydroxyurea
–          Folic acid
–          Chronic pain medications
 AllergiesPhysical Exam
–          VS, pulse oximetry reading
–          General appearance, jaundice
–          Pain assessment
–          Respiratory, Circulatory, Neurologic                     status
–          Evidence of focal infection
–          Spleen size
–          Presence of rash or petechiae

LABS

  • CBC w/ differential – determine if there is any hemolytic or inflammatory process
  • Reticulocyte count – determine if there is any hemolytic or inflammatory process
  • Type and Screen
    • Pale, persistent tachycardia, ill appearing
    • Suspected splenic sequestration
    • Acute chest syndrome
    • Focal neurologic findings
    • Hgb < 5 g/dL or Hgb drop > 2 g/dL from baseline Hgb
    • Reticulocyte count < 1% (unless hemoglobin > 10 g/dL)
  • Chest Radiograph – new hypoxia, chest pain, clinical suspicion for pneumonia/acute chest syndrome
  • HCG – any females ≥ 12 years or < 12 with menarche
  • Blood cultures – if infection is suspected

TREATMENT

Oxygen

  • Recommended onlyif O2 saturation is less than 92%

IVF

    • Recommended: D5 ½ NS.
    • As clinically indicated for: clinical dehydration/intravascular volume depletion
    • If need to place patient on maintenance fluids because they are not tolerating adequate PO, then place on hypotonic solution, not hypertonic or isotonic solution. Note: IVF offers no therapeutic benefit for patients with VOE who have no signs of volume depletion.
PAIN MEDICATIONS
MEDICATION ROUTE DOSAGE COMMENTS
Ketorolac IVP or IM 0.5 mg/kg
(Max 30mg/dose)
Ensure patient has no history of renal insufficiency
Fentanyl IN 0.2 mcg/kg
(Max 100mcg/dose;
Max volume
1ml/nare)
Great for those patients who are in a lot of pain, while you are trying to get IV access.
Morphine IV 0.1-0.15 mg/kg/dose
(Max 8 mg/dose)
Hydromorphone IV 0.015-0.02 mg/kg/dose
(Max 2 mg/dose)
Diphenhydramine PO 1mg/kg/dose
(Max 50mg/dose)
No indication to give IM or IV, unless patient truly can’t tolerate PO, but may try giving PO after giving anti-emetic.
Oxycodone PO < 6 yrs: 0.15 mg/kg/dose up to 2.5 mg
6-12 yrs: 0.2 mg/kg/dose up to 5 mg
> 12 yrs: 0.2 mg/kg/dose up to 10 mg
For outpatient management. Give up to 3 days, until they can see their heme-onc doctor.
Tylenol PO 10-15mg/kg/dose
(Max 975mg/dose)
Use as an adjunct to decrease opioid use provided there is no contraindication.
Motrin PO 10 mg/kg/dose
(Max 600mg/dose)
Use as an adjunct to decrease opioid use provided there is no contraindication.

Incentive Spirometry – RECOMMENDED FOR ADMITTED PATIENTS

      • Provide to all patients who are admitted for VOC.
      • This will help decrease development of acute chest syndrome. Acute chest syndrome normally develops during inpatient stay. (We will discuss this in depth in another pearl.)

Steroids

      • Based on studies, high dose methylprednisolone may help in the acute event, but has been associated with high rate of rebound pain after stopping steroids.
      • Currently, it is not routinely recommended for VOC.

Ketamine – need more studies

      • In ED recommend 0.25-1 mg/kg; inpatient can place on continuous infusion of 3-5 mcg/kg/min
      • Has been shown to be effective in some case series, but need more data and large, randomized control trials

Nitrous oxide – needs more studies

      • May try as another modality to control pain
      • Has been shown to be effective in some case series, but need more data and large, randomized control trials

Patient controlled analgesia (PCAs) – RECOMMENDED FOR ADMITTED PATIENTS

      • Pain management, which is under anesthesia can help with setting this up. You can get pager number from the operator. Recommended for patients who are admitted, and pain is not controlled with opioid pushes. Discuss with heme-onc team and may consider starting in ED, especially if patient is not going to get a bed for some time.

Other adjuncts

      • Laxatives should be provided around the clock to prevent side effects of opioids.
      • Antiemetics as needed.
      • Antipyretics as needed.

CALCULATING PARENTERAL DOSE BASED ON HOME MEDICATIONS

The website listed below can help you convert a patient’s home medication into the parenteral dose you should be starting at in the ED. You can also do it manually using the conversion table provided below. On the right side is an example case on how to use the table. Whenever you are converting opioids, always convert to morphine and then convert to another opioid agent.

https://opioidcalculator.practicalpainmanagement.com/conversion.php

ADMISSION vs. DISCHARGE CRITERIA

Admission:

  • < 3 months of age
  • Focal neurologic findings
  • Acute chest syndrome
  • Splenic sequestration
  • Reticulocyte count < 1 % (unless Hgb > 10 g/dL)
  • Severe anemia (Hgb < 5 g/dL)

Discharge:

  • Patients with pain relief: After 1 – 3 doses of IV analgesia
  • Patient continues to be pain free at least 60 minutes after PO analgesia
  • Discharge with 3 days of PO analgesia until they can follow up with heme-onc doctor
  • Absence of other complications of sickle cell disease

PEARLS

  • TRUST the patient’s self-reported pain score
  • Vital signs can be normal even if patient is in pain, so do not rely on vital signs as an indicator of pain.
  • There is no lab test to definitively say a patient is having VOC or not.
  • Acute VOC is considered acute, not chronic pain, and opioids are indicated and should be used to treat pain.
  • Rapidly initiate analgesic therapy within 30 minutes of triage or within 60 minutes of registration.
  • In adults and children with SCD and a VOC associated with mild to moderate pain who report relief with NSAIDS in the absence of contraindications to the use of NSAIDS, continue treatment with NSAIDS.
  • In adults and children with SCD and a VOC associated with severe pain, rapidly initiate treatment with parenteral opioids.
  • Calculate the parenteral (IV or subcutaneous) opioid dose based on total daily short-acting opioid dose currently being taken at home to manage the VOC.
  • Administer parenteral opioids using the subcutaneous route when intravenous access is difficult.
  • Reassess pain and re-administer opioids if necessary for continued severe pain every 15–30 minutes until pain is under control per patient report.
  • Maintain or consider escalation of the dose by 25 percent until pain is controlled.
  • Reassess after each dose for pain relief and side effects.
  • In adults and children with SCD and a VOC, do not use meperidine unless it is the only effective opioid for an individual patient.
  • In adults and children with a VOC, administer oral NSAIDS as an adjuvant analgesic in the absence of contraindications.
  • In adults and children with a VOC who require antihistamines for itching secondary to opioid administration, prescribe agents orally, and do not re-administer with each dose of opioid in the acute VOC management phase. Re-administer every 4 to 6 hours if needed.
  • To reduce the risk of acute chest syndrome in adults and children hospitalized for a VOC. Encourage use of incentive spirometry while awake. Encourage ambulation and activity as soon as possible.
  • In adults and children with VOC, use adjunctive nonpharmacologic approaches to treat pain such as local heat application and distraction.
  • In euvolemic adults and children with SCD and a VOC who are unable to drink fluids, provide intravenous hydration at no more than maintenance rate to avoid over-hydration.
  • Assess all patients with sickle cell disease who present with acute pain to determine whether their pain is being caused by an acute painful sickle cell episode or whether an alternative diagnosis is possible, particularly if pain is reported as atypical by the patient.
  • Patients who experience three or more acute painful episodes per year that require treatment with parenteral opioids in a medical facility are considered to have severe disease.

Pediatric Pearl

OCTOBER Foreign Body Ingestion – Hima Khamar

FOREIGN BODY INGESTION

By: Hima Khamar M.D., PGY3

HISTORY
WITNESSED or UNWITNESSED
Time of ingestion
Description of object: Size, Shape, Length, Width Sharp end, similar object for comparison
Last meal time
History of GI anomaly, surgery or disease

Symptoms:
FB sensation
Refusing oral intake
Drooling, dysphagia, gagging
Choking or coughing with PO intake
Respiratory symptoms: Stridor, Hoarseness
Chest pain
Abdominal pain, vomiting (signs of perforation, obstruction)
GI Bleeding

PHYSICAL EXAM
Vital signs
Drooling, oral lesions
Tripod position
Neck crepitus, stridor
Wheezing, unequal breath sounds
Check ears and nose, especially if FB not confirmed on X-ray
Signs suggesting acute abdomen

 IMAGING TIPS

AP and lateral view of chest, neck, and abdomen

Flat object location on AP:
-Esophagus: Coin appears circular
-Trachea: Coin appears as a slit

Batteries:
-Double ring on AP view
-Step-off between the anode and cathode on lateral view

Magnets:
-Difficult to reliably distinguish single from multiple magnets

Non-radiopaque FB:
-Avoid GI contrast studies for suspected esophageal FBs: May obscure visualization on endoscopy and also increases the risk of aspiration if there is an esophageal FB
-Endoscopy favored

-CT scan may be considered in special circumstances

WHO NEEDS ENDOSCOPY & WHEN 

EMERGENT URGENT NON-URGENT
Esophageal location
-Button battery – NO DELAY
-Obstructive symptoms
-Respiratory distress
-Significant pain
-Sharp pointed objects
-Multiple magnetsStomach location
-Multiple magnets
Esophageal location
-Minimal symptoms
-Sharp longer objects in stomach with no symptoms
Stomach location
–        FB > 2cm wide
–        FB > 5cm long

BUTTON BATTERY INGESTION

Button Battery Facts
-Serious burns can occur within 2 hrs of ingestion
-Symptoms may be delayed
-If mucosal injury is present after removal, observe for delayed complications (esophageal perforation, TEF, vocal cord paralysis, tracheal stenosis, mediastinitis, aspiration pneumonia, perforation into a large vessel)
-Complications may be delayed weeks, months
-Lithium cell batteries are most frequently involved in esophageal injuries
-Determination of battery diameter prior to removal or passage is unlikely in at least 40% of cases
-Assume hearing aid batteries are < 12 mm
-X-ray overestimates the diameter

Coins/Blunt Objects Facts
-Items within the stomach:
—Width > 2 cm, length > 5 cm (less likely to pass pylorus/duodenum)
—Repeat X-ray:
Within 2-3 weeks if Age < 2 yrs or Quarter
Within 1 week if Cylindrical battery
Sooner if symptomatic

Items beyond the stomach:
-Return if symptoms

Coins usually appear larger on the X-ray due to magnification
-Quarter à 24 mm
-Nickel à 21 mm
-Penny à 19 mm
-Dime à 18 mm

 COINS/BLUNT OBJECTS INGESTION

MAGNETS INGESTION
 

RADIOPAQUE/SHARP RADIOTRANSLUSCENT OBJECT INGESTION

Pediatric Pearls – Bronchiolitis

Pathophysiology
  • Disorder that is commonly caused by a viral lower respiratory tract infection in infants
  • Characterized by acute inflammation, edema and necrosis of epithelial cells lining small airways and increased mucus production

  • Etiology
    • Coronavirus
    • Influenza
    • Rhino virus
    • Adenovirus
    • Parainfluenza virus
    • RSV (respiratory syncytial virus) – MOST COMMON!
  • Incidence – December-March
      • Most infections occur within first 2 years of life
      • About 40% experience lower respiratory infection during initial infection
      • RSV doesn’t grant permanent or long-term immunity – RE-INFECTION COMMON
      • The risk of significant viral or bacterial lower respiratory tract infection or pneumonia in an infant is low
  • Transmission
    • Direct contact with secretions
    • Young children shed virus for >2 weeks
    • 30-70% of household contacts become ill
  • Natural history
    • Begins with URI – Rhinorrhea, congestion, cough
    • Progresses to LRI in 2-6 days – Airway obstruction (tachypnea, wheezing, respiratory distress)
    • Variable and dynamic course
    • Lasts 2-4 weeks

Case

7-month-old male presents to the emergency room with his parents due to cough, runny nose, congestion and SOB that started 3 days ago.

VS: RR – 65, HR – 140, Temp – 99.1°F, O2 sat – 93% on RA


History
  • Typical Presentation of Bronchiolitis
    • Viral URI and cough with signs of lower respiratory tract infection
      • Work of breathing – grunting, nasal flaring, intercostal/subcostal retractions
      • Tachypnea
      • Wheeze
      • Coarse rales

Physical Exam
  • TIPS for a better exam
    • Upper airway obstruction can contribute to work of breathing
    • Suctioning and positioning may decrease the work of breathing and improve the quality of your examination
    • Counting respiratory rate over the course of 1 min is more accurate than shorter observations
  • Assess mental status, respiratory rate, work of breathing, oxygen status, listen to breath sounds, and assess hydration status


Diagnosis
  • DIAGNOSIS IS CLINICAL – NO LABS OR RADIOLOGICIAL STUDIES ARE NEEDED
    • When to consider CXR – if child has had >2 days of fever, an asymmetric chest exam, does not demonstrate improvement or has an unusually high O2 need
    • Diagnostic testing may be considered if:
      • Need cohorting – this is why we get testing for those we admit
      • Uncertain clinical diagnosis
      • Age <2 months
      • To assess for influenza – also needed this for those we admit

Management

Classify patient as mild, moderate, or severe based on the above physical exam

Mild Moderate Severe
1. Consider suction bulb

2. Discharge

1. Suction bulb

2. No bronchodilators

3. Discharge or admit

1. Suction bulb or wall

2. No bronchodilators

3. If no improvement consider starting high flow NC

4. Admit

  • Rehydration
    • IVF – moderately or severely dehydrated, secretions are thick and difficult to mobilize or severe respiratory distress
    • PO feeds – mildly to moderately dehydrated and can tolerate PO
  • Considerations for severely ill patients
    • Consider ONE TIME albuterol MDI trial if:
      • Severe respiratory distress OR
      • Increased risk for asthma
        • >12 months old, wheeze and once of the following
          • personal history of atopy or recurrent wheezing
          • strong family history of atopy or asthma
        • if responds to albuterol then consider switching to asthma pathway
      • Consider HFNC for significant hypoxia OR severe respiratory distress not improving with rigorous supportive care

 

Discharge criteria Admission criteria
–       Oxygen saturation >90%

–       Awake

–       Adequate oral intake

–       Mild/moderate work of breathing

–       Reliable caretaker

–       Able to obtain follow up care

–       MDI/spacer teaching if response to albuterol

–       Admit if discharge criteria not met:

o   Inpatient: Requires 02 or progression expected

o   OBS: Mild disease with expected LOS < 24 hours

o   ICU: Apnea, severe distress; Requires HFNC / CPAP / intubation

–       Infants with these risk factors present early in the illness have higher risk of progression:

o   Gestational age < 34 weeks

o   Respiratory rate ≥ 70

o   Age < 3 months

Additional Notes
  • Differentiate infants with probable viral bronchiolitis from those with other disorders
  • The above management points to do take into consideration patients with significant medical history such as congenital heart disease, anatomic airway defects, neuromuscular disease, immunodeficiency, chronic lung disease – ADMIT, HIGH RISK!
  • The physical exam will vary from minute to minute depending on child’s position, level of alertness, response to treatment – CONSTANTLY RE-EVALUATE!
  • If patient presents within the first couple of days, they may worsen and need admission at a later point – PARENT EDUCATION IS KEY!
    • Viral illness, treated by hydration and suction
    • Signs of respiratory distress
    • How to suction
    • When to suction
    • Frequent feeds and watch hydration status
    • Cough may last 2-4 weeks, do not use OTC cough and cold medications
    • Avoid tobacco smoke
  • NOT RECOMMENDED!
    • Albuterol – Wheezing is due to the airways being clogged with debris not bronchospasm
    • Racemic epinephrine
    • Corticosteroids
    • Chest physiotherapy
    • Montelukast
    • Antibiotics
    • Hypertonic Saline
    • Routine testing
    • Chest X-rays

References

  1. http://pediatrics.aappublications.org/content/134/5/e1474
  2. http://www.chop.edu/clinical-pathway/bronchiolitis-emergent-evaluation-clinical-pathway
  3. http://www.cochrane.org/CD001266/ARI_bronchodilators-for-bronchiolitis-for-infants-with-first-time-wheezing
  4. http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/

Special thanks to Dr. Hima Khamar, MD PGY-2 for her contribution to this month’s Pediatric Pearls!

Case of the week COW #11

CC: Can’t see for 2 months

HPI: 10 year old male with no significant past medical history presents to the Emergency Dept. complaining of painless vision loss in the right eye for 2-3 months. Patient states he has been having difficulty seeing out of his right eye for 2 months despite changing positions in class, taking on and off his glasses and using eye drops. Vision loss has become progressively worse and now he can only distinguish whether lights are on or off. Mother states she did not do anything about this problem because she thought he was kidding and she didn’t’ have money or health insurance to seek medical attention. Patient has been wearing Bifocals for myopia since the age of 6, with corrective vision lenses at age 5. Denies associated trauma. Patient moved to the U.S from Nigeria 5 years ago. He lives with his mother and sister. Vaccines are up to date.

PMH/Birth History: NSVD at 39 weeks, 1 day. Birth took place in Nigeria and mother denies any infection during or after pregnancy. Following birth, patient did not have any complications such as pneumonia, eye infections or rashes.

Social History: Denies drug abuse. Denies exposure to chemicals. Denies contact with dirt, dogs or pigs. Patient did not live on a farm. As per mother, there was no domestic abuse in the family

PHYSICAL EXAM 

Vitals within normal Limits

General: In no acute distress, appears stated age.

Head: Atraumatic, normocephalic. No deformities.

Eye: Right (OD): pupil non-reactive and remains white in color and approximately 2mm. Afferent reflex is present CN II; efferent reflex is absent. There is a complete visual field defect on the right side. Visual Acuity: Can only distinguish between light and dark. Unable to count fingers at any distance or visual objects even in motion. On Fundoscopic exam, the fundus is gray/dull, with no retina visualized. ALL CONSISTENT WITH LEUKOCORIA

Respiratory: Lungs CTA bilaterally.

Cardiac: +S1/S2, no MRG, regular rate and rhythm

Abdomen: soft NT ND

Neuro exam: CN III –XII intact. No motor, sensory, vibratory, temperature or pain deficits. Gait is steady and normal, without any difficulty. Cerebellar function intact, no dysmetria bilaterally.

Extremities: Full ROM in all extremities. 5/5 strength in all extremities

Skin: No edema, rashes, lacerations, or abrasions. Skin is warm, pink, moist and intact.

LABS

CBC: Unremarkable with        WBC: 7.1     Hemoglobin: 13.5       Platelets 211.

CMP: WNL       CRP and ESR = WNL

Tonometry: IOP approx. 17-18 x 3 times

Wood lamp: No corneal abrasion, dendritic ulcers, lesions or depositions OU

Bedside U/S: Completed within 10 minutes of arrival ( Only Right eye is shown)

Working Differential Diagnosis:

  • Retinoblastoma
  • Intraocular Mass
  • Cataract
  • Syphilis
  • Parasitic infiltrate
  • Posterior Infarct

CT Max/Facial w/o Contrast to rule out intracranial pathologies: Negative for masses; positive for homologous material in the right lobe. MRI was recommended for further evaluation

ED/Hospital course:  Ophthalmologist on call was consulted, and said there was nothing more to do. Unfortunately because his vision loss was > 2 months, no life saving surgery was imminent as the retina was already detached causing ischemia to the rods and cones within it.  Patient was to follow up in ophthalmology clinic the following day. Patient’s Pediatrician was also contacted and he referred the patient to a Pediatric Ophthalmic specialist in University Hospital, with a scheduled appointment within the same week. Approximately one week ago, patient underwent surgery and the leading diagnosis was Toxocariasis as per MRI. Biopsy results to follow. As per mother, the patient is still without vision in his right eye.

LEUKOCORIA, UNILATERAL, 10 YO MALE DIFFERENTIALS

Coats disease is an exudative retinal vascular disorder characterized by retinal telangiectasias and subretinal exudation leading to serous retinal detachment. Presenting complaints include decreased visual acuity, strabismus, or leukocoria. The leukocoria in Coats disease is generally more yellow than white due to the presence of subretinal lipid. Coats disease is almost always unilateral and the vast majority of cases occur in boys. The majority of cases presenting with leukocoria are diagnosed between five and nine years of age, which is older than the majority of retinoblastoma patients.

Clinical examination: subretinal lipid and abnormal telangiectatic vessels US: demonstrates complete retinal detachment with massive subretinal lipid. Intraocular calcification is almost never present in Coats disease, another feature that helps to distinguish it from retinoblastoma.

The retinal photograph depicts bullous retinal detachment in the Left eye of a 1-year-old child with Coat’s disease simulating retinoblastoma. The magnetic resonance images confirm the diagnosis of retinal detachment and exclude retinoblastoma because of the absence of intraocular mass.

 

Toxocariasis — Toxocariasis, or visceral larva migrans, is an infection caused by the dog ascarid Toxocara canis or, less commonly, the cat ascarid Toxocara catis. There may be a history of living in an underdeveloped country, and exposure to dirt or undomesticated dogs. It occurs most commonly in children one to five years of age. Common presenting signs of toxocariasis are strabismus and poor vision. The ocular lesion is caused by the inflammatory response to the second-stage larva, which may localize in the one eye or both eyes

Chorioretinitis characteristic of toxoplasmosis. A pigmented scar is seen with an adjacent area of active chorioretinitis. The diagnosis of toxoplasmosis is based primarily on the appearance of the chorioretinal lesion rather than serologic studies. Courtesy of James T Rosenbaum, MD.

 Retinopathy of prematurity (ROP) — developmental vascular proliferative disorder that occurs in the incompletely vascularized retina of preterm infants and can lead to retinal detachment and permanent blindness. The most important risk factor for developing ROP is prematurity. There needs to be a history of prematurity, and/or mother mentions patient was on O2 for awhile.

Vitreous hemorrhage — Vitreous hemorrhage causes leukocoria when there is extensive organization of the blood into a clot before degradation. With time, the reddish hue of the blood is lost and the hemorrhage transforms into “whitish debris.” Etiology includes advanced ROP,  trauma (MOST common), leukemia or hemorrhagic disease of newborn

Retinablastoma– Retinoblastoma is the most common primary intraocular malignancy of childhood and accounts for 10 to 15 percent of cancers that occur within the first year of life. Retinoblastoma typically presents as leukocoria in a child under the age of two years. Untreated retinoblastoma is a deadly disease; however, with advances in treatment, survival in the contemporary era is >95 percent. Most common age group is birth- 2 years. Very uncommon in children over the age of 5, although 1-2 case reports have occurred in 18 year old males

 Pearls & Takeaways:

  • Leukocoria Requires further investigation – On exam, History and Diagnostic
  • The use of tonometry, fundoscopy and ocular ultrasound are an easy, noninvasive way to add to your ophthalmic exam. Slit-lamp exam could have been considered here
  • Ocular ultrasound is really cool and fun!
  • Advocate for your patients!  Make sure they have proper follow up with a specialist
  • If any abuse or neglect is suspected, be sure to turn on “Sherlock Holmes” senses and investigate.

 

Case presented by Dr. Sarah Bolan

 

Case of the Week COW #9

CC: “Post Surgical Pain” ; Abdominal pain

HPI: 8 year old Male with PMH of Sickle Cell Disease (HbSC), Post-opt Day 10 for laparoscopic splenectomy for recurrent sequestration crises presents to the Emergency Department (ED) complaining of abdominal pain x 2 days. The pain is described as diffuse and worse in the RUQ. Denies exacerbating or relieving factors. Pain is associated with constipation; last Bowel movement was 7 days prior. Mother states he did have one small BM shortly after surgery. He is tolerating PO without difficulty and does report flatus. She has been giving him Oxycodone 2mg every 6 hours for pain with minimal relief. Upon review of systems, patient reports feeling hot for the past 2 days but without a recorded temperature at home. Additionally, patient complained of a non-productive cough for 2 days and has been “breathing fast” for the same duration of time.

Physical Exam:

BP 112/74    HR 129     RR 24   SpO2 93% on RA   Temp 99.9F      26.3 kg

Constitutional: Well developed, well-nourished child who is awake, alert and in moderate distress due to pain and feeling hot; making tears

HEENT: NCAT, pupils PERRLA, neck supple

Respiratory: CTA B/L, no wheezing, rales or rhonchi

Chest/Axilla: Normal symmetrical motion, no tenderness

Cardiac: +S1/S2, RRR, no MRG,

Abdomen: Scars noted over splenectomy site which are clean dry and intact, healing well without discharge; Diminished Bowel Sounds in all quadrants; soft, non-distended with mild tenderness in all 4 quadrants. No rebound or guarding.

Neuro exam: AAO x 3. No deficits

Extremities: no edema, no tenderness or swelling

Pertinent Labs:

CBC: 42.1

HBG: 12.5

HCT: 36.9

Platelets: 721

Seg: 79

Lymphs: 9

Mono: 12

Reticulocyte count: reported as normal

Pertinent Imaging and other tests:

Working Diagnosis:

Generalized abdominal pains

Elevated WBC

Abscess of spleen

ED/Hospital course:

Surgery was consulted in the ED and they believed the pain was not related to the surgery. Abdominal U/S performed at their request showed “s/p splenectomy with gallbladder sludge.” Patient had moderate improvement in his pain after Toradol 15mg IV and Morphine 2mg IV were given in the ED. Patient also received Rocephin 75mg/kg and NS 500mL IV Fluid bolus for presumed infection with the leukocytosis of 42.1.

The patient was admitted to Pediatric Step down for further evaluation and management. Overnight, he remained comfortable with stable vital signs, afebrile and saturating 94-96% on 2L NC. On Hospital day #1, patient became febrile to 103F and continued to deny chest pain, SOB or difficulty breathing. The cough remained unchanged since admission. A repeat Chest X-Ray was obtained and the patient was diagnosed with Acute Chest Syndrome and received exchange transfusion the same day (Refer to Image below) Additionally, he received Ceftriaxone, Azithromycin, Nitric oxide and IVF at ¾ maintenance ate throughout hospitalization. On Hospital Day #4 he was discharged home.

Pearls:

Acute Chest Syndrome

  • It is the leading cause of death in patients with SCD in the United States
  • Most often occurs as a single episode, but patients may have multiple attacks resulting in chronic lung disease
  • Multiple Etiologies
    • Pulmonary infections
    • Iatrogenic cause including aggressive hydration for sickle cell painful crisis ——à causing Pulmonary Edema
    • Opioid use —–à Decreased inspiratory effort——à Atelectasis
  • New infiltrate identified on Chest X-Ray with at least one of the following: Fever, cough, wheezing, tachypnea, chest pain, hypoxemia.
  • Radiographic changes often lag behind clinical features so initially the Chest X-Ray may actually be normal (as in our case)
  • Treatment
    • Supportive: Early Supplemental Oxygen, analgesics and IV Hydration up to 1.5x maintenance rate
    • Antibiotic irrespective of cultures
    • Transfusion is believed to be lifesaving; recommendations based on empirical observations and not on firm evidence
    • Exchange transfusion seems to be more advantageous, especially in patients with a hemoglobin of > 9.0
      • It decreases the concentration of sickled hemoglobin with little iron gain
    • Inhaled Nitrous Oxide is beneficial
      • Due to its vasodilatory effects –à improved ventilation/perfusion in damaged lung tissue
      • Reduced RBC and leukocyte adhesion to endothelial cells, therefore affecting disease progression
    • Hydroxyurea reduces occurrence of acute chest syndrome

Case Presented by Greg Cassidy, MD

 

References:

  1. Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide (8th ed.). New York, N.Y.: McGraw-Hill Education LLC..

 

EM Conference Pearls (9/20)

Pediatric congenital heart disease

  • Congenital HD: Two types: Neonates with ductal dependent lesions and infants (2-6months) presents with CHF
  • Cyanosis presentation: When ductal-dependent lesion is required for pulmonary blood flow (Will not respond to oxygen)
  • Shock presentation: When ductal-dependent lesion is required for systemic blood flow (appear septic and not response to fluids, may get worse with fluids)
  • Hypoxic/cyanotic or shocky/acidotic baby treatment = Prostaglandin E1 (PGE1) and transfer to facility with pediatric cardiovascular surgeon.
  • PGE1 treatment may cause apnea (monitor closely and consider intubation)
  • CHF in infants = wheezing, retractions, tachypnea, sweating/crying, difficulty feeding

EBM in the ED

  • EBM = What the evidence shows in the literature + What the physician wants for the patient + what the patient wants for themselves
  • Just like we need to practice intubation, central lines –> Learning to read and interpret literature is a skill that needs to be practiced.

Aortic Dissection

  • AD: Chest pain plus disease (ex: CP + Neurodeficit)
  • If you find your self giving large amounts of strong pain meds (narcotics) while treating what is seemingly ACS…STOP..think about AD or alternative diagnosis of chest pain
  • The 3 important questions, aortic dissection is the subarachnoid hemorrhage of the torso, migrating pain, colicky pain + opioids = badness and pain that comes and goes can still be a dissection.
  • Treatment: Treat pain, HR, BP
  • Pain: Fentanyl 25 – 50 mcg bolus
  • HR: Goal of 60 bbpm
  • Esmolol 0.5 mg/kg bolus then 50 – 300 mcg/kg/min or
  • Labetalol 10 – 20 mg bolus then 0.5-2 mg/minor
  • BP control: Goal SBP =110
  • Nitroprusside 0.25 – 0.5 mcg/kg/min then titrate (CN toxicity)
  • Nicardipine 5 mg/hr
  • Warning: Giving a vasodilator without concomitant reduction in ionotropy may cause progression of dissection. Start BB first before vasodilation meds.

When kids eat coins

Kids eat up your money in more ways than one.  Some may eat it up in the form of $50,000 a year in college tuition and some eat it up as a meal.  For coins that get stuck in the esophagus the American Society for Gastrointestinal Endoscopy recommends watching asymptomatic patients for a period of 24 hours prior to any intervention.  Once the coins passes into the stomach most will traverse the GI tract without any complication.  There are multiple different methods of retrieving coins that are lodged in the esophagus: endoscopy, foley catheter technique, glucagon and bougienage is a method of pushing the coin into the stomach.  Classically, you use a Hurst dilator (or build your own) and advance it down the child’s esophagus to push the coin past the lower esophageal sphincter (step-by-step instructions).  Bougienage, when used on appropriate patients, is a safe modality for treating esophageal coins with only minor complications reported.  Some have reported success rates as high as 95%; however, you have to stick to the following inclusion criteria:

  1. Witnessed ingestion
  2. Foreign body is a coin
  3. Coin is seen in the esophagus on x-ray
  4. Single coin is present
  5. Ingestion < 24 hrs
  6. No previous esophagus procedure or pathology
  7. No respiratory symptoms
  8. Performed by trained personnel

If you successfully get the coin to pass into the stomach then the patient can be discharged home.  If the piggy bank doesn’t give up the coin in the next 2 weeks, then the patient will need a repeat xray to see where it is.  Check out this ACEP Now article for a more detailed discussion of bougienage.

Post by: Terrance McGovern DO, MPH (@drtmcg13)