TCP Week 3 - Pediatric Emergencies

What are the major causes of pediatric dehydration?

Fluid loss through the gastrointestinal tract from vomiting or diarrhea; losses through the skin from fever or burns; less common causes include bleeding, urinary losses, glucosuria, diuretic therapy, and diabetes insipidus.

What gastrointestinal problems commonly cause dehydration in children?

Vomiting and diarrhea.

What skin-related conditions can cause dehydration in children?

Fever and burns.

What less common causes of pediatric dehydration were listed in the presentation?

Bleeding, urinary losses, glucosuria, diuretic therapy, and diabetes insipidus.

What percentage of body-weight loss defines mild dehydration?

A 3% to 5% decrease in body weight.

What percentage of body-weight loss defines moderate dehydration?

A 6% to 10% decrease in body weight.

What percentage of body-weight loss defines severe dehydration?

An 11% to 15% decrease in body weight.

What are the typical skin findings in mild dehydration?

Skin turgor is normal or only minimally decreased, skin color is normal, and the mucous membranes are dry.

What are the typical skin findings in moderate dehydration?

Decreased skin turgor, pale skin, and dry mucous membranes.

What are the typical skin findings in severe dehydration?

Markedly decreased skin turgor with mottled, gray, or parched skin and markedly dry mucous membranes.

What are the hemodynamic findings in mild dehydration?

Normal pulse, capillary refill of 2 to 3 seconds, normal blood pressure, and normal perfusion.

What are the hemodynamic findings in moderate dehydration?

Slightly increased pulse, capillary refill of 3 to 4 seconds, normal blood pressure, and generally preserved perfusion.

What are the hemodynamic findings in severe dehydration?

Tachycardia, capillary refill greater than 4 seconds, low blood pressure, and possible circulatory collapse.

How does urine output change with mild, moderate, and severe dehydration?

Mild dehydration causes mild oliguria; moderate dehydration causes oliguria; severe dehydration causes anuria.

How do tears change with dehydration?

Tears are decreased in mild dehydration and absent in severe dehydration.

What urinary indices are typical of mild to moderate dehydration?

Urine specific gravity greater than 1.020 and urinary sodium less than 20 mEq/L.

What urinary indices are expected in severe dehydration with anuria?

Urine specific gravity and urinary sodium cannot be assessed because the child is anuric.

What physical findings suggest severe dehydration?

Poor skin turgor, sunken eyes, dry skin and mucous membranes, lethargy, and a depressed anterior fontanelle.

What is the initial treatment for mild pediatric dehydration?

Oral rehydration solution given in small amounts, usually 5 to 15 mL at a time.

Which oral rehydration products were listed as appropriate for pediatric dehydration?

Pedialyte, Enfalyte, and WHO oral rehydration solution.

Which commonly offered drinks are not appropriate for treating pediatric dehydration?

Broth, soda, juice, and tea.

How much oral rehydration solution should be given for mild dehydration?

Provide 50 mL/kg over 4 hours.

How much oral rehydration solution should be given for moderate dehydration?

Provide up to 100 mL/kg over 6 hours.

What should be done if a child with mild to moderate dehydration fails an oral fluid challenge?

Begin intravenous fluid therapy.

What is the immediate treatment for severe pediatric dehydration?

Immediate IV administration of an isotonic fluid.

What IV bolus is recommended for severe pediatric dehydration?

Normal saline or lactated Ringer solution at 20 mL/kg; the bolus may be repeated once.

What is the 100-50-20 rule used for?

Calculating daily pediatric maintenance fluid requirements.

How is daily maintenance fluid calculated for the first 10 kg of body weight?

100 mL/kg/day for each of the first 10 kg.

How is daily maintenance fluid calculated for the second 10 kg of body weight?

50 mL/kg/day for each kilogram from 11 to 20 kg.

How is daily maintenance fluid calculated for weight above 20 kg?

20 mL/kg/day for each kilogram above 20 kg.

How is the maintenance infusion rate calculated from the daily fluid volume?

Divide the total daily fluid volume by 24 hours.

What is the 4-2-1 rule used for?

Calculating the hourly pediatric maintenance fluid rate.

How is the hourly maintenance rate calculated for the first 10 kg?

4 mL/kg/hour for each of the first 10 kg.

How is the hourly maintenance rate calculated for the second 10 kg?

Add 2 mL/kg/hour for each kilogram from 11 to 20 kg.

How is the hourly maintenance rate calculated for weight above 20 kg?

Add 1 mL/kg/hour for each kilogram above 20 kg.

What maximum hourly pediatric maintenance rate was listed?

120 mL/hour.

What is bacterial meningitis?

A life-threatening medical, neurologic, and sometimes neurosurgical emergency caused by bacterial infection of the meninges with resulting tissue inflammation.

How do bacteria commonly reach the central nervous system in bacterial meningitis?

Through hematogenous spread or direct extension from a contiguous site after invading the host's natural defenses.

What are major risk factors for pediatric bacterial meningitis?

Birth to a GBS-positive mother, immunodeficiency, basilar skull fracture, trauma, ventriculoperitoneal shunt, prematurity, low birth weight, and younger age.

Which age group has the highest incidence of bacterial meningitis?

Neonates during the first month of life.

What neonatal incidence of bacterial meningitis was provided?

Approximately 0.25 to 0.35 cases per 1,000 live births.

How does the rate of bacterial meningitis change in older children and adolescents?

It declines sharply.

Why have bacterial meningitis rates decreased in many areas?

Widespread use of Hib conjugate, pneumococcal, and meningococcal vaccines.

Which organisms commonly cause bacterial meningitis in neonates younger than 4 weeks?

Group B Streptococcus, Escherichia coli, Listeria monocytogenes, Streptococcus pneumoniae, and Klebsiella.

Which organisms commonly cause bacterial meningitis in infants and children?

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B, Group B Streptococcus, and Escherichia coli.

Which organisms commonly cause bacterial meningitis in adolescents?

Neisseria meningitidis and Streptococcus pneumoniae.

What is the classic triad of bacterial meningitis?

Fever, neck stiffness, and altered mental status.

How may bacterial meningitis present in an infant?

Fever or hypothermia, altered level of consciousness, lethargy, poor feeding, fussiness, bulging fontanelle, vomiting, diarrhea, seizures, grunting, or respiratory distress.

How may bacterial meningitis present in an older child?

Fever, tachycardia, tachypnea, headache, nausea, vomiting, confusion, lethargy, and irritability.

How is Kernig sign tested?

Flex the hip and knee, then attempt to straighten the knee; pain and resistance constitute a positive sign.

What does a positive Kernig sign suggest?

Meningeal irritation.

How is Brudzinski sign tested?

Flex the patient's neck and observe for involuntary flexion of the hips and knees.

What does a positive Brudzinski sign suggest?

Meningeal irritation.

What rash is concerning for meningococcemia?

A scattered petechial or purpuric rash that does not blanch with palpation.

Which organism causes meningococcemia?

Neisseria meningitidis.

What initial blood tests are recommended for suspected bacterial meningitis?

CBC with differential, serum glucose, C-reactive protein, procalcitonin, and blood cultures.

What test is required to confirm bacterial meningitis?

Lumbar puncture with cerebrospinal fluid analysis and culture.

Should antibiotics be delayed until after lumbar puncture in suspected bacterial meningitis?

No. Antibiotic therapy should not be delayed.

What CSF studies should be obtained during lumbar puncture for suspected meningitis?

Opening pressure, Gram stain, culture with sensitivities, cell count and differential, protein, glucose, and PCR testing.

Which additional CSF PCR tests should be considered?

Herpes simplex virus PCR, especially in neonates, and enteroviral PCR.

What CSF Gram stain result supports bacterial meningitis?

A positive Gram stain.

How is CSF opening pressure typically affected in bacterial meningitis?

It is elevated for age.

What CSF white blood cell pattern is typical of bacterial meningitis?

An elevated WBC count with neutrophil predominance.

What CSF glucose level supports bacterial meningitis?

Low CSF glucose, typically less than 40 mg/dL.

What CSF protein level supports bacterial meningitis?

Elevated protein, greater than 58 mg/dL, although this may be less accurate in neonates.

What finding confirms the diagnosis of bacterial meningitis?

A positive CSF culture.

When is a noncontrast head CT indicated before lumbar puncture?

With altered mental status, focal neurologic deficits, signs of increased intracranial pressure such as papilledema, immunocompromise, or a recent seizure.

Why is head CT obtained before LP in selected meningitis patients?

To rule out an intracranial mass or other condition that could make lumbar puncture unsafe.

What is the empiric antibiotic regimen for bacterial meningitis in neonates 0 to 28 days old?

Ampicillin plus an expanded-spectrum cephalosporin such as ceftazidime, cefotaxime, or cefepime.

What is an alternative empiric neonatal meningitis regimen?

Ampicillin plus an aminoglycoside such as gentamicin, tobramycin, or amikacin.

When should acyclovir be considered in a neonate with suspected meningitis?

When neonatal herpes is suspected.

Why is ceftriaxone not recommended for neonates?

It can displace bilirubin from albumin and increase the risk of kernicterus, and it may precipitate with calcium-containing solutions.

What is the empiric antibiotic regimen for bacterial meningitis in infants and children at least 1 month old?

IV vancomycin plus ceftriaxone or cefotaxime.

When should ampicillin be added to the standard regimen in a child at least 1 month old?

When Listeria monocytogenes is being considered, although it is rare.

When is dexamethasone recommended in bacterial meningitis?

When Haemophilus influenzae type B or Streptococcus pneumoniae is confirmed by Gram stain.

What is the dexamethasone dose for bacterial meningitis?

0.15 mg/kg IV.

When should dexamethasone ideally be administered in bacterial meningitis?

Approximately 10 to 20 minutes before the first antibiotic dose.

How often and for how long is dexamethasone continued for bacterial meningitis?

Every 6 hours for 2 to 4 days.

Why is dexamethasone used in selected cases of bacterial meningitis?

To help prevent neurologic complications.

What major complications can occur with bacterial meningitis?

Neurologic complications, possible need for neurosurgical intervention, and death.

What is a febrile seizure?

A seizure associated with fever above 100.4°F, without evidence of intracranial infection or another known cause, occurring between 6 months and 5 years of age.

What age range is typical for febrile seizures?

6 months to 5 years.

What are the features of a simple febrile seizure?

Generalized seizure, duration less than 15 minutes, and no postictal focal neurologic deficit.

Is family history common in febrile seizures?

Yes. A family history of febrile seizures is often present.

What temperature pattern may trigger a febrile seizure?

A rapid rise in temperature, often above 101.8°F, near the onset of illness.

What infections most commonly cause febrile seizures?

Viral infections; bacterial infections are less common causes.

What is known about the precise mechanism of febrile seizures?

The precise mechanism is unknown.

Can immunizations cause febrile seizures?

Certain immunizations carry a very small risk.

What common febrile illnesses may be associated with febrile seizures?

Upper respiratory infection, gastroenteritis, and urinary tract infection.

What is the main goal of evaluating a child after a febrile seizure?

Identify the cause of fever and exclude serious conditions such as meningitis, encephalitis, bacterial sepsis, toxic exposure, or neurologic abnormality.

When is lumbar puncture needed after a febrile seizure?

Only when an intracranial infection is suspected.

When does the AAP recommend considering LP in an infant 6 to 12 months old with a febrile seizure?

When the infant is unimmunized for Hib or Streptococcus pneumoniae.

Why might LP be considered in a child already taking antibiotics after a febrile seizure?

Antibiotics may obscure the signs and symptoms of meningitis.

What is the immediate management of a febrile seizure?

Assess and control the airway, protect the child from injury, and monitor blood pressure, oxygenation, and ECG.

What acetaminophen dose may be used for comfort during a febrile illness?

10 to 15 mg/kg per dose orally or rectally.

What ibuprofen dose may be used for a febrile illness?

10 mg/kg per dose in children older than 6 months.

Do antipyretics prevent another febrile seizure?

No. They are used for comfort but do not prevent recurrence.

Does a simple febrile seizure require antiepileptic medication?

No.

Are routine blood tests, lumbar puncture, and imaging required after an uncomplicated simple febrile seizure?

No, not in the absence of other concerning signs or symptoms.

When may a child with a simple febrile seizure be discharged?

When the child has returned to baseline mental status, is tolerating oral fluids, is well appearing, and has close pediatric follow-up.