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Common Acute Pediatric Urgent Issues Encountered in Primary Care Settings Andrew Hashikawa, MD, MS, FAAP Assistant Professor Children’s Emergency Services University of Michigan Medical School
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Conflict of Interest No Conflicts of Interest to Report
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Background Undergraduate: University of Michigan-Flint (Chemistry and History) Medical School and Pediatric Training: Mayo Clinic Pediatric Emergency Medicine Fellowship: Children’s Hospital of Wisconsin
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Objectives 1. Review case-based treatment and management pearls of common infectious and injury complaints in urgent care settings. 2. Learn procedures for common complaints in primary care and urgent care settings 3. Understand urgent issues that should be referred to the ED.
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Case 1: Wrist complaint 6-year-old male Fell at playground Wrist pain No snuff box tenderness No deformity, open wound, or swelling Some tenderness at wrist with palpation
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Case 1: Buckle Fracture Small buckle fracture distal radius
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Case 1: Buckle Fracture – Removable Splint Data support - removable splint in 6+ year old children who will keep splint on No difference vs. casting Healing Pain Better function and parent satisfaction Plint, AC et al. A Randomized Control Trial of Removable Splinting Vs. Casting for Wrist Buckle Fracture in Children. Pediatrics 2006.
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Case 2: Asthma 4 year-old-female Hx of URI & wheezing and one prior ER visit with no hospitalization Clears after one Duoneb Parents says nebulizer worked best and wants Rx for nebulizer
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Case 2: MDI vs. Nebulizer Meta-analyses show nebulizer and MDI clinically equivalent Nebulized albuterol (0.15 mg/kg per dose max 5mg) higher doses than MDI But . . . MDI delivers particles more effectively to lungs, cheaper, faster, and portable, and shorter ED stays = so tie goes to MDI. Must use higher doses of MDI 2-4 puffs young children 4-6 puffs older children 4-8 puffs adolescents Cates CJ et al. Holding chambers versus nebulizers for beta-agonist treatment of acute asthma. Cochrane Database of Systematic Reviews. 2003.
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Case 2: PEARL If fails initial treatment in the clinic or urgent care (moderate exacerbation) . . . Give steroids as soon as possible before sending to ED to treat inflammatory process.
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Case 3: Asthma not getting better 15 year old male – seen by urgent care for asthma 2 days ago Using albuterol MDI every 2 hours (2 puffs) On day 2 of steroids Patient says albuterol “not working.” Mild, scattered diffuse wheezing Looks well and no distress One neb treatment later he looks well and is completely clear
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Case 3: How are you going to make him better? Steroid dosing? MDI # of puffs? Technique?
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Case 3: Pearls Consider single or 2-dose regimens of dexamethasone as a alternative to a 5-day course of prednisone/prednisolone. Prednisone 60 mg or Dexamethasone (0.6 mg/kg) 12-16 mg max for adults ( 1 or 2 dose regimen) MDI # of puffs? 6-8 puffs Technique: Lack of spacer (Rx cost) – little medication in lungs.
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Case 4: Croup 24 month old Female (13 kg) Barky cough this morning Hoarse voice Noisy breathing last night Currently no stridor Child looks well, no cough
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Case 4: Pearl: Dexamethasone Low threshold to give – sx likely to get worse tonight, day 2 or 3 Dexamethasone liquid 0.5 mg/5 mL (majority of outpatient pharmacies) 13 kg at 0.6 mg/kg = 8 mg One dose = 80 mL = over 2 ½ ounces of dexamethasone liquid. Taste is terrible! Dexamethasone tablets Small (2 small tablets) Easily crushed and mixed with applesauce or chocolate syrup
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Case 5: Hives 20 month old infant An in-home child care setting Ate yogurt for the 2nd time Developed hives and vomited once Crying and inconsolable No tongue swelling, diarrhea, hypotension, wheezing or stridor.
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Case 5: Anaphylaxis True food allergies affect 6-8% of children < 4 years of age Among Peanut Allergy Registry, 16% with allergic reaction to peanut/tree nut in school or child care, with 64% of reactions occurring in preschool or child care. 25% of allergic reactions occurring in preschool or child care centers represent the first reaction. Majority of reactions begin with GI symptoms. NEISS data base – 13% of all food allergies had anaphylaxis, but 50% pediatric patients.
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Case 5: Epinephrine Autoinjectors Younger children that are inconsolable - worrisome for abdominal pain (gut edema) Many providers do not recognize GI symptoms/fussiness as symptom of anaphylaxis Very low threshold for Epipen Jr.
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Case 5: Have you given Epipen to patient? Yes No Practice only Don’t know how to give
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Case 5 Pearl: Epipen Mnemonic Blue to the sky Orange to the thigh Count 10 to 1 (hold) Then call 911.
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Case 6: Not using arm. 2 year old infant Pulled up by arms and swung around Now not using the right arm Exam reveals no swelling
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Case 6: Nursemaid Elbow Hyperpronation: Required fewer attempts than supination more often successful than supination, and was often successful when supination failed. Macias et. Al. A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations Pediatrics. 1988
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Case 7: Fever without a source 11 month old M with 2 days of fever eating less. Looks nontoxic and TM’s are fine Patient is teething (drooling more) and fussy, but consolable
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Case 7: Pearl Don’t forget to look in posterior pharynx (need to use tongue depressor) Will often miss source of fever Herpangina Clues are decreased eating, more drooling, fever, “teething”
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Case 7: Herpangina/Hand-Foot-Mouth Cause? Coxsackievirus A16 and Enterovirus 71 Spread? Virus shed several weeks; respiratory, direct, fecal-oral Exclude from School/Child Care? No, unless fever, behavior change, unable to participate Return? When exclusion criteria end. Ibuprofen!
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Case 7: Variables increasing diagnostic accuracy in UTI in young females Males < 1 year old Uncircumcised Or history of UTI > 3% risk Females < 1 year Temperature >39C White Race Fever > 2 days Absence of another source of fever on hx or exam 3 or more have best accuracy in making diagnosis. Gorelick, MH: Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection. Pediatr Emerg Care, 2003.
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Case 7: Variables increasing diagnostic accuracy in UTI in young females Males < 1 year old Uncircumcised Or history of UTI > 3% risk Females < 1 year Temperature >39C White Race Fever > 2 days Absence of another source of fever on hx or exam 3 or more have best accuracy in making diagnosis. Gorelick, MH: Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection. Pediatr Emerg Care, 2003.
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Case 8 1-year-old Blisters, rash on feet. Fussy but consolable.
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Case 8: Scabies (Sarcoptes scabiei) Often palms, soles, head, neck in children Treatment? Permethrin cream (1% or 5% cream?) Head to toes overnight (8 – 12 hr) Wash, repeat 2 weeks Close contacts Itching may persist – hypersensitivity Topical steroids, antihistamines
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Case 9: 4 year old girl Clinical findings of strep. Rapid strep is positive.
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Case 9: Pearl: Consider once daily dosing Treatment? – Amoxicillin (best tasting) 50 mg/kg dose (max 1 g) daily x 10 days Penicillin G benzathine IM x 1 Consider first dose in ED + Rx note
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Case 9: 17-year-old female Sore throat What else to consider besides strep?
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Case 10: Conjunctivitis 4 year old Male Some clear drainage from both eyes. His temperature is 97.5° axillary.
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Case 10: Conjunctivitis Viral Exclude from school/child care? Only if fever, behavior change Return? – AAP recs: Antibiotics – no longer required Consider Rescue Rx and Note May be child care issue
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Case 10: 5 year old Male Honey colored, crusty lesion.
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Case: 10 Impetigo Exclude From School or Child Care? At end of day, not immediate Return? Treatment – “24 hours” Treatment: Single lesion: Topical mupirocin If multiple lesions or near mouth or outbreak, systemic antibiotic* If strep - Concerns about acute rheumatic fever? - No
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Case 11 : 3 year old Male Yellow, crusted area for several weeks Feels indurated, boggy.
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Case 11: Ringworm Cause? Kerion – cell-mediated response to tinea capitis Often confused with bacterial skin infection Oral antibiotics and incision and drainage not recommended Treatment? Griseofulvin 10-20 mg/kg (max 1g) (microsize) 4-6 weeks, 2 weeks past resolution symptoms Terbinafine (≥4yo) 6 weeks equivalent ±Selenium sulfide shampoo Return to school or child care? Treatment started
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Case 12: 2 year old Male Presents with intense scratching of anus. Mild irritation around rectum 4 yo sister with vaginal itching What is the cause?
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Case 12: Pinworms (Enterobius vermicularis) Exclude? No. Treatment? Mebendazole 100 mg po x1 Repeat 2 weeks Treat family Return to school? Immediately after 1st treatment
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Case 13 5 y/o M Febrile Pain Has otitis media
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Case 13: Acute Otitis Media (AOM) • Middle Ear Effusion (MEE) - demonstrated by pneumatic otoscopy, tympanometry, air fluid level, or a bulging tympanic membrane plus • Evidence of acute inflammation – opaque, white, yellow, or erythematous tympanic membrane or purulent effusion plus • Symptoms of otalgia, irritability, or fever
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Case 13: Pearl If well, no severe pain, or fever – Rescue Rx (50% will not fill) Azithromycin 30 mg/kg ( 1 dose) Cefdinir (10-15% cross over allergy) but 14 mg/kg once daily dosing Side effect of Cefdinir?
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2013 Otitis Media Guidelines The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain regardless of the use of antibiotics. Pain associated with AOM can be substantial the first few days and often persists longer in young children. Antibiotic tx does not provide symptomatic relief in the first 24 hours Even after 3 to 7 days, there may be persistent pain, fever, or both in 30% of children < 2 years of age. Analgesics do relieve pain associated with AOM within 24 hours
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Case 14: 2 year old itching scalp.
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Case 14: Lice How long has it been there? Occur in all socioeconomic groups Exclude? Only at end of day. Treatment Over-the-counter None of old remedies (mayo) have been show n to work. No evidence that combing improves treatment success if using chemical tx Return? No nit policy? – nits farther than ¼ inch from scale do NOT have live lice in them 1st treatment; may need 2nd; Vacuum effective; 5 minutes > 129 degrees and dried hot setting; Itching persists: why? - reaction to saliva (may persist for weeks) Treatment may cause scalp to itch
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2. Procedures
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Case : Nasal Foreign Body 3 year old Male
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Case: Nasal Foreign Body
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Extractor or 6 to 8 French Foley with balloon
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Scalp Lac?
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Hair apposition method
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Twist and drop of glue (not tie)
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Apply only 1 drop per bundle
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3. Cases to Refer to the ED
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Case 3: Severe Asthma in Clinic 6 year old brought by mom No wheezing History of bad asthma Looks tired Sats 87% Not better after couple Duonebs
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Case 3: What’s your next step? Call EMS Next step while waiting?
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Next step while waiting Intubate Start IV Epipen Inhaled steroids Xray
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Status asthmaticus Pearl: Epipen Mnemonic Blue to the sky Orange to the thigh Count 10 to 1 Then call 911.
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Case 9: Foreign Bodies 2 year old Male “Swallowed a coin”. No respiratory distress.
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How about this?
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F.B. Pearls Button Battery or Magnets – urgent removal Typically once in stomach – we let foreign bodies pass (except magnets)
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Dental Injury 6 year old Male Playground (vs. pole) 30 min ago Dad kept tooth Unsure if permanent or baby tooth
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Tooth Mamelon
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Avulsed tooth Can store in Cold milk or Hank’s Balanced Salt Solution Saline (less preferred) ED (if avulsed permanent tooth) Can reimplant avulsed PERMANENT tooth Don’t scrub Rinse with saline Insert root of tooth into socket Send to ED for splint. 90% survival (30 min); Declines 1% every minute beyond 30 min > 60 minutes (dry) almost never viable.