Common Acute Pediatric Urgent Issues Encountered in Primary Care Settings - PowerPoint Presentation

Slide1

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 SchoolSlide2

Conflict of Interest

No Conflicts of Interest to ReportSlide3

Background

Undergraduate

:

University of Michigan-Flint

(Chemistry and History)

Medical School and Pediatric Training

:

Mayo Clinic

Pediatric Emergency Medicine Fellowship

:

Children’s Hospital of WisconsinSlide4

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. Slide5

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 palpationSlide6

Case 1: Buckle Fracture

Small buckle fracture distal radiusSlide7

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.Slide8

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 nebulizerSlide9

Case 2: MDI vs. Nebulizer

M

eta-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.Slide10

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.Slide11

Case 3: Asthma n

ot 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 clearSlide12

Case 3: How are you going to make him better?

Steroid dosing?

MDI # of puffs?

Technique?Slide13

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. Slide14

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 coughSlide15

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 syrupSlide16

Case 5: Hives

20 month old infant

An in-home child

c

are setting

Ate yogurt for the 2

nd

time

Developed hives and vomited once

Crying and inconsolable

No tongue swelling, diarrhea, hypotension, wheezing or stridor.Slide17

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. Slide18

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. Slide19

Case 5

: Have you given

Epipen

to patient?

Yes

No

Practice only

Don’t know how to giveSlide20

Case 5 Pearl:

Epipen

Mnemonic

Blue to the sky

Orange to the thigh

Count 10 to 1 (hold)

Then call 911. Slide21

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 swellingSlide22

Case 6: Nursemaid Elbow

Hyperpronation

:

R

equired

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. 1988Slide23

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 consolableSlide24

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”Slide25

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!Slide26

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. Slide27

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. Slide28

Case 8

1-year-old

Blisters, rash on feet.

Fussy but consolable.Slide29

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 weeksClose contacts

Itching may persist – hypersensitivity

Topical steroids, antihistaminesSlide30

Case 9

:

4 year old girl

Clinical findings of strep.

Rapid strep is positive.Slide31

Case 9

: Pearl: Consider once dail

y 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 noteSlide32

Case 9

:

17-year-old female

Sore throat

What else to consider besides strep? Slide33

Case 10

: Conjunctivitis

4 year old Male

S

ome clear drainage from both eyes. His temperature is 97.5° axillary. Slide34

Case 10

: Conjunctivitis

V

iral

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 issueSlide35

Case 10

:

5 year old Male

Honey colored, crusty lesion. Slide36

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? - NoSlide37

Case 11

:

3 year old Male

Yellow, crusted area for several weeks

Feels indurated, boggy.Slide38

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 startedSlide39

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? Slide40

Case 12

: Pinworms

(

Enterobius

vermicularis

)

Exclude?

No.

Treatment?

Mebendazole

100 mg

po

x1

Repeat 2 weeks

Treat family

Return to school?

Immediately after 1

st

treatmentSlide41

Case 13

5 y/o M

Febrile

Pain

Has otitis mediaSlide42

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 Slide43

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

? Slide44

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

E

ven

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

hoursSlide45

Case 14:

2 year old itching scalp

.Slide46

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 2

nd

; 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 itchSlide47

2

. ProceduresSlide48

Case : Nasal Foreign Body

3

year old MaleSlide49

Case: Nasal Foreign BodySlide50

Extractor or 6 to 8 French Foley with balloonSlide51

Scalp Lac?Slide52

Hair apposition methodSlide53

Twist and drop of glue (not tie)Slide54

Apply only 1 drop per bundleSlide55
Slide56

3

. Cases to Refer to the EDSlide57

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

DuonebsSlide58

Case 3: What’s your next step?

Call EMS

Next step while waiting? Slide59

Next step while waiting

Intubate

Start IV

Epipen

Inhaled steroids

XraySlide60

Status asthmaticus

Pearl

:

Epipen

Mnemonic

Blue to the sky

Orange to the thigh

Count 10 to 1

Then call 911. Slide61

Case 9: Foreign Bodies

2

year old Male

“Swallowed a coin”.

No respiratory distress. Slide62
Slide63

How about this? Slide64
Slide65

F.B. Pearls

Button Battery or Magnets – urgent removal

Typically once in stomach – we let foreign bodies pass (except magnets)Slide66

Dental Injury

6 year old Male

P

layground (vs. pole) 30 min ago

Dad kept tooth

U

nsure if permanent or baby toothSlide67

Tooth Mamelon Slide68

Avulsed tooth

Can store in

C

old milk or Hank’s Balanced Salt Solution

Saline (less preferred)

ED (if avulsed permanent tooth)

Can

reimplant

avulsed PERMANENT toothDon’t scrubRinse 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.