What is the probability that a well appearing 18 month old caucasian female infant with fever of 102.2 F (39 C) and URI symptoms has a concurrent UTI? Would you obtain a urinalysis to r/o UTI?

3% - 8%.

One proposed diagnostic algorithm for febrile female infants aged 3 to 24 months suspected of having a UTI.  Click image to enlarge.

Source

Singh, R. and Carpenter, C.  "Does This Child Have a Urinary Tract Infection?"  Annals of Emergency Medicine.  May 2009.

Shaikh N, Morone NE, Lopez L, et al. "Does this child have a urinary tract infection?" JAMA 2008; 298:2895.

Can a 5 month old have a simple febrile seizure?

No.  By definition "simple" febrile seizures occur in children 6 months - 5 years old.  A seizure is a 5 month old is, by definition, complex.


Peer VIII: Physician's Evaluation and Educational Review in Emergency Medicine, American College of Emergency Physicians

Name 6 causes of GI bleeding in neonates (< 1 month)? What is your clinical approach to diagnosis?

1. anorectal fissures (most common cause of rectal bleeding in patients less than 1 year)
2. swallowed maternal blood (examine mother's nipples)
3. coagulopathy
4. necrotizing enterocolitis 
5. malrotation with midgut volvulus 
6. Hirschsprung disease 

If patient appears well and there is an obvious cause of bleeding such as a fissure or swallowed maternal blood, a minimalist workup can probably be pursued with close outpatient followup.  However, if the patient is ill and/or there is no obvious cause of bleeding consider checking labs and an abdominal x-ray to start.  


Source

Ramsook, C. and Endom, E.  "Diagnostic approach to lower gastrointestinal bleeding in children"  Up to Date. May 2011.

2 month old female has fever and UTI. She's otherwise healthy and clinically non-toxic. Okay for discharge? If so, which antibiotic?

Oral antibiotics are appropriate in children older than 1 month who have had a first febrile UTI and are non-toxic and can tolerate PO. 

IV antibiotics and admission to the hospital for febrile UTI should be considered for children less than 1 month of age and those who are toxic or can't tolerate PO.

Antibiotic Options.  Click to enlarge.

Source

Montini, G. et al.  "Febrile Urinary Tract Infections in Children"  N Engl J Med.  2011.

A fall of what height (in feet) is considered a severe head injury mechanism injury in children less than 2 years? Greater than 2 years?

Less than 2 = 3 feet
Greater than 2 = 5 feet

Consider head CT in children with head injury after this mechanism of injury. For further details regarding Kuppermann's head CT decision rule for children with head trauma, click here.


Source

Kuppermann N et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009 Sep 15

A septic hip joint is classically held in what position?

Flexion, abduction and external rotation.  This position maximizes the joint space and offers maximal comfort.

Source

Mattu, A. et al.  Avoiding Common Errors in the Emergency Department.  2010.

Image source: http://pediatroskondylis.blogspot.com/2009/08/arthritis.html

American Academy of Pedatrics changes recommendations regarding lumbar puncture after simple febrile seizure

The updated guidelines - directed at children 6 - 60 months old who have sustained a simple febrile seizure - recommends that a LP be considered for the following groups of children:

• ill appearing
• between 6 - 12 months whose immunizations are not up to date
• pretreated with antibiotics 

This replaces the previous AAP recommendation in 1996 that an LP be "strongly considered" in all children < 12 months  who present with a simple febrile seizure.


Source

Subcommittee on Febrile Seizures. Clinical practice guideline — Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011 Feb; 127:389.

How is periodic breathing of infancy defined?

Periodic breathing is a benign entity that must be distinguished from life threatening mimics. It is defined as the repeated occurrence of three or more respiratory pauses lasting 3 - 20 seconds with less than 20 seconds of breathing between pauses and NO associated color change or hypotonia.


Source

Adams, J. "Clinical features and management of apnea of prematurity" Up to Date. Sep 2010.

Burnett, L. "Pediatrics, Sudden Infant Death Syndrome" eMedicine. March 2009.

9 month old presents s/p simple febrile seizure. Has had nasal congestion. Clinically appears well with no other localizing fever source by history or physical. LP or no LP?

The American Academy of Pediatrics' (AAP) recommends in "Practice Parameter: The Neurodiagnostic Evaluation of the Child With a First Simple Febrile Seizure" published in 1996 that a lumbar puncture be "strongly considered" in infants younger that 12 months with first simple febrile seizure and be "considered" in a child between 12 and 18 months.

A recent study by Amir Kimia et al at Boston Childrens Hospital however finds that the risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is exceedingly low and concludes that these AAP recommendations be reconsidered.

LP or no LP? What is your call?




Source

Kimia, A. et al. "Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 months of Age" Pediatrics. 2009.

American Academy of Pediatrics. "Practice Parameter: The Neurodiagnostic Evaluation of the Child With a First Simple Febrile Seizure" 1996

True or False. The treatment of a retropharyngeal abscess is surgery.

False.

Antibiotics alone successfully treat 37%.


Source

Shah, S. and Sharieff, G.  "Pediatric Respiratory Infections"  Emerg Med Clin N Am.  2007

Why do retropharyngeal abcesses occur more frequently in young children?

96% of retropharyngeal abscesses occur in children less than 6 y/o because the nodes of Rouviere that drain the retropharyngeal space typically atrophy after this age.


Source

Shah, S. and Sharieff, G.  "Pediatric Respiratory Infections"  Emerg Med Clin N Am.  2007

A septic appearing croup-y child should raise concern for what diagnosis?

Choose one. 

A) Really really bad croup

B) Bacterial tracheitis

Answer: B


Source

Shah, S. and Sharieff, G.  "Pediatric Respiratory Infections"  Emerg Med Clin N Am.  2007

Push here to save the day: Laryngospasm Notch

Laryngospasm is a rare but well know complication of using ketamine for conscious sedation, particularly in young kids. Treatment for this involves the usual maneuvers:

• Chin lift 
• Jaw thrust 
• Suction
• Positive pressure ventilation via bag-mask, occluding pop-off valve if necessary to generate high enough pressures to open the vocal cords 
• Neuromuscular blockade 

Another helpful albeit less well known technique that can be tried is application of pressure to the laryngospasm notch.

The mechanism by which this technique works is uncertain but it is endorsed in the anesthesia literature.  Click here to read a good review of this technique by Dr. Philip Larson, a Professor Emeritus of Anesthesia and Neurosurgery at Stanford.


Source

Gorelick, M et al.  "Pediatric Sedation Pearls"  Clin Ped Emerg Med. Dec 2007.

Larson, P. "Laryngospasm - The Best Treatment"  Anesthesiology.  Nov 1998.

Febrile 18 month old male has non-focal seizure for 5 min, stops, then seizes again for 2 min. Nl exam. Is this a complex or simple febrile seizure?

Simple.

Simple febrile seizures are characterized by seizures that last less than 15 minutes, have no focal features, and, if they occur in a series, the total duration is less than 30 minutes.


Source

Fishman, M. "Febrile seizures" Up to Date. Sept 2009.

2 y/o child chokes while eating peanuts but now in the ED is asymptomatic. Exam and chest x-ray (w/ lateral decub) normal. Bronch or not?

Aspirated foreign bodies, particularly organic material, can cause pneumonia, lung abscess and empyema.

Given the risks of retained aspirated foreign bodies and the small, albeit known risks of bronch (laryngeal lacerations, pneumomediastinum, pneumothorax, etc), a negative bronchoscopic evaluation rate of 10-15% is acceptable.

Hence, the decision to bronch or not lies in the pre-test (bronch) probability of retained foreign body which can be assessed by the usual means (history, physical, chest x-ray [expiratory, decubitus]) as well as admission for short period of observation and/or expert consultation. CT and MRI are generally not part of the evaluation given the young age of the patients, time and expense involved and the need for sedation in a patient with potential pulmonary compromise.


Source

Taussig: Pediatric Respiratory Medicine, 2nd ed.

4 month old male falls (3.5 ft) out of mother's arms onto floor hitting head. Cries immediately, small frontal hematoma, acting normal now. Head CT?

According to Kuppermann et al's recent study published in the Lancet, YES because of severe injury mechanism.

In abbreviated form:

For those metric challenged, 1.5 m = 4.92 ft and 0.9 m = 2.95 ft.


Source

Kupperman et al. "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study" Lancet. Oct 2009.

Image source: http://www.medscape.com/viewarticle/711739

At what age can children generally be defibrillated using standard adult sized pads?

1 year of age or about 10 kg; earlier as long as the pads don't touch each other (to avoid electrical arcing).


Source

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Quick! What are you going to do?!? .... You can't intubate or ventilate this 7 year old kid.

If you can't intubate or ventilate a child despite attempting several airway techniques ie LMA, boogie, glide scope, etc ... there's always the handy, but rarely used, cricothyrotomy.

In children, pediatric needle cric kits exist out there but unless you're at a hospital that sees lots of sick children, the likelihood that they're stocked and easily accessible is about nil.

But not to despair, the majority of physicians can quickly assemble a "make shift" system from the following items found in most EDs.

• 14 gauge IV catheter
• 3 cc syringe
• 7.0 endotracheal tube adapter

Procedure:

1. Prep crichothyroid membrane
2. Attach 3 cc syringe 1/2 filled with saline to the 14 gauge angiocath
   
3. Puncture cricothyroid membrane with needle directed at 45 degree angle caudally while pulling back on the syringe's plunger
   
4. Stop advancing the angiocath once bubbles are noted in the syringe
5. Remove syringe and needle, leaving plastic IV catheter in trachea
   
6. Remove plunger from 3 cc syringe. Empty water. Attach syringe to IV catheter.
   
7. Attach 7.0 endotracheal tube adapter to 3 cc syringe.
8. Bag ventilate.
   

Source

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Walls, R. Manual of Emergency Airway Management.

What is the prevalence of UTI in febrile 6 - 12 month old males, circumcised and uncircumcised?

Circumcised: 0.3%

Uncircumcised: 7.3%

Hence, febrile circumcised males in this age group rarely need a urinalysis as part of their febrile workup.


Source

Shaikh, N. et al. "Prevalence of Urinary Tract Infection in Childhood: A Meta-Analysis" The Pediatric Infectious Disease Journal. v 27, n 4, April 2008.

What are the Kocher criteria?

1. history of fever
2. non-weight bearing
3. erythrocyte sedimentation rate (ESR) > 40
4. WBC > 12,000 per cubic millimeter

The more criteria met, the greater the chances of septic hip relative to a more benign cause of pediatric hip pain such as transient synovitis.

• 0/4 criteria = 0.2% chance of septic hip
  
• 1/4 = 3%
• 2/4 = 40%
• 3/4 = 93.1%
• 4/4 = 99.6%

Source

Kocher, M. MD et al. "Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm" The Journal of Bone and Joint Surgery 81: 1662-70 (1999)