Topnotch Pediatrics For Moonlighters

ì
GETTING READY FOR PEDIATRICS
Ruby L. Punongbayan, MD, MA, FPPS

Associate Professor in Pediatrics
Intended Learning Outcomes:
ì To recognize the salient features of the clinical condition

encountered by the general practitioner in the pediatric
outpatient and emergency setting
ì To come up with an initial diagnosis based on thorough history
taking and a comprehensive and focused physical examination
ì To formulate an appropriate diagnostic plan of management for
the pediatric patient seen by a general physician and correctly
interpret its results
ì To create a therapeutic plan of management for the patient
that is appropriate and justifiable for the given clinical scenario
 
ì Consider the age group in establishing rapport and doing

PE.
ì Make entries in the history and PE that are age-
appropriate.
ì Perform the invasive procedures last.
ì Use acceptable ways of immobilization.
ì Know the natural course of the illness.

Age-specific blood cell indices
Age Hb (g/dL) Hct (%) WBC (x10 to 2/uL)
1-3 days old 18.5 (14.5) 56 (45) 18.9 (9.4-34)
2 weeks old 16.6 (13.4) 53 (41) 11.4 (5-20)
1 month old 13.9 (10.7) 44 (33) 10.8 (4-19.5)
2 months old 11.2 (9.4) 35 (28) -----
6 months old 12.6 (11.1) 36 (31) 11.9 (6.-17.5)
6 mo-2 years old 12.0 (10.5) 36 (33) 10.6 (6-17)
2-6 years old 12.5 (11.5) 37 (34) 8.5 (5-15.5)

Age-specific blood cell indices
Age Hb (g/dL) Hct (%) WBC (x10 to 2/uL)
6- 12 years old 13.5 (11.5) 40 (35) 8.1 (4.5-13.5)
12- 18 years old

Male 14.5 (13.5) 43 (36) 7.8 (4.5-13.5)
Female 14.0 (12) 41 (37) 7.8 (4.5-13.5)
Vital signs at various ages
AGE Heart rate Blood RR

(Beats/ Pressure (breaths/
min) min)
Prema-ture 120-170 55-75/ 40-70

35-45
0-3 months 100-150 65-85/ 35-55
45-55
3-6 months 90-120 70-90/ 30-45
50-65
6-12 80-120 80-100 25-40
months 55-65
Vital signs at various ages
AGE Heart rate Blood RR (breaths/

(Beats/ Pressure min)
min)
1-3 yrs 70-110 90-105/ 20-30

55-70
3-6 yrs 65-110 95-110/ 20-25
60-75
6-12 yrs 60-95 100-120/ 14-22
60-75
>12 yrs 55-85 110-135 12-18
65-85
Important Points re: taking the BP
ì Use the RIGHT SIZE BP CUFF!
Blood chemistries
Reference values Conventional units SI units
Serum ALT (SGPT)
infant 13-45 U/L 13-45 U/L
adult male 10-40 U/L 10-40 U/L
adult female 7-35 U/L 7-35 U/L
Amylase
newborn 5-65 U/L 5-65 U/L
adult 27-131 U/L 27-131 U/L
Serum AST (SGOT)
infant 15-60 U/L 15-60 U/L
1-3 yrs old 20-60 U/L 20-60 U/L
4-6 yrs old 15-50 U/L 15-50 U/L
7-9 yrs old 15-40 U/L 15-40 U/L
10-11 yrs old 10-60 U/L 10-60 U/L
12-19 yrs old 15-45 U/L 15-45 U/L

Blood chemistries
BILIRUBIN (TOTAL)
1-2 days
preterm <12 mg/dL <205 umol/L
term <11.5 mg/dL <197 umol/L
3-5 days
term <12 mg/dL <205 umol/L
Older infant
term <1.2 mg/dL <21 umol/L
BILIRUBIN (CONJUGATED)
Neonate <0.6 mg/dL <10 umol/L
Infants / Child <0.2 mg/dL <3.4 umol/L
Blood chemistries
C-REACTIVE PROTEIN 0.0.5 mg/dL
CREATININE
Infant 0.2-0.4 mg/dL 18-35 umol/L
Child 0.3-0.7 mg/dL 27-62 umol/L
Adolescent 0.5-1.0 mg/dL 44-88 umol/L
ESR
Child 4-20 mm/hr
LIPASE
3-12 months old 9-128 U/L 9-128 U/L
1-11 yrs old 10-150 U/L 10-150 U/L
> 11 yrs old 10-220 U/L 10-220 U/L
Blood chemistries
GLUCOSE (serum)
Preterm 20-60 mg/dL 1.1-3.3 mmol/L
Newborn, > 1 day 50-80 mg/dL 2.8-4.5 mmol/L
Child 60-100 mg/dL 3.3-5.5 mmol/L
> 16 years old 74-106 mg/dL 4.1-5.9 mmol/L
Blood chemistries
LIPIDS CHOLESTEROL (mg/dL)
Child / Adolescent Desirable Borderline High

170 170-199 >200

LDL (mg/dL)
Child/ Adolescent <110 110-129 >130
HDL (mg/dL)
Child / Adolescent 45 ----- ------
Common reasons for  
pediatric consultations:
ì Difficulty of breathing / respiratory distress
ì Diarrhea and/or vomiting
ì Fever with or without rashes
ì Abdominal pain
ì Seizures
ì Chest pain
ì Headache
ì Trauma
ì Allergies
ì Parasitism
respiratory distress /
dyspnea
ì
Respiratory problem by severity:
Respiratory distress Respiratory failure
Clinical state characterized by abnormal Clinical state of inadequate oxygenation,
respiratory rate and effort ventilation, or both
End stage of respiratory distress

Respiratory effort: ➢ Tachypnea (early), bradypnea (late)
> Increased: nasal flaring, retractions, use of ➢ increased, decreased, or no respiratory
accessory muscles effort
> Inadequate: e.g. hypoventilation, bradypnea ➢ poor to absent distal air movement
➢ Tachycardia (early), bradycardia
➢ Cyanosis
➢ Stupor, coma (late)
Change in airway sounds
Associated changes in skin color and mental
status
Question:
ì A 4 year-old girl presents with fever for 3 days,
rhinorrhea, and a barking cough. On PE, she was heard
to be hoarse with a musical adventitious breath sound
heard on inspiration. What is the expected neck X ray
finding in this patient?
a. Diffuse infiltrates on both lung fields
b. Right upper lung consolidation

c. Subglottic narrowing (steeple sign)
d. Thumbprint sign
ì A 15 year-old girl ate out with her family in a seafood
restaurant. Two hours later, she developed wheezing, hives,
and tongue swelling. She was brought to the ER 20 minutes
later. A delay in the administration of which of the following
medications has been strongly associated with mortality from
this condition?
a. IV crystalloid c. IV Methylprednisolone
b. Epinephrine IM d. inhaled salbutamol

IDENTIFICATION OF RESPIRATORY
PROBLEMS BY TYPE:
ì Upper Airway Obstruction
(croup, anaphylaxis, foreign body aspiration)
❖ SIGNS:
❖ Tachypnea
❖ Increased inspiratory respiratory effort (inspiratory retractions, nasal

flaring)
❖ Changes in voice (e.g. hoarseness), cry, or presence of barking cough
❖ Stridor (usually inspiratory but may be biphasic)

❖ Poor chest rise
❖ Poor air entry on auscultation

Laryngotracheobronchitis
ì also called viral croup
ì acute inflammatory disease of the larynx (within the

subglottic space)
ì most common etiology is parainfluenza virus
ì SSx: rhinorrhea, pharyngitis, and low-grade fever 1-3
days before signs of UAO, inspiratory stridor, hoarse
voice, barking cough
ì neck x-ray: subglottic narrowing - “steeple sign” (X ray
findings do not correlate well with disease severity)
Westley croup score:
Clinical sign Degree Score
Stridor None 0
At rest on auscultation 1
At rest without auscultation 2
Chest wall None 0

Mild 1
retractions Moderate 2
Severe 3
Air entry Normal 0

Decreased 1
Severely decreased 2
Cyanosis None 0
With agitation 4
At rest 5
Consciousness Normal 0
Altered 5
level
LTB
➢ Westley croup score: 0-17

➢ Mild: 0-4
➢ Moderate: 4-6
➢ Severe: >6
ì Tx:
ì It is strongly recommended that a single dose of
glucocorticoids be administered to children
presenting to the ED with mild, moderate, or
severe croup. (2011, Level 1A)
Management of croup:
SEVERITY OF CROUP INTERVENTION
MILD Consider dexamethasone (0.6 mg/kg/dose po/IV/IM)
MODERATE TO SEVERE Administer humidified 02

Give nothing by mouth
Administer nebulized epinephrine (<4 yrs: 0.05 ml/kg/dose
diluted to 3 ml NS with max of 0.5 ml/dose; > 4 yrs: 0.5 ml/
dose diluted to 3 ml NS)
Observe for at least 2 hours
Administer dexamethasone
IMPENDING RESPIRATORY Administer a high concentration of 02
FAILURE Use non rebreathing mask if available:
Assist ventilation (bag mask ventilation)
Administer dexamethasone IV/IM
Perform endotracheal intubation
Use smaller ET tube size
Management of LTB:
ì Airway management and treatment of hypoxia
ì mild (at home): oral fluids
ì moderate to severe stridor at rest, hypoxia, need for

intubation: nebulized racemic epinephrine (<4 yrs old:
0.05 ml/kg/dose diluted to 3 ml NSS with max of 0.5 ml/dose; >4
yrs old: 0.5 ml/dose diluted to 3 ml NSS)
ì Single dose of oral dexamethasone 0.6 mg/kg (as

effective as IM) to decrease laryngeal edema
Adverse reactions to food
ì Any untoward reaction following ingestion of food and divided
into:
➢ Food intolerance – adverse physiologic responses based on
functional properties of food
➢ Food allergy – adverse immunologic response and allergies due to
IgE-mediated and/or cell-mediated mechanisms
ì EPINEPHRINE- drug of choice for anaphylaxis

➢ Prevents or reverses airway obstruction and cardiovascular
collapse
➢ Dose: 0.01 ml/kg with 0.5 ml max IM
ANAPHYLAXIS
ì Diagnostic criteria:
➢ Criterion 1:
1. Acute onset of illness involving skin, mucosal tissue,

or both
2. Respiratory compromise
3. Reduced blood pressure

ANAPHYLAXIS
ì Diagnostic criteria:
➢ Criterion 2:
1. 2 or more of the following that occur rapidly after exposure to a
“likely allergen” for that patient:
a. Involvement of the skin-mucosal tissue

b. Respiratory compromise
c. Reduced BP or associated symptoms
d. Persistent gastrointestinal symptoms
Signs and symptoms:
ì SKIN
ì RESPIRATORY
➢ Flushing
➢ Nose: itching, congestion,
➢ Itching rhinorrhea, sneezing
➢ Urticaria ➢ Lungs: shortness of breath,
dyspnea, chest tightness,
➢ Angioedema wheezing, cough
➢ Hair standing on end ➢ Laryngeal: pruritus &
tightness in throat,
ì ORAL dysphagia, hoarseness
> Itching or tingling of lips,
tongue, or palate
Signs and symptoms:
ì CARDIOVASCULAR ì GASTROINTESTINAL
➢ Nausea
➢ Feeling of faintness or
➢ Abdominal pain
dizziness
➢ Vomiting
➢ Syncope ➢ Diarrhea
NEUROLOGIC
➢ Chest pain
➢ Anxiety
➢ Palpitations ➢ Apprehension
➢ Sense of impending doom
➢ Hypotension (tunnel
➢ Confusion
vision, difficulty hearing)
➢ Headache
➢ seizures
Signs and symptoms
ì OCULAR ì OTHERS
➢ Periorbital itching ➢ Lower back pain due to

uterine cramping in
➢ Erythema females
➢ Edema ➢ Vaginal bleeding
➢ Tearing
➢ Conjunctival erythema
Management
ì Airway, breathing, circulation (02, fluids)
ì EPINEPHRINE- drug of choice
➢ Prevents or reverses airway obstruction and cardiovascular
collapse
➢ Dose: 0.01 ml/kg with 0.5 ml max IM
ì ANTIHISTAMINE:
➢ H1: relieve itching & hives: Diphenhydramine (1 mg/kg IM max
50 mg), Cetirizine, Hydroxyzine
➢ H2: minimal evidence to support use
Management
• BETA-ADRENERGIC AGONISTS
➢ Nebulize with Albuterol or Salbutamol if with wheezing
• GLUCOCORTICOIDS
➢ May help prevent biphasic or protracted course
➢ Do not provide rapid relief or upper/lower airway obstruction,

shock, or other symptoms
➢ Hydrocortisone 5 mg/kg or Methylprednisolone 2 mg/kg IV
Management of foreign body aspiration:
1. For a conscious infant or child, use manual techniques appropriate for

age.
< 1 year - give 5 slaps followed by 5 chest thrust
> 1 year – give abdominal thrust
2. If become unresponsive, start CPR beginning with chest compression

Before you deliver a breath, look into the mouth, if you see a foreign body that can easily
be removed.
* Do not do blind finger sweep in an effort to dislodge foreign body. This may push
the foreign body further into the airway. It may also cause bleeding and trauma.
Question:
ì A 2 year-old male presents with 3 days cough, colds, and fever.
On PE, his RR 55 breaths/min, with subcostal retractions, had
wheezes on all lung fields, and a prolonged expiratory phase.
What is the most likely etiologic organism of this patient’s
condition?
a. Respiratory syncitial virus
b. Parainfluenza virus
c. Streptococcus pneumoniae
d. Mycoplasma pneumoniae
Bronchiolitis
ì acute inflammation of the small airways in children less than 2
yrs old
ì most commonly caused by RSV (respiratory syncitial virus)
ì S/sy: low-grade fever, rhinorrhea, cough, wheezing,

hyperresonance to percussion, prolonged expiratory phase
2014 AAP guidelines on management
of bronchiolitis:
ì Routine radiographic and laboratory tests are unnecessary and
clinicians should diagnose it and assess its severity based on
history and PE.
ì The AAP no longer recommends a trial dose of a
bronchodilator because evidence to date shows that it is
ineffective in changing the course of bronchiolitis. (evidence
quality B, strong recommendation)
ì NO chest physiotherapy nor use of epinephrine
ì 1st yr of life: (+) heart disease or CLD of prematurity:

Palivizumab (max.of 5 monthly doses, 15 mg/kg/dose during
the RSV season)
Question:
ì A 5 year-old girl presented with cough for 5 days and
undocumented low-grade fever for the past 2 days.
His sleep is interrupted by his coughing. 4 hrs PTC, he
was seen to have increased difficulty of breathing and
was only able to speak in phrases.
ì PE: irritable, hunched forward, CR= 130/min, RR=65/

min, T=36.8°C, 02 sat 90%, no TPC, (+) subcostal
retractions, (+) wheezing on lower lung fields, no
murmurs.
ì Which of the following is incorrect in the
management of this patient’s acute condition?
a. Inhaled beta 2 agonist
b. Oral Prednisolone
c. Cetirizine tablet
d. Methylprednisolone IV
Management:
ì Management of acute attacks:
ì short-acting inhaled beta2-agonist
ì oral or IV steroids (Prednisolone/
Methylprednisolone)
ì anticholinergics (ipratropium bromide) – never
used alone
ì methylxanthines (theophylline, aminophylline) -
NOT first line
ì Management in between attacks:
ì inhaled corticosteroids
ì long-acting inhaled beta2-agonist
ì leukotriene modifiers (Montelukast)
IDENTIFICATION OF RESPIRATORY
PROBLEMS BY TYPE:
ì Lower Airway Obstruction
(bronchiolitis, acute asthma)

SIGNS:
ì Tachypnea
ì Wheezing (most commonly expiratory but may be inspiratory or

biphasic)
ì Increased respiratory effort (retractions, nasal flaring, and prolonged
expiration)
ì Prolonged expiratory phase associated with increased expiratory effort
(i.e. expiration is an active rather than passive process)
ì Cough
Management of asthma exacerbations  
in acute care setting  
(children 6 years & older):
ì Initial assessment ì Are any of the ff

(Airway, Breathing, present? drowsiness,
Circulation) confusion, silent chest
No
Yes
Further TRIAGE BY CLINICAL Consult ICU, start SABA and

STATUS according to worst O2 and prepare patient for
feature intubation
in acute care setting (children 6 years & older):
Mild or moderate Severe
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forward
Not agitated Agitated
Increased RR RR >30/min
Accessory muscles not used Accessory muscles being used
PR 100-120 bpm PR >120 bpm
02 sat on air 90-95% 02 sat on air < 90%
PEF > 50% predicted or best PEF less than or equal to 50%
SABA SABA
Consider ipratropium bromide Consider ipratropium bromide
Controlled 02 to maintain 02 sat at 93-95% Controlled 02 to maintain 02 sat at
(children 94-98%) 93-95% (children 94-98%)
Oral glucocorticosteroids Oral glucocorticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as
severe & re-assess for ICU
in acute care setting (children 6 years & older):
Assess clinical progress frequently

Measure lung function
in all patients 1 hour after initial tx
FEV1 or PEF 60-80% of predicted or FEV1 or PEF < 60% of predicted or

personal best and symptoms personal best or lack of clinical
improved response
MODERATE SEVERE
Consider for discharge planning Consider Tx as above and re-assess
frequently
Treatment of exacerbations in acute care setting
such as the ED:
■ Oxygen by nasal cannula or mask
➢ 94-98% children 6-11 yrs old; 93-95% for adolescents
➢ Severe exacerbation: low flow 02 therapy associated

with better physiological outcome than with high flow
100% 02 therapy
such as the ED:
ì Inhaled SABA
➢ Most cost effective and efficient delivery is
by MDI with a spacer
➢ Conflicting results for intermittent vs
continuous nebulized SABA
➢ Reasonable approach: initial continuous
therapy followed by intermittent on-demand
therapy for in-patients
such as the ED:
■ Systemic corticosteroids
➢ Speed resolution of exacerbations and
prevent relapse & should be utilized in all but
the mild attacks in adults, adolescents, and
children 6-11 years old
➢ Should be given to patients within 1 hour of
presentation
➢ Route ???
such as the ED:
■ Systemic corticosteroids
➢ OCS 50 mg Prednisolone daily as a single

morning dose
➢ Children: Prednisolone 1-2 mg/kg up to a
max. of 40 mg
➢ Duration: 5-7 days for adults; 3-5 days for
children (NO tapering needed)
such as the ED:
■ Inhaled corticosteroids
➢ Within the ED: high dose given within the 1st

hr after presentation reduces the need for
hospitalization in patients not receiving
systemic steroids
➢ Conflicting evidence when given in addition
to systemic steroids
such as the ED:
■ Inhaled corticosteroids
➢ Upon discharge: prescribe regular ongoing

ICS tx because:
1. The occurrence of a severe exacerbation is a
risk factor for future exacerbations
2. ICS-containing meds significantly reduce the
risk of asthma-related death or hospitalization
Other treatments:
■ Ipratropium bromide
➢ For adults and children with moderate-severe

exacerbations, treatment in the ED with both
SABA and ipratropium was associated with
fewer hospitalizations and greater
improvement in FEV1 and PEF compared
with SABA alone.
Other treatments:
■ Aminophylline and theophylline

➢ NOT used in the management of
exacerbations due to poor efficacy and safety
profile
➢ Use of IV aminophylline is associated with
severe and potentially fatal side effects esp.
in patients already treated with sustained-
release theophylline
Other treatments:
ì Magnesium
➢ IV Mg sulfate not for routine use however when

administered as a single 2 g infusion over 20 mins,
it reduces hospital admissions in some patients like
those who have persistent hypoxemia and in
children whose FEV1 falls to 60% predicted after
1 hr of care
➢ Overall efficacy is still unclear
Other treatments:
■ LTRA
➢ Limited evidence to support a role for oral or IV
LTRA in acute asthma
■ Antibiotics (NOT recommended)
➢ Evidence does not support antibiotics in
exacerbations unless there is strong evidence of
lung infection
➢ NO sedatives !!!
Initial assessment of  
acute asthma in children:
SYMPTOMS MILD SEVERE

Altered No Agitated, confused,
consciousness drowsy
02 sat > 95% < 92%
Talks in… sentences words
Pulse rate < 100 bpm >200 bpm (0-3 yrs);

>180 bpm (3-5 yrs)
Central cyanosis absent Likely to be present
Wheeze intensity variable May be quiet

How to use PEFR:
ì (Ht in cms - 100) x 5 + 175 in males

ì (Ht in cms - 100) x 5 + 170 in females
ì The answer to this represents the EXPECTED PEFR.
ì Let the patient use the peak flow meter 3x and get the
highest value which represents the ACTUAL PEFR.
ì actual / expected x 100%
Example: Ht is 160 cms. male
ì Given: actual PEFR 300
ì Answer 63%
ì Based on the table:
➢ mild: >80
➢ Moderate: 60-80
➢ Severe: <60
*** an increase in 15- 20% from the baseline after 3

nebulizations --> response to bronchodilators
Case:
ì A 2 year-old girl presents with cough and colds for
the past 3 days with undocumented fever. No
consultation at that time. On the day of consultation,
she was noted to have decreased appetite and
irritability. Vital signs: CR = 160/min, RR was 65/
min, T=38.8°, 02 sat 90%, no TPC, no murmurs, (+)
intercostal retractions, (+) crackles on both lung
fields.
ì What is your impression?

Identification of respiratory  
problems by type:
ì DISORDERED CONTROL OF BREATHING

(neuromuscular disease)
ì LUNG TISSUE DISEASE (pneumonia, cardiogenic
pulmonary edema, ARDS, pulmonary contusion)
LUNG TISSUE DISEASE
SIGNS:
ì Tachypnea (often marked)
ì Increased respiratory effort
ì Grunting
ì Crackles (rales)
ì Diminished breath sounds
ì Tachycardia
ì Hypoxemia (may be refractory to administration of
supplemental 02)
Cardiogenic pulmonary edema:
ì High pressure in the pulmonary vessels causes fluid

to leak into the lungs interstitium and alveoli
ì e.g., congenital heart disease, myocarditis,

inflammatory processes, hypoxia, and cardiac
depressant drugs
 
MANAGEMENT: 
ì A. PNEUMONIA
1. Perform diagnostic test

2. Administer antibiotic therapy
3. Consider using CPAP or non invasive ventilation
4. In severe cases, endotracheal intubation and mechanical
ventilation maybe required.
5. Reduce metabolic demand by normalizing temperature and
reducing the work of breathing
 
MANAGEMENT 
B. CHEMICAL PNEUMONITIS 
1.Treat wheezing with nebulized bronchodilator
3. With rapidly progressive symptoms, obtain early consultation

4. Refer to a specialized center
C. ASPIRATION PNEUMONITIS
2. Intubation and mechanical ventilation

3. Consider antibiotics if with fever and infiltrates
DISORDERED CONTROL OF BREATHING:
SIGNS:
ì Variable or irregular respiratory rate (tachypnea
alternating with bradypnea)
ì Variable respiratory effort
ì Shallow breathing (frequently resulting in hypoxemia)
ì Central apnea (apnea without respiratory effort)

Case:
ì A 6 year-old boy had colds for the past 10
days. Fever was noted on the 7th day of
the illness along with signs of irritability
and tugging of his ear on the day of
consultation.
ì What is your initial diagnosis?
Acute Otitis Media
ì Cough and colds, fever, irritability, decreased

appetite, vomiting
ì Hyperemic TM, bulging TM, effusion, absent
cone of light
ì Strep. pneumoniae, H.influenzae b, Moraxella
catarrhalis
ì 1st line drug: Amoxicillin (40 mg/kg/day for
7-10 days)
Sample computation:
ì Wt 20 kgs
ì 20 kgs x 40 mgkgday x 5/250 = 5 ml every 8 hrs
ì Amoxicillin has 100 mg/ml; 125 mg/5 ml; 250 mg/5ml
ì Co-Amoxiclav has 312.5mg/5 ml; 457 mg/5 ml; 600

mg/42.9 ml
AOM management: 2013 guidelines:
ì Clinicians should prescribe an antibiotic with

additional β-lactamase coverage for AOM when:
1. a decision to treat with antibiotics has been made
2. and the child has received amoxicillin in the last 30
days
3. has concurrent purulent conjunctivitis
4. has a history of recurrent AOM unresponsive to
amoxicillin
Case:
ì A 17 year-old male
presents with
mucopurulent
discharge on both
eyes. He has colds 3
days prior to the eye
discharge.
Impression?
Conjunctivitis
ì Inflammation of the loose connective tissue that

covers the surface of the eyeball (bulbar) and the
inner layer of the eyelid (palpebral)
ì Staph.epidermidis, Strep.pyogenes, Strep.
pneumoniae, Moraxella, H.influenzae
ì Viral / bacterial / allergic
AAO Conjunctivitis guidelines 2013:
ì The choice of antibiotic is usually empiric. Because
a 5-7 day course of a broad spectrum topical
antibiotic is usually effective, the most convenient
or least expensive option can be selected; there is
no clinical evidence suggesting the superiority of
any particular antibiotic. (Level III evidence)
ì Mild bacterial conjunctivitis is usually self-limited
and typically resolves spontaneously without
specific treatment in immune competent adults.
(Level I evidence)
ORBITAL & PERIORBITAL CELLULITIS
ì Infection preceded by a break in the skin caused by S.

aureus, grp A strep, Moraxella catarrhalis,
pneumococcus, HiB
ì Both present with warm, tender, erythematous lid
swelling, mucoid discharge, conjunctival swelling
ì Orbital: proptosis, limited EOM, change in VA, ocular
pain, chemosis
ì Cephalexin or Cefadroxil; Nafcillin or Cefuroxime
Common Colds/ Rhinitis
ì organisms: rhinovirus*, parainfluenza virus,

RSV, coronavirus (children are reservoirs)
ì incubation of 2-5 days, resolved by 5-7 days
ì SSx: sore throat, sneezing, rhinorrhea, nasal
congestion, pharyngitis
ì Tx: supportive
ì complications are otitis media, sinusitis,
pneumonia
Sinusitis
ì organisms: S. pneumoniae, H. influenzae type b, M.
catarrhalis (acute), anaerobes (chronic)
ì anything that impairs mucociliary transport or
causes nasal obstruction predisposes to sinusitis
ì SSx: cold symptoms >7-10 days, purulent nasal
discharge, headache, tenderness over the sinuses
ì x-ray: air-fluid levels, opacification of the sinuses
ì Tx: antibiotics x 14 days (Amoxicillin)
ì complications are abscess, meningitis
Acute Pharyngitis
Viral GABHS
➢gradual onset ➢headache, vomiting, abdominal
➢moderate throat pain pain
➢symptoms of viral URTI ➢NO URTI symptoms
➢contacts with cold Sx ➢palatal petechiae & diffuse
➢vesicles & ulcers (HSV)

erythema of tonsils and pillars
➢sandpaper rash in inguinal &
➢conjunctivitis (adenovirus)
antecubital areas
Acute Pharyngitis
ì Dx for GABHS: rapid strep Ag test, throat culture

ì Tx for viral: symptomatic
ì Tx for GABHS: Penicillin or Amoxicillin x 10 days
ì complications of GABHS:
ì rheumatic fever
ì post-streptococcal glomerulonephritis
ì peritonsillar / retropharyngeal abscess
Case:
ì A 17 year-old boy was having fever and sore

throat for the past 7 days without any consultation
with a doctor. He was given Paracetamol 500 mg
prn by his mother for the fever. On the day of
consultation, he was still febrile and has
dysphagia. When asked to open his mouth, you
saw this:
Peritonsillar Abscess
ì Bacterial invasion through the capsule of the tonsils

ì Adolescents
ì Group A streptococcus and anaerobes
ì Fever, sore throat, dysphagia, trismus
ì PE: tonsils may be markedly red with swelling and uvula is
displaced
ì CT scan - ideally
ì Surgical drainage and antibiotics
Retropharyngeal abscess
ì 3-4 years old
ì Retropharyngeal space located between the

pharynx & the cervical vertebrae & extending
down into the superior mediastinum
ì Can result from penetrating trauma to the
oropharynx, dental infection, and vertebral
osteomyelitis
What are the manifestations?
ì Group A streptococcus, anaerobes,

Staphylococcus aureus
ì Fever, progressive dysphagia
ì PE: drooling, neck held in hyperextension, bulge

seen behind the posterior pharyngeal wall, neck
pain, muffled voice, respiratory distress
ì
Approach to RASHES
Case:
A 7 year-old male presents
at the ER with 1 day
history of pruritic rash
on the trunk and
extremities. PE: wheals
on trunk, arms, and
thighs, clear breath
sounds, non tender
abdomen with T=37.6 C
Hypersensitivity reaction
■ Spectrum: urticaria -->
erythema multiforme -->
anaphylaxis
■ Papules or wheals are
evanescent, raised,
erythematous lesions that
are pruritic
■ Bull’s eye lesions in EM
■ 2 or more systems involved
(gastrointestinal, circulatory,
skin, etc.): consider
anaphylaxis
Hypersensitivity Reaction
■ Identify and avoid/discontinue the offending agent.
■ Nuts, fish, seafood, preservatives, eggs, chocolates,
change in weather, plants, hormonal changes, dust
mites, insect bites
■ Diphenhydramine 1 mg/kg/dose IM (max. 50 mg)
■ Prednisolone 1-2 mg/kg/day for 3-5 days
■ Epinephrine 0.01 ml/kg/dose IM, anterolateral part of
the thigh (max. 0.5 ml)
■ H2 receptor antagonist
■ Fluids (crystalloid) at 20 cc/kg fast drip if in shock
Case:
ì 15 year-old male with
pruritic papules for 1
week most prominent
on the waist, inguinal
area, abdomen,
interdigital areas
ì Other younger siblings
have the same lesions
Scabies
■ Secondary impetigo is common
■ Treat the infection first with Cloxacillin (50-100
mg/kg/day q 6h 7 days) OR Cefalexin (50-100 mg/
kg/day q 6h 7 days)
■ Permethrin 5% applied in the body for 12 hours for
5 days (cure rate 98%)
■ Lindane lotion 1 6-hr application on the body for 5
days
■ Antihistamine for pruritus (Cetirizine, Loratadine)
Candidiasis
■ Neonates & infants: white plaques on a red base

(thrush) in the buccal mucosa; intertriginous areas
(beefy erythema with elevated margins and satellite
red plaques) like inframammary, axillary, neck &
inguinal body folds
■ Adolescent females: whitish plaques on red mucous
membrane of vulvovaginal areas with cheesy vaginal
discharge
■ Oral thrush: oral Nystatin 4x/day for 5 days
■ Skin: Ketoconazole, Miconazole, Clotrimazole
Oral thrush
Case:
ì A 14 month-old male
presents with fever and
irritability for 3 days.
PE: tender bullae on the
trunk and thighs with
moist, shiny surface that
tend to separate
ì Impression?
Staphylococcal Scalded Skin Syndrome
■ Spectrum: from bullous impetigo to generalized

involvement
■ Skin rapidly becomes tender with crusting around the
mouth, eyes & neck
■ Mild rubbing of the skin results in epidermal separation

leaving a shiny, moist, red surface---(+)Nikolsky sign
■ Oxacillin 100-200 mg/kg/day q 6 hrs IV; fluid and

electrolyte correction
Case:
ì A 4 year-old girl
presents with honey-
crusted lesions on the
face with low-grade
fever.
ì No other systemic
manifestations
Impetigo
■ Erosions covered by moist, honey-colored crusts in face,
nares, extremities, trunk
■ Bullous – lesions with central moist crust and an outer

zone of translucent blister
■ Staph.aureus, group A streptococcus
■ Cefalexin 50-100 mg/kg/day q 6 hrs 7 days OR

Cloxacillin 50-100 mg/kg/day q 6 hrs 7 days
Case:
ì A 9 year-old girl with

fever, erythematous legs
with ill-defined border,
warm & tender to touch.
It started as an insect bite
and after vigorous
scratching, it developed
into a swollen, tender
plaque; patient walks
with a limp
ì Impression?
Cellulitis
ì Strep, Staph, H.influenzae b

ì Penicillin 600,000 – 1.2 M units/kg/day q 6 hours IV
for streptococci
ì Oxacillin 100-200 mg/kg/day q 6 hours IV
ì Ampicillin (100-200 mg/kg/day) + Chloramphenicol
(50-100 mg/kg/day) for H.influenzae
ì Cefuroxime (20-30 mg/kg/day BID po q 12 hrs),
Ceftriaxone, Cefotaxime
What type of rash is this?
Measles
ì prodrome of high-grade fever with conjunctivitis,
catarrh (3-5 days)
ì Height of fever: maculopapular rash appears on the
hairline or face and spreads cephalocaudally
ì Branny desquamation
ì Supportive
ì Vitamin A
➢ Less than 6 months old: 50,000 units po
➢ 6-12 months old: 100,000 units po
➢ More than 12 months old: 200,000 units po
Vitamin A
Management
■ Postexposure prophylaxis: measles Ig for prevention
& attenuation of measles within 6 days of exposure
(0.25 mL/kg max.of 15 mL) intramuscularly
■ Measles vaccine can be given for susceptible

children > 1 yr old within 72 hours
■ Pregnant & immunocompromised persons should

receive Ig but not active vaccine
Identify!
Rubella
■ Most characteristic sign: retroauricular, posterior
cervical & postoccipital lymphadenopathy (begins
24 hrs before the rash and remains for 1 week)
■ Maculopapular rash beginning on the face, trunk and
extremities
■ Active vaccine can theoretically prevent illness if
given within 72 hours of exposure
■ Use of immune globulin for post exposure
prophylaxis is not routine but may be considered if
termination of pregnancy is not an option (0.55 mL/
kg IM)
Temporal relation of rash to fever
Roseola (HHV-6)
■ more than 95% occur in < 3 yrs old with peak at
6-15 months old
■ HHV-6 can suppress all cellular lineages within the
bone marrow
■ High grade fever for 3-5 days but most behave
normally despite this
■ Rash appears within 12-24 hours of fever resolution:
discrete, small pink lesions on the trunk then spreads
to the neck, face & extremities that fades in 1-3 days
Identify the lesions!
Varicella
• Rash start from the trunk then spread to other parts
of the body
• Rapid progression; all stages are present
simultaneously; pruritic
• Macule/papule à vesicle à crust
■ Increased risk of severity: Acyclovir 30 mg/kg/day
IV q8 hrs or 80 mg/kg/day PO QID for 5 days
(max.dose 3200 mg/day)
■ Active vaccine within 72 hours of exposure
■ VZIG 1 dose up to 96 hours after exposure
Herpes Zoster
ì same rash as varicella
with severe pain &
tenderness along the
posterior nerve roots
ì Acyclovir
ì antihistamine
Case:
ì A 2 year-old female
presents with tender
vesicles on the
palms, soles, and oral
mucosa, low-grade
fever, and poor
appetite for the past
48 hours.
ì Impression?
Hand, foot, and mouth disease
ì Coxsackievirus A16
ì Ulcerative intraoral lesions seen esp. in the
tongue & buccal mucosa, hands, and feet
ì Clear by absorption of fluid in about 1 wk
Case
ì A 3 year-old male
presents with fever,
anorexia, irritability &
vomiting.
ì PE: Small vesicles &
ulcers with a red ring
found mainly on the
anterior tonsillar pillars;
may be seen on the soft
palate, uvula &
pharyngeal wall
ì Impression?
Where is the rash most obvious?
Erythema Infectiosum
ì Prodrome: low grade fever, headache, URTI
ì Hallmark: rashà erythematous facial
flushing (“slapped-cheek”) and spreads
rapidly to the trunk & proximal extremities as
a diffuse macular erythema
ì Palms and soles are spared
ì Rash resolves without desquamation
Check the predilection of ulcers
Herpetic gingivostomatitis
ì Initially with irritability, sore throat, anorexia
ì Thin walled vesicles on a red base usually at the

mucocutaneous junction & gum line that heal without
scars within 7-10 days
ì Oral acyclovir 15 mg/kg 5x/day for 7 days started within

72 hours of onset of lesions has benefits in children with
HGS
Case:
ì An 18 month-old girl
had 2 days high-grade
fever, chills, irritability,
and vomiting. Red rashes
were noted all over the
body that spread quickly
on the 2nd day. PE:
lethargic, tachycardic,
tachypneic, diffuse rales
on both lung fields,
purpuric & ecchymotic
lesions all over the body
ì Impression?
Meningococcemia
ì Neisseria meningitidis with 13 recognized serotypes:
A,B,C, W135, Y
ì Mode pf transmission: person to person through infected
droplets
ì Period of communicability: until 24 hours after initiating
effective treatment
ì Abrupt onset of fever, chills, headache, vomiting
ì Rapid worsening of symptoms within hours
ì Initially morbilliform rash --> petechial then purpuric
within hours
Diagnosis and Management:
■ Culture of blood, CSF, petechial scrapings, sputum
■ Penicillin G 200,000-300,000 U/kg/day IV in 4 - 6

divided doses for at least 7 days and until patient is
afebrile for 72 hours
■ Chloramphenicol (if allergic to Pen) 50-100 mg/kg/day

IV q6h; Ceftriaxone 50 mg/kg IV q12h or Cefotaxime 50
mg/kg IV q6h
Post-exposure prophylaxis:
ì Household, school. or day care contacts should
receive antibiotic prophylaxis within 24 hours of dx
ì Prophylaxis NOT routinely recommended for
medical personnel except those with intimate
exposure
ì Rifampicin <1 mo: 5 mg/kg PO q12h for 2 days; >1
mo: 10 mg/kg PO q12h for 3 days
ì Ciprofloxacin (adults only): 500 mg PO single dose
ì Ceftriaxone: <15 yrs: 125 mg IM single dose; >15
yrs: 250 mg IM single dose
ì
DIARRHEA
Fluid management for diarrhea
ì ICF – 2/3
ì ECF – 1/3
> ¼ - plasma volume
> ¾ - interstitial fluid
➢ Infant has a relatively larger interstitial volume

ì A larger surface area in relation to the height and the
weight compared with adults.
Clinical assessment of changes 
in fluid compartments:
ì Plasma compartment – fixed compartment with

continuous circulation composed of forward or
afterload (pulse & BP) & backward or preload
circulation (venous pressure)
ì Interstitial compartment – edema, skin elasticity,
dryness of mucous membranes, anterior fontanel
ì Intracellular compartment – indirect assessment;
headache, confusion, seizures
Maintenance Fluids:
ì Body weight method for calculating maintenance fluid
volume (Holliday-Segar method)
ì weight (kg) daily requirement
3- 10 100 ml/kg
10-20 1000 ml + 50 ml/kg for each kg >10
>20 1500 ml + 20 ml/kg for each kg >20
Maintenance electrolytes:
1. Sodium: 2-3 mEq/kg/24 hrs
2. Potassium: 1-2 mEq/kg/24 hrs
ì Average composition of diarrhea:

Sodium – 55 mEq/L
Potassium – 25 mEq/L
Bicarbonate – 15 mEq/L
Composition of IV fluids:
Fluid Na K Cl HC03 Dextrose

0.9 NSS 154 ---- 154 --- ---
D5 LRS 130 4 109 28 5
D5 0.3 NaCl 51 --- 51 --- 5
0.45 NaCl 77 --- 77 --- ---
D5 IMB 25 20 22 23 5
D5 NM 40 13 40 16 5
D5 NR 140 5 98 27 5
Example:
Calculate the total fluid volume required
by a 10 kg child:
First 10 kg = 100 ml/ kg

= 1,000 ml over 24 hours
= 40 cc/ hr
Caloric Requirements:
ì Recall that D5 means 5 grams in 100 ml
ì Therefore 50 grams in 1000 ml
ì How much glucose does D10 contain?
10 grams in 100 ml
100 grams in 1,000 ml
Case:
Calculate the fluid and electrolytes

and glucose requirements of a 1-
year old boy who weighs 10 kg.
Answer:
ì Water required 1,000 ml
ì Na required 3 x 10 = 30 mEq
ì K required 2 x 10 = 20 mEq
ì glucose required 1 g/kg = 10 g
What fluid contains approximately the above

electrolytes?
Composition of IV fluids:
Fluid Na K Cl HC03 Dextrose

0.9 NSS 154 ---- 154 --- ---
D5 LRS 130 4 109 28 5
D5 0.3 NaCl 51 --- 51 --- 5
0.45 NaCl 77 --- 77 --- ---
D5 IMB 25 20 22 23 5
D5 NM 40 13 40 16 5
D5 NR 140 5 98 27 5
WHO ASSESSMENT CHART
Clinical A B C
Parameter No Some Severe Dehydration
Gen. Condition well, alert restless, irritable lethargic, unconscious
Eyes normal sunken sunken
Thirst* none drinks eagerly drinks poorly

Skin retraction* quick slow (< 2 sec) very slow (> 2 sec)
Wt loss (%) <5% 5-10% 11% or more

Fluid deficit (ml/kg) < 50 50-100 > 100
* Major sign of dehydration Only 2 parameters needed in category

Recommendations: Unified Fluid & Electrolyte Management, 2000
Clinical Parameter Mild Dehydration Moderate Dehydration
Mental status normal irritable

Thirst slightly increased moderately increased
Anterior fontanel normal sunken
Eyes normal sunken
Tears present reduced to absent
Mucous membranes slightly dry dry
Respiration normal deep/rapid
Skin retraction immediate slowly; < 2 sec
Radial pulse, HR normal rapid, weak
Extremities warm slightly cool
Urine flow slightly reduced reduced; <1ml/kg/hr
Capillary refill normal < 2 sec
Estimated fluid deficit 3-5% 6-9%
Recommendations: Unified Fluid & Electrolyte Management, 2000 
Severe Dehydration
ì normal to lethargic to comatose
ì very thirsty or too weak to drink
ì very sunken eyes, anterior fontanel; tears absent;
parched mucous membranes
ì skin retraction > 2 sec
ì cool, mottled, acrocyanotic; capillary refill > 2 sec
ì Inc. or dec.HR, (N) or dec. BP, rapid, feeble to
imperceptible pulses, deep/rapid respiration
ì severe oliguria to anuria (< 1 ml/kg/hr)
ì estimated fluid deficit: > 10% (> 100 ml/kg)
Joint WHO/UNICEF Statement 
(August 2004)
■ Efficacy of glucose-based ORS for

treatment of children w/ acute non-cholera
diarrhea is improved by reducing sodium to
50-75 mEq/L, glucose to 75-90 mmol/L and
total osmolarity to 210- 268 mOsm/L
Composition of Standard ORS:
Standard WHO-ORS Reduced Osm ORS
(mEq or mmol/L) (mEq or mmol/L)
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245
Composition of Various ORS:
Solution Osm
(mOsm/L)
Na
(mmol/L)
K
(mmol/L)
Cl
(mmol/L)
Base
(mmol/L)
Oresol (Old) 311 90 20 80 10 (citrate)

Cholyte 247 50 20 40 10 (citrate)
Glucolyte 60 255 60 20 50 10 (citrate)
Glucolyte Plus 245 75 20 65 10(citrate)
Hydrite 245 75 20 65 30 (HCO3)
Pedialyte 45 250 45 20 35 30 (citrate)
Pedialyte 90 346 90 20 80 30 (citrate)
Reduced Osm 245 75 20 65 10(citrate)
Composition of Commonly Used Fluids:
Fluid Na (mmol/L) K (mmol/L) Osmolality (mOsm/
kg H2O)
Commercial soups 114 - 251 2.2 - 17 290 - 507
Apple juice 0.1 - 3.5 24 - 30 654 - 734
Orange juice 0.6 - 2.5 41 - 65 290 - 507
Grape juice 1.3 - 2.8 28 – 32 1167 - 1190
Pepsi/Coke 1.3 - 1.7 0.1 591 - 601
Seven-up 5.0 - 5.5 1.0 - 2.0 523 - 548
Coconut 0 - 5.4 32.6 - 53.5 255 - 333
Gatorade 14.6 3.5 58g (S + G/Fr)
Powerade 8 4 80g (S + maltdex)
Pocari Sweat 21 5 641
WHO recommendation 50-75 20 210-268
Case:
Calculate the fluids, electrolytes, and

glucose requirements of a 20 kg child.
Answer:
ì Total fluid = 1, 500 ml

ì Na = 60 meq
ì K = 40 meq
ì Glucose = 100 grams
ì D5 NM fits the requirements of a 20 kg child

ì But it contains only 13 meq of potassium
ì You can add at most 40 meq of potassium to a 1,000 ml
bag if child is totally NPO and has a peripheral line
11 kg child with severe dehydration
ì Hypotensive shock
1. FLUID RESUSCITATION: Correct shock: plain NSS or
plain LRS 20 ml/kg as bolus
( repeat as needed )
2. After fluid resuscitation, compute DEFICIT:

ì Severe dehydration (15%)
Recommendations: Unified Fluid &  
Electrolyte Management, 2000 
Severe Dehydration
ì normal to lethargic to comatose
ì very thirsty or too weak to drink
ì very sunken eyes, anterior fontanel; tears absent;
parched mucous membranes
ì skin retraction >2 sec
ì cool, mottled, acrocyanotic; capillary refill > 2 sec
ì Inc. or dec.HR, (N) or dec. BP, rapid, feeble to
imperceptible pulses, deep/rapid respiration
ì severe oliguria to anuria (< 1 ml/kg/hr)
ì estimated fluid deficit: > 10% (> 100 ml/kg)
Dehydration
ì Percent of dehydration is equivalent to the % body

weight loss
ì In the example: 15% dehydration
MAINTENANCE PLUS  
DEFICIT IN 24 HOURS:
ì Maintenance is 1,050 ml; Deficit is 1,650 ml (post-bolus)
ì 1st 8 hrs: give 1/3 of M+ 1/2D
ì 2nd 16 hrs: give 2/3 of M+ 1/2D
ì 1st 8 hrs: 350 + 825 ml = 1,175 / 8 =
147 cc/hr
ì 2nd 16 hrs: 700 + 825 ml = 1,526 / 16 =
95 cc/hr
11 kg child with mild dehydration
1. Compute for maintenance fluids first.

➢ 10 kgs with excess of 1 kg = 1000 ml + 50 ml =
1,050 ml
2. Add deficit: for mild: add 30 ml/kg
➢ 1,050 ml + 330 ml = 1,380 ml in 24 hrs
➢ Rate: 57 cc/hr
➢ this is also true if you opt to compute it as 1,050 x
30% (315) = 1,365 ml to run in 57 cc/hr
WHO ASSESSMENT CHART
Clinical A B C
Parameter No Some Severe Dehydration
Gen. Condition well, alert restless, irritable lethargic, unconscious
Eyes normal sunken sunken
Thirst* none drinks eagerly drinks poorly

Skin retraction* quick slow (< 2 sec) very slow (> 2 sec)
Wt loss (%) <5 5-10 >10

Fluid deficit (ml/kg) < 50 50-100 > 100
* Major sign of dehydration Only 2 parameters needed in category

Another example:
ì 18 kg child with mild dehydration at 30%
ì Compute for maintenance fluids.
ì Add deficit.
ì What is the rate?

Answers:
ì Maintenance rate of 1,400 ml in 24 hrs

ì Deficit of 540 ml (at 30 ml/kg)
ì M + D = 1,940 ml in 24 hrs
ì Rate = 80 ml/hr
** if you opt to do it as 1,400 x 30% (420) = 1,820
ml/24 = 76 cc/hour
ì
Fever
Case:
ì An 8 year-old girl was brought to the ER because
of 5 days moderate to high grade intermittent fever
with headache and abdominal pain. Worsening of
symptoms noted with body malaise and anorexia.
PE: weak-looking, CR 106/min, RR 25/min, T
39°C and BP=80/60; with clear breath sounds,
flushed skin, fair pulses.
ì Impression ?
Dengue Fever
• Transient, macular, generalized rash that blanches

under pressure seen during the 1st 24-48 hrs of fever
• 1-2 days after defervescence, a generalized

maculopapular rash appears which spares the palms
& soles & disappears in 1-5 days with desquamation
(Hermann’s rash)
Dengue fever rash
Helpful laboratory tests:
ì Dengue blot IgM : samples should be collected not

earlier than 5 days nor later than 6 wks after onset
ì Dengue NS-1 Ag : Day 1 until Day 3 of the illness
ì CBC: hematocrit and platelet, PT, PTT

Timing of diagnostic tests of dengue fever
ì At the end of the acute phase of infection:
➢ Serology is the method of choice
➢ IgM detected in 80% of patients by day 5 and 99%

by day 10
➢ IgM peaks in 2 wks after onset of symptoms &
decline in 2-3 months
Timing of diagnostic tests in dengue fever
ì Primary infection: anti-dengue serum IgG is

detectable in low titers at the end of 1st wk of
illness --> increases slowly after --> IgG detectable
after several months
ì Secondary infection: IgG detected even in the

acute phase & persists from 10 months to life
Dengue Fever Guidelines 2012:
ì DENGUE WITHOUT WARNING SIGNS:
➢ Fever and 2 of the following criteria:
1. Nausea, vomiting
2. Rashes
3. Aches / pains
4. Tourniquet test (+)
5. Leukopenia
ì DENGUE WITH WARNING SIGNS:
1. Abdominal pain with tenderness
2. Persistent vomiting
3. Clinical fluid accumulation
4. Mucosal bleed
5. Lethargy, restlessness
6. Liver enlargement >2 cms
7. Increase in Hct with concurrent rapid decrease in
platelet count
ì SEVERE DENGUE:
1. Severe plasma leakage (leading to):
a) Shock (DSS)
b) Fluid accumulation with respiratory distress
2. Severe bleeding
* As evaluated by clinician
3. Severe organ involvement

a) Liver: AST or ALT >/=1000
b) CNS: impaired consciousness
c) Heart and other organs
Management of dengue  
without warning signs:
ì Encourage oral fluids.

ì If not tolerated, start IVF therapy of NSS or LRS
with or without dextrose at maintenance rate.
a) 4 mL/kg/h for first 10 kg body weight
b) + 2 mL/kg/h for next 10 kg body weight
c) + 1 mL/kg/h for subsequent kg body weight

With compensated shock
ì Start IVF resuscitation with isotonic crystalloid

solutions at 5-10 ml/kg/hr over 1 hr
ì Re-assess condition: vital signs, CRT, hct, UO
ì (+)improvement: reduce IVF to 5-7 ml/kg/hr to 1-2
hrs, then 3-5 ml/kg/hr for 2-4 hrs, and then further
depending on hemodynamic status which can be
maintained for 24-48 hrs.
With decompensated / hypotensive shock
ì Give crystalloid at 20 ml/kg as a bolus over 15 minutes
ì If (+) improvement, continue crystalloid at 5-7 ml/kg/

hr at 1-2 hrs, then 3-5 ml/kg/hr at 2-4 hrs, then 2-3
ml/kg/hr or less which can be maintained at 24-48 hrs
ì If shock persists, get Hct; if low, cross-match and
transfuse
With decompensated / 
hypotensive shock
ì If Hct is high compared to baseline, use colloid

solution at 10-20 ml/kg as a 2nd bolus for 30 mins-1
hr
ì After the 2nd bolus, re-assess the pt.
ì If (+) improvement, reduce the rate to 7-10 ml/kg/hr

for 1-2 hrs, then change back to crystalloid and
reduce the rate of infusion as mentioned above
Interpreting Hematocrit Changes
1. a rising or persistently high hct with unstable vital
signs (esp. narrowing of the pulse pressure)
indicates active plasma leakage and the need for a
further bolus of fluid replacement
1. a rising or persistently high hct with stable

hemodynamic status and adequate urine output
does not require extra IVF; continue to monitor
closely and it is likely that the hct will start to fall
within the next 24 hours as the plasma leakage
stops
Interpreting Hematocrit Changes
3. A decrease in hct with unstable vital signs
(particularly narrowing of the pulse pressure,
tachycardia, metabolic acidosis, poor urine output)
indicates major hemorrhage and the need for urgent
blood transfusion
4. A decrease in hct with stable hemodynamic status
and adequate urine output indicates hemodilution
and/or reabsorption of extravasated fluids, IVF must
be discontinued immediately to avoid pulmonary
edema
Management of dengue fever  
with warning signs
➢ Obtain a reference hematocrit before fluid therapy.
➢ Give only isotonic solutions such as 0.9% saline,

plain LRS, or Hartmann’s solution. Start with 5-7 ml/
kg/hour for 1-2 hours, then reduce to 3-5 ml/kg/hr
for 2-4 hours, and then reduce to 2-3 ml/kg/hr or
less according to the clinical response.
Management of DF  
with warning signs
■ Reassess the clinical status and repeat the hematocrit.
If the hematocrit remains the same or rises only
minimally, continue with the same rate (2-3 ml/kg/hr)
for another 2-4 hours.
■ If the vital signs are worsening and Hct is rising rapidly,

increase the rate to 5-10 ml/kg/hour for 1-2 hours.
■ Reassess the clinical status, repeat the Hct, and review

fluid infusion rates accordingly.
Management of DF  
with warning signs
ì Give the minimum IVF volume required to
maintain good perfusion & UO of about 0.5 ml/kg/
hr.
ì IVF are usually needed for 24-48 hrs.
ì Reduce IVF gradually when the rate of plasma
leakage decreases towards the end of the critical
phase indicated by:
a. UO and/or oral fluid intake that is/are adequate
b. Hct decreasing below the baseline value in a stable
patient.
Case:
ì A 7 year-old female presents with 9 days
intermittent fever, abdominal pain, nausea,
malaise, anorexia. PE: BP 100/60, CR=90/
min, RR=20/min, T=38.5 C, non-hyperemic
pharyngeal wall, periumbilical tenderness,
soft abdomen, with loose stool on
consultation.
ì Impression?
Enteric Fever / Typhoid Fever
ì High-grade fever, generalized myalgia, abdominal

pain, hepatosplenomegaly, anorexia, diarrhea /
constipation
ì If no complications occur, the symptoms & physical
findings gradually resolve wihtin 2-4 wks
ì (+)blood culture in 40-60% early in the disease; (+)
stool & urine culture after the 1st week
ì Mainstay of diagnosis remains clinical.
ì Typhidot --- has cross-reactions
Typhoid Fever
ì Intestinal hemorrhage (<1%) & perforation (0.5-1%),

typhoid ileitis, toxic myocarditis
ì Antibiotic tx influenced by the prevalence of antimicrobial
resistance in the area
ì Uncomplicated & fully sensitive: Chloramphenicol 50-75
mg/kg/day Q 6h for 14-21 days
ì Uncomplicated multidrug resistant: Fluoroquinolone 15
mg/kg/day for 5-7 days or Cefixime 15-20 mg/kg/day 7-14
days
Typhoid Fever
■ Uncomplicated quinolone resistant: Azithromycin 8-10 mg/
kg/day for 7 days or Ceftriaxone 60-75 mg/kg/day for 10-14
days
■ For severe typhoid fever:

1. Sensitive: Ampicillin 100 mg/kg-day for 14 days or
Ceftriaxone 60-75 mg/kg/day for 10-14 days
2. Multidrug resistant: Fluoroquinolone 15 mg/kg/day for
10-14 days
3. Quinolone resistant: Ceftriaxone 60-75 mg/kg/day for 10-14
days
***Typhoid fever vaccine (oral vs intramuscular)
Case:
ì A 20-day old male presents with his mother to the ED for a
rectal temperature of 38°C. Maternal and birth history were
unremarkable. He is feeding 3 ozs every 4 hours and has
adequate UO. PE revealed flat anterior fontanel and a well
hydrated baby. When you explain to the mother that he will
need to undergo the full sepsis workup, including lumbar
puncture, she asks if all the testing is necessary.
ì What is the probability, since her baby looks well, that he has a
SBI?
ì Can other infections besides bacterial ones cause a fever and
does the baby need testing for these?
ì Will the baby need to be admitted to the hospital?
Clinical Pathway for Evaluation of Febrile Young Infants
(<29 days old):
ì Age < 29 days old

ì Ill
appeari
ì Well
ng appearing
ì > ABCs, glucose ì > Full sepsis workup (Class I)

ì > Consider HSV testing if <21 days
ì >Admit; full sepsis workup if stable (Class II)
ì > IV Ampicillin, Cefotaxime ì > Admit (Class II)
ì > Consider Vancomycin in patients ì > IV Ampicillin, Cefotaxime (add
Vancomycin if CSF pleocytosis or if
with CSF pleocytosis with gm+ on CSF Gram stain)
ì > IV Acyclovir ì > Consult infectious disease
specialist if gm-negative organisms
ì >Consider prostaglandin if cardiac on CSF Gram stain
disease suspected ì > IV Acyclovir if HSV testing
performed (Class II)
Risk management pitfalls:
■ “The neonate had a fever but he was so well-

appearing, I couldn’t justify doing the full sepsis
workup.”
➢ The febrile neonate is at high risk for an SBI; nearly 1

in 5 febrile neonates will have an SBI.
➢ The rate of infection is too high to defer testing in this
age group.
ì “The mother denied any history of HSV so her baby
most probably does not have neonatal HSV.”
➢ Consider testing for HSV in <21 days old even in the
absence of vesicles or maternal history of HSV
infection (Long SS, Pool TE et al 2011 case series,
Kimberlin DW, Lin CY et al 2001, prospective)
➢ Highest risk for transmission of neonatal HSV is to
babies born to mother who have a primary infection
at the time of delivery (Brown et al 2003) – rate of
30.8%
On neonatal HSV infection:
ì Incidence of neonatal HSV is 9.6 per 100,000 births or about
1,500 cases per year
ì Aside from vesicles (63% of patients), other symptoms are

lethargy, fever, seizure, and coagulopathy
ì Most cost-effective strategy for febrile neonates with CSF

pleocytosis: test with CSF HSV PCR and empirical treatment
with IV Acyclovir à delay in acyclovir therapy is associated
with worse outcomes (Shah SS, Aronson PL, Mohamad Z et
al 2011 – retrospective 1086 patients)
ì “The urinalysis, CBC, and CSF cell count were all normal so
he met the low-risk criteria. I felt comfortable sending him
home and just follow up the culture results with his doctor.”
➢ The low-risk criteria do not perform well as in neonates as
shown by retrospective studies that showed a lower NPV of
the criteria. (Schwartz, S., Raveh, D. et al 2009; Baker MD,
Bell LM 1999)
➢ Potential to falsely classify 1 in 10 febrile neonates as low
risk
➢ Therefore, neonates should be admitted on empiric
antibiotics pending culture results.
Most common low-risk criteria for management of febrile
young infants:
Criterion Rochester criteria Philadelphia criteria Boston criteria (28-89

(0-60 days old) (29-56 days old) days old)
History and PE ➢ Full-term ➢ Well appearing ➢ No antibiotics

➢ Normal prenatal ➢ No focal infection within preceding
and postnatal 48 hours
histories ➢ No immuniza-
➢ No postnatal tions within preceding
antibiotics 48 hrs
➢ Well appearing ➢ Well appearing
➢ No focal infection ➢ No focal infection
Most common low-risk criteria for  
management of febrile young infants:
Criterion Rochester criteria Philadelphia criteria Boston criteria (28-89
(0-60 days old) (29-56 days old) days old)
Laboratory ➢ WBC 5000-15,000/ ➢ WBC <15,000/ ➢ WBC <20,000/

parameters (defines mm3 mm3 mm3
low risk) ➢ Absolute band ➢ Band:total neu- ➢ UA <10 WBC/hpf
count <1500/mm3 trophil ratio <0.2 ➢ CSF <10 WBC/mm3
➢ UA equal or less ➢ UA equal or <10 ➢ Chest X ray: no
than 10 WBC/hpf WBC/hpf infiltrates
➢ Stool equal or less ➢ CSF: <8 WBC/mm3
than 5 WBC/hpf ➢ CSF: Gram stain
negative
➢ Normal chest X ray
➢ Normal stool
Most common low-risk criteria for
management of febrile young infants:
Criterion Rochester criteria (0-60 Philadelphia criteria Boston criteria (28-89

days old) (29-56 days old) days old)
Treatment for high-risk Hospitalize + empiric Hospitalize + empiric Hospitalize + empiric

patients antibiotics antibiotics antibiotics
Treatment for low-risk ➢ Home ➢ Home, if patients ➢ Home, if caregiver
patients ➢ 24-hr follow-up lives within 30 available by
required minutes of the telephone
➢ No empiric hospital ➢ Empiric IM
antibiotics ➢ 24-hr follow-up Ceftriaxone 50 mg/
required kg
➢ No empiric ➢ Return for 24-hr
antibiotics follow-up for 2nd
dose of drug
Performance of low- NPV: 98.9% NPV: 100% NPV: 94.6%

risk criteria
Case:
■ You are looking at a 40 day-old febrile baby who
was very irritable on examination. The laboratory
tests were normal so he met the low-risk criteria
and you sent him home.
■ All the low-risk criteria require the baby to be well

appearing on PE. Even with normal lab studies, if
the infant is ill appearing or has a focal infection,
the baby should be admitted on empiric antibiotics.
Clinical pathway for evaluation of  
febrile young infants (29-56 days old):
Age 29-56 days old
Ill appearing
Well appearing
➢ Admit; full sepsis

work-up if stable
➢ IV Cefotaxime No bronchiolitis Bronchiolitis
➢ Consider
Vancomycin in
patients with CSF
pleocytosis
➢ Consider Acyclovir
Full sepsis workup ➢ UA and urine culture

(Class I) (Class I)
➢ Strongly consider CBC
and blood culture (Class
Low risk per II)
High risk per criteria: ➢ Strongly consider CSF if
criteria:
>Admit (Class I) high WBC count (Class III)
➢ Discharge
>IV Cefotaxime
home if 24 hr
(+Vancomycin if CSF
follow-up
pleocytosis or gm+ on
arranged
CSF Gram stain) Admit if high risk per criteria
➢ No empiric
>Consult ID specialist if or in respiratory distress
antibiotics
Gm(-) on CSF Gm stain (Class III)
(Class I)
Workup up for alternative 
sources of infection in <56 days old:
■ Does the febrile infant aged less than 56 days with

bronchiolitis require the full sepsis workup?
■ Can the fever be attributed to a viral source?
■ Levine et al (2004) prospective study of 1,248 febrile

patients: 269 were (+) for RSV
■ Results: RSV (-) patients had an SBI rate of 12.5%; RSV (+)
patients had an SBI rate of 7% (lower rate of SBI in febrile
young infants with RSV was significant and all infections
were UTI)
Workup up for alternative 
sources of infection in <56 days old:
ì Febrile young infants with RSV or

bronchiolitis are still at risk for serious
bacterial infection, especially UTI, and they
should be thoroughly evaluated for sources
of infection.
Case:
■ “A 70-day old baby is highly febrile but is well appearing
and no other symptoms were elicited. He is beyond the
upper age limit of both the Philadelphia and Rochester
criteria. I did not have to do any testing.”
➢ The Boston criteria extend the upper age limit for doing the
full sepsis workup through 89 days old.
➢ Infants of this age group does not become low risk for SBI.
➢ Incidence of UTI is still high (Hsiao AL, Chen I, Baker MD

2006 prospective study)
Workup of febrile infants  
57-89 days old:
■ Urinalysis and urine culture should be performed

(at minimum)
■ Consider CBC and blood culture
■ If infant is ill-appearing or has a high serum WBC,

CSF studies should be ordered.
febrile young infants (57-89 days old): 
Age 57-89 days old
Ill appearing
Well appearing
➢ Admit; full sepsis

work-up if stable
➢ IV Cefotaxime No bronchiolitis Bronchiolitis
➢ Consider
Vancomycin in
patients with CSF
pleocytosis
➢ UA and urine culture (Class I)

UA and urine culture (Class
➢ Consider CBC and blood culture (Class
II)
II)
➢ Consider CSF if high WBC count (Class
III)
High risk per criteria:

➢ Admit (Class II) Low risk per criteria:
➢ IV Cefotaxime ➢ Discharge home
➢ Add Vancomycin if CSF pleocytosis or gm+ ➢ No empiric antibiotics
on CSF Gram stain
➢ Consult ID specialist if gm(-) on CSF Gram
stain
Antibiotic therapy for neonates and  
high-risk febrile infants 29-60 days old:
■ Susceptible to GBS, E.coli, S. pneumoniae, S. aureus, L.

monocytogenes
■ Well-appearing febrile neonate: IV Ampicillin 200 mg/kg/day

every 6 hours and IV Cefotaxime 150 mg/kg/day every 8
hours
■ Well-appearing febrile infant >28 days: Cefotaxime or

Ceftriaxone monotherapy is sufficient
Antibiotic therapy for neonates and  
high-risk febrile infants 29-60 days old:
■ Ill-appearing febrile infant or infants with CSF

pleocytosis or (+) Gram stain: addition of
Vancomycin to the aforementioned antibiotics (15
mg/kg/dose for 0-89 day-old infants)
■ If (+) CSF Gram stain of gram-negative rods:

consult ID specialist and cover with broad-
spectrum antibiotics (Imipenem or Amikacin)
Do we adjust the CSF WBC 
count for CSF RBC?
■ 2010 cross-sectional study by Kestenbaum et al provided the
best evidence for CSF norms in the febrile young infant
➢ Low-risk criteria used <8 WBC/mm3 to define normal CSF
➢ For neonates: cutoff of <19 WBC/mm3 is reasonable
■ Retrospective study by Greenberg RG, Smith PB, Cotton CM et al

(2008) : adjustment of CSF WBCs for CSF RBCs only improved
specificity slightly while decreasing sensitivity
*** Adjustment for RBCs should not be performed in the high-risk

febrile young infant
Urinalysis in 57-89 days old?
■ The well-appearing febrile infant should undergo
testing with urinalysis and urine culture.
*** Hsiao Al, Chen L, Baker MD (2006 prospective
study)
Risk management pitfall:
■ ”I checked a bag urine sample in my 70 day-old patient. The
urinalysis was negative so I did not do a catheterization for
urine culture.”
➢ In infants <90 days, the urinalysis is not as sensitive as in

older infants and children (McGillivray et al, 2005 cross
sectional study; Schroeder AR et al 2005 prospective study)
à 77% sensitivity from bagged specimens
➢ AAP 2011 UTI CPG recommends that catheterized or

suprapubic aspiration be used to obtain both urinalysis and
culture in febrile children age 2-24 months.
How about imaging studies?
■ Routine chest X ray in the febrile young infant is NOT
recommended unless signs and symptoms of pneumonia
are present.
➢ None of the 361 febrile patients <90 days old without

respiratory signs or symptoms had an abnormal chest X ray
(Bramson et al 1993 prospective study)
➢ Only 2 of 148 asymptomatic infants had an abnormal chest

X ray (Crain et al 1991 prospective study)
Fever without a source 
in 3-36 months old:
■ Fever 39°C or higher is the threshold above which

evaluation for a source of occult infection (like UTI) may be
warranted (Baraff et al 1993)
■ Immunization to prevent Hib and pneumococcal disease

has dramatically lowered the incidence of occult
bacteremia from 5 to <1% (Bressan et al 2012, Benito-
Fernandez et al 2010, Craig et al 2010, Waddle et al 2009,
Wilkinson et al 2009, Carstairs et al 2007, Herz et al 2006,
Sard et al 2006, Stoll et al 2004)
Sources of infection:
■ Serious bacterial infections that occur in children 3-36
months old include meningitis, pneumonia, and focal skin
infections.
■ Subtle sources of infection (like pneumonia or

osteomyelitis) can sometimes be identified with a careful
history and PE.
■ Relatively common occult sources of infection include

pneumonia and UTI with occasional cases of bacteremia.
Approach to ill-appearing child:
■ Full evaluation for serious infection with cultures of blood,
urine, and CSF if meningitis is suspected
■ Chest X ray in patients with tachypnea or respiratory

distress and is also warranted for those with WBC equal or
>20,000 even in the absence of PE findings of pneumonia
■ Admit and start IV antibiotics targeting the likely pathogens

(S. pneumoniae, S. aureus, N. meningitidis, Hib)
Approach to well-appearing child:
ì Workup of INCOMPLETELY IMMUNIZED:
ì Risk of occult bacteremia is as high as 5%
➢ CBC
➢ Blood culture (for those with WBC of equal or >15,000)
➢ Urinalysis and urine culture by bladder catheterization or

suprapubic aspiration
➢ Chest X ray if WBC is equal or >20,000 even in the absence of

respiratory distress and 02 sat of equal or <95%
■ Preliminary evidence suggests that rise in levels of

inflammatory mediators (like CRP and procalcitonin) may be
better markers of SBI than WBC and ANC in children at
significant risk for bacterial infection (Gilsdorf, JR. Journal of
Pediatrics, 2011)
■ CRP concentrations do not generally increase until 12 hours after
the onset of fever and can rise in both viral and bacterial
infections (Peltola et al, 1998)
■ CRP has wide range of sensitivity and specificity that vary by

cutoff levels in identifying SBI in young children (Lacour et al
2008, Fernandez-Lopez et al 2003, Isaacman et al 2002, Pulliam
et al 2001)
■ Procalcitonin levels rise in response to bacterial
infections more rapidly than those of CRP.
➢ Limited preliminary data suggest that PCT levels

may be more sensitive and specific markers for
severe invasive bacterial infection than WBC, ANC,
and CRP. (Dubos et al 2008, Andreola et al 2007,
Hsiao et al 2005, van Rossum et al 2004)
■ Meta-analysis of 5 studies (1,379 children) found

that the diagnostic accuracy of CRP and
procalcitonin were comparable for serious
infection. (Van den Bruel et al, British Medical
Journal, 2011)
➢ High risk: >80 mg/L for CRP and >2 ng/mL for PCT
(sensitivity 40-50%, specificity 90%)
➢ Low risk: <20 mg/L for CRP and <0.5 ng/mL for PCT (80%
sensitivity and 70% specificity for both)
Recommended treatment for well-appearing
incompletely immunized child:
■ Selective treatment of high-risk children with FWLS and WBC
of equal or >15,000 pending culture results (AAP and ACEP
practice guidelines) – Grade 1B ***Lee GM, Fleisher GR et al
2001
➢ Give IM Ceftriaxone 50 mg/kg
➢ IV Clindamycin 10 mg/kg followed by oral form 8 hours later

for patients allergic to cephalosporins
■ Outpatient follow-up within 24 hrs; admit if uncertain to

follow-up
■ COMPLETELY IMMUNIZED:
■ Risk of bacteremia is <1%
■ Risk of UTI as an occult source of infection remains

substantial depending on age, gender, and circumcision
status (Jhaveri et al, 2011)
Recommended treatment for  
well-appearing completely immunized child:
■ For >6 months old with FWLS: urinalysis and urine culture
for girls <24 months old and uncircumcised boys <12
months by catheterization or suprapubic aspiration
(Hoberman et al 1993, Shaikh et al 2007)
■ For girls >24 months old, uncircumcised boys >12 months

old and circumcised boys >6 months old with FWLS: no
routine laboratory evaluation and should not receive
presumptive treatment with antibiotics – Grade 1B
Recommended treatment for well-appearing 
completely immunized child:
■ Do urinalysis and urine culture in those with signs or
symptoms of UTI, with a prior history of UTI, urogenital
abnormalities or >48 hours fever
■ Patients with a (+) urine culture require treatment tailored

to the identified organism and their clinical status
■ Children with fever that persists for >48 hrs or with a

deterioration in clinical condition undergo repeat medical
evaluation
Recommended treatment for well-appearing  
completely immunized child:
■ (+) blood culture require re-evaluation and management
based on their appearance, persistence of fever, and
specific isolate
■ WBC of equal or >15,000 had a sensitivity of 86% and a

specificity of 77% for occult bacteremia with frequency of
bacteremia of 1.5% (Lee et al, 1998 prospective single
center observational study)
■ WBC of <15,000 had a NPV of 99.5% with a frequency of

bacteremia of 1.6% (Herz et al 2006 multicenter
retrospective observational study)
What of probable culture contaminant?
■ With the decline in the prevalence of occult

bacteremia, it is now more likely that a blood culture
will be (+) for a contaminant than for a pathogen.
(Herz et al 2006, Sard et al, 2006, Stoll et al 2004,
Alpern et al, 2000)
■ Microbiologic features like Gram stain, (+) rods, (+)

cocci that are coagulase (-), and slow growth suggest
a contaminant.
Urinary tract infection  
2011 AAP guidelines:
1. Diagnosis
– Abnormal urinalysis as well as positive culture
– Positive culture = ≥50,000 colony-forming units (cfu)/mL
– Assessment of likelihood of UTI
2. Treatment: oral as effective as parenteral
3. Imaging: Voiding cystourethrography (VCUG) not

recommended routinely after first febrile UTI
4. Follow-up: Emphasis on urine testing with subsequent febrile

illnesses
Urinary tract infection  
2011 AAP guidelines:
ì Infants and young children, 2–24 months of age,

with unexplained fever
ì Rate of UTI: ~5%
ì Rate of scarring: Higher than in older children
Action statement 1:
If a clinician decides that a febrile infant with no apparent

source for the fever requires antimicrobial therapy
because of ill appearance or another pressing reason, a
urine specimen should be obtained by catheterization for
both culture and urinalysis before an antimicrobial is
given.
✓ Evidence quality: A
✓ Strong recommendation
Methods of collecting specimen:
ì Suprapubic aspiration is “gold standard” but:
ì Variable success rates: 23–90% (higher with
ultrasound guidance)
ì Requires technical expertise and experience
ì Often viewed as invasive
ì More painful than catheterization
ì May be no alternative in boys with severe phimosis or
girls with tight labial adhesions
ì Bag urine
ì Cannot avoid getting “vaginal wash” in girl or
contamination in uncircumcised boy
ì Not suitable for culture
▪ Negative culture rules out UTI, but
▪ Positive culture likely to be false-positive
o 88% false-positive overall
o 95% in boys
o 99% in circumcised boys
ì Positive culture requires confirmation, which is not
possible once antibiotic is started.
ì Catheterization
ì Compared to suprapubic aspiration:
▪ Sensitivity = 95%
▪ Specificity = 99%
ì Requires some skill, particularly in small infant
girls.
Action statement 2:
If a febrile infant is assessed as not requiring immediate
antimicrobial therapy, then the likelihood of UTI should be
assessed.
• If likelihood is low (<2%), it is reasonable to follow the child
clinically.
• If the likelihood is not low, there are two options:
– Obtain specimen by catheter for culture and urinary
analysis (UA).
– Obtain specimen by any means for UA and only culture
those with positive UA.
Probability of UTI: Infant GIRLS
Probability of UTI # of Factors

Individual Factors
Present
• Race: White
No more than
• Age: <12 months ≤1%
1
• Temperature: ≥39⁰C
• Fever: ≥2 days
No more than
• Absence of another ≤2%
2
source of infection
Probability of UTI: Infant BOYS
Individual Factors # of Factors Present

Probability
• Race: Non-black Circumcised
of UTI
• Temperature: ≥39⁰C No Yes
• Fever: >24 hours No more
Absence of another ≤1% *
• than 2
source of infection
No more
≤2% None
than 3
*Probability of UTI exceeds 1% even with no risk factors other than being
uncircumcised.
Action statement 3:
Diagnosis of UTI requires both:

• Positive culture
– ≥50,000 cfu/mL of uropathogen cultured from
catheter specimen, AND
• Positive urinalysis
✓Evidence quality: C
✓Recommendation
Urinalysis
ì Positive urinalysis required for diagnosis
ì Positive culture with “negative” urinalysis
ì Contamination
ì Asymptomatic bacteriuria
ì Urinalysis not sensitive enough
ì Positive
ì Dipstick: +LE (leukocyte esterase) and/or +nitrite
ì Microscopy: White blood cells ± bacteria
Action statement 4:
Choice of route: Initiating treatment orally or parenterally is

equally efficacious, so choice is based on practical
considerations.
Choice of drug: Based on local sensitivity patterns, adjusted

according to sensitivity of particular uropathogen
Duration of treatment: 7–14 days

✓ Evidence quality: B
✓ Recommendation
Action statement 5:
Febrile infants with UTIs should undergo RBUS.

✓Evidence quality: C
✓Recommendation
Why:
• Yield of abnormal findings: 12–16%
• Permanent renal damage (1 year later)
– Sensitivity: 41%
– Specificity: 81%
• Actionable findings sufficient to warrant?
When:
• Decide clinically: Within 48 hours if not responding to
treatment as expected, unusually ill, or extenuating
circumstances; otherwise, when convenient.
Action statement 6:
VCUG is not recommended to be performed routinely after the first

febrile UTI if RBUS is normal.
If RBUS is abnormal, VCUG may be part of additional imaging

required to evaluate the abnormality.
Further evaluation should be conducted if there is a recurrence of

febrile UTI.
✓ Evidence quality: C
ì
Abdominal pain:
Case:
ì A 12 month-old male presents with paroxysmal

abdominal pain characterized as episodes of being
well and incessant crying for the past 24 hrs. He was
noted to have flexed legs with loud crying. PE: tender
mass on the RUQ which becomes firm during crying
ì Impression?
Intussusception
ì Upper portion of
bowel
(intussusceptum)
invaginates into the
lower part
(intussuscipiens)
ì 60% of infants pass
currant jelly stool
Intussusception
ì Plain abdominal X-ray: (+)density
ì Barium enema: filling defect or cupping in the head

of barium; coiled-spring sign (thin rim of barium
trapped around the invaginating part within the
intussuscipiens)
ì Ultrasound: tubular mass & a doughnut or target
appearance
ì Hydrostatic reduction vs “air” reduction
Acid-related disease /  
peptic ulcer disease
ì Classic symptom of epigastric pain alleviated by

ingestion of food is present only in a minority of
children
ì Majority with poorly localized pain
ì After 6 yrs old, clinical features may be similar to

those in adults; dull or aching pain, GI blood loss,
have exacerbations & remissions
Peptic Ulcer Disease
ì AlMgOH empiric dose after meals and at bedtime
ì Ranitidine 2-4 mg/kg/day q 8h IV or oral for 4-6
weeks
ì Endoscopy
ì H.pylori testing (urea breath test, Ag detection in
stool)
ì Amoxicillin (14d) + Clarithromycin (14d) + PPI (1
month) OR Amox + Metronidazole + PPI OR Clarithro
+ Metro + PPI
ABDOMINAL PAIN in children in the ED:
ì Surgical causes:
1. Acute appendicitis
2. Intussusception
3. Pyloric stenosis
4. Gastrointestinal obstruction/perforation
5. Incarcerated hernia
6. Meckel diverticulum
7. Trauma including abuse
8. Torsion of testes
9. Peritonitis
The Alvarado score for predicting acute appendicitis:  
A systematic review (BMC Medicine, Ohle, et al, 2011)
Feature Score
ì 1-4: discharge
Migration of pain 1
ì 5-6: observation / admission
Anorexia 1
ì 7-10: surgery
Nausea 1
Tenderness in RLQ 2
➢ Predicted number of patients
Rebound pain 1 with appendicitis:
Elevated 1
temperature Score 1-4: 30%
Leukocytosis 2
Score 5-6: 66%
Shift of WBC 1
count to the left Score 7-10: 93%
TOTAL 10
 
Conclusion of systematic review:
ì The Alvarado score is a useful diagnostic “rule out”

score at a cut point of 5 for all patient groups.
ì The score is well calibrated in men, inconsistent in
children, and over predicts the probability of
appendicitis in women across all strata of risk.
ì Medical causes:
1. Gastrointestinal: colic (until 6 wks old), gastroenteritis,

constipation, pancreatitis, peptic ulcer disease, hepatitis,
acute cholangitis, lactose intolerance
2. Diabetic ketoacidosis
3. Urinary tract infection / stones / renal / colic
4. Lower lobe pneumonia / effusion / aspiration pneumonia
/ concomitant lung pathology
ì Gynecological causes:
1. Pelvic inflammatory disease
2. Ectopic pregnancy
3. Primary amenorrhea
4. Torsion of fallopian tubes
*** Do RECTAL exam!

History:
1. Course and character of pain

2. Diarrhea
3. Melena/ Hematochezia
4. Fever
5. Last oral intake
6. Menstrual history
7. Vaginal discharge/bleeding
8. Urinary symptoms
9. Respiratory symptoms
10. Assess past GI history, travel history and diet
Examination:
1. General state: drowsy, toxic appearing, jaundice,

dehydration
2. Abdomen: Always fully expose and check for hernia,
palpate testes if male, site of abdominal pain/tenderness:
➢ Epigastric: peptic ulcer disease/acid related disease,
pancreatitis
➢ RUQ: hepatitis
➢ RLQ: appendicitis
➢ LLQ: diverticulitis, constipation, torsion
➢ Suprapubic: UTI, torsion of ovary
Investigation:
ì Clinical judgment is required to order investigations:
1. CBC
2. Urinalysis (UTI, DKA)
3. Pregnancy test (all girls after menarche presenting with abdominal pain)
4. Electrolytes
5. ESR
6. Amylase, lipase
7. AXR (Intestinal obstruction, perforated viscus, foreign body or
calcification)
8. CXR: perforated viscus (free gas under the diaphragm)
9. Abdominal UTZ
Indications for admission:
1. Surgical abdomen
2. Abdomen difficult to examine
3. Severe dehydration or inability to retain
4. Significant blood loss
5. Abdominal pain persisting more than 4 hours
6. ALL tender testes
Important Reminders:
ì Never discharge a patient if there is still residual

abdominal pain. Prior to discharge, you must
document that there is no more abdominal pain and
tenderness.
ì Patients with appendicitis may or may not have

pyuria.
ì Patients with prior antibiotic therapy may have

abdominal signs masked due to partial treatment
with the antibiotics.
Helminth/Protozoal infections
■ For amebiasis: Metronidazole
35-50 mg/kg/day in 3 doses
for 7-10 days; if
asymptomatic, Diloxanide
Furoate 20 mg/kg/day in 3
doses for 10 days
■ For ascariasis: Mebendazole

100 mg BID po for 3 days or
500 mg PO once for all ages
or Pyrantel Pamoate 11 mg/
kg PO once
Helminth/Protozoal infections
■ Ascariasis: Piperazine citrate 150 mg/kg PO initially then 6
doses of 65 mg/kg Q 12 hrs PO (causes neuromuscular
paralysis of the parasite and rapid expulsion of the worms
is TOC for intestinal or biliary obstruction given as syrup
through NGT)
■ Hookworm and Trichuriasis: Mebendazole 100 mg BID for
3 days po
■ Enterobiasis: Mebendazole 100 mg PO for all ages and
the family members repeated in 2 weeks
Febrile Seizure
ì 6 months- 6 years old: incidence
ì (+) family history
ì Normal neurological exam
ì Simple vs. complex
ì SIMPLE: <15 minutes duration, occurs once in 24

hours, no focal lateralizing signs, normal
developmental milestones
Evaluation: History:
ì Investigate source of fever from associated
symptoms
ì Check oral intake (hypoglycemia or hyponatremia)
ì recent immunization (DPT)
ì recent medication use (anticholinergic)
ì recent head trauma
ì previous CNS dysfunction and infection

Evaluation: PE:
ì Vital Signs & GCS
ì Hydration status
ì Look for focus of infection especially fontanel and
neck stiffness
ì Scalp hematoma
ì Pupil size and symmetry, eye movements,
asymmetry of movement, muscle tone, reflexes and
upgoing toes
ì Complete neurologic examination
ED Management:
ì Glucose, CBC
ì Diazepam 0.2-0.5 mg/kg/dose IV or per rectum
ì Paracetamol suppository 10-15 mg/kg/dose
ì Put in the recovery position and give supplemental
oxygen if drowsy
ì Correction of dehydration and hypoglycemia
Criteria for admission:
ì All first febrile seizure episode if patient is <18 months old
ì After 18 months old: If partially treated meningitis cannot be

excluded (recent antibiotic use)
ì Complex febrile seizure
ì Abnormal neurological findings
ì Serious infections
ì Abnormal glucose
ì Anxious parents/unable to cope

Discharge from the ED &  
follow-up plans:
ì Discharge criteria:
1. No recurrence of seizure at the ED
2. Temperature going down
3. GCS 15
4. Child is well
5. Parents able to cope and confident to monitor at home
ì Discharge medications:
1. Paracetamol 10-15 mg/kg/dose Q4 hours, or:
2. Ibuprofen 5-10 mg/kg/dose Q6 hours
STATUS EPILEPTICUS
ì Recurrent seizures without recovery of consciousness between
convulsions lasting 30 minutes
ì Goals of management:
1. Ensure adequate brain oxygenation and cardiorespiratory function
2. Control seizure as soon as possible
3. Identify causative and precipitating factors
4. Treat metabolic and medical complications
5. The seizure should be terminated while the child is still in ED.
Management:
ì A - establish airway, clear secretions, recovery position
ì B - supply 100% 02 with respiratory support, monitor RR

and 02 sat
ì C - evaluate circulation and establish IV access (NSS

maintenance unless hypovolemic); monitor BP, CR, do CBC,
serum Na, K, Mg, Ca, glucose, tox screen
* If glucose is <40 mg/dL: give 5 ml/kg 10% dextrose IV (<30

mg/dL in newborns)
Management:
■ If with IV access: Diazepam 0.2-0.3 mg/kg slow IV

over 2 mins (IO); after 5 minutes, re-assess and give
another dose if still with seizures
■ If seizure persists, load with Phenobarbital IV 15-20
mg/kg/dose at 1 mg/kg/min (not to exceed 25 mg/
min) – use plain NSS or LRS to avoid crystallization in
dextrose fluids
■ Give another dose of Phenobarbital at 5 mg/kg/dose
during the 0-5 minute timeline
Management:
ì 30-60 minutes: Add Phenobarbital at 5-10 mg/kg IV : a total

of 30 mg/kg if symptoms persist
ì If symptoms persist, may give additional 5-10 mg/kg/dose of

Phenobarbital IV but do NOT exceed 30 mg/kg as it is
cardiotoxic (i.e. conduction block) at a rate of 1 mg/kg/min
with max. of 25 mg/min
ì If symptoms are controlled, maintain Phenobarbital IV at 5

mg/kg/DAY in 2 divided doses -à 1st maintenance dose given
12 hours after the loading dose (do NOT use Phenobarbital if
with cardiac disease)
Management:
ì If symptoms persist, use either Phenytoin or Valproic

acid
ì Child >2 years old: in shock or if patient with cardiac
disease: Valproic acid IV loading dose 20-30 mg/kg at
a rate of 3 mg/kg/min of infusion
ì If seizures are controlled, maintain VPA at 5-6 mg/kg/
dose every 6 hours
Management:
ì 60 minutes: REFRACTORY SEIZURES
ì Load with Midazolam at 0.2 mg/kg IV bolus followed

by IV infusion à Start at 2 mg/kg/min and increase
by 4 ug/kg/min every 5 minutes until seizure stops or
maximum of 24 ug/kg/min is reached
ì Preparation: Dilute 3 mg/kg in 50 ml D5W where 1
ug/kg/min is equivalent to 1 ugtt/min or cc/hr
Management:
■ Phenobarbital can cause respiratory depression and
hypotension
■ If patient does not have good airway protection

reflexes, prophylactic intubation prior to administration
■ Transfer to PICU and under EEG monitoring

Chest pain / Arrhythmias ì
Case:
ì A 15 month-old male presents with high-grade

fever, irritability, and tachypnea at the ER. He was
being treated as an outpatient for the past 2 days
for an acute viral infection. Few minutes PTC, he
was noted to be very irritable and having difficulty
of breathing. Vital signs: T=40.4°C, CR=190 beats/
min.
ì What is the most likely diagnosis?
 
Ventricular complexes are normal in contour with fixed RR interval 
SVT
ì Palpitation, shortness of breath, chest pain,
respiratory distress, dizziness, syncope, irritability,
pallor, poor feeding
ì Heart rate 150-300 bpm
ì Vagal maneuvers; pharmacotherapy (adenosine,

verapamil, digoxin)
Difference between  
SVT & sinus tachycardia:
ì Increased HR for age originating from the sinus node
ì Most common causes: anxiety, fever, anemia,

hypovolemia, CHF, exercise, hyperthyroidism,
medications
ì Rate between 100-180 bpm
ì Negative P waves in leads I and AVF (SVT)
ì Treat underlying condition

Ventricular tachycardia
ì In the ED, assume that a wide complex tachycardia is
ventricular tachycardia.
ì QRS duration varies with age
ì Series of 3 or more consecutive ectopic beats
ì Etiologies: primary electrical disease, hyperkalemia,
ingestions
ì Rate is 120-200 bpm
Management of VT:
ì Stable patients: IV Lidocaine (1 mg/kg)

ì Unstable patients: cardioversion 1 J/kg
Pediatric Tachycardia:
Approach to Chest Pain:
ì Common complaint in late childhood and
adolescence
ì Note characteristic of pain, subjective quality,
position in which it is greatest, radiation, duration,
alleviating or exacerbating factors
ì Cardiac pain usually associated with exercise and
improves with rest
Noncardiac etiologies:
1. Musculoskeletal problems
ì Most common cause of chest pain
ì Tietzes’s syndrome (costochondritis)
ì Precordial catch syndrome (intercostal muscle cramping)
2. Psychogenic causes
ì Hyperventilation or anxiety
ì Hysterical behavior
Noncardiac etiologies:
3. Pulmonary chest pain
ì Pleuritic in nature exacerbated by deep inspiration,
swallowing or coughing
ì Inflammation or irritation of the pleura
ì Pneumonia, pleurodynia, pneumothorax
4. Gastroesophageal disease
ì GER, esophagitis, gastritis, GI spasm
ì Similar segmental innervation of heart and
esophagus---”burning” pain
Cardiac etiologies:
1. Pericarditis
ì Pleuritic-type of pain relieved by sitting up and

referred to the neck, shoulders, and abdomen
ì Unable to assume supine position
ì Pericardial friction rub on supine
ì ECG shows ST-segment elevation and cardiomegaly

or pericardial effusion on chest X-ray
Cardiac etiologies
2. Arrhythmias
ì Inadequate coronary blood flow
3. Mitral Valve Prolapse

ì Vague anterior chest pain
ì Midsystolic click and late systolic murmur confirmed by 2D-
echo
4. Aortic dissection
ì Extremely rare in childhood
ì Connective tissue disorders
Cardiac etiologies
ì Severe pain, sudden in onset, “tearing” in quality
ì Radiates to the neck and back
5. Coronary artery disease

ì Extremely rare in pediatric age group
ì Myocardial ischemia, angina pectoris, myocardial
infarction
Initial Approach to Trauma:
A. Historical findings
1. Mechanism of injury to assess severity, likelihood /

location of injuries; assess if consistent with injury
and developmentally appropriate
1. Preceding events to assess for precipitating

etiologies: syncope, seizure, cardiac arrhythmias
B. PE findings
1. Primary survey: ABCDEFG
a. Airway and cervical spine control; suction secretions,
reposition airway, or placement of advanced airway
b. Breathing and ventilation: supplemental 02, pneumothorax
decompression, chin lift, or intubation
c. Circulation and hemorrhage control: pulses, perfusion, HR,
BP
d. Disability, decontamination, dextrose: assess mental
status (GCS) and pupillary response to light; remove
clothing, Hgt
e. Exposure: undress patient and log roll to find injuries,
then cover
f. Fasting: last time the patient ate/drank
g. General health
Indications for endotracheal intubation  
in children with trauma:
1. Inability to ventilate by bag mask ventilation
2. GCS score of equal or less than 8
3. Concern for impending brain herniation
4. Respiratory failure from hypoxemia or

hypoventilation
5. Decompensated shock to initial fluid resuscitation
6. Loss of laryngeal reflexes

GCS and Modified Infant GCS:
Action GCS Infant GCS Score
Eye opening Spontaneous Spontaneous 4

To voice To voice 3
To pain To pain 2
None None 1
Verbal response Oriented Coos/babbles/smiles 5

Confused Irritable / consolable 4
Inappropriate Cries to pain 3
Incomprehensible Moans to pain 2
None None 1
Motor response Obeys commands Spontaneous movements 6
Localizes pain Withdraws to touch 5
Withdraws to pain Withdraws to pain 4
Flexion (decorticate) Flexion (decortication) 3
Extension (decerebrate) Extension (decerebration) 2
Flaccid Flaccid 1
Some primary survey findings and
life-threatening conditions:
Abnormal findings Life-threatening conditions
Airway Hoarseness, stridor, subcutaneous Obstruction by blood, secretions,

emphysema, airway foreign body or laryngeal tear
secretions
Breathing Decreased, asymmetric breaths Tension pneumothorax,

sounds, flail chest, tracheal deviation, hemopneumothorax, flail chest,
hypoxia pulmonary contusion
Circulation Tachycardia, abnormal pulses or Hemorrhagic shock, pneumothorax,

perfusion pericardial effusion
Disability Abnormal GCS score, mental status, Intracranial injury, increased ICP, brain
pupillary response herniation
2. Secondary survey: head-to-toe examination and focused
history
a. Inspect entire body
b. Head/face: intraoral trauma, rhinorrhea
c. Eyes: pupils, eye movements, raccoon eyes
d. Ears: hemotympanum, CSF otorrhea, Battle sign
e. Neck: deformity, tenderness, tracheal deviation
f. Chest: accessory muscle use: breath and heart sounds

2. Secondary survey: head-to-toe examination and focused
history
g. Abdomen/pelvis: tenderness, guarding, compress pelvis for
integrity
h. Urogenital: urethral and vaginal bleeding
i. Rectal: exam if concerned for spinal cord injury; trauma
j. Musculoskeletal: assess pulses; examine all joints and limbs
k. Neurologic: level of consciousness, cranial nerves, strength,
sensation, DTRs
3. Tertiary survey: identify potentially missed injuries,
consider comorbidities
C. Laboratory tests/imaging:
➢ Type and screen, CBC, hepatic and pancreatic
enzymes, electrolytes
➢ Urine pregnancy, toxicology screen if needed
➢ Imaging guided by mechanism of injury and PE

findings
Head trauma decision rules for <2 Head trauma decision rules for >2
years old (at very low risk of TBI years old (at very low risk of TBI
who do not need head CT) who do not need head CT)
Normal mental status Normal mental status

No hematoma or isolated frontal hematoma No loss of consciousness
No LOC or loss of consciousness for <5 seconds No vomiting
Non-severe injury mechanism Non-severe injury mechanism:

Severe defined as any of the ff: Severe defined as any of the ff:
➢ MV crash with patient ejection ➢ MV crash with patient ejection
➢ Death of another passenger ➢ Death of another passenger
➢ Rollover ➢ Rollover
➢ Pedestrian or bicyclist without helmet struck ➢ Pedestrian or bicyclist without helmet struck
by a motorized vehicle by a motorized vehicle
➢ Falls of >3 feet ➢ Falls of >5 feet
➢ Head struck by a high-impact object ➢ Head struck by a high-impact object
No palpable skull fracture No signs of basilar skull fracture
Acting normally according to caretaker No severe headache

Concussion
ì brain injury not
demonstrable in
radiographs but
associated with
a transient loss
of
consciousness
Contusion
➢ area of focal
edema with or
without
hemorrhage on
CT scan; with
LOC and focal
deficit
Epidural hematoma
➢ tear in middle
meningeal artery;
temporoparietal
skull fracture in 75%
➢ concussion followed
by a lucid interval
and LOC with inc.
ICP; rare in <2 year
old kids
Subdural hematoma
➢ tearing of the
bridging veins
between the
cerebral cortex &
dura asso.with
severe brain injury;
coma or seizures
➢ common in infants
Basilar skull fracture
ì common fracture of the base of the skull including longitudinal
or transverse fractures of the petrous portion of the temporal
bone and of the cribriform plate
➢ (+)hemotympanum or Battle’s sign, CSF otorrhea, racoon’s eye

(periorbital ecchymosis), facial palsy, hearing loss = petrous
fracture
➢ hemorrhage in nose or nasopharynx, CSF rhinorrhea, anosmia =
cribriform plate fracture
Approach to poisoning:
A. Epidemiology
1. Children <5 y/o: unintentional
2. Teens: intentional (suicide attempt, recreational substance
abuse)
3. Any age: forced (child abuse)
B. Historical findings
a. History may not be accurate if unwitnessed or unknown
b. Drug, concentration and dose, type, time of ingestion
C. PE findings
1. Toxidrome
2. VS, mental status, pupils
a. Sympathomimetics / stimulants: tachycardia, hypertension,

hyperthermia, agitation, mydriasis (normal light response)
b. Anticholinergics: tachycardia, hypertension, hyperthermia,

agitation, mydriasis (sluggish light response)
c. Opioids and barbiturates: lethargy, bradycardia, hypotension,

decrease in RR, miosis
Toxidromes:
Toxin Clinical findings Therapy
Opiates Miosis, coma, CNS and respiratory Naloxone
depression, low BP, low HR, low T
Organophosphates Nicotinic: muscle fasciculations, Atropine improves
(irreversible AChE weakness, paralysis muscarinic activity;
inhibitors) CNS: coma, seizures, apnea Pralidoxime treats
Muscarinic: often improve with atropine muscarinic and
challenge nicotinic blockade;
➢ lacrimation, bronchorrhea activated charcoal as
➢ Delayed onset, improves in 2 wks indicated;
➢ Delayed neurotoxicity: occurs 1-3 benzodiapines for
weeks post ingestion seizure
Tricyclic antidepressants Coma, arrhythmia, seizure, widened QRS NaHC03

complexes, dilated unreactive pupils
Methanol Decreased visual acuity, metabolic NaHCO3,

acidosis, osmolar and anion gap, hemodialysis
hyperventilation
Toxidromes:
Toxin Clinical findings Therapy
Carbon monoxide Flu-like illness, Hgb desaturation, 100% 02

metabolic acidosis
Digitalis visual disturbances, nausea, vomiting, Atropine for low CR
low BP and CR
Hydrocarbons Pneumonitis, pulmonary edema and Gastric
hemorrhage, typical odor decontamination for
benzenes, heavy
camphor, halogenated
compounds
Iron Vomiting, diarrhea, abdominal pain, Deferoxamine

coma, metabolic acidosis
Mothballs (paradichloro- Weakness, pallor or jaundice, dark Activated charcoal
benzene and naphthalene) urine, oliguria
D. Laboratory testing and imaging

➢ Depends on suspected toxins and clinical status:
1. Urine toxicology screen: mostly illicit drugs
2. Serum toxicology screen: acetaminophen, salicylate,

ethanol, other drugs
3. Other tests depending on situation (pregnant?) or
toxidrome (LFTs?)
Ingestions
ì Conditions that give a metabolic acidosis with increased
anion gap:
M – methanol
U – uremia
D – DKA
P – paraldehyde
I – idiopathic acidosis, iron, INH
E – ethylene glycol, ethanol
S - salicylates
Ingestions
ì Toxins that may be seen on abdominal X-ray:
C – chloral hydrate
H – heavy metals (Pb, Fe, Sb)
I - iodides
P – phenothiazines
E – enteric-coated medications
S – sodium, calcium, potassium, bismuth

ED Management:
1. Secure a patent airway.
2. Establish adequate ventilation.
3. Maintain hemodynamic status.
4. GI decontamination: activated charcoal or whole bowel

irrigation for Fe and aspirin
5. Skin decontamination for organophosphates or
gasoline/caustics
6. Ocular decontamination >20 mins w/ NSS
Decontamination:
1. Activated charcoal
a. Works best if given within 1 hour of ingestion
b. Does NOT absorb heavy metals, corrosives, alcohols,

hydrocarbons, inorganic ions
2. Whole bowel irrigation
a. Large volume balance electrolyte solution usually given by

NGT
b. For sustained-release drugs

Acetaminophen poisoning:
ì Peak serum concentration: 4 hours after ingestion
ì Minimum single toxic dose: 150 mg/kg
ì Chronic toxic ingestion: 150 mg/kg over 2-4 days
ì Acetaminophen level drawn 4-24 hours after dose: plot value

on nomogram
ì Include serial LFTs, BUN/creatinine ratio, ABG if severe

ingestion
ì Clinical features:
a. Stage 1 (30 minutes-24 hours after ingestion): nausea,

sweating, lethargy, or asymptomatic; normal labs
b. Stage 2 (24-72 hours): hepatotoxicity, nephrotoxicity
c. Stage 3 (72-96 hours): peak of LFT levels, hepatic

encephalopathy, hyperammonemia, bleeding,
hypoglycemia, lactic acidosis, death
d. Stage 4 (4-14 days): recovery, improved symptoms, LFTs

recover
ì Activated charcoal indicated if within 4 hours of ingestion
ì Indications for NAC antidote (acts as glutathione precursor):
1. Level above “possible hepatic toxicity” line on nomogram
2. Single ingestion of >150 mg/kg when level not obtainable
3. Unknown ingestion time and acetaminophen level >10 mcg/

mL
4. Hepatotoxicity and history of ingestion

Salicylate poisoning
ì MOA: activates respiratory center of medulla causing
tachypnea, respiratory alkalosis
ì Significant coagulopathy through decreased platelet
function and clotting factors
ì Mild overdose: inc. RR and HR, tinnitus, vertigo,
nausea, diarrhea
ì Later findings: noncardiogenic pulmonary edema,
altered mental status, death
Management of salicylate poisoning:
ì Beware of endotracheal intubation: must maintain very high
minute ventilation to avoid acidosis
ì Careful fluid resuscitation with alkalinized fluids
ì Correct hypokalemia and hypoglycemia
ì GI decontamination
ì Urine alkalinization to improve salicylate removal (goal = urine

pH 7.5-7.6)
ì Hemodialysis in severe cases

Calcium channel blocker Beta-blocker poisoning
poisoning
Abnormal AV node conduction or AV block Changes in mental status (lipophilic BBs)
Glucose level is high Glucose level is low

➢ IV calcium ➢ Glucagon
ì ECG: prolonged PR interval, bradyarrhythmias, prolonged QRS

in BBs
ì Aggressive fluid resuscitation for hypotension
ì Atropine for bradycardia, norepinephrine for low BP
ì GI decontamination
Oral hypoglycemic poisoning
Sulfonylureas Metformin
Cause hypoglycemia 8-12 hours after ➢ Normal glucose
ingestion ➢ Metabolic acidosis peaks at 4-6
hours after ingestion
Lethargy or seizure from lack of brain Nausea, abdominal pain, inc. HR and
glucose RR, low BP from metabolic acidosis
➢ IV dextrose ➢ Bicarbonate and/or dialysis only if

➢ Octreotide (inhibits insulin release severe acidosis
from pancreas) considered if unable ➢ Observe for 6-8 hours after
to maintain blood glucose despite ingestion to monitor for symptoms
dextrose
➢ Observe for 12-24 hours
➢ Hgt, electrooytes, ABG, consider ➢ Hgt, electrolytes, ABG, consider

activated charcoal activated charcoal
Anticholinergic ingestion
ì Acetylcholine actions
➢ Muscarinic receptors: sweating, salivation, intestinal and urinary

motility, miosis, dec. HR
➢ Nicotinic receptors: sympathetic ganglia, NMJ
➢ Central receptors: memory, cognition, motor coordination
ì Extreme hyperthermia, myoclonus, seizure, coma
ì Arrhythmia, inc. QT and QRS intervals
ì Activated charcoal if alert, benzodiazepines for agitation,

bicarbonate IV for ECG abnormalities
ì Physostigmine in severe cases
Caustic ingestions
ì Cosmetics, cleaning agents, button batteries
ì Alkali: usually cause more injury than acids with esophagus

most severely affected (liquefaction necrosis, resultant burn,
perforation, delayed injury from stricture formation)
ì Acids: penetrate less deeply, mostly cause gastric or upper

airway injury; coagulation necrosis
ì Button batteries: electrical discharge in esophagus and rapid

corrosive injury to esophagus
Caustic ingestions
ì PE: signs of upper airway injury: stridor, hoarseness,
respiratory distress; oral lesions do not predict esophageal
lesions; abdominal pain
ì Neck, chest, abdomen X rays
ì Stabilize ABCs
ì Emergent removal of esophageal button battery
ì Immediate upper airway laryngoscopy or upper GI endoscopy

Hydrocarbon poisoning
ì Due to low viscosity, often inhaled: pulmonary toxicity à

destruction of surfactant, alveoli collapse, pneumonitis
ì Systemic toxicity with only some compounds; poorly absorbed

from GIT
ì Aspiration: immediate or delayed coughing, wheezing,

respiratory distress
ì Large ingestions: emesis, CNS symptoms, arrhythmias, hepatic/

renal injury with some compounds
ì Chest X ray; supportive treatment

Methemoglobinemia
Congenital Acquired
Dec. reduction of methgb back to hgb Ingestion: agents that cause metHgb
reductase (nitrites, lidocaine, dapsone)
Infectious: diarrhea in young children with
nitrite-forming bacteria
Usually asymptomatic or “cyanotic” ➢ Low level (<20%): asymptomatic

➢ Moderate level (20-40%): headache,
lethargy, fatigue, dyspnea
➢ High level (>40%): altered mental status,
shock, seizure, death
Avoid exposure to aniline derivatives and ➢ If symptomatic: methylene blue

nitrates
Methemoglobinemia
ì PE findings
➢ Cyanosis (“slate gray” in severe cases) in presence of normal

Fi02
➢ Pulse oximeters often inaccurate
ì Laboratory evaluation
➢ Serum testing for metHgb presence and level

Acute iron poisoning
ì Highest risk: prenatal vitamins; children’s vitamins less likely to

cause harm
ì Clinical features of toxidrome:
1. GI phase: 30 minutes to 6 hours
a. Abdominal pain, vomiting, diarrhea, hematemesis, melena,
shock
b. Vomiting most sensitive sign of severe toxicity
2. Latent phase: 6-24 hours: usually asymptomatic 

3. Shock/metabolic acidosis/hepatoxicity: 6-96 hours
4. Bowel obstruction: 2-8 weeks later from scarring
The art of discovering the key
findings in the initial history
taking and examination of a
child is one of the hallmarks
of a skilled clinician.

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ì

GETTING READY FOR PEDIATRICS

Ruby L. Punongbayan, MD, MA, FPPS

ì To recognize the salient features of the clinical condition

ì Consider the age group in establishing rapport and doing

ì Use acceptable ways of immobilization.

ì Know the natural course of the illness.

1-3 days old 18.5 (14.5) 56 (45) 18.9 (9.4-34)

2 weeks old 16.6 (13.4) 53 (41) 11.4 (5-20)

1 month old 13.9 (10.7) 44 (33) 10.8 (4-19.5)

2 months old 11.2 (9.4) 35 (28) -----

6 months old 12.6 (11.1) 36 (31) 11.9 (6.-17.5)

6 mo-2 years old 12.0 (10.5) 36 (33) 10.6 (6-17)

2-6 years old 12.5 (11.5) 37 (34) 8.5 (5-15.5)

Age Hb (g/dL) Hct (%) WBC (x10 to 2/uL)

6- 12 years old 13.5 (11.5) 40 (35) 8.1 (4.5-13.5)

12- 18 years old

AGE Heart rate Blood RR

Prema-ture 120-170 55-75/ 40-70

AGE Heart rate Blood RR (breaths/

1-3 yrs 70-110 90-105/ 20-30

Child / Adolescent Desirable Borderline High

ì Diarrhea and/or vomiting

ì Fever with or without rashes

End stage of respiratory distress

b. Right upper lung consolidation

b. Epinephrine IM d. inhaled salbutamol

ì Upper Airway Obstruction

(croup, anaphylaxis, foreign body aspiration)

❖ Increased inspiratory respiratory effort (inspiratory retractions, nasal

❖ Stridor (usually inspiratory but may be biphasic)

❖ Poor air entry on auscultation

ì also called viral croup

ì acute inflammatory disease of the larynx (within the

Chest wall None 0

Air entry Normal 0

➢ Westley croup score: 0-17

MILD Consider dexamethasone (0.6 mg/kg/dose po/IV/IM)

MODERATE TO SEVERE Administer humidified 02

ì Airway management and treatment of hypoxia

ì mild (at home): oral fluids

ì moderate to severe stridor at rest, hypoxia, need for

ì Single dose of oral dexamethasone 0.6 mg/kg (as

ì EPINEPHRINE- drug of choice for anaphylaxis

1. Acute onset of illness involving skin, mucosal tissue,

3. Reduced blood pressure

a. Involvement of the skin-mucosal tissue

➢ Periorbital itching ➢ Lower back pain due to

➢ Do not provide rapid relief or upper/lower airway obstruction,

1. For a conscious infant or child, use manual techniques appropriate for

2. If become unresponsive, start CPR beginning with chest compression

a. Respiratory syncitial virus

ì most commonly caused by RSV (respiratory syncitial virus)

ì S/sy: low-grade fever, rhinorrhea, cough, wheezing,

ì 1st yr of life: (+) heart disease or CLD of prematurity:

ì PE: irritable, hunched forward, CR= 130/min, RR=65/

a. Inhaled beta 2 agonist

(bronchiolitis, acute asthma)

ì Wheezing (most commonly expiratory but may be inspiratory or

ì Initial assessment ì Are any of the ff

Further TRIAGE BY CLINICAL Consult ICU, start SABA and

Assess clinical progress frequently

FEV1 or PEF 60-80% of predicted or FEV1 or PEF < 60% of predicted or