COMMON ILLOGICAL DECISIONS
Daniel Rauch, MD, FAAP, FHM
Associate Professor of Pediatrics
Mount Sinai School of Medicine
Associate Director of Pediatrics
Elmhurst Hospital Center
Congratulations to the San
Francisco Giants
2010 World Series Champions
Case 1
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4yo boy with CC of fever, HA, lethargy, and
vomiting (ie. He’s sick).
HPI: well until yesterday when had tactile temp, dec
PO, dec active, went to sleep early, woke up and
then back to sleep and now difficult to arouse,
previously well, no trauma
PE sig for T 103° HR 170 RR 28 BP 85/56, ill
appearing, lethargic, meningismus
Case 1
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DD – Meningitis at top of list
Plan – LP + other tests then lots of antibiotics
But, someone suggests that he needs a head CT
prior to LP in case of high ICP and possible
herniation during LP so off he goes to radiology
CT – Really?
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Herniation risks
 Rennick
G et al. Cerebral herniation during bacterial
meningitis in children. BMJ 1993; 306(6883):953-5
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The temporal relation between lumbar puncture and herniation
strongly suggests that a lumbar puncture may cause herniation in
some patients,
and normal results on computed tomography do not mean that it is
safe to do a lumbar puncture in a child with bacterial meningitis.
 Shetty
AK et al. Fatal cerebral herniation after lumbar
puncture in a patient with a normal computed
tomography scan. Pediatrics 1999; 103:1284-7.
Maybe too sick for LP?
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When the OP is very high, just enough fluid (usually 2 to 4 mL)
should be removed to permit a careful examination
The use of a small bore needle (21- or 22-gauge) is recommended
whenever there is concern about increased ICP to minimize the CSF
leak from the LP site.
Joffe AR. Lumbar Puncture and Brain Herniation in Acute Bacterial
Meningitis: A Review. J Int Care Med 2007; 22:194-207
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The risk of not doing an LP when it is considered contraindicated because of
concern of the risk of herniation is very small.
Van Crevel H et al. Lumbar puncture and the risk of herniation: when
should we first perform CT? J Neurol 2002; 249 : 129–137

Of course CT should be preceded by obtaining blood cultures and starting
antibiotic treatment without delay
What if LP not done before abx?

Kanegaye JT et al. Lumbar Puncture in Pediatric
Bacterial Meningitis: Defining the Time Interval for
Recovery of Cerebrospinal Fluid Pathogens After
Parenteral Antibiotic Pretreatment. Pediatrics
2001;108;1169-1174
 complete
sterilization of meningococcus within 2 hours
and the beginning of sterilization of pneumococcus by 4
hours into therapy
Case 2
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4yo boy with hx of RAD presents with 3d URI sx, 2d
fever, 2d cough, today with post-tussive emesis
PE sig for RR 32, 1+ wheeze, 1+ retractions, good
air movement, rhonchi at bases R>L, POX RA 93%
CXR done because of fever and resp sx sig for
atelectasis R base
Still in mild resp distress after 3 albuterol/atrovent
and PO steroids so given Ceftriaxone and admitted
with dx of Asthmonia
Why CXR?
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Pneumonia is a clinical dx
 Hypoxia
unusual in “mild” pneumonia
 Hypoxia
results from V/Q mismatch – need a large amount
of lung involvement
 CXR
NOT helpful in differentiating bacterial vs viral
 CXR
known to ‘lag’ behind clinical sx
 CXR of asthma can look like pneumonia
 CXR
not recommended for routine assessment of asthma
- NHLBI guidelines
Asthma vs Pneumonia
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Wheeze – TRUE musical sounds – suggestive of
NOT classic bacterial etiology
 RAD,
viral, or mycoplasma
 BTS
Guidelines for the Management of Community Acquired
Pneumonia in Childhood. Thorax 2002;57(Suppl. 1)1—24.
 Ruuskanen O, Mertsola J. Childhood community-acquired
pneumonia. Semin Respir Infect 1999;14:163–72.
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The co-incidence of asthma and pneumococcal
pneumonia is exceedingly small
Treatment – Cefakillall
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First line abx for CAP in children is high-dose
Amoxicillin
 T.
Hazir et al. Ambulatory short-course high-dose oral
amoxicillin for treatment of severe pneumonia in children: a
randomised equivalency trial, The Lancet 2008; 371: 49-56
2nd then 3rd generation commonly used
from prior to Hib vaccine
 True pneumococcal resistance still rare
 Cephalosporins,
 Intermediate
resistance common – a lab designation and not
clinically relevant
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Steroids???
Case 3
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2yo boy presents with Diarrhea and vomiting for 2
days, decreased urine output. Parents tried ginger
ale. During 2-hour wait more vomiting. IV fluids
ordered upon assessment; IV takes 3 attempts and
vomits during attempts, Chem 7 drawn: BUN 15,
Creat .8, HCO3 12
Admitted to hospital 5 hours post-arrival for
dehydration, low bicarb, and failed PO
Made NPO overnight and continued on IVF
Dehydration assessment
WHO Hydration Assessment or
Either way…poor reliability
Dehydration Scores
Gorelick score
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Characteristic
Score of 0
Score of 1
Gen
appearance
Normal
Abnormal
Cap refill
<2 sec
>2 sec
Mucus
membranes
Moist
Dry
Tears
Present
Absent
Gorelick MH et al. Validity
and Reliability of Clinical
Signs in the Diagnosis of
Dehydration in Children
Pediatrics 1997; 99: e6
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0=no dehydration
1=mild dehydration
2=mod dehydration
3-4=severe dehydration
Dehydration Scores
Clinical Dehydration Score
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Characterisitc
Score of
0
Score of 1
Score of 2
Gen
appearance
Normal
Thisty,
restless, or
lethargic
Drowsy,
limp, cold,
sweaty,
comatose
Eyes
Normal
Slightly
sunken
Very sunken
Mucus
membranes
Moist
Sticky
Dry
Tears
Tears
Decreased
Absent
Goldman RD et al.
Validation of the Clinical
Dehydration Scale for
Children With Acute
Gastroenteritis. Pediatrics
2008, 122;545-549
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0=no dehydration
1-4=mild dehydration
5-8=mod/severe
dehydration
Labs?
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AAP, CDC, and ACEP guidelines agree that routine
laboratory testing does not contribute to the
assessment of hydration in children with
uncomplicated gastroenteritis
 AAP
and CDC endorsed: King CK et al. MMWR Recomm
Rep. 2003;52:1-16
www.cdc.gov.mmwr/preview/mmwrhtml/rr5216al.htm

ACEP. The Management of Children with Gastroenteritis and
Dehydration in the Emergency Department. J Emerg Med 2010;
38: 686-96
 No single laboratory value has been found to be accurate in
predicting the degree of dehydration and this is not routinely
recommended.
ORT vs IVF
Oral Rehydration Therapy
First choice for mild-to-moderate dehydration
Physiologic
Improved parent satisfaction
Simple, noninvasive, low cost
Requires less time and fewer resources than IVRT
Avoids need for catheter placement and potential
complications associated with IVRT
Can be administered in any setting
NOT for severe dehydration
Atherly-John YC et al. Arch Pediatr Adolesc Med. 2002;156:12401243
 Spandorfer PR et al. Pediatrics. 2005;115:295-301
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NPO and IVF?
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NPO for AGE – why?
ORT…
 Cincinnati AGE guidelines 2006
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It is recommended that refeeding of the usual diet be started at
the earliest opportunity after an adequate degree of rehydration
is achieved – not BRAT, not dairy-free
IVF
Rehydration over 24 hrs (48 for hypernatremia)
 Vs evidence of iatrogenic hyponatremia


Moritz ML, Ayas JC. Prevention of Hospital-Acquired
Hyponatremia: A Case for Using Isotonic Saline. Pediarics 2003;
111: 227-30
Case 4
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2 yo girl with CC of increasing neck mass despite oral
Augmentin. Sx started 5d ago with URI sx and sore
throat, 3d PTA pt noted with fever and L neck swelling,
seen by PMD where rapid strep was neg, no tx given,
following day neck mass increased so started on PO
Augmentin, mom filled rx yesterday morning, pt has
taken 2 doses and still with fever and neck mass so
admitted for failure of PO to start Unasyn
PE sig for VSS, T 101, well appearing other than L high
ant cerv mass 3x4cm, warm, tender, red, firm. Pt able
to take PO well
Oral vs PO

“The bacteria don’t know how the antibiotics got
there”
 PO
vs IV for UTI, Osteo, CAP, cellulitis
 Dependent on illness severity, bacterial coverage, and
bioavailability
What is ‘Failure of PO’?
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Assume no findings suggestive of malignancy – rare
in acute presentation of cervical lymphadenitis
Natural history is up to 2 weeks
No evidence of clinical resolution within 24-48 hrs
of any antibiotics, although some improvement likely
May progress to drainage – spontaneous or
surgical – regardless of treatment
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Leung AKC et al. Cervical Lymphadenitis: Etiology, Diagnosis, and
Management. Curr Infect Dis Reports 2009; 11:183-9
Gosche JR et al. Acute, subacute, and chronic cervical lymphadenitis
in children. Sem in Ped Surg 2006; 15: 99-106
“If it’s called the ‘World Series’,
then why is it usually played in
New York?”