Common Paediatric Emergency
Referrals
Mark Anderson
Consultant Paediatrician
Great North Children’s Hospital
Case 1
Archie, 18 months
 Unwell for 2 days with runny nose and cough
 Felt hot
 Difficulty breathing & wheezy today
Archie, 18 months
 Examination
 Coryzal
 Mild subcostal recession
 Quiet wheeze throughout chest
Differential diagnosis?
Differential diagnosis
 Viral induced wheeze (VIW) – episodic wheeze
 1st presentation “asthma” – multi-trigger wheeze
 (Bronchiolitis)
How to differentiate VIW from
“asthma”?
How to differentiate VIW from
“asthma”?
 Can be difficult!
 Asthma more likely if
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Multiple triggers for wheeze
Interval symptoms
Personal or family history of atopy
Absence of virus (!)
Specific Therapy?
Specific therapy
 Inhaled bronchodilator
 Salbutamol
 Ipratropium bromide
 ?Steroids
Steroids in preschool VIW
 Little evidence for efficacy
 120 children aged 1-5y given prednisolone or placebo
 No effect on parental reported respiratory symptom
score at 7 days
 700 preschool children given prednisolone or placebo
 No effect on duration of hospitalisation
 No effect on respiratory symptom score in first 24 hours
Steroids in preschool VIW
 Short burst therapy probably should be reserved for
clinical features suggestive of atopic asthma
 History of multi-trigger wheeze
 Severe eczema
 Family history of atopy
What determines need for
admission?
What determines need for
admission?
 Oxygen requirement (SpO2 <93%)
 Respiratory effort
 Hydration concerns
 Social complications
Take home points
 Preschool wheeze appears to have multiple
phenotypes
 Short burst oral steroids no longer the cornerstone of
management for all preschool wheeze
 Questions?
Case 2
Micah, 2 years
 Unwell for 2 days with runny nose and cough
 Feels hot
 Mum noticed lump in neck
What do you want to know?
What do you want to know?
 Well/unwell
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Location
Size
Heat
Other lymphadenopathy
 Spleen/liver
Micah, 2 years
 4-5cm diameter firm swelling in upper cervical chain
 Non-fluctuant
 A few other small lymph nodes
 No swallowing issues
 Well otherwise
Plan of action?
Plan of action?
 Do nothing?
 Investigations?
 Oral antibiotics?
 Intravenous antibiotics?
Causes of acute cervical
lymphadenopathy
 “Reactive”
 Infection
 Bacterial
 Atypical mycobacterium
 TB
 Other
Plan(s) of action
 Fluctuant node
 Incision & drainage/excision
 Well
 Oral antibiotics for 7-10 days – review in 48-72h
 Unwell
 IV antibiotics
 Investigations probably only indicated for persistent
adenitis (>2 weeks)
Take home points
 Acute adenitis
 If collection suspected, needs I&D
 Oral antibiotics & review appropriate for the majority of
well children
 Questions?
Case 3
Bethany, 6 years
 Awoke complaining of left hip and thigh pain
 Previously fit and well apart from an upper
respiratory tract infection 7 days previously
What else do you want to know?
What else do you want to know?
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Characteristics of the pain
Systemic features
Recent travel or systemic illness
Medication history
 (Trauma)
Bethany, 6 years
 Refused to weight bear
 Became very distressed at attempted examination
 Temperature 38.7
 Flushed & tachycardic
Differential diagnosis of the limping
child?
Differential diagnosis of the limping
child
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Transient synovitis/ ”reactive” arthritis
Septic arthritis/osteomyelitis
Perthes’ disease
Slipped Upper Femoral Epiphysis
JIA
Malignancy
Abdominal/testicular pathology
Discitis, Lyme disease, NAI
Red flags
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Severe & unremitting pain
Complete non-weight bearing
Pseudoparalysis
Night pain
Fever
Back pain
 Features of malignancy
Bethany, 6 years
 Differential diagnosis
 Septic arthritis
 Reactive arthritis
Investigations?
Investigations
 White cell count 11.5 x 109/L
 CRP 30mg/L
 ESR 15 mm/h
 Plain X-ray normal
 Urgent ultrasound – hip effusion
Kocher’s clinical prediction rule
 Factors
 Fever >38
 Unable to weight bear
 ESR>40mm/hr in the first hour
 Serum WCC >12x106/L
 Probability of septic arthritis
 No factors present <0.2%
 2 factors present 40%
 3 factors present 93%
 4 factors present >99%
Bethany, 6 years
 Presumptive diagnosis septic arthritis
 Joint aspiration & wash out
 Gran stain negative
 >50,000 white cells/mm3 on microscopy
 IV antibiotics for 2 weeks, oral for 4 weeks
Take home points
 Limping is a common presentation
 Limping is not a diagnosis
 Not all children need excessive investigation
 All children need clear follow up plans
Thank you!