Pediatrics Review 2015
Dr. Andrea Boone, MD, FRCPC
Alberta Children’s Hospital
Foothills Medical Centre
University of Calgary
Disclosures

I have no financial disclosures or academic conflicts.
Objectives



Pediatric emergenices…in 50 minutes!
Review key pediatric emergencies – from neonates
to adolescents
Evidence base reviews of select emergencies
Fever: Neonate (0-28 days)


Full septic work up: CBC + diff, Blood culture, Urine culture,
lumbar puncture
Empiric antibiotics:


Ampicillin/cefotaxime or Ampicillin/Gentamicin
To cover typical bugs causing neonatal sepsis:





Group B Strep
E. Coli
Listeria monocytogenes
Chlamydia trachomatis
N. gonorrhea
Add acyclovir





Herpetic skin lesions
Seizure
Maternal history genital HSV
Abnormal LFTs
Fever: Infant (29-90 days)
Philadelphia
Rochester
Boston
Age
29-60d
<60days
28-89d
Temp
>38.2C
>38C
>38C
History
Not specified
Term infant
No perinatal Abx
No underlying disease
Not hospitalized longer than
the mother
No immunizations < 48h
No antimicrobial < 48h
Not dehydrated
Physical
Exam
Well-appearing
Unremarkable exam
Well-appearing
No ear, soft tissue or bone
infection
Well-appearing
No ear, soft tissue, or
bone infection
Labs (define
Lower risk)
WBC<15,000
Band-neutrophil ratio<0.2
UA <10 WBC/hpf
Urine gm stain: negative
CSF<8 wbc/hpf
CSF gm stain: negative
CXR: no infiltrate
Stool: no RBC, no WBC
WBC 5,000-15,000
Absolute band <1500/mm3
UA<10 WBC/hpf
Stool smear <5WBC/hpf
WBC <20,000
CSF<10/mm3
UA<10wbc/hpf
CSF < 10 WBC/hpf
CXR: no infiltrate
Fever: Infant (29-90 days)




Designed to detect low risk patients that could be
managed as outpatients
Boston criticized for higher WBC cut off resulting in
high rate of SBI (~5%) in patients identified as low
risk; requires empiric antibiotics
Philadelphia requires LP, but no empiric antibiotics
Rochester criteria, no LP, no empiric antibiotics, rate
of SBI in low risk infants < 1 %
Fever: Infant (29-90 days)
Approach – partial septic work-up:
Well appearing, >37 wks, no identifiable soft tissue
infection/source, not hospitalized longer than mom
 Low risk infants:

WBC: 5000-15000, < 1500 bands
 Urine cath R&M: WBC < 10 /hpf
 Stool analysis, only if diarrhea: < 5 /hpf

Discharge with 24 hour follow up pending cultures.
 No empiric antibiotics.
 If plan for empiric antibiotics (ceftriaxone 50 mg/kg), do LP.

UTIs in Children > 2 months


Check urine in 2-36 months with unexplained fever
Urine collection:

Not toilet trained, < 2 y/o
Urine cath or suprapubic aspirate for U/A, C&S
 Bag specimen – screen only. If positive, need cath for C&S (not
exam answer….do cath on exam)

Toilet trained



Mid stream/clean catch urine for R/M, C&S
Risk factors for UTI:



Uncircumcised male < 12 mo, circumcised < 6 mo
GU abnormalities
Female < 24 months, fever > 39 C without focus
UTIs in Children > 2 months

Management:
 Antibiotics
geared towards local susceptibility patterns
and usual bugs
 E.
Coli, Klebsiella, Serratia, Enterbacter, Citrobacter
 Common
 PO
choices cefixime, septra, clavulin
vs IV for uncomplicated febrile UTI > 2 months
 PO
acceptable provided HD stable, not toxic, tolerating po,
normal GU anatomy, with close follow up available
UTIs in Children > 2 months

Indications for ED Imaging:
 Not
clinically improving within 48 hours:
 Renal
Bladder US (RBUS) for ?abscess ?hydronephrosis to
suggest obstruction/high grade VUR

Indications for f/u imaging with family MD:
 1st
episode febrile UTI – RBUS indicated
 2nd episode febrile UTI - VCUG indicated
Case






2 yr old boy wakes up at 3 AM with difficulty
breathing
URTI sxs for 3 days. Hoarse voice and barky cough.
T 39, RR 48, HR 140, O2 sat 95%
Moderate distress. Stridor at rest. Indrawing.
Management?
Differential diagnosis?
Croup

Parainfluenza most common








RSV, influenza, adenovirus
Hoarse voice, barky cough, stridor
Young children, Peak fall and spring
Neck soft tissue xray if atypical, severe, not improving
Dexamethasone (0.6 mg/kg) for all, effect by 6 hrs
Nebulized Epinephrine effect by 30 min
Consider Nebulized Budesonide 2 mg if severe
Difficult airway!!!
Croup: Westley Croup Score


Mild 0-3, Moderate 47, Severe >8
Respiratory failure if
>12

Mild (0-2)
No stridor
 No to minimal indrawing


Moderate (3-5)
Stridor/indrawing at rest
 No distress/agitation


Severe (6-11)
Stridor/indrawing at rest
 Agitation/distressed


Resp. failure > 12

Lethargy/cyanotic
Retropharyngeal Abscess



Complication of Pharyngitis, Head & Neck
infections, Penetrating trauma
Grp A strep, oral anaerobes and S. aureus
< 6 yrs
 Retropharnygeal



lymph nodes regress
Stridor, sore throat, muffled voice
Neck pain and stiffness
Fever, unwell appearance
Retropharyngeal Soft Tissues *
Age (yrs)
Maximum (mm)
0-1
1.5 x C2
1-3
0.5 x C2
3-6
0.4 x C2
6-14
0.3 x C2
*
Retrotracheal Soft Tissues *
Age (yrs)
Maximum (mm)
0-1
2.0 x C5
1-2
1.5 x C5
2-3
1.2 x C5
3-6
1.2 x C5
6-14
1.2 x C5
*
Retropharyngeal Abscess

Complications
Airway compromise
 Erosion into carotid artery
 Aspiration pneumonia
 Mediastinitis
 Lateral pharyngeal space rupture
 Extension into spine




IV Ceftriaxone and Clindamycin
Consult ENT
Consider CT
Epiglottitis


Involves all supraglottic tissues
GAS, Strep pneumoniae
 H.influenza




rare
Rapid onset of severe sore throat, stridor, drooling,
sniffing/tripod position
Do not disturb patient
Consult Anesthesia, ENT- Intubate in OR
IV Ceftriaxone and Clindamycin
Bacterial Tracheitis




Toxic, unwell appearing
Severe Croup sxs – non responsive to treatment
Mortality 4%
Staphylococcus aureus




Also S. pneumo, H.influenza, M.catarrhalis, C.diphtheriae
ICU admission
Consult anesthesia if need intubation
IV Ceftriaxone and Clindamycin (or Clox, or Vanco)
Foreign Body Aspiration

Highest risk between 1 -3 yrs old


Immature dentition, poor food control
More common with food than toys


peanuts, grapes, hard candies, sliced hot dogs
Acute respiratory distress (resolved or ongoing)



Witnessed choking
Cough, Stridor, Wheeze, Drooling
Uncommonly…. Cyanosis and resp arrest
Inspiratory
Expiratory
Respiratory Emergencies - Bronchiolitis

Bronchiolitis
<
2 y/o, most common < 12 y/o
 “first episode wheeze”, clinically variable presentation,
viral URTI to severe LRTI
 Typically coryza, cough, variable WOB with
crackles/wheeze on exam
 RSV most common cause
 human
metapneumovirus, influenza, parainfluenza,
adenovirus
 Higher
risk – preterm < 35 wks, < 2 months of age,
Congenital heart disease, immunodeficiency
Respiratory Emergencies - Bronchiolitis

Investigations:
 Routine
labs not helpful, including NP swab
 CXR not helpful, misleading, leads to inappropriate
antibiotics
 Fever + bronchiolitis
 Neonate
– full septic work up, rate of SBI still high
 1-3 months – rate of UTI 5%, do urine cath C&W; rate of
bacteremia <1%; meningitis rare
 VBG/ABG
– only in impending respiratory failure
Respiratory Emergencies - Bronchiolitis

Management:
Supportive care is the mainstay
 Epinephrine – short term response, may trial
 Nasal suctioning – superficial/frequent; short term response
 Salbutamol – not recommended
 Hypertonic saline nebs – not recommended; some evidence
to support use in inpatient, need to give with epi as
bronchoconstrictor
 Epi + dexamethasone (Plint et al. NEJM 2009)


CanBest – one study, approached significance in reduction in
admissions, controversy re large steroid doses; not routinely
recommended
Respiratory Emergencies - Bronchiolitis
Indications for admission:
 Persistent
sats < 90% room air
 Dehydration requiring NG/IV fluids
 Significant WOB
 High risk infants
 History of apnea at home or in department
 Family not coping
Pertussis


Most commonly < 6 months
3 clinical stages:
Catarrhal – mild URTI symptoms, 1-2 weeks
 Paroxysmal – staccoto cough, post-tussive emesis, apnea,
classic whoop often absent < 3 y/o; 2-4 wks
 Convalescent – gradual resolution



Diagnosis – clinical, suspect if prolonged cough contact,
NP swab for C&S, PCR; CXR often normal
Management
admit if < young age, apnea, increased WOB
 Erythomycin to reduce spread of infection

Congestive Heart Failure

Left to Right shunts


Presentation at 1 month
Decreasing pulmonary vascular resistance 1st month of life


Symptoms



Increased blood flow into lungs
Irritability, Diaphoresis
Poor feeding (early fatigue), Failure to thrive
Signs



Tachypnea, Tachycardia, Respiratory distress
Enlarged liver
Gallop/murmur
Congestive Heart Failure

VSD most common


Other: ASD, PDA
Diagnosis
Pansystolic Murmur, Hyperactive precordium
 ECG – LVH
 CXR – cardiomegaly, vascular redistribution


ED Management
ABC’s, Glucose
 Furosemide 1mg/kg
 CPAP

Congenital Heart
Disease - Age of
presentation
Cardiac Emergencies: A Case








EMS call enroute with blue baby, 6 wk male
On arrival ++crying, RR 60 Sats 55% on 100% NRBM,
HR 180, BP 72/48, T 37.2 R glucose 5.1
CR 4 sec, mottled
Clear lungs.
Single S2. + systolic murmur
No hepatomeglay.
Benign abdo
Further history – term baby, poor feeding since birth,
poor weight gain, known murmur
Cardiac Emergencies: A Case
Tetralogy of Fallot




Right ventricular
outflow tract
obstruction (RVOTO)
Right ventricular
hypertrophy(RVH)
Overriding aorta
Ventricular septal
defect (VSD)
Cardiac Emergencies: Tet Spell
Pathophysiology:
 Worsening right to left shunt secondary to sudden
decrease in SVR
 Metabolic acidosis increases hyperpnea/preload
Precipitants:
 Crying, exercise (feeding), tachycardia, defecation,
hypovolemia
Management principles:
 Increase SVR, abort hyperpnea, correct hypoxia,
correct acidosis
Cardiac Emergencies: Tet Spell
Management:
 100% Oxygen - pulmonary vasodilation
 Knees to chest/squat – increases SVR
 Soothe child – stops crying/hyperpnea cycle/drops
venous return
 Fluid bolus 10-20 cc/kg – improve RV filling
 Morphine 0.1 mg/kg IV – anxiolysis
 Propranolol 0.1 mg/kg IV – reduces RVOTO spasm
 Refractory cases – HCO3/ketamine/phenylephrine
Case








2 yr old boy with fever for 6 days.
Red eyes but no discharge.
Generalized rash.
Erythema of the palms of hands and soles of
feet.
Red, swollen lips.
Enlarged cervical lymph nodes.
Diagnosis?
Complications?
Kawasaki Disease

Usually < 4 yrs old


peak 1-2 yrs
Fever for >/= 5 days and 4 of:
Bilateral non-purulent conjunctivitis
 Rash
 Changes of peripheral extremities

•
•


Initial stage: reddened palms and soles, edema
Convalescent stage: desquamation of fingertips and toes
Changes of lips and oral cavity
Cervical lymphadenopathy ( >1.5 cm)
Kawasaki Disease

Subacute phase - Days 11-21
 Desquamation
of extremities
 Arthritis

Convalescent phase - > Day 21
 If

untreated ~ 25% coronary artery aneurysms
Other manifestations:
 Uveitis,
Pericarditis, Myocarditis
 Hepatitis, Gallbladder hydrops
 Aseptic meningitis
Incomplete Kawasaki’s Disease
Incomplete
(Atypical)
 5 d fever

2 -3 criteria
AAP Kawasaki statement Newburger et al.
Pediatrics, 2004
Kawasaki Disease
Supplemental Lab Criteria
 ESR >40
 CRP >3
 WBC > 15 000/mm
 Anemia
 Platelets after 7 days > 450
 Elevation of ALT
 Albumin < 3
 Urine >10 WBC/hpf
Kawasaki Disease
Treatment

IV Immunoglobulin (2 g/kg)
Reduces coronary aneurysms to 3% if given within 10 days
of onset of illness
 Defervescence with 48 hrs


ASA
During acute phase high dose (80-100 mg/kg/day) then
low dose (3-5 mg/kg/day) for 6-8 weeks
 Stop if normal ECHO

Neonatal Jaundice

Most common neonatal presentation in 1st week of life

Unconjugated vs conjugated

Acute bilirubin encephalopathy
Early: High pitched cry, lethargy, hypotonia
 Late: Hypertonia, seizures, coma, death


Chronic bilirubin encephalopathy

Athetoid cerebral palsy, seizure d/o, deafness
HYPERBILIRUBINEMIA
Conjugated
Hemolysis
Immune
Blood group
•ABO
•Rh
•minor
Enzyme
•G6PD
•Pyruvate kinase
Non-immune
Membrane
•HS
•Poikilocytosis
•Elliptocytosis
Non-hemolytic
•Breast feeding associated
•Breast milk
•Sepsis
•Hypothyroid
•Bruising/cephalohematoma
•Polycythemia
•Hypoxia/Acidosis
•Intestinal obstruction
•Gilbert syndrome
•Lucey Driscoll
•Crigler Najjar (I, II)
Neonatal Jaundice

Key components of assessment:
 Septic
risk factors?
 PPROM,
 Septic
GBS +, intrapartum fever, prior neonate with GBS
behaviour?
 Poor
feeding, irritability, lethargy, vomiting, colour change,
difficulty breathing, decreased urine output
 Unwell
appearing neonate?
 Pallor,
mottling, irritability, lethargy, high pitched cry,
abnormal vital signs, weight loss > 10% of birth weight
Neonatal Jaundice

Investigations:
 Total
serum bilirubin (TSB) + direct (conjugated)
bilirubin
 CBC, Blood group, DAT (direct antibody test=Coombs
test)
 Consider: Septic work up – blood culture, urine culture,
lytes, creat, VBG
 ~8% of jaundice requiring treatment have UTIs (even in
absence of symptoms/signs of infection) – so check
urine if meet treatment threshold
Neonatal Jaundice
Risk Factors:
•
•
•
•
•
•
•
•
Isoimmune
hemolysis
G6PD
Asphyxia
Resp distress
Lethargy
Temp
instability
Sepsis
Acidosis
Neonatal Jaundice

Management:
 Start
intensive phototherapy
 Consider IV fluids
 Keep baby warm
 Consider IV antibiotics if concerning for sepsis
 Check exchange transfusion chart!
Case







3 week old boy vomiting every feed for 24 hours.
Vomit is yellow/green. No diarrhea. Dry diaper since
this morning.
HR 180, RR 40, T 37.2 R. Irritable and restless.
Eyes sunken. Mouth dry. Cap refill 5 sec.
Abd distended and diffusely tender.
What is your approach to this infant?
Differential diagnosis?
Volvulus

Malrotation with midgut volvulus


Short small bowel mesentery, ligament of Treitz poorly fixed
Twisting of the bowel around the superior mesenteric artery

Sudden onset of bilious vomiting, usually 1st month of life

Acute abdomen with shock





Bowel ischemia and necrosis, GI bleeding
ABC’s, Fluid resuscitation, Glucose, NG tube
Plain AXR – cannot rule out
Upper GI series – definitive test
Emergent surgery
Pyloric Stenosis

4-6 weeks of age
Male to female 4:1, first born males
5% of siblings and 25% if mother was affected

Symptoms of gastric outlet obstruction


Non-bilious vomiting
 Emesis increases in frequency and eventually becomes
projectile
 Peristaltic wave, palpable mass in epigastrium “olive”




Labs – hypochloremic hypokalemic metabolic alkalosis
Ultrasound
Rehydration, correction of metabolics prior to surgery
Case








1 yr boy with vomiting and diarrhea since last night.
This morning he had three loose stools with blood.
He cries intermittently in cycles of 10 to 20 minutes.
T36.5, HR 118, RR 40, BP 100/50.
Pale and lethargic.
Abd soft, mild tenderness. Mass palpable in RLQ.
Investigations?
Diff Dx?
Intussusception
Usually invagination of ileum into cecum (75%)
 6 months to 3 yrs



Males to female 3:2
90% are idiopathic
Post viral illness – hypertrophy of Peyer patches
 Pathologic causes - Meckel diverticulum, polyps,
hematoma (Henoch-Schonlein Purpura),
lymphoma/leukemia, cystic fibrosis

Intussusception

Classic triad present in 10-30%



Intermittent, crampy abdominal pain
Vomiting
“Currant jelly" stools




Late sign, indicates intestinal edema and mucosal bleeding
Lethargy in 25%
Ultrasound (Sens 97-100%, Spec 88-100%)
AXR (Sens 45%, Spec 21%)


Lack of air in RLQ, obstruction
Target sign, Crescent sign
Intussusception
Plain AXR:
 Paucity of air in RLQ
 Absent liver edge
 Obstruction
 Target sign
 RUQ
mass, sometimes looks
like a target

Crescent sign
 Intussceptum
lead point
protruding into gas filled
pocket
Management:

Air Contrast Enema
•
•

Recurrence rate 10-15%
•
•

Success rate 95%
Bowel perforation in 1-3%
50% within first 24 hrs
Other 50% within 10 mos
Admit for observation
Case





4 yr old with bruising to both
legs today
Pain with walking, swollen
ankles.
Abdominal pain with blood in
stool.
Diagnosis?
Complications?
Henoch-Schonlein Purpura



IGA mediated vasculitis
2-11 yrs
Rash 100%


Arthritis 70%


Ankles > knees >wrists > elbows
Abdominal pain 50%


Palpable petechiae/purpura, can be urticarial, buttock/leg
Intussusception 2%
Nephritis 40% (ESRD in ~1%)
Henoch-Schonlein Purpura

Investigations

CBC, PT PTT, Lytes, BUN, CR; Urinalysis
Prot, Alb, Immunoglobulins
 Strep testing – Throat swab, ASOT



Weekly U/A and BP until sxs resolve then monthly for 6 mos
Treatment
NSAID’s for pain relief
 Consider steroids for abdominal, testicular, CNS involvement



Controversial for renal complications
Nephrology consult if hypertension, nephrotic sx’s
Case



4 yr old with 2 week history of polyuria and
polydipsia
Very sleepy today. Complaining of headache.
Normal vital signs. Tired but arousable. Dry MM.
Eyes sunken. Normal cap refill.

Blood sugar at triage “HIGH”

Initial Management?
Diabetic Ketoacidosis
DKA Diagnostic criteria:
 pH<7.30 and/or HCO3<15 mmol/L
 random serum glucose > 11.1 mmol/L
 + urine ketones
Symptoms


Polyuria/Polydipsia, Wt loss
Abdominal pain, Fatigue
Signs




Kussmaul respirations
Ketotic breath
“Look dry”; usually mild-mod dehydration
CNS changes – headache, confusion, irritability, lethargy
Diabetic Ketoacidosis


Cerebral edema in 0.7-3.0%
Patient risk factors





Age < 2 years
New onset DM, Longer duration of Sx
More severe dehydration – high urea, K+, hct
Greater acidosis - Low initial pC02, pH < 7.1
Treatment risk factors





Rapid administration of hypotonic fluids
IV bolus of insulin
Early insulin infusion
Failure of serum Na to rise during treatment
Use of NaHCO3
Wolfsdorf J et al. Pediatric Diabetes 2014
Diabetic Ketoacidosis

Fluid bolus only if hypotensive
 10


ml/kg over 30-60 min
Calculate fluids based on 10% dehydration
replaced over 48 hrs; do not exceed 2x
maintenance
NS + 40 meq KCl/L (if voiding and K<5)
Diabetic Ketoacidosis

Start Insulin infusion 1-2 hrs after IV fluids
 Insulin



0.05 – 0.1 units/kg/hr
No Insulin bolus
No Bicarbonate
Monitor hourly VS, neurovitals, glucose
 Gas,
lytes, osm, urine ketones q2-4h
Diabetic Ketoacidosis
Cerebral Edema
 For headache alone
Raise head of the bed to 30o
 Decrease fluids to maintenance


If altered LOC (GCS<10)
3% Saline 5 cc/kg over 20 min
OR
 Mannitol 0.5 gm/kg iv over 20 min
 Prepare for intubation
 STAT CT scan

Febrile Seizure

Simple Febrile Seizure
T>38.5
 6 mo-5 yr
 Generalized seizure, < 15 min
 One seizure within 24 hours
 Neurologically normal before and after


Occur in ~ 5% of children
Recurrence in 30%

Management – as per fever management.

Febrile Seizure

Risk of epilepsy is 1%
 Epilepsy

in general population 1%
Higher risk (2.4%) if:

Complex febrile seizures
2
or more in 24 hr
 Prolonged > 15 min
 focal
<
12 mos at the time of first febrile seizure
 Family history of epilepsy
Seizure Management
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ABC’s, Check Glucose
Extended lytes
Anticonvulsant levels
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Phenytoin, Phenobarbitol, Valproic acid, Carbamazepine
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Anion gap, Osm gap, ASA, Acet, Toxic alcohols
Septic work up? Imaging?
Consider ingestion
1st line - Benzodiazepines
2nd line – Fosphenytoin or phenytoin, Phenobarb
3rd line - Midazolam infusion
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Other – Thiopental, Pentobarbitol, Paraldehyde, Propofol,
Valproic acid, Topiramate, Levetiracetam
Status Epilepticus
CPS Guidelines
Paediatr Child Health
2011;16(2):91-7
Minor Head Injury: CATCH
CATCH - Canadian Assessment of Tomography for
Childhood Head Injury
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Inclusion criteria
Witnessed loss of consciousness or disorientation
 Definite amnesia
 Persistent vomiting (two or more distinct episodes of vomiting
15 minutes apart)
 Persistent irritability in the ED if < 2 yrs
 GCS > 13 in the ED
 Injury within the past 24 hours.
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Osmond et al,
CMAJ 2010
Minor Head Injury: CATCH
Osmond et al,
CMAJ 2010
Minor Head Injury: CATCH
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Subsequent multi-centre validation of CATCH rule
Sensitivity of 87% with 4 high risk factors
Sensitivity of 98% with 7 high and medium risk factors
Required 38% of patients to undergo CT
Main criticism:
increased rate of CT likely due to inclusion of all MVCs and
boggy hematoma
 Poor sensitivity with high risk criteria – missed 4 ciTBI EDH
 Improved sensitivity with 7 criteria but still missed 1 EDH
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Osmond et al.
CJEM. Vol 14. S1, 2012
Minor Head Injury: PECARN
Identification of children at very low risk of
clinically-important traumatic brain injuries:
 Inclusion criteria
 Any
child with injury < 24 hours
 GCS 14-15
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Looks at who does not need a CT rather than who
needs a CT
Kupperman et al,
Lancet 2009
Minor Head Injury: PECARN < 2 y/o
Kupperman et al,
Lancet 2009
Minor Head Injury: PECARN > 2 y/o
Kupperman et al,
Lancet 2009
Minor Head Injury
Optimal clinical decision rule not yet established
 PECARN vs CATCH vs CHALICE
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 Single
site external validation comparing physician
judgment to 3 decision rules
 Physician judgment and PECARN only rules to identify
all clinically important TBIs
 Both CATCH and CHALICE missed clinically important
TBIs
 CATCH had lowest specificity (Sens 91%, Spec 44%
Annals of EM. 64 (2). Aug 2014
Child Abuse
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Suspect if history vague, changing, inconsistent with
degree of injury or child’s development
Bruises
 Can not date bruises by color
 “If they don’t cruise they don’t bruise”
 Uncommon
for toddlers to bruise buttocks, genitalia,
inner arms or legs, neck or trunk
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Patterned marks – linear, hand prints
Bites – adult if > 3 cm
Child Abuse
Fractures
 Metaphyseal (corner, bucket handle)
shearing force from shaking
 usually < 1yr
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Posterior ribs
Femoral in non-ambulatory child
Scapular, sternal, spinous process
Multiple fractures, different ages
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Low risk – clavicle, tibia in toddler
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Child Abuse
Skull fractures
 Multiple, occipital, wide
Retinal hemorrhages
 Multiple layers with peripheral extension
 most
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specific for abuse
Bilateral, flame shaped
 uncommon
in accidental trauma (<1.5%)
Child Abuse
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Admit all children < 2 yrs
Skeletal survey for < 2 yrs (consider for 2-5 yrs)
CT head if < 1 yr
Opthalmologic exam
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within 24 hours (must be <72 hrs)
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Arrange clinical photography of marks/bruises
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Mandatory reporting to child welfare agency
Questions?
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Thank you!