Sneezing, Wheezing, Having Trouble Breathing

This chapter deals with one of the most common chronic diseases of childhood—asthma. It reviews the diagnosis of this disease and the acute emergency management of a pediatric patient who presents to the emergency department in respiratory distress from asthma. The current treatment modalities and indications for their use are discussed. Key points include that asthma diagnosis in the pediatric patient is largely clinical; early recognition and intervention are critical for successful management of asthma exacerbations; early administration of corticosteroids is important as it has been shown to reduce the rate of hospitalization; and routine chest radiographs do not play a part in the management of asthma.

Why Is My Child Shaking All Over?

Seizures are a common reason for pediatric patients to present to the emergency department for evaluation. Differentiating between the different categories of seizures is essential when determining the approach to evaluation and management of these patients. These categories include simple and complex febrile seizures, first time non-febrile seizures, and known epilepsy. There are no universal guidelines so understanding these categories can help the emergency provider obtain appropriate laboratory evaluation, neuroimaging, and possibly electroencephalogram as indicated. Management of pediatric seizures and special considerations are discussed, taking into consideration key history and physical exam findings.

Another Day, Another GI Bug

This chapter presents 3 cases of vomiting in children and explores less common diagnoses not to be missed by the astute clinician. The first case of a child with recurrent progressive vomiting has unusual lab abnormalities which leads to the final diagnosis of an inborn error of metabolism. The second case presents a child with several Emergency Department visits for vomiting and a skin finding leads to a final diagnosis of non-accidental trauma. The final case reviews a vomiting child with electrolyte abnormalities and an abnormal radiograph, leading to a diagnosis of malrotation with volvulus. Each case gives the clinician key pearls to distinguish these high risk cases from everyday gastroenteritis.

Tummy Ouchie

Intussusception is one of the most common abdominal emergencies in children. The classic triad of symptoms involves colicky abdominal pain, an abdominal mass, and red currant jelly stools, but this is seen in only about 15% of cases of children with intussusception. Early diagnosis and management reduce morbidity, risk for complications, and surgical intervention. Abdominal ultrasound is generally accepted as the gold standard for diagnosis. Treatment typically involves an air or hydrostatic enema; however, variability and controversies still exist in treatment and post-care management for nonsurgical cases. Variability also still exists in post-reduction care of children with intussusception. Feeding and monitoring times after nonoperative management differ between institutions. Some patients are advanced to feeds as tolerated while some others are placed in fasting to rest the bowel and prevent recurrence.

What Goes Down, Might Come Up!

In infants, vomiting is usually benign, but it can also portend significant underlying illness or injury. It is important to remember that although vomiting is commonly from the gastrointestinal (GI) tract itself, it may also be due to more generalized, systemic disorders or injuries (non-GI causes). As with most pediatric complaints a comprehensive history and physical exam is critical to direct both diagnostic testing and management. Remember the past medical history in infants includes neonatal history, growth and developmental history (include weight gain), social and family history. A history of bilious vomiting in an infant should always raise concerns occurs with obstruction, therefore, bilious vomiting always warrants evaluation.

Sugar and Spice . . . Not Always Nice

The case of a tachypneic 8-year-old exemplifies the diversity of etiologies for tachypnea and is a good reminder to avoid conformation bias given a patient’s history. In this case, the child has new onset diabetes and is in diabetic ketoacidosis (DKA). DKA is due to a deranged metabolism given the lack of insulin, leading to hyperglycemia, ketosis, and acidosis as well as dehydration. The chapter highlights the treatment including diligent rehydration and correction of acidosis. This is accomplished by restoring typical metabolic pathways with insulin all while closely monitoring and correcting changes in glucose and electrolytes. Finally, clinical symptoms are monitored closely to avoid pitfalls, which can include altered metal status, respiratory failure, cerebral edema, coma, and death.

No Poop

Hirschsprung’s disease and Hirschsprung-associated enterocolitis are functional disorders of the enteric nervous system leading to a functional bowel obstruction. Patients will often present in the first few days of life with delayed passage of meconium, abdominal distention, and poor feeding. Hirschsprung-associated enterocolitis is associated with increased morbidity and mortality and will present with signs and symptoms consistent with bowel obstruction, frankly bloody diarrhea, lethargy, fever, and, in severe cases, septic shock. Suspected cases should receive aggressive fluid resuscitation and broad-spectrum antibiotics. The gold standard for diagnosis is rectal biopsy and definitive management is surgical. Though many patients report some degree of bowel dysfunction later in life, a great number of patients do well.

The Not-So-Happy Wheezer

Bronchiolitis is a common viral infection of the lower respiratory tract that usually affects young infants. Bronchiolitis commonly presents with rhinorrhea, increased work of breathing, and wheezing, caused by inflammation in the bronchioles of the lung. Bronchiolitis remains a clinical diagnosis. Laboratory studies, viral panels, and radiographs are not helpful. Once the diagnosis of bronchiolitis is made, the next important step is to assess the severity of the illness since this will drive the treatment options as well as the disposition. Many therapeutic options such as albuterol, steroids, and hypertonic saline have been shown to not be effective. High flow oxygen as compared to continuous positive airway pressure therapy has been shown to be the only modality that decreases intensive care unit length of stay and intubation rates. Patients with mild/moderate cases of bronchiolitis can be discharged home, if they are able to maintain oxygen saturation of 90% with appropriate work of breathing, adequate oral intake, and reliable follow-up. In moderate to severe cases of bronchiolitis, care should be taken to monitor the vital signs and the respiratory status and escalate supportive care as necessary.

He Went Wee, Wee, Wee All Night Long

Hyperosmolar hyperglycemic syndrome is a condition occurring with increasing frequency in the pediatric population that carries a high mortality rate. Obese males of African American descent are most at risk. Diagnosis requires a high degree of suspicion as patients often present with nonspecific symptoms. A fingerstick glucose sample and laboratory testing are primary identifiers of type 2 diabetes mellitus. The hallmark of management of these patients involves aggressive fluid resuscitation and close management of their electrolytes. Patients may present with features of diabetic ketoacidosis, which presents a unique challenge to treatment. Complications such as rhabdomyolysis, malignant hyperthermia, and cerebral edema need to be identified early and managed promptly.

What’s This Pounding in My Head?

Headaches are a common chief complaint within the pediatric emergency department. They can be a source of significant morbidity in the pediatric population causing severe pain, cognitive dysfunction, and missed school days. It is critical that the physician delineates between life-threatening versus non-life-threatening etiologies of headache and obtain imaging of the head when appropriate. Computed tomography and magnetic resonance imaging are the modalities of choice. Each imaging modality presents advantages and disadvantages. Common causes of headaches in the pediatric emergency department include migraine, tension headaches, and viral illness. Physicians must be aware of more serious etiologies (such as space occupying lesions) that may warrant further investigation.