Pediatric Overview

Pediatric Overview
• Pediatric emergencies are rare and they are high stakes
• Drug dosing and equipment size is different
• Know what is normal
• Good news: more likely to successfully resuscitate a child than a nursing
home patient
• Set up a system for success
• Estimating weight by age
o 1 year old !! 10 kg
o 3 year old !! 15 kg
o 5 year old !! 20 kg
o 7 year old !! 25 kg
• Can use the formula (age x 2) + 10 = estimated weight in kg
• Estimating normal heart rate (HR) and respiratory rate (RR)
o 0-1 year old !! HR 140 and RR 40
o 1-4 year old !! HR 120 and RR 30
o 4-12 year old !! HR 100 and RR 20
o >12 year old !! HR 80 and RR 15
• Estimating blood pressure (5th percentile)
o Neonate !! 60 mmHg
o Infant !! 70 mmHg
o 1-10 year old !! (age x 2) + 70
o >10 year old !! 90 mmHg
• Children have a predisposition for respiratory failure compared to
adults
o High resting metabolic rates !! use up oxygen quickly
o Young children have an anatomical predisposition to respiratory
failure
o 95% of all cardiac arrests are related to respiratory etiology
• Children have increased sympathetic tone !! hold onto their blood
pressure until lose almost half of blood volume !! decompensate suddenly
• Access can be a problem in children !! use the intraosseous (IO) needle,
locations:
o Proximal tibia
o Distal tibia
o Distal femur
o Proximal humerus
o Sternum (age> 5 years old)
o Anterior iliac spine
o Distal radius
o Clavicle
 o Os calcis
o Complication rate of IOs are low if examine and maintain them, ex.
look for extravasation
• Do simulations: run through steps and anticipate problems
o Practice critical cases with nursing staff
o Equipment familiarity
o Minimize human error !! use Broselow Tape, applications, and
perform simulation

Pediatric Resuscitation
Pediatric Resuscitation
• Children have more of a predisposition for respiratory failure: 95% of cardiac arrests are from a
respiratory etiology
• Children have increased sympathetic tone: can maintain blood pressure during sepsis or
hemorrhage for a long time ! suddenly crash

Sepsis
• Sepsis hemodynamics
o Hypotension is a late finding in children
o Cold shock is more common than warm shock
• Sepsis treatment goals: improve perfusion
o Distal pulses = central
o Capillary refill < 2 seconds
o Normal mental status
o Normal urinary output
o BP > 5th percentile for age
o Lactate <4 mmol/L
o Hgb > 10 g/dL
o ScvO2 > 70% (if available)
• Treatment
o Aggressive IV Fluids: 20 mL/kg crystalloid ! up to 60 mL/kg over 5 minutes
o Goal with IV fluids: improve perfusion or fluid overload
o Administer antibiotics in < 1 hour
o Supplement with glucose if hypoglycemic
o Supplement with calcium if ionized calcium is low: infants rely on extracellular calcium for
cardiac contractility (ionotropic affects)
• Caution in aggressive fluid resuscitation in a resource-limited setting

Vasopressors
• Dopamine if poor perfusion, (more commonly used in children)
• Cold shock: hypotensive and vasoconstricted ! epinephrine (need more Beta-1 support due to
children having high SVR and decreased cardiac function)
• Warm shock: hypotensive and vasodilated ! norepinephrine (need increased SVR)
• Milrinone is often used in children: ionotropic agent which improves contractility
Intubation
• Success rate improved using RSI
• Atropine: controversial
o No minimum dose
o Children become bradycardic with increased vagal stimulus
o Children tolerate tachycardia well (better than bradycardia)
o Have atropine available at the bedside ! in emergent intubations children are more likely to
develop bradycardia
o PALS recommends atropine for every child under 1 year of age, and under 5 years of age
when using succinylcholine
• Avoid etomidate in sepsis

Resuscitation Mechanics
• Compressions
o Hard (1/3 AP diameter) and fast (100-120/min)
o End-tidal CO2 ! monitor CPR quality (no established value in children)
• Ventilation
o 15:2 if no advanced airway
o 1 breath/6 seconds (10 breaths/min) with continuous chest compressions

PALS Continued
• Consider reversible causes of asystole and PEA
• Shock with 2-4 J/kg (max 10 J/kg) in VF/VT
• Veno-arterial ECMO
o Improved survival in reversible underlying disease processes (ex. myocarditis, asthma)
• Post-Arrest Care
o Avoid hyperthermia
o Normoxia (>94%)
o Maintain SBP>5th percentile for age ! parenteral fluids and/or inotropes/vasoactive drugs

Neonates and Young

Infants
Neonates
Normal and Abnormal Signs and Patterns
• Neonates breastfeed q1-3 hours
• If bottle-fed (formula) 2-4 oz q2-4 hours (~6-9 feeds in 24 hours)
• Initially lose weight after birth !! at 10 days = birth weight

Jaundice
• Not normal to have jaundice in first 24 hours
• Not normal to have conjugated hyperbilirubinemia
• Many etiologies of jaundice
 o Physiologic (normal) jaundice occurs day 2-3 related to immaturity
o Breast feeding refers to a relative dehydration (ex. delay in milk)
exacerbating physiologic jaundice
o Breast milk has an inhibitor of bilirubin conjugation
o Infection can cause jaundice
o Consider hemolysis
• Jaundice work up
o Direct/indirect bilirubin
o CBC
o Blood type
o Peripheral smear (hemolysis)
o Reticulocyte count
o Antibody titer
o Liver function
• Jaundice: plot bilirubin level on nomogram !! determines risk zone and
need for treatment
o >25 !! exchange transfusion
o >18 !! treatment (phototherapy)

Crying
• Neonates cry, our job is to determine if any abnormalities
• Obtain a good history: social history, screen for non-accidental trauma
• Perform a thorough physical exam !! head-to-toe:
o Look for atypical bruising
o Look for frenulum tear
o Consider testicular torsion
o Look for hair tourniquets
o Fluorescein the eyes
o Consider infection
• To comfort crying children: 5 S’s (Harvey Karp) !! recreate environment of
the womb
o Suck
o Swaddle
o Shush
o Sway
o Side position

Omphalitis
• Omphalitis: erythema on abdominal wall
o Very concerning = necrotizing fasciitis of the abdominal wall
o Risk for sepsis and peritonitis

Sick Neonate
• Top five etiologies of sick neonate
o Sepsis
o Cardiac
o Metabolic
o GI Catastrophe
o Non-accidental trauma (NAT)
Sepsis
• At risk for infection due to decreased immunity (do not fight or localize
infections), increased risk for serious bacterial infections, and have an
unreliable exam

Congenital Heart Disease

• Congenital heart disease: over half is undiagnosed at birth !! present with
ductal dependent lesions in first month of life or CHF in young infant
• Patients with ductal dependent lesions affecting pulmonary blood flow will
present with (hypoxia) cyanosis !! administer prostaglandin E1
• Patients with ductal dependent lesions affecting systemic blood flow will
present with acidosis/shock (not responsive to fluid) !! administer
prostaglandin E1

GI Catastrophes
• Necrotizing enterocolitis (typically in ex-premie): pneumatosis intestinalis,
presents with feeding intolerance, distended abdomen and bluish
discoloration
• Bilious vomiting and feeding intolerance = surgical emergency

Metabolic Emergencies
• Hypoglycemia is most common: in neonates administer 5 mL/kg of D10W,
Glucose “Rule of 50”, do not give higher concentrations of dextrose
because can sclerose their veins
• Life-threatening inborn errors of metabolism (IEM) cause metabolic
acidosis, hypoglycemia, and hyperammonemia
• IEM treatment
o Resuscitation: respiratory support and IV fluids
o Treat for sepsis
o NPO !! eliminate harmful proteins/sugars
o Replete glucose @ D10 1.5x maintenance
o Control seizures
o Correct hyperammonemia, metabolic acidosis and electrolyte
abnormalities

ALTE / BRUE
• BRUE = brief resolved unexplained event
• Chief complaint, not a diagnosis
• Acute concerning change in breathing, appearance, and/or behavior
• Heterogeneous etiology
o Reflux
o Neurological cause (seizure)
o URI (ex. central apnea from bronchiolitis)
o NAT
o Sepsis
• Order tests based on history and physical exam
• Admit if physiologic compromise suspected (ex. child limp, changed color,
 suspicious circumstances)

SIDS / SUID
• The sudden death of an infant that remains unexplained after a thorough
investigation
• Peak incidence is 2-4 months
• Prone sleeping position !! strongest modifiable risk factor (decreased
incidence)

Neonatal Resuscitation
Neonatal Resuscitation
Basics
• At full term during the time of birth:
o 85% initiate spontaneous respirations within 10-30 seconds
o 10% respond to drying and stimulation
o 3% need PPV (positive pressure ventilation)
o 2% need intubation
o 0.1% require chest compressions
• Initiate PPV if heart rate < 100
• Initiate compressions if heart rate < 60
• CPR technique
o Two thumb technique is superior during CPR than two finger
method
o 3:1 ratio of compressions:ventilations (~90 compressions/min) if no
advanced airway
o Compression rate 120/minute continuous if intubated
• Medications and equipment:
o Intubation equipment
o Epinephrine
o IV Fluids
o Blood
o Antibiotics
• Criteria for withholding support
o <23 weeks
o <400 grams
o Severe congenital anomalies
• Use room air and titrate oxygen up as needed
o Initial normal O2 saturation can be 70’s
o Keep in mind it normally takes 10-15 minutes until oxygen
saturation improves due to open ductus arteriosus
• Ventilation is the priority
• Cardiac arrest is usually due to respiratory etiology
• Discontinue resuscitation after 10 minutes if no heart rate
 Pediatric Fever
Pediatric Fever
• Most children have self-resolving fever from viral infection and will do well
• It is important to consider serious bacterial illness (SBI) every time a child
presents with a fever
o Meningitis
o Bacteremia
o Sepsis
o Bone and joint infections
o UTI
Pneumonia
o Bacterial enteritis
• Children are evaluated differently based on age: decreasing risk of SBI
with age

Febrile Neonate
• Neonates have decreased immunity and increased risk of SBI
• Neonates have an unreliable exam
• 12% of neonates have an SBI when febrile
• Work up is extensive: full septic work up
o Blood cultures
o CSF (perform lumbar puncture)
o Urinalysis and urine culture
o CBC, electrolytes
• Admit for IV antibiotics
o Ampicillin
o Cefotaxime (better CSF penetration) or gentamycin
o Add acyclovir with maternal history of herpes or if lesions/vesicles
present, or pleocytosis in CSF
o Add vancomycin in a very sick neonate or if prior NICU admission

Febrile Infant: 4-8 Weeks

• Controversial age, consider full septic work up
• Lumbar puncture: controversial, most likely need to obtain CSF
• Can use ceftriaxone at this age (do not use in younger age due to
displacement of bilirubin, avoid kernicterus)

Febrile Infant: 8 Weeks+

• At two months of life the child has increased immunity, decreased risk of
SBI (<5%) and is more interactive
• Perform lumbar puncture based on clinical exam
UTI
• Most common SBI due to vaccinations
• Risk factors for UTI
o Girls < 2 years old
o Uncircumcised boys (especially under 3 months and up to age 1
year old)
o Prior UTI
o Temperature > 39 C
o Fever without a source
o Fever > 24 hours
o Nonblack race
o Ill appearance
o Suprapubic tenderness
• Best work up in an infant: obtain a catheterized specimen and a urine
culture
• Young infants do not hold urine in their bladder long enough to develop
WBCs/leukocyte esterase (only 83-94% sensitive), and nitrites are only
95-99% specific but not sensitive

Pneumonia
• Pathogens !! treatment varies based on age
o Neonates: Group B Strep, gram negative enteric bacteria, Listeria,
Chlamydia !! same antibiotics as septic neonate
o Infants/Toddlers: Viral (RSV, influenza, parainfluenza,
metapneumovirus, adenovirus), Bacterial (strep pneumoniae,
haemophilus, Staph aureus, pertussis, atypicals) !! over 3 months
of age administer amoxicillin (high dose)
o >4-5 years of age: Mycoplasma !! macrolides
• If neonate has afebrile staccato cough (chlamydia) !! azithromycin

Bacteremia
• Incidence is < 1% in the general population
• More likely to obtain a false positive if draw blood cultures when not
indicated in a febrile child

Otitis Media
• Treatment guidelines:
o Bilateral otitis media
o Severe symptoms
o Symptoms for several days
o Less than 6 months of age
 • Option to watch and wait !! provide prescription to fill 48 hours later if child
has not improved
• Antibiotics:
o High dose amoxicillin 80-90 mg/kg/day
o Increase to Augmentin (amoxicillin-clavulanate) if recently treated
for otitis media, or if they have bilateral conjunctivitis (suggests
haemophilus influenzae that is resistant to amoxicillin)

Lymphadenopathy
• Normal sizes: 1 cm axillary and cervical, 1.5 cm inguinal, and 0.5 cm
epitrochlear lymph nodes
• Lymphadenitis: 80% unilateral, cervical due to staph or strep !! may have
abscess formation (obtain ultrasound and may need to drain)

Pediatric Cardiac
Emergencies
Congenital Heart Disease (CHD)
• Over half of all congenital heart disease remains undiagnosed at birth !!
shows up with complications to the ER
• Two ways CHD presents: neonate with ductal dependent lesions and 2nd-
6th months presents with congestive heart failure

Ductal Dependent Lesions

• Presents in first week of life up until about 1 month
• Two types of ductal dependent lesions: one is dependent on pulmonary
blood flow and the other is dependent on the ductus for systemic blood
flow
• When dependent on pulmonary blood flow !! presents with cyanosis (not
responsive to oxygen)
• When dependent on systemic blood flow !! presents with shock (appear
septic and not response to fluids, may get worse with fluids)
• Treatment: Prostaglandin E1: hypoxic/cyanotic or shocky/acidotic baby
• Prostaglandin E1
o Monitor for side effects like apnea
o Consider differential diagnosis and treat concomitantly with IV fluids,
antibiotics (cover for sepsis), glucose, supportive care
o Transfer to facility with pediatric cardiovascular surgeon
Congestive Heart Failure in Infants
• Presents with respiratory symptoms
o Wheezing (looks like asthma)
o Retractions
o Tachypnea
• Presents with difficulty feeding
o Sweating or crying with feeds
o Infant stress test
o Failure to thrive
• May have hepatomegaly, more common than peripheral edema
• Work up with chest Xray, EKG, labs, echocardiogram if available
• Treatment: supportive care and admission

Arrhythmias
SVT
• Heart rate >220 in infant and >180 in a child
• Treatment:
o Vagal maneuvers: ex. ice to the face, blowing through a syringe,
holding toddler upside down by ankles
o Adenosine 0.1 mg/kg
o Cardioversion 0.5-1 J/kg

Acquired Heart Disease

• Pericarditis
• Endocarditis
• Kawasaki Disease
• Cardiomyopathy
• Myocarditis
o Myocardial inflammation / necrosis
o Young infants: fulminant disease !!75% is fatal
o Adolescents may present after a viral syndrome and subsequently
decompensate quickly
o Treatment: supportive care and ECMO

Pediatric Chest Pain

• Most is not cardiac
• Obtain a good history, EKG and chest Xray
• Pediatric EKG
o Right heart dominant at birth: RVH
o Heart rate is faster
o Intervals are shorter (except QTc in infants)
 o T wave inversions V1-V3 are normal (Juvenile T Waves persistent
into adolescence)
o Q waves in inferior/left precordial leads

Pediatric Respiratory
Emergencies
Respiratory Emergencies
URI
• Very common
• Most of the time self-limited and self-resolving
• Most coughs last 2 weeks
• Treatment:
o No cough medication for children under 4 years old
o OK to recommend honey over 1 year old (in younger child, risk of
botulism)

Croup
• Classical history: may be preceded by URI !! wake up in the middle of the
night with barking cough and increased work of breathing
• Every child that presents to the ER with croup gets a dose of steroids:
o One dose of dexamethasone: dose is 0.15 mg/kg up to 0.6 mg/kg
o No difference in outcome with range of dosing
o Decreases recurrence and severity of croup
• Mild, moderate and severe croup
• If increased work of breathing / respiratory distress and stridor at rest
o Nebulize epinephrine
o Observe for 2 hours to ensure increased work of breathing does not
return
• Differential diagnosis of croup
o Epiglottitis (rare)
o Bacterial tracheitis (longer course of symptoms than croup and
appear very sick) do not respond well to steroids / epinephrine
!! most need intubation, staph aureus most common etiology
o Peritonsillar abscess
o Uvulitis
o Retropharyngeal abscess
o Allergic reaction
 o Foreign body aspiration
o Neoplasm

Bronchiolitis
• Diagnosis made on history and physical exam
• Typically occurs in children < 2 years old
• Occurs November through April (peak is January and February)
• Classic presentation: O2 saturation 89%, tachypnea, nasal flaring,
intercostal retractions, often have secretions
• Exam: fine rales, diffuse / fine wheezing
• Be aware of apnea in neonates and ex-premies
• High morbidity and mortality in young children
• No good treatment, AAP states do not give:
o Albuterol
o Epinephrine
o Hypertonic saline
o Corticosteroids
o Oxygen (if >90%)
o Chest physiotherapy
o Antibiotics
• Clinically in the Emergency Department, treatment to try:
o Suction
o Oxygen
o NPPV (Non-Invasive positive pressure ventilation if needed), ex.
nasal cannula
o May try albuterol (especially if family history of asthma), nebulized
hypertonic saline (may decrease hospital length of stay) and
nebulized epinephrine (may decrease work of breathing)
• No role for steroids or routine antibiotics
• Bacterial superinfection is very rare in bronchiolitis: if obtain an Xray may
have some diffuse fluffy infiltrates / atelectasis !! end up treating for
“pneumonia” with antibiotics when it is not indicated
• Bronchiolitis admission:
o Hypoxia
o Tachypnea (>70-80 bpm)
o Respiratory distress (retractions)
o Comorbid conditions
o Ex-premie
o Central apnea
o PO intolerance
o Low threshold in neonate/young infant to admit (can die)

Pertussis
• The cough of 100 days with three stages:
 o Catarrhal stage: nasal discharge
o Paroxysmal stage: episodes of persistent coughing with “whoop,”
may have posttussive emesis, subconjunctival hemorrhage /
petechiae from coughing, or infants may have apnea
o Convalescent stage: episodic cough
• Think about exposure to infants and the elderly due to mortality associated
with pertussis

Pediatric Asthma
• Asthma still kills children
• Most common medical condition of children that is of consequence
• Do not under-dose albuterol in status asthmaticus, children can tolerate
high doses over 20 mg/hour !! treat aggressively
• MDIs are better tolerated than nebulizer in children (do not use in status
asthmaticus)
• Any child (or infant) can use an MDI with a spacer
• Two doses of dexamethasone can be administered (instead of
prednisolone) !! one dose in the ER (0.6 mg/kg) and second dose on day
2 or 3
o Can give IV dose of dexamethasone PO
o Second dose: pills can be crushed up and put in food (ex.
applesauce)

Pediatric Neurologic
Emergencies
Seizures
Status Epilepticus
• Children have lower seizure thresholds than adults
• Initiate treatment early
• Do not be afraid to use the IO (intraosseous device)
• Check the glucose
• First line treatment
o Benzodiazepines 0.1 mg/kg, administer at least two good doses
• Second line treatment: 20 mg/kg, choose two second line agents
o Phenytoin/Fosphenytoin
o Phenobarbital (use in NICU and young infants)
o Levetiracetam
 o Valproic Acid (do not use in children under 2 years old due to risk of
metabolic abnormalities !! can cause hepatotoxicity)
• If patient is in refractory status after two doses of benzodiazepines and
two second line agents !! secure the airway and start a third line
treatment
o Midazolam drip (0.05- 2mg/kg/hour)
o Pentobarbital (5-15 mg/kg bolus, then 0.5-5 mg/kg/hour)
o Propofol (2 mg/kg bolus, then 1-15 mg/kg/hour)
o Ketamine (0.5 – 2 mg/kg/hour)
o Administer pyridoxine in the cases of refractory status, ex. due to
INH toxicity, inborn error of metabolism, and in some cases patients
respond for unclear reasons
• Determine why the patient is in refractory status
o Check the glucose and recheck the glucose !! use “Rule of 50” to
replace (ex. 5 mL/kg of D10W)
o Hyponatremia: during active seizure administer 3% NaCl @ 5
mL/kg over 20 minutes (if no seizure give over one hour) !! avoid
central pontine myelinolysis
o Hypocalcemia !! 10% calcium gluconate, 0.3 ml/kg over 5-10
minutes (ex. undiagnosed DiGeorge Syndrome)
o INH Toxicity !! administer pyridoxine (vitamin B6) 70 mg/kg,
maximum 5 grams

Simple Febrile Seizure

• Simple febrile seizures:
o Occur in children 6 months – 6 years
o Generalized seizure lasts < 15 minutes
o Generalized tonic-clonic seizure
• Work up as a child with a fever
• Manage underlying cause of fever
• Very well appearing !! typically only require parental reassurance

Complex Febrile Seizure

• Complex febrile seizures:
o Seizure lasts > 15 minutes
o Focal seizure (not generalized) = most concerning type
o Recurrent in 24 hours (some children with two febrile seizures in 24
hours and appear well, are fine)

First Time Afebrile Seizure

• In first time afebrile seizures, obtain emergent imaging for:
o Persistent AMS
o Focal deficit
o <1 year of age
 o Suspicious circumstances (do a thorough history and exam)
• First time afebrile seizures do not need medications and 40% have
recurrence !! need outpatient follow up, MRI and EEG

Neonatal Seizures
• Neonatal seizures can be very subtle
• Examples of neonatal seizures
o Lip smacking
o Fine movements of hands
o Eye deviation
o Bicycling motion of legs
• Neonatal seizures are almost never benign
• Need full septic work up and admission

Altered Mental Status

• Perform a good history and physical
• Check the sugar
• Low threshold to treat infection / meningitis
• Consider toxic exposure
• Consider non-accidental trauma
• Consider intussusception (presents with lethargy, intussusception is the
most common abdominal emergency in infants)

Stroke
• More common than brain tumors
• Childhood mortality: top 10
• About 50% of strokes are hemorrhagic
• Often do not make the diagnosis in a timely manner because the
differential of more likely causes is extensive:
o Todd’s paralysis
o Migraine
o Encephalopathy
o Non-accidental trauma
o Seizure
o Demyelination
o Meningitis
o Hypoglycemia
o Brain tumor
o Inborn errors of metabolism
o Postinfectious cerebellitis
o Idiopathic intracranial hypertension
o Ingestion
• Risk factors
 o Infection (ex. cerebral venous sinus thrombosis)
o Arteriopathies / inflammation / dissection
o Cardiac disease
o Hematologic disease: ex. Sickle cell disease (over 10% have some
clinical signs of stroke by age 20) !! treat with exchange
transfusion, high morbidity / mortality
o Other (drugs, chemotherapy, radiation)
• Management: controversial, pathophysiology different in children
o Heparin and aspirin used in arteriopathies / ischemic strokes
o Do not use TPA unless involved in a study, it is being used off-label
in the community

Infantile Botulism
• May be due to eating honey or inhaling spores (ex. living near construction
site)
• Exam findings
o Poor feeding
o Lethargy
o Decreased tone
o Constipation
o Eye paralysis
• Management:
o Admit to monitored setting
o Often intubated
o Call CDC: administer Baby BIG (Botulism Immune Globulin)

Pediatric Endocrine
Emergencies
Dehydration
• All children can be rehydrated orally
• Oral rehydration solution:
o Rehydrate first with 50-100 mL/kg in 3-4 hours
o Plus 10 mL/kg per episode
• IV fluid resuscitation
o 20 mL/kg isotonic crystalloid
 o Replete glucose if needed

Pediatric DKA
• Leading cause of morbidity and mortality
• Cerebral edema occurs in children
• Typical presentation may be a child with vomiting, abdominal pain,
headache, and altered mental status with a very high blood sugar, ex. 800
• Fluids: be gentle with fluids due to possible risk of cerebral edema
o Provide 10 mL/kg bolus of IV fluids over one hour
o Provide a second 10 mL/kg bolus over two hours if circulation
compromised
o Provide 1.5-2x maintenance fluids after the bolus
o Measure glucose, electrolytes, and pH q hour x 3-4 hours
o Insulin gtt if potassium within normal at 0.1 units/kg/hour
o Have mannitol at the bedside in young children
• Cerebral edema in DKA
o Risk factors include age<5, severe acidosis, initial presentation of
their diabetes
o Treatment: decrease fluids, mannitol 1 g/kg IV if acutely herniating,
hypertonic saline

Congenital Adrenal Hyperplasia

• Presents in first couple of weeks of life
• Newborns are screened at birth but some lost to follow up or born at home
• Chief complaint may be vomiting
• On exam baby may be lethargic, mottled and dehydrated
• Electrolyte abnormalities:
o Hyperkalemia
o Hyponatremia
o Hypoglycemia
• May have arrhythmias due to hyperkalemia and acidosis
• Hypoglycemia (or hyponatremia) !! seizures
• Draw extra blood for inpatient team
• Treatment
o IV fluid
o Glucose – Rule of 50: 5 mL/kg D10W (infant) or 2 mL/kg of D25W
(child), or 1 mL/kg of D50W (adolescent)
o Hydrocortisone: 25 mg (neonate/infant), child 50 mg,
adolescent/adult 100 mg

Inborn Errors of Metabolism (IEM)

• Presents with vomiting, lethargy, seizures, hepatomegaly, metabolic
acidosis, or a peculiar odor
 • May have normal labs and imaging
• May have very subtle presentation
• Enzyme deficiency !! toxic metabolite
• Life-threatening IEM in neonates
o Metabolic acidosis
o Hypoglycemia
o Hyperammonemia
o Risk of sepsis
• Labs to order: VBG (acidosis), CMP (liver, kidney, anion gap), ammonia,
lactate, urine (ketones, reducing substances), extra tubes for more tests
• Treatment:
o Resuscitation: support respiratory status, IV fluid bolus
o NPO: eliminate harmful proteins/sugars
o Replete glucose: D10 @ 1.5x maintenance
o Control seizures
o Correct hyperammonemia (may need dialysis), metabolic acidosis
and electrolyte abnormalities
o Treat for sepsis

Pediatric GI
Emergencies
GI Emergencies
Bilious Vomiting
• Bilious vomiting = surgical emergency
• Bilious vomiting = malrotation with midgut volvulus until proven otherwise
• Time is bowel
• Most children present in first month of life
• Bowel goes through a series of rotations during development !! broad
based mesentery tacks the intestines down
o Malrotation: may have bands that cause duodenal obstruction
!! bilious vomiting !! can lead to small bowel ischemia (bowel
twisting on a pedicle)
• Work up
o Transfer baby to a location with a pediatric surgeon as soon as
possible
o If stable: involve the surgeons and order an upper GI study
 o Upper GI study: 10-15% false positive rate and 3-14% false
negative rate, (imperfect test)
o If unstable !! operating room

Hirschsprung’s Disease
• Absent rectal intramural intraganglion cells !! rectum does not function
properly
• Presentation in neonates: no meconium stool, may have slightly distended
abdomen
• Presentation in infants/children: constipation (less severe mutation
diagnosed in later life)

Pyloric Stenosis
• Hypertrophy of the gastric outlet !! gastric fluid will not pass through
pylorus
• Baby presents ~6 weeks with vomiting, hunger, and frequent attempted
feeds
• Diagnosis: ultrasound of thickened pylorus
o >4 mm thick
o >15 mm long
• If no ultrasound, can also make diagnosis with NGT aspiration: >5cc is
suspicious
• On exam may palpate olive-shaped mass in middle or right upper
quadrant of abdomen
• Treatment:
o Correct dehydration
o Correct metabolic abnormalities (if any)
o Contact surgery for semi-emergent operation

Intussusception
• Classic triad in only 30% of cases
o Abdominal pain
o Red current jelly stools
o Palpable abdominal mass
• Most common abdominal emergency in infants
• Generally presents from ages 3 months-2 years old
• Typical presentation
o Vomiting
o Lethargy (may be only sign)
o Paroxysms of pain
o SBO
o PO intolerance
• Diagnosis
o Ultrasound
 o Can diagnose with enema but 1% perforation risk
• Treatment
o Enema (barium, air or contrast) 80-95% success rate
o 10% recurrence (may need to involve surgeons, can attempt
reduction again with enema)

Meckel’s Diverticulum
• Painless rectal bleeding
• Occurs around 2 years of age
• Can present with obstruction and intussusception

Appendicitis
• Can present with acute gastroenteritis (AGE) symptoms
o 1/3 of appendicitis in children presents with vomiting and diarrhea
• Less common in infants (due to funnel-shaped appendix) but it may occur

Vomiting and Diarrhea (AGE)

• Most likely viral etiology
• Consider serious etiology
• Perform a thorough exam
• Observe and reassess
• Provide good return instructions
• Dehydration is common: all children can be rehydrated orally
• Oral rehydration solution:
o Rehydrate first with 50-100 mL/kg in 3-4 hours
o Plus 10 mL/kg per episode of vomiting/diarrhea
• IV fluid resuscitation
o 20 mL/kg isotonic crystalloid
o Replete glucose if needed
• Start regular diet as soon as possible
• Consider probiotics (may help decrease diarrhea)

Hemolytic Uremic Syndrome (HUS)

• May initially present with watery diarrhea !! bloody diarrhea
• Three components
o Acute renal failure (most common cause of acute renal failure
in childhood)
o Thrombocytopenia
o Microangiopathic hemolytic anemia (MAHA)
• Remember to consider TTP if neurological findings and fever
• HUS signs/symptoms
o Pallor
o Abdominal pain
 o Decreased urine output
o Low energy/AMS
o Hypertension
o Edema
o Petechiae (thrombocytopenia)
o Icterus (liver involvement)
• Treatment
o Supportive treatment
o 50% require dialysis

Pediatric GU
Emergencies
GU Emergencies
Phimosis
• Phimosis = foreskin cannot be fully retracted over the glans penis
o 90% of neonates cannot fully retract the foreskin
o Half of all infants at 1 year of age can retract foreskin
o 90% of 4 year olds can retract foreskin
• Not an emergency unless they have urinary obstruction / retention

Paraphimosis
• Urologic emergency: paraphimosis !! paramedic
• Retracted foreskin cannot be reduced to the normal position !! trapped
behind glans penis
• Can lead to ischemia of the glans penis and autoamputation
• Must be reduced in the emergency department
• Paraphimosis reduction
o Pain control (penile block/sedation)
o Reduce edema (ice/ace bandage/hold pressure and constrict
penis)
o Manual technique: thumbs on glans penis and gentle traction
o Iced glove
o May need Babcock clamps
o If necessary, needle decompression to decrease edema
o Dorsal slit (if other techniques fail)

Balanoposthitis
 • Irritation and inflammation of the foreskin and glans due to bacterial,
fungal or chemical etiologies
• May be due to diaper dermatitis, poor hygiene or local trauma
• Cellulitis can be secondary to break in foreskin / penile skin
• Treatment:
o Good hygiene
o Void in warm water if painful
o Antifungals
o Antibiotics as needed
o Recurrent infection !! circumcision

Epididymitis / Orchitis
• In older child think of STDs: Chlamydia trachomatis and gonorrhea
• Viral causes are common: adenovirus, EBV, coxsackievirus, echovirus
• Other causes: HSP
• Treatment:
o Analgesics
o Elevation of scrotum (induce Prehn’s sign)
o Antibiotics if bacterial (send urinalysis and urine culture)
o May take weeks to resolve

Testicular Torsion
• Surgical emergency
• Peaks occur in neonates and adolescents (12 – 18 years old)
• On exam
o Generally no cremasteric reflex (but may be present)
o Red, swollen testicle
o Abnormal lie (often horizontal)
• Time is testicle: testicular salvage rate is time dependent
o 96% salvage rate at <4 hours of symptom onset
o 93% at 4-8 hours
o 80% at 8-12 hours
o 40% at 12-24 hours
o 10% if >24 hours
• Management
o Emergent urology consult first
o Obtain an ultrasound
o Perform manual detorsion if surgical delay (most cases torse
medially !! consider “opening the book” to detorse, but be aware
they can torse laterally)

Hydrocele
• Fluid filled sac around the testicle
• Most resolve between 1-2 years of age
 • Often benign
• Can have underlying pathology, ex. underlying hernia or torsion
• Types include communicating (at risk for inguinal hernia, changes with
position) and non-communicating

Vulvovaginitis
• Related to poor hygiene and irritation
• May have a chemical contact dermatitis
• Young girls more at risk due to decreased estrogen !! irritates epithelium
• Treatment: good hygiene daily, no bubble baths, avoid irritants

Labial adhesions
• Common in infants and young preschool age children
• Only emergent if have acute urinary retention
• May provide topical estrogen cream as a treatment !! can lead to
secondary sex characteristics

Urethral Prolapse
• Most commonly occurs in young African American girls
• May present with some blood in underwear
• May have history of constipation
• Treatment
o Sitz baths
o Good hygiene
o Topical estrogen cream
• Usually resolves on own

Imperforate Hymen
• Presents in young girls with cyclical abdominal pain and no period with all
other secondary sex characteristics
• On exam: imperforate hymen !! vagina full of blood (causing pain) !!
treatment is surgery

Ovarian Torsion
• Risk factors: pregnancy, adnexal mass > 4 cm
• Unique factors in children
o Pre-pubescent children can torse a normal ovary
o Female infant with an inguinal hernia is more likely to have a
herniated ovary than herniated bowel
 Pediatric
Hematology/Oncology
Hematology/Oncology Emergencies
Leukemia
• Leukemia presentation
o Nonspecific insidious symptoms, ex. initial presentation with viral
syndrome
o Fatigue/malaise
o Fever
o Petechiae
o Bruising
o Bone pain/limp
o Hepatosplenomegaly
o Lymphadenopathy
• Obtain a peripheral smear and CBC (may have high/low/normal WBC
counts)

Lymphoma
• Presentation of lymphoma can include “B-symptoms”
• Lymphadenopathy
o Common in children
o Biopsy if persistent lymphadenopathy for over 2-3 weeks and with
associated findings/mass/abnormal chest x-ray/abnormally large
lymph node or in specific locations (ex. supraclavicular)
• Night sweats
• Fever
• Pruritis
• Respiratory distress (ex. mediastinal masses)

CNS Tumors
• Presentation of CNS tumor
o Headache, worse when wake up in the morning
o Vomiting
o Focal neurologic findings are common and can be subtle, ex.
cranial nerve deficit
• Perform a thorough neurologic exam
Abdominal Mass
• Differential is wide
• Most common abdominal mass is stool
• Neuroblastoma
• Hepatoblastoma
• Wilms’ tumor
• Lymphoma
• Germinoma
• Sarcoma
• Metastatic disease

Cancer Emergencies
• Infectious presentations, ex. neutropenic fever, typhlitis
• Respiratory distress
• Neurologic emergencies, ex. stroke from sludging
• Hematologic emergencies
o Bleeding
o Hypercoagulation
• Metabolic emergencies: tumor lysis syndrome
• If a child is being treated for cancer they have risk of having a secondary
malignancy ex. hematologic cancer

Pediatric Orthopedic
Emergencies
Pediatric Orthopedic Overview
• Consider age / mechanism !! children are growing
• Make sure injuries are consistent with the history
• Ligaments are stronger than physis: fracture is more common than a
sprain in young children
• Bony avulsions are more common
• History from a child can be difficult, ex. patient complaining of knee pain
but they have a hip injury
• Children have elastic bones: unique fracture patterns
o Torus / buckle fracture
o Lead pipe fracture
 o Bowing fracture: can be subtle on xray !! it is a series of
microfractures, compare curvature to other arm !! often need
operative reduction

Salter-Harris (SH) Fractures

• Occur in growing children
• SALTR pneumonic
o Slipped (SH-1): fracture is through the physis, xrays can be normal
o Above (SH-2): most common, fracture is above the physis
(metaphysis fracture), fracture line goes away from the joint
o Lower (SH-3): fracture line goes through the epiphysis, towards the
joint
o Through (SH-4): fracture goes through the metaphysis and
epiphysis, +/- growth arrest
o Rammed (SH-5): growth plate is crushed !! growth arrest

Limping Child
• Do a thorough history and physical (include back, GU, and abdominal
exam)
• Differential
o Fracture, ex. Toddler’s fracture: plant leg and turn !! spiral fracture
of tibia !! if no fracture seen on Xray but highly suspicious !! splint
and repeat Xrays in a week
o Discitis
o Transient synovitis, most common cause of limp, may have recent
URI, walk more than a child with a septic joint, respond well to
NSAIDs
o Septic joint
o Avascular necrosis
o SCFE
o Malignancy (bony tumor, leukemia)
o Apophysitis, overuse injuries and avulsion fractures
• If more concerning exam !! do an ultrasound to look for an effusion and
perform arthrocentesis
• Septic arthritis clinical features:
o Refusal to bear weight or range joint
o Increased temperature
o Increased CRP
o Increased ESR
o Increased WBC
o Joint effusion on ultrasound / Xray
• Avascular necrosis: Legg-Calve-Perthes Disease
o Progressive necrosis of femoral head
o Median age is 7 years old
o Often idiopathic cause
 o May have insidious onset
o May present with groin, thigh, knee, or hip pain
o Make the patient non-weight bearing and discuss with / follow up
with orthopedics (may admit)
• SCFE: slipped capital femoral epiphysis
o Obtain frog-leg view
o Usually occurs in more overweight children with increased BMI
o Present with hip/knee pain
o Draw a Klein’s line along the superior edge of the femoral neck
!! should pass through the femoral head, if it does not pass
through femoral head: concern for SCFE
o 20% of the time patients have bilateral SCFE
o Make the patient non-weight bearing and discuss with / follow up
with orthopedics (may admit)

Juvenile Idiopathic Arthritis

• A heterogeneous group of arthritides
o Oligoarticular
o Polyarticular
o May have systemic symptoms, ex. intermittent fevers and
lymphadenopathy
• Unknown cause
o Multifactorial
• Children <16 years old
• May be transient or chronic
• On labs: ANA>>RF

Congenital / Dysplastic Hip

• Typically a breech / c-section baby: diagnose with ultrasound and later
with xrays
• Maneuvers done in newborn nursery to detect this diagnosis
o Barlow maneuver: provocative maneuver with infant in supine
position with hips flexed to 90 degrees and abducted !! grasp and
adduct the thigh !! apply downward and lateral pressure
!! palpable clunk indicates femoral head dislocates
o Ortolani maneuver: flex infants hips to 90 degrees !! abduct the
hips while lifting forward on the femur !! positive test is if the hip is
dislocated, it clunks !! reduces the dislocation
• Early diagnosis !! better prognosis
• Treatment: Pavlik harness

Non-Accidental Trauma (NAT)

• Consider NAT in any injured child
• Consider mechanism
 • Concerning patterns for NAT
o Be worried about metaphyseal lesions / “bucket-handle” lesion (can
result from forced swinging)
o Posterior rib fracture
o Multiple injuries
o Skull fractures
o Serious injury
o Recurrent Visits
• Children that die from non-accidental trauma are often seen in the ER for
injuries on prior visits

Pediatric Dermatologic
Emergencies
Dermatologic Emergencies
• Keep in mind, common rashes are common
• More likely to see atypical presentation of something common
• Avoid the normalcy bias and consider the serious diagnoses
o Kawasaki disease (consider in rash with a fever)
o Necrotizing fasciitis (pain out of proportion)
o Meningitis
o Systemic illness

Viral Exanthems
• Many different presentations: macular, papular, vesicular, urticarial,
petechial
• May be widespread or may be localized

Slapped Cheek / Fifth disease

• Parvovirus B19
• Red cheeks with perioral and perinasal sparing of the erythema
• Lacy reticular pattern of rash on body
• Worry about this condition in pregnancy (hydrops fetalis) and Sickle Cell
Disease (aplastic crisis)

Measles
 • With any rash look for an associated enanthem (Koplik spots on mucous
membranes that may be white or purple)
• May present with conjunctivitis
• Fever
• May have high morbidity / mortality
• Can cause blindness
• Report measles to public health services

Varicella
• Varicella = chickenpox
• Lesions are in different stages of development
• Occurs in people that have had chicken pox and in the unvaccinated
population (adults more severe form)
• Macules !! papules !! vesicles !! pustules !! crusted papules
• Treatment: Administer acyclovir > 12 years old, VZIG (immunoglobulin) in
neonates and immunocompromised because of risk for significant
complications

Scarlet Fever
• Toxin mediated: group A strep
• Diffuse erythematous rash
• Palatal petechiae
• Pastia’s lines
• “Gooseflesh with a sunburn” and feels like “sandpaper”
• May have “white strawberry tongue” or ”red strawberry tongue”
• Desquamation
• Spread from trunk !! periphery
• Treatment: Penicillin

Staphyloccal Scalded Skin Syndrome

• Toxin mediated
• Positive nikolsky sign
• Common in younger children
• Prognosis is good
• Treatment: anti-staph antibiotics

Henoch-Schonlein Purpura
• Occurs more commonly in children
• Four defining features
o Palpable purpura in dependent areas (usually more in lower
extremities), typically symmetric and may have edema
o Arthralgia / Arthritis (50-84%), may have erythema of the joints
 o Abdominal pain (50%) due to vascular lesions in the bowel, can
serve as lead points for intussusception !! obtain an ultrasound
when presenting with abdominal pain (can get bowel ischemia and
necrosis)
o Renal Disease (20-50%), many patients develop this complication
within 2 months !! obtain a urine dip, renal function testing
(especially in adolescents/adults even if urine is normal)
• Treatment is supportive care and NSAIDs

Erythema Multiforme Minor

• Target like lesions
• Lesions may be diffuse around the body, may be purple
• No mucosal involvement of lesions in erythema multiforme minor
• Mucosal involvement of lesions in erythema multiforme major
• Negative Nikolsky sign
• 90% associated with infection (most commonly HSV) a week prior
• Treatment: symptomatic and reassurance

Steven’s Johnson Syndrome

• Most common cause is medication exposure, ex. Bactrim
• Over 90% involve 2 or more mucous membranes
• Positive Nikolsky sign
• Bullae may be present
• Can be sight threatening
• On exam may have pain out of proportion of skin
• Treatment
o Admit
o Discontinue inciting medication
o IVF
o Wound care
• Rash involves <10% body surface area
• On spectrum with TEN (toxic epidermal necrolysis) which is the same as
SJS but >30% involvement of total body surface area

Kawasaki Disease
• Signs/Symptoms: high fever x 5 days + 4/5 of the following criteria:
o Polymorphous diffuse rash (80%)
o Conjunctivitis (85%)
o Mucous membrane changes, ex. strawberry tongue (90%)
o Cervical lymphadenopathy (40%), usually unilateral
o Changes of extremities, ex. peeling and swelling of fingers/toes
(75%)
• There are atypical and incomplete forms of Kawasaki disease: more likely
in infants !! infants more likely to have complications
• Important to consider Kawasaki disease due to cardiac complications:
coronary artery aneurysms
• Treatment: high dose aspirin until defervesce and IVIG
• With treatment drop complications of coronary artery aneurysms from 25%
down to 4-5%