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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
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
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?
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
Transient synovitis/ ”reactive” arthritis
Septic arthritis/osteomyelitis
Perthes’ disease
Slipped Upper Femoral Epiphysis
JIA
Malignancy
Abdominal/testicular pathology
Discitis, Lyme disease, NAI
Red flags
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!