Overall no new major updates since 2006. In children tachycardia likely most sensitive marker. Don’t forger hypothermia is just as concerning as fever. Viruses can also cause sepsis and is treated the same with regard to resuscitation. Consider epinephrine for low cardiac output failure, and norepinephrine for high output failure and septic shock. No changes in broad spectrum empiric antibiotics.
For screening, consider using TEN <4 pneumonic. For any fracture in children <4 months, or in children <4 years look for bruising to the “Trunk” area typically covered by a swimming suit, “Ears,” or “Neck.” Red flags continue to be any fracture in non-ambulatory patients (typically <4 mo), metaphyseal fractures, “bucket handle” fractures, any perineal brushing, brushing or other injuries in linear patterns or burn patterns. Also consider round burns (cigarette burns).
Consider diagnosis in chest pain and fever. Look for signs of heart failure (hepatomegaly, edema, rales, hypotension / tachycardia). ECG findings continue to be rare but typically new BBB and concave diffuse ST elevation. TNI insensitive. Echocardiogram most useful for pericarditis. Consider dobutamine for low output failure, amiodarone for arrhythmia, cardioversion for instability. Therapy for pericarditis is NSAIDs (ibuprofen). No longer using steroids or IVIG. Antibiotics or viral only for suspected causes.
- UTI: consider in febrile non symptomatic girls <1yr and boys uncirc <2 yr and circ <1 yr. Must have both signs of infection (pyuria or nitrite pos) and urine culture with >50,000 disease causing organisms. Still most likely E. coli. If does not meet this definition or culture results, avoid prescribing or stop antibiotics. In kids and with local resistance patterns, consider amox-clav, cefazolin, ceftriaxone, ciprofloxacin. Can consider TMP-SMX but higher resistance. If nitrite neg, consider amox-clav (Augmenting) as more likely non E. coli pathogen and more sensitive to this agent. Usually treat 7-14 days, but in afebrile females 3-5 days should be sufficient.
- Pneumonia, antimicrobials not recommended routinely for kids 3mo-4yr, healthy appearing without respiratory distress, immunized with CAP as mostly viral in etiology. If rapid viral testing is positive, avoid antibiotics. Unless, unionized, sick, septic child then consider bacterial co-infection. 90% of CAP in >3 mo to 4yrs due to viral causes. However, poor evidence for this and few if any prospective trials looking out morbidity and mortality. Ok not to get chest X-ray and no other testing necessary except for possibly viral testing. Most commonly pneumococcus and mycoplasma. Best empiric therapy is for high dose amoxicillin. Sick inpatients can also receive ceftriaxone. Older children (>12 yo) still ok for macrolide monotherapy.
- Skin Infections, still drive by IDSA and Clinical Infectious Disease. MB has a practice guidelines. Cutaneous abscess without cellulitis or sepsis do not need empiric antibiotics following I&D (with exception of immunocompromised host or systemic signs / symptoms of SIRS). Consider Loop drain in place of packing, studies showing more comfortable and more effective. When using antibiotics for skin / soft tissue infections, consider Clinda and TMP-SMX for staph aureus susceptibility. Currently TMP-SMX > Clinda. For MRSA, consider TMP-SMX 8-12 mg/kg/day for TMP divided BID. Up to 2 DS tabs BID (larger kids and adults). 7 days should be adequate in most cases.
Still no indication for X-ray or labs in bronchiolitis. consider only for critically ill, severely hypoxic, asymmetric chest exam. Current therapy recommendations continue to not support bronchodilators. Consider only with recurrent wheezing despite suction in children >12 mo or strong family history of atopy / asthma. No role for steroids or antibiotics unless evidence of secondary bacterial infections. Trials under way regarding hypertonic saline (PECARN). Consider using respiratory scores for comment language, especially for admissions and consults. Use the MBED Pathways (intranet only) for the MBED protocol. No indication for viral testing, HTS, racemic epic, albuterol or radiography. Disposition mainly dependent on work of breathing, oxygen sat <90% awake (88% asleep), and respiratory score (see protocol).
Severe pediatric asthma, go straight to continuous albuterol 20 mg over the first hour. Dexamethasone ok for steroid use. For moderate exacerbation, can also use 8-12 MDI puffs. Higher doses of atrovent likely more beneficial than previously thought. With severe asthma, don’t forget fluid bolus 20 ml/kg and consider PPV and mag (2 mg/kg/dose up to 2g).
Suspected aspiration, especially with asymmetric lung exam, still indication for bronchoscopy, many foreign bodies not radio opaque.