Antonio E. Muniz

Management of febrile infants and children by pediatric emergency medicine and emergency medicine : Comparison with practice guidelines

Objectives Management of febrile infants and children remains controversial despite the 1993 publication inPediatrics and Annals of Emergency Medicineof practice guidelines. Our aim was to determine the management of febrile infants and children by pediatric emergency medicine (PEM) fellowship directors and emergency medicine (EM) residency directors and compare their approach with the published practice guidelines. Methods Four case scenarios were sent to 64 PEM directors and 100 EM directors in the United States and Canada, describing four febrile, nontoxic infants and children aged 25 days (case 1), 7 weeks (case 2), 5 months (case 3), and 22 months (case 4). Respondents were asked to select which laboratory tests and radiographs they would obtain and to decide on treatment and disposition for each hypothetical case. Results Ninety-two percent (53/64) of PEM directors and 64% (64/100) of EM directors responded (overall response rate 74%). Compliance with the guidelines (PEM/EM) was 54%/16% for case 1, 31%/6% for case 2, 35%/19% for case 3, and 20%/11% for case 4. Only 11% of PEM and 2% of EM directors followed the guidelines for all four cases. Overall, directors performed fewer laboratory tests, ordered more chest radiographs and treated fewer patients with antibiotics than the expert panel suggested. EM directors ordered more chest radiographs (cases 1–4) and admitted more patients (case 2) than PEM directors. Conclusions There is poor compliance with published practice guidelines in the management of febrile infants and children among PEM and EM directors.

Edema, anemia, hypoproteinemia, and acrodermatitis enteropathica: an uncommon initial presentation of cystic fibrosis.

Abstract: Cystic fibrosis is a genetic disorder characterized by chronic obstructive pulmonary disease, pancreatic exocrine deficiency, and abnormally high sweat electrolyte concentrations. Less frequently, the presenting features in infants may include edema, anemia, hypoproteinemia, and acrodermatitis enteropathica. Liver involvement may produce hepatomegaly and mild elevation of transaminases. This clinical symptom usually presents within the first 6 months of life and is associated with a high morbidity and mortality. Early recognition and institution of appropriate nutritional supplementation and pancreatic enzymes is essential to improve outcome. Since the sweat test may be falsely negative, emergency physicians must maintain a high index of suspicion to make the diagnosis of cystic fibrosis in an infant who presents with edema, anemia, hypoproteinemia, and acrodermatitis enteropathica.

Hereditary angioedema presenting as epiglottitis.

Abstract: Hereditary angioedema is a disorder characterized by decreased levels or function of complement C1 esterase inhibitor. Symptoms in children generally consist of recurrent episodes of soft tissue swelling. On rare occasion, it can cause airway edema which may lead to airway obstruction. A case is presented of a child presenting with epiglottitis requiring intubation. Initial management of this rare complication should be directed at establishing an adequate airway and ensuring good oxygenation and ventilation. In addition, prompt administration of C1 esterase inhibitor concentrate is the most effective means of stopping progression of laryngeal edema and other forms of swelling. Commonly used agents for airway edema such as glucocorticoids, antihistamines, H1-blockers, and epinephrine tend not to be effective for reducing swelling related to hereditary angioedema.

Sturge-Weber syndrome presenting as an acute life-threatening event

Abstract: Young infants may present to an emergency department after an acute life-threatening event. The differential diagnosis for an acute life-threatening event is quite extensive. Fortunately, most will have benign or treatable causes. A case of Sturge-Weber syndrome is described in a 2-day old who presented to the emergency department after an acute life-threatening event. A thorough history and detailed physical examination are generally helpful in discerning the etiology for most acute life-threatening events and may at times reveal unusual diseases such as Sturge-Weber syndrome.

Craniofacial injuries from television tip-over

Background Craniofacial injuries caused by television (TV) sets falling on small children are becoming a frequent event seen in emergency departments. Injuries occur primarily to the head and neck regions and range from contusions to intracerebral hemorrhage, which at times can be fatal. Objectives Epidemiology and potential complications from TV tip-over injuries are presented. Case Three cases of craniofacial injuries are described from blunt trauma incurred from TV tip-over events. Conclusions It is important to teach parents about the dangers of the new large slim TV sets and the occurrence of injuries when these are not secured properly or placed away from the reach of the child.

Thrombolytic therapy for acute stroke in a teenager.

Background The importance of thrombolytic therapy within the first 3 hours of onset of symptoms of an acute stroke has been stressed, and in consequence, the diagnosis is most commonly made based on clinical grounds. Intracranial hemorrhage is the major life-threatening complication with the use of thrombolytic therapy. Because of the very small time window before administering thrombolytics, it is often not possible to investigate the unusual causes of a stroke that occurs most often in children. Objective This study aimed to present the decision and risk of thrombolysis for an acute ischemic stroke in children. Case A case of a teenager with an acute ischemic stroke who received thrombolysis and had resolution of symptoms. Conclusions Thrombolytic therapy is effective in acute ischemic strokes; however, in children, one must consider and exclude stroke mimickers and recognize that potentially life-threatening bleeding complicates the use of these medications.

Venezuelan equine encephalitis in a teenager visiting Central America.

Background Stupor, coma, and other alterations of consciousness are among the most serious life-threatening emergencies faced by the emergency department physician. When a patient arrives with altered mentation from Central or South America, the usual causes that occur in the United States must be considered; however, other unusual tropical disease must be excluded, such as Venezuelan equine encephalitis (VEE). Objective This study aimed to review the clinical features of VEE. Case A 17-year-old female traveled to Belize and developed vomiting, diarrhea, fever, headaches, and myalgias. Over the next few hours, she became disoriented and had a generalized seizure. She was given diazepam, 50% dextrose, phenytoin, mannitol, and vitamin K. A computed tomographic scan of the head was unremarkable. Her parents arranged for a medical air transport. After eliminating other possibilities, she was diagnosed with VEE, which was confirmed in the laboratory. Over the next week, her mental status improved back to her normal neurologic baseline. Conclusions Venezuelan equine encephalitis is an acute viral disease that causes acute illness in equines and humans, with symptoms ranging from a mild, flu-like syndrome to encephalitis or death. Laboratory abnormalities are common and include elevated hepatic transaminases, lymphocytosis, eosinophilia, and thrombocytopenia. Treatment is supportive, and complete recovery is expected within several weeks in most patients.

Ischemic electrocardiographic changes and elevated troponin from severe heatstroke in an adolescent.

Background Heatstroke can result in significant diffuse tissue derangement, which can result in multiple organ system dysfunction. The heart can equally be affected and ischemia and infarction may occur. Objective This study aimed to present the potential complications from heatstroke to the myocardium. Case A case of a 15-year-old adolescent boy who collapsed after playing football in a hot summer day was found to be hyperthermic and poorly perfused. He had ischemic electrocardiographic changes and elevated cardiac enzymes but with normal coronary arteries. Conclusions Heatstroke can lead to morbidity and mortality. Tissue damage during heatstroke is believed to result from uncoupling during oxidative phosphorylation. It is important to realize that heart damage can occur from heatstroke and that appropriate diagnostic and therapeutic measures are required for a good outcome.

Lumbar vertebral fractures in children: four cases and review of the literature.

Background Vertebral fractures and severe injuries to the spine cord in children are rare and account for a small proportion of all childhood injuries. Pediatric vertebral and spinal cord injuries have unique characteristics depending on their age. Young children sustain upper cervical spine injuries, which are more serious injuries and have a higher mortality rate. Older children have lower spine injuries and thoracoabdominal injuries. Objectives This study aimed to present the epidemiology and potential complications from lumbar spine fractures. Cases There were 4 cases of older children who sustained lumbar vertebral fractures. Conclusions Fractures of the lumbar spine in children, although relatively rare, are important to understand. Patterns of injury with vertebral and spinal cord injuries in children vary from those of adults. The biologic differences of children make differences in fracture patterns and alter the management necessary for successful treatment. Errors in management can have adverse effects on these injuries.

Elevated cardiac troponin I in a 9-week-old infant.

Abstract: Myocardial ischemia in children is generally not suspected when they present to an emergency department with congestive heart failure. However, the opposite holds true for an adult patient. Elevated cardiac troponin is a specific biochemical marker for myocardial damage for both adults and children, however, they have not been routinely used in children at risk for myocardial damage. A case is presented of an infant with a complex congenital heart defect with congestive heart failure who was found to have an elevated cardiac troponin. Infants at risk for myocardial damage should have an evaluation of cardiac markers, as infants with elevated levels are prone to dysrhythmias or worsening cardiac function and thus warrant closer observations and therapy.