Adrenal Crisis in Pediatric Emergency

An adrenal crisis is a physiological event caused by an acute relative insufficiency of adrenal hormones. It may be precipitated by physiological stress, such as infection or surgery in a susceptible patient. It should be considered in patients with:

• congenital adrenal hyperplasia

• hypopituitarism with replacement therapy

• previous or current prolonged steroid therapy

• a history of central nervous system pathology or neurosurgical procedures.

Assessment

Signs of both glucocorticoid deficiency and mineralocorticoid deficiency should be looked for if adrenal insufficiency is suspected. In the history and examination, you should look for the following:

• glucocorticoid deficiency presenting with weakness, anorexia, nausea and/or vomiting, hypoglycemia, hypotension (particularly postural) and shock

• mineralocorticoid deficiency presenting with dehydration, hyperkalemia, hyponatremia, acidosis and prerenal renal failure.

Investigations

Prompt treatment is essential and should be based on the following investigations:

• immediate blood glucose using a Dextrostix

• serum glucose, urea, sodium and potassium

• arterial or capillary acid base

Where the underlying diagnosis of adrenal insufficiency is suspected, you should collect at least 2 ml of clotted blood for later analysis (cortisol and 17-hydroxyprogesterone). The results are unlikely to be available to help in the emergency management of the patient.

Management

Susceptible patients who present with vomiting

Susceptible patients who present with vomiting but who are not other-wise unwell should be considered to have incipient adrenal crisis. To prevent this from possibly developing further:

• Administer i.v. or i.m. hydrocortisone 2 mg /kg weight

• Give oral fluids and observe for 4–6 hours before considering discharge.

• Discuss with appropriate consultant.

For all other children

For all other children where adrenal insufficiency is suspected, the various abnormalities should be considered, namely, fluid requirements, hydrocortisone requirements, hypoglycemia, hyperkalemia and precipitating causes such as sepsis.

1. Give intravenous fluids

The level of dehydration should be assessed and intravenous fluids given accordingly. For management of various levels of dehydration,

Management of dehydration in adrenal insufficiency

a. For shock and severe dehydration

• Normal saline 20 ml/kg weight i.v. bolus. Repeat until circulation is restored.
• Administer remaining deficit plus maintenance fluid volume as normal saline in 5% dextrose evenly over 24 hours.
• Check electrolytes and glucose frequently.
• After the first few hours, if serum sodium is >130 mmol/liter, change to half normal saline.
• 10% dextrose may be needed to maintain normoglycemia.

b. For moderate dehydration in adrenal insufficiency

• Normal saline 10 ml/kg i.v. bolus. Repeat until circulation is restored.
• Administer remaining deficit plus maintenance fluid volume as normal saline in 5% dextrose evenly over 24 hours.

c. For mild dehydration in adrenal insufficiency

• No bolus.
• 1.5 times maintenance fluid volume administered evenly over 24 hours.

2. Give hydrocortisone

Hydrocortisone must be given intravenously. If intravenous access is difficult, hydrocortisone should be given intramuscularly while you are establishing the intravenous line, in the following doses:

Neonate: hydrocortisone 25 mg stat and then 50 mg/m² per 24 hours by continuous infusion

• 1 month–1 year: hydrocortisone 25 mg stat, then 50 mg/m² body surface per 24 hours by continuous infusion
• Toddlers (1–3 years): hydrocortisone 25–50 mg stat then 50 mg/m² per 24 hours by continuous infusion
• Children (4–12years): hydrocortisone 50–75 mg stat, then 50 mg/m² per 24 hours by continuous infusion
• Adolescents and adults: hydrocortisone 100–150 mg stat, then 50 mg/m² per 24 hours by continuous infusion

When the patient is stable, you should reduce the intravenous hydrocortisone dose, and then switch to triple dose oral hydrocortisone therapy, gradually reducing to maintenance levels (10–15 mg/m² per day).

In patients with mineralocorticoid deficiency, start fludrocortisone at maintenance doses (usually 0.1mg daily) as soon as the patient is able to tolerate oral fluids.

3. Treat hypoglycemia

Hypoglycemia is common in infants and small children. Treat with an intravenous bolus of 5 ml/kg weight 10% dextrose in a neonate or infant and 2 ml/kg weight of 25% dextrose in an older child or adolescent. Maintenance fluids should contain 5–10% dextrose.

4. Treat hyperkalemia

Hyperkalemia usually normalises with fluid and electrolyte replacement.

• If potassium is above 6 mmol/liter, perform an ECG and apply a cardiac monitor as arrhythmias and cardiac arrest can occur.
• If potassium is above 7 mmol/liter and hyperkalemic ECG changes are present (e.g. peaked T waves, wide QRS complex), give 10% calcium gluconate 0.5 ml/kg weight i.v. over 3–5 minutes. Commence an infusion of insulin 0.1 units/kg weight per hour i.v. together with an infusion of 50% dextrose 2 ml/kg weight per hour.
• If the potassium is above 7 mmol/liter with a normal ECG, give sodium bicarbonate 1–2 mmol/kg weight i.v. over 20 minutes, with an infusion of 10% dextrose at 5 ml/kg weight per hour.

5. Identify and treat potential precipitating causes such as sepsis.

6. Admit to appropriate inpatient facility.

Prevention

The prevention of a crisis is usually possible in susceptible individuals. Situations likely to precipitate a crisis should be anticipated and the patient given:

• triple normal oral maintenance steroid dose for 2–3 days during stress (e.g. fever, fracture, laceration requiring suture)

• intramuscular hydrocortisone when absorption of oral medication is doubtful (e.g. in vomiting or severe diarrhea)

• increased parenteral hydrocortisone (1–2 mg/kg weight) before anesthesia, with or without an increased dose postoperatively.

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Jaundice Icteric in Pediatric Emergency

Jaundice in early infancy

There are many causes of jaundice in early infancy. It is clinically defined as the yellow colouration of the skin and sclera. The best approach is to define it, if it is unconjugated or a conjugated jaundice, as this will dictate the approach to investigation and treatment.

Physiological jaundice

Jaundice is very commonly noted in the first 2 weeks of life. It is part of a normal physiological process and affects 50–70% of babies. Mild jaun-dice with onset after 24 hours of life and which is fading by 14 days needs no investigation or treatment.

Causes of neonatal jaundice

Unconjugated

• Breast milk jaundice: 3–5% of breastfed babies
• Prematurity: exaggerated physiological pattern; may last 4 weeks
• Bruising or cephalohematoma: breakdown of heme
• Hemolysis (Rhesus, ABO, G6PD or pyruvate kinase (PK) deficiency, spherocytosis): early onset for ABO, Rhesus
• Sepsis: rarely presents with jaundice alone (occasional for UTI); usually unwell
• Metabolic (e.g. hypothyroidism): prolonged jaundice, can be mixed conjugated/unconjugated
• Polycythemia: delayed cord clamping, twin-to-twin transfusion
• Gilbert or Crigler—Najjar: rare, usually presents as prolonged jaundice
• GI obstruction (e.g. pyloric stenosis)

Conjugated—pale stools/dark urine, raised conjugated bilirubin (>25% total or >25 µ mol/Liter)

• Biliary atresia
• Choledochal cyst
• Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency,often idiopathic)
• Metabolic (galactosemia, fructose intolerance—ask about sucrose/fructose in food/medication)
• Complication of total parenteral nutrition (TPN)

Breast milk jaundice

This is the most common cause of prolonged jaundice beyond 14 days but other causes should be eliminated before this diagnosis is made. A breastfed baby with prolonged unconjugated jaundice, normal stool and urine colour, normal FBC, blood film and Coombs test who is well and thriving probably has breast-milk jaundice. Do not stop breastfeeding. The child should have a review in a general pediatric clinic if not improving or if there are any changes—especially in stool colour.

Conjugated hyperbilirubinemia

This must be excluded as the causes of this pattern need urgent evaluation and treatment. Surgery for biliary atresia is most successful when the condition is diagnosed and treated early. Don’t forget to ask about the color of urine and stools. View a dirty nappy yourself if possible.

Phototherapy or rarely exchange transfusion

This may be necessary in a baby with severe unconjugated jaundice associated with prematurity, hemolytic disease, or rare disorders such as Crigler—Najjar. Outside of these conditions, unconjugated jaundice is unlikely to lead to CNS or hearing problems, and no treatment is usually necessary

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Diarrhea and Vomiting in Pediatric Emergency

Most diarrhea and vomiting in children is due to infective gastroenteritis ) but not all. It may be the presentation of a urinary tract infection (UTI), meningitis, appendicitis, intussusception or systemic illness. In the unwell child, especially if anuric, consider hemolytic uremic syndrome (hemolytic anemia, acute renal failure and thrombocytopenia).

Assessment

There are essentially two aspects to the assessment of a child with gastroenteritis:

• Diagnosis: Does the child have a cause other than infective gastroenteritis?

• Degree of dehydration: Does the child need admission to hospital? Is there any reason why oral rehydration is not appropriate?

An initial weight measurement should form part of the initial assessment of any child who presents with diarrhea and vomiting. Any child who is toxic, vomiting blood or bile or has severe abdominal pain or abdominal signs needs immediate consultant referral. Be especially careful of those children with chronic illnesses and poor growth, and of the very young.

You must assess degree of dehydration on clinical signs and change in body weight (if recent weight available).

• With mild dehydration (<4%) there are no clinical signs.

• Moderate dehydration (4–6%) tends to be accompanied by dry mucous membranes and sunken eyes.

• With increasing severity to 7–9%, the signs of dehydration are more pronounced with cool peripheries, decreased skin turgor, impaired peripheral circulation and acidotic breathing.

• A shocked child needs immediate intravenous resuscitation.

Fecal samples should be collected for microbiological culture if the child has significant associated abdominal pain or blood in the motions, as a bacterial cause of gastroenteritis is more likely.

Management

The child with diarrhea should continue to be fed unless severely dehydrated. Most children can be rehydrated with oral or nasogastric feeds unless shocked. Do not give medications to reduce the vomiting or diarrhea. They do not work and may be harmful.

Oral rehydration

There is no evidence that milk, or other foods, should be diluted or excluded during the diarrheal illness, unless there is documented lactose intolerance, although a short period without food will not harm children. Breastfeeding should continue.

For mildly dehydrated children, increased frequency of normal drinks, giving small amounts often, will be adequate. Do not give fizzy drinks or fruit juice as their osmolarity is too high. For moderately dehydrated children, who are still drinking, small frequent amounts of fluids should be given according to the volumes given on the charts below. The fluids should be oral rehydrating fluids.

Commercially available preparations usually have 35–50 mmol sodium/Liter. Examples include Diorylate or Rehydrat. Clear instructions and a written information sheet should be given to the parents together with an indication of when to seek review. Indications for admission are:

• refusal to take fluid

• severe pain

• bilious vomiting

• abdominal distension

• blood in the motions

• altered level of consciousness

• increasing dehydration

• parents coping poorly

Nasogastric rehydration

Nasogastric rehydration is a safe and effective way of rehydrating most children with moderate to severe dehydration, even if the child is vomiting. There are a number of possible regimens. Current practice is to replace deficit over 6 hours and then give daily maintenance over the next 18 hours using oral rehydration solution. To calculate hourly rates see Table 7.4. 

However, recent recommendations from the American Academy of Pediatrics say that rapid nasogastric rehydration over a 4-hour period is safe and effective. Using 100 ml/kg weight over 4 hours for a moderately dehydrated child or for more severe even 150 ml/kg weight over 4 hours is an appropriate replacement rate. In most cases it is not necessary to check electrolytes.

Intravenous rehydration

Any child with severe dehydration requires immediate boluses of 20 ml/kg weight normal saline until circulation restored (i.v. or i.o.). Urgent U&Es, glucose, FBC, blood gas and urinalysis. Consider whether a septic work-up and parenteral antibiotics are needed or a surgical consultation.

Always remember the ABC approach to a sick child. If serum Na+ is between 130 mmol/liter and 150 mmol/Liter, aim to replace deficit and maintenance over 24 hours after the circulation has been restored by fluid boluses. Reassess clinically and reweigh on the ward at 6 and 12 hours.

Contact a gastroenterology consultant if the child is hemodynamically unstable, has a past history of gut surgery or other significant disease. If serum Na+ is less than 130 mmol/Liter or more than 150 mmol/Liter, aim to replace deficit carefully over 48–72 hours, and consult with senior staff.

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Constipation in Pediatric Emergency

Constipation is defined as hard stools that are difficult to pass. Defecation may be painful and may be less frequent than normal. There is a wide range of normal stool frequency: normal breastfed infants may have a stool following each feed or only one every 7–10 days; bottle-fed infants and older children will usually have a bowel action at least every 2–3 days. Constipation occurs more commonly in older children when they have been switched from breast milk or formula to cow’s milk. Constipation may be associated with abdominal pain, reduced appetite and irritability. Vomiting is rarely a sign of constipation alone.

Children may develop constipation as a result of:

• a natural tendency related to reduced gut motility

• a poor diet

• a toddler behavior pattern

• inadequate fluid intake (sometimes after acute illness)

• reduced activity

• painful anal conditions, e.g. fissures

• sometimes following sexual abuse.

Organic causes are rare after early infancy.

Assessment

All infants under 3 months should be discussed with the registrar or consultant. They may require referral for exclusion of Hirschsprung disease. Suggestive symptoms and signs include delayed passage of meconium, vomiting, failure to thrive, abdominal distension and a positive family history.

Do not perform a rectal examination—it is rarely helpful and usually traumatic to the child. An inspection of the anus is important to exclude painful conditions. Acute anal fissures are generally posterior and may occur after passage of a large stool or may complicate inflammation of the perianal skin, e.g. in pinworm (or threadworm) infestation. Perianal cellulitis is caused by group A streptococcal infection and is characterised by induration and marked erythema of the perianal skin with mucopurulent exudate. An abdominal X-ray is not helpful in the initial assessment and should not be ordered. Remember that urine infections are more common in constipated children and should be sought if symptoms are suggestive.

Assesment Constipation in Pediatric Emergency

Management

Carers need to be reassured about the safety of laxatives in children. Rectal medications should be avoided in the first instance and not prescribed without discussion with a consultant. Management can be divided into three main steps

Step 1

Initially give a high fibre diet with adequate fluid intake, adequate exercise and regular toileting.

Step 2

The child will need laxatives, including a stool softener and an aperient.

A suggested regime is: Parachoc or Lactulose; plus sennakot

• Liquid paraffin (<5 years: 10 ml daily; 6–12 years: 15 ml daily). Parachoc should be avoided if there is an increased risk of aspiration, e.g. in cerebral

palsy with bulbar involvement. Children may be given up to 25 ml of Parachoc per dose.

• Lactulose (<5 years: 5 ml b.i.d.; >5 years: 10 ml b.i.d.). Children may be given up to 25 ml of Lactulose per dose.

• Senna granules: (2–6 years: 1/2 teaspoon nocte; 6–12 years: 1 teaspoon nocte). The maximum daily dose of Sennakot granules should be 3 teaspoons per day

Abdominal pain may occur as a side effect. Increased doses may be required in some children with chronic constipation. The dose should be titrated to achieve at least one soft stool per day.

If overflow incontinence is present, warn families that it may worsen initially with treatment.

Step 3

Rarely patients may require admission to achieve bowel emptying. Treatment will involve a bowel preparation agent either Picoprep (Picolax in the UK) sachets (sodium picosulphate 10 mg, magnesium oxide 3.5 mg, citric acid 12.0 g, aspartame 36 mg): <2 years—1/4 sachet; 2–4 years—1/2 sachet; 4–9 years—3/4 sachet, repeating in 6 hours if no response; or colonic lavage solution (e.g. Golytely: orally or via a nasogastric tube).

Disposition

All patients should be referred for follow up in a general pediatric clinic within 7 to 10 days.

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Abdominal Pain in Pediatric Emergency

Causes of abdominal pain in childhood Abdominal pain is one of the more common reasons for parents to bring their child to the Emergency Department. While many diagnoses traverse all age groups, some are more age specific (Table 1).

Assessment of abdominal pain

The assessment of the child with acute abdominal pain depends on a good history and careful examination. The nature of the pain itself must be carefully elicited, including its characteristics, relieving and precipitating factors. Truly severe colicky pain suggests an obstruction of the gastrointestinal, genitourinary or hepatobiliary tract. Pain can be referred from elsewhere such as the testes and the lungs. Associated features must also be elicited such as gynecological symptoms in adolescent girls. A full and careful but sensitive examination must follow. If acute activity precipitates pain, it suggests peritonitis. Acute serious problems need rapid combined surgical and medical assessment and management. The algorithm (Table 1) may be used as a guide to the systematic consideration of various categories of causes of acute abdominal pain. Typical features of some important causes of acute abdominal pain in children are described in the following table (Table 2).

Notes:

• Acute appendicitis must be considered in any child with severe abdominal pain, aggravated by movement such as walking, or a bumpy car ride. The child is often flushed, with a tachycardia and a mildly elevated temperature. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical—no laboratory or radiological tests are required, although there is usually an elevated white cell count.

• The peak age for intussusception is 6–12 months. The child may present in shock. Plain anterior chest X-ray may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflation or barium enema, with reduction usually possible by the same means (unless there are signs of peritonitis, which increase the risk of perforation).

• Mid-gut volvulus is commonest in the newborn period, but can occur in later childhood. Predisposing factors include malrotation and abnormal mesentery.

• Vomiting is rarely due to constipation.

• Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (e.g. family, school issues) need to be considered. These children should be referred for general pediatric assessment.

• Some less common diagnoses need to be considered in patients with certain underlying chronic illnesses. Hirschsprung disease can be complicated by enterocolitis, with sudden painful abdominal distension and bloody diarrhea. These patients can become rapidly unwell with dehydration, electrolyte disturbances, and systemic toxicity, and are at risk of colonic perforation. Primary bacterial peritonitis can occur in children with nephrotic syndrome, splenectomy and those with VP shunts.

Table 1.  Causes of abdominal pain by age

Table 2. Assessment of abdominal pain in pediatric

Management

An algorithm for abdominal pain management is given in Table 1.

Intravenous access should be established. The electrolytes should be measured in a child who appears dehydrated and blood and stool cultures obtained if the child is potentially septic. The patient should be given and fasted until a surgical opinion has been sought. In addition, a nasogastric tube will be needed if there is bowel obstruction.

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Meningitis in Pediatric Emergency

The presentation of a child with meningitis varies with age. Infants with meningitis frequently present with non-specific signs and symptoms such as fever, irritability, lethargy, poor feeding and vomiting. The fontanelle may or may not be full. Older children may complain of headache or photophobia. Neck stiffness may be present (although this is not a reliable sign in young children). A purpuric rash is suggestive of meningococcal septicemia. It is important to examine for spinal and cranial abnormalities such as dermal sinuses, which may have predisposed the child to meningitis.

Note: This guideline is not for use in children with spinal abnormalities or ventriculoperitoneal shunts where the neurosurgical team should be consulted.

Assessment

Assess airway, breathing and circulation. Monitor pulse, blood pressure, respiratory rate, oxygen saturation and consciousness. Insert intravenous line and take blood for glucose, FBC and blood cultures and U&Es, meningococcal PCR, and CRP (C-reactive protein). Do nose and throat swabs, as occasionally the organism is isolated from these. If the clinical diagnosis is meningitis and there are contraindications for a lumbar puncture give intravenous antibiotics without delay.

Lumbar puncture (LP)

An LP is used to confirm the diagnosis of bacterial meningitis and to identify the organism and its antibiotic sensitivities. In some cases it should be postponed because of the risk of coning. There are contraindications to performing an LP, including:

• Coma—Glasgow Coma Scale (GCS) <13 or rapid deterioration in conscious state or absent or non-purposeful responses to painful stimuli (squeeze earlobe hard for up to 1 minute. Children should localise response and seek a parent)

• Focal neurological signs

• Papilledema

• Cardiovascular compromise

• Evidence of coagulopathy.

If any of these signs are present the patient is in danger of coning, and management in Intensive Care is usually required. Notify a PICU immediately (for retrieval or transfer), perform blood cultures, commence antibiotics.

Remember cerebrospinal fluid (CSF) findings in early bacterial meningitis may mimic a viral pattern or even be normal (see Table 6.1). In a traumatic tap, allow 1 white blood cell for every 500 red blood cells, and 0.01 gl−1 of protein for every 1000 red cells. Request culture and analysis for bacterial antigens (this is non-urgent as it does not change immediate management and there is no need for it to be performed out of hours).

Management

a. Admission to a PICU

Admission to PICU should be discussed with the consultant in the following circumstances:

Meningitis: Factors requiring consultant opinion

•Age less than 2 years

•Coma

•Cardiovascular compromise

•Intractable seizures

•Hyponatremia

b. Antibiotics

In a child aged over 2 months the usual organisms causing bacterial meningitis are Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b (HiB—uncommon after the age of 6 and the incidence is reduced following HiB vaccination).

Empirical treatment consists of cefotaxime (50 m g/kg weight per dose up to a maximum of 3 g, 6 hourly) given prior to determination of the organism responsible and its sensitivities. Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins. You may need to consider the addition of vancomycin if pneumococcus is suspected in an area of high incidence of penicillin-resistant pneumococcus.

Continue empirical treatment until cultures are known to be negative or an organism and its sensitivity pattern are known. A positive culture result with sensitivities should lead to narrower spectrum treatment.

In a child aged under 2 months, the organisms to consider in this age group include group B streptococcus, Escherichia coli and other Gram negative organisms, Listeria monocytogenes, Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b.

Initial therapy is with i.v. benzylpenicillin (50mg/kg weight per dose, 6 hourly), and i.v. cefotaxime (50 mg/kg weight per dose, 6 hourly), and i.v. gentamicin (dose according to age). Ongoing therapy is modified according to culture and sensitivity results. Consult local guidelines.

Treatment in meningjtis with positive cultures with sensitivities

• Neisseria meningitidis—give i.v. benzylpenicillin 50 mg/kg weight per dose up to a maximum of 3 g, 4 hourly for 7 days (in penicillinsensitive cases)
• Streptococcus pneumoniae—give i.v. benzylpenicillin 50 mg kg−1 per dose up to a maximum of 3 g, 4 hourly for minimum of 10 days (in penicillinsensitive cases)
• Hemophilus influenzae—give i.v. cefotaxime 50 mg/kg weight  per dose up to a maximum of 3 g, 6 hourly for 7–10 days, or i.v. amoxycillin 50 mg/kg weight  per
• dose 4 hourly for 7–10 days (depending on sensitivities)
• Other—if an organism is not isolated, but significant CSF pleocytosis is present, a minimum of 7 days treatment with i.v. cefotaxime is recommended.

c. Fluid management

Careful fluid management is important in the treatment of meningitis as many children have increased antidiuretic hormone (ADH) secretion. The degree to which fluid should be restricted varies considerably from patient to patient depending primarily on their clinical state.

Shock should be corrected with 20 ml/kg weight of normal saline. A patient who is not in shock and whose serum sodium is within the normal range should be given 50% of maintenance fluid requirements as initial management. If the serum sodium is less than 135 mmol/l give 25–50% of maintenance requirements. The serum sodium should be repeated every 6–12 hours for the first 48 hours and the total fluid intake altered accordingly. If the serum sodium is less than 135 mmol/l, reduce the fluid intake.

d. General measures

• Neurological observations including blood pressure should be performed every 15 minutes for the first 2 hours and then at intervals determined by the child’s conscious state.

• Weight and head circumference should be monitored on a daily basis.

• Control seizures.

• Early consultation with intensive care unit is necessary for any child who is experiencing a deterioration in conscious state, hemodynamic instability or seizures.

• Electrolytes should be checked every 6–12 hours until the serum sodium is normal.

• Ensure adequate analgesia (e.g. paracetamol) for children in the recovery phase who may have significant headache.

• The role of steroids is still controversial and we have opted generally not to use them, although they may be indicated in Hemophilus meningitis.

Isolation

Children with meningococcal disease require isolation until they have had 24 hours treatment. Other children with meningitis can be nursed on the open ward.

Fever persisting for more than 7 days

This may be due to nosocomial infection, subdural effusion or other foci of suppuration. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.

Contact chemoprophylaxis

Practice differs in different countries. Below is one regime used in Australia. It is important that prophylaxis be given early to both the index case and contacts as follows:

• Index Case and all household contacts if household includes other children under 4 years of age who are not fully immunized.

 Index Case and all household contacts in households with any infants under 12 months of age, regardless of immunization status.

• Index Case and all household contacts in households with a child 1–5 years of age who is inadequately immunized.

• Index Case and all room contacts including staff in a child-care group if Index Case attends over 18 hours per week and any contacts under 2 years of age who are inadequately immunized. (NB. Inadequately immunized children should also be immunized.)

• Index Case (if treated only with penicillin) and all intimate, household or day-care contacts who have been exposed to the Index Case within 10 days of onset.

• Any person who gave mouth-to-mouth resuscitation to the Index Case.

Australian contact chemoprophylaxis regimen

• Hemophilis influenzae type b—give rifampicin 20 mg/kg weight orally as a single daily dose to a maximum 600 mg) for 4 days. For infants <1 month give rifampicin 10 mg/kg weight  orally daily for 4 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight  i.m. (<12 years) or 250 mg/kg weight  i.m. (>12 years) as a single dose.
• Neisseria meningitidis—give either: rifampicin 10 mg/kg weight  orally 12 hourly up to a maximum 600 mg for 2 days. For infants <1 month give rifampicin 5 mg/kg weight  orally 12 hourly for 2 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight  i.m. (<12 years) or 250mg/kg weight  i.m. (>12 years) as a single dose. or ciprofloxacin 500 mg orally as a single dose.
• Streptococcus pneumoniae—there are no increased risks to contacts, so no antibiotic required.
• Rifampicin may cause orange-red discoloration of tears, urine and contact lenses, skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy or severe liver disease.

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Headaches in Pediatric emergency

Headache is a common symptom in children, affecting 80–90% by the age of 15. The common causes are systemic illness with fever, local ENT problems, migraine and tension headache. Meningitis, raised intracranial pressure (ICP), e.g. from tumors, and subarachnoid hemorrhage (SAH) are much rarer causes but these need to be considered. Any headaches that wake a child from sleeping or that are associated with focal signs such as a hemiplegia require investigation as an inpatient

Assessment

History

It is useful to classify headache as acute or recurrent. The following list gives the causes and key features to help make a diagnosis, based on careful history and examination:

Acute

• Systemic: fever and general illness (e.g. ’flu, pneumonia, septicemia)

• Local sinusitis, dental caries, otitis media

• Trauma: head injury

• Meningitis: reduced conscious level, toxicity, photophobia, neck stiffness

• SAH: sudden onset, severe occipital pain; possible reduced conscious level, neck stiffness

Recurrent

• Migraine: aura, nausea, vomiting, pallor, family history

• Tension: throbbing pain (involving neck muscles) at end of day

• Behavioral: family/social/school problems (may be difficult to identify)

• Raised ICP: morning headaches ± vomiting, worse with coughing/sneezing/bending

• Progressively worsening raised ICP: personality or behavioral changes, focal neurological symptoms

• Benign intracranial hypertension, systemic hypertension, uremia, recurrent hypoglycemia, recurrent seizures, lead or CO poisoning.

It may be useful to make out a possible family headache patterns diagram to help identify the nature of the headache.

Examination

As part of the examination it is important to document the following:

• ABC: blood pressure, heart rate

• General: toxic, unwell, temperature, rash

• Neurology: conscious level, fundi, visual fields, cerebellar signs, neurocutaneous stigmata, neck stiffness, cranial bruits

• Local causes: cervical lymphadenopathy, teeth, sinus, ears

• Growth and puberty: head growth, height, weight, growth velocity, pubertal status.

Investigations

In the acute situation, the two most important questions to answer are:

• Does the child need an urgent computerised tomography (CT) scan of the head? and

• Should a lumbar puncture (LP) be performed? In making the decision, you should consider the following factors:

• If the child has altered state of consciousness, focal neurological signs, raised blood pressure or papilledema, consider management of raised ICP and CT scan of head. Discuss this with senior medical staff.

• Consider LP (in the absence of the contraindications) if you are concerned about meningitis or SAH. You may need to do a CT scan first (discuss with consultant).

• If there are no symptoms and signs suggesting raised ICP/SAH/ meningitis and the story is suggestive of migraine, then treat symptomatically (see below).

• If other causes are suspected, do the appropriate investigations (e.g. septic screen, urea, carboxyhemoglobin or lead level [wrist X-rays], blood sugar profile).

Management

If there is a specific diagnosis such as meningitis, SAH, tumor, systemic infection or local infection, then treat as appropriate. Most recurrent headaches can be managed by a pediatrician and do not need to be referred to a neurologist.

Abort attack

Avoid opiates. Initially try simple oral analgesics such as paracetamol (20 mg/kg weight stat then 15 mg/kg weight per dose every 4 hours, to a maximum of 4g per day) or codeine (1 mg/kg weight per dose every 4 hours) or NSAID (ibuprofen 2.5–10 mg/kg weight per dose 6–8 hourly). For adolescents give 1 g of aspirin, 1 g of paracetamol, 10 mg of metoclopramide. Some, but not all, pediatricians use intravenous anti-emetics in severe vomiting. For example, if vomiting is a prominent feature in children over 10 years give slow i.v. prochlorperazine

(0.1–0.2 mg/kg weight).

Prophylaxis

Refer to a local doctor or general pediatric outpatient clinic for long-term management. Consider beta blockers, pizotifen or calcium channel blockers. Non-pharmacological interventions (e.g. avoidance of triggers, relaxation) often play an important role in prevention. Consider getting the child or parents to make a headache diary.

Headache patterns

It may be a good idea with the use of the chart below to explore the pattern of the child’s headaches .

• Acute recurrent includes migraine (common, classical, complicated).

• Chronic non-progressive includes tension (stress related); muscle contraction; anxiety; depression; somatisation headaches.

• Chronic progressive includes headaches from tumor; benign intracranial hypertension; brain abscess; hydrocephalus.

• Acute on chronic non-progressive includes tension headache with coexistent migraine.

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