SELECTED PEDIATRIC EMERGENCIES, PART I
From Topics in Emergency Medicine, presented October 24-27, 2005, by the University of California, San
Francisco, School of Medicine, Department of Medicine, Division of Emergency Medicine
Andrea Marmor, MD, MSEd, Assistant Clinical Professor, Department of Pediatrics, University of California, San
Francisco, School of Medicine
| Case: girl, 6 yr of age, with cold symptoms and wheezing (despite 2 doses of albuterol at home); asthma diagnosed at 3 yr
of age; no history of asthma-related hospitalizations, but wheezes with vigorous exercise and after onset of cold symptoms;
2 emergency department (ED) visits for asthma exacerbations in past year (mother reports oral prednisone administered
but child vomited medication); clinical findings include tight lung examination and O2 saturation of 97%
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| Metered dose inhaler (MDI) with spacer vs nebulizer: nebulizers—popular in ED for delivery of bronchodilators for
outpatient management of asthma; commonly used at home for infants and young children with asthma; MDI with
spacer—faster, portable method of delivery; efficacy similar to or greater than nebulizer when equivalent dose given
(holds true for infants and young children and during acute exacerbations of moderate severity); cost-effectiveness depends
on availability of medications and equipment; once educated on use, parents generally prefer MDI with spacer over
nebulizer for portability, ease of use, and speed of action
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| Use of MDI in ED: treating acute asthma exacerbation with MDI and spacer reinforces efficacy of method and models appropriate
action and correct technique for parents; dosing—8 puffs from standard 80-µg albuterol MDI equivalent to 2.5
mg delivered by nebulizer; important to educate parent about dosing equivalents; recommendations—prescribe MDI with
spacer for all outpatients (nebulizers rarely necessary at home); teach appropriate technique to parents (child in lap; good
seal over nose and mouth; 1 dose discharged; child takes 5 breaths before parent discharges next dose)
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| Oral corticosteroids: systemic steroids effectively treat acute exacerbations, prevent hospitalizations, and reduce duration of
symptoms (most effective when given early in exacerbation); oral corticosteroids have bioavailability and efficacy similar
to intravenous (IV) or intramuscular (IM) formulations; oral prednisone—standard of care, but poorly tolerated by
many children, resulting in problems with compliance
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 | Dexamethasone: half-life 36 to 72 hr (longer than prednisone); safety in children well established; IV formulation more
concentrated than most oral formulations (tablet or liquid), pH-neutral, well tolerated (when given orally), and tasteless;
efficacy—randomized controlled trial compared 2 doses of dexamethasone, given 24 to 36 hr apart, to standard
5-day course of prednisone for outpatient treatment of asthma; tolerance and compliance better with dexamethasone;
no differences in efficacy; dosage—0.6 mg/kg; 2 doses given 24 to 36 hr apart; IV formulation mixed with cherry
syrup or crushed tablet mixed with apple sauce or jelly good options for oral delivery; recommendations—consider
dexamethasone when steroids indicated (eg, asthma, croup, bronchiolitis)
|
| Discharge planning from ED: 2002 update to guidelines by National Heart, Lung, and Blood Institute (NHLBI) indicate
inhaled corticosteroids (ICS) as first-line therapy for children with persistent asthma; presentation to ED—patients
with acute exacerbations stabilized in ED, then referred to primary care physician for follow-up and management;
model ineffective for high-risk patients and those most likely to use ED for episodic care; follow-up often nonexistent
or insufficient; Cochrane review of data on adults shows initiating ICS in ED may reduce relapses (no studies in children);
providing action plans and follow-up (by phone or in person) known to reduce relapses; study—speaker’s urgent
care clinic initiated guidelines for asthma management and developed forms to help classify and treat patients
with acute exacerbations; standard of care included classifying asthma severity based on symptoms, prescribing appropriate
controller medication at discharge, and providing action plan, MDI with spacer, education, and appropriate referral;
since implementing policies, percentage of patients prescribed ICS has steadily increased, and asthma-related
hospitalizations (absolute number and as percent of total hospitalizations) have significantly decreased
|
| Recommendations: strongly consider beginning long-term management of asthma in ED or urgent care setting; classify severity
of asthma; begin ICS in children with persistent asthma; provide action plan; telephone or other follow-up, if possible
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| Classifying asthma severity: patients who have >2 daytime symptoms per week, >2 nighttime symptoms per month, or 2
visits to ED or hospitalizations during last year qualify as having persistent asthma; ICS first-line therapy for children
with persistent asthma
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| Case: boy, 3 mo of age, presents with increased work of breathing; O2 saturation 92% on room air; respiratory rate 45 breaths/
min; temperature 38.5°C; diffuse coarse wheezes audible on examination; consistent with bronchiolitis
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| Natural history: self-limited disease; supportive care (O2 , fluids, observation) mainstay of treatment; clinical presentation
very similar to asthma, but pathophysiology and treatment differ; infants with bronchiolitis have increased risk of developing
asthma; distinguishing bronchiolitis from first episode of asthma sometimes difficult
|
| Diagnosis: systematic review of evidence (Bordley et al) concluded routine testing for respiratory syncytial virus (RSV),
chest x-ray, and complete blood count (CBC) do not reliably affect clinical management or outcome or predict severity of
disease; evidence-based practice guidelines decrease testing, admissions, and overall cost without increasing complications,
hospital admissions, or morbidity
|
| Treatment: primarily supportive care; albuterol—2 meta-analyses found no clinically significant effects overall, but suggested
benefit in some groups of patients (those with recurrent wheezing or strong history to suggest asthma); racemic
epinephrine—meta-analysis and Cochrane review showed short-term improvement over placebo and β2 -agonists; treatment
correlated with decreased respiratory rate and improvement in O2 saturation and patient’s general appearance; although
admission rate unaffected, treatment reduced length of stay; studies found no evidence of rebound effect;
corticosteroids—meta-analysis found statistically significant improvement in symptom score, days of symptoms, and
length of stay in hospital (decreased by ≈0.5 day); greatest effect seen in sicker infants and those with recurrent wheezing;
differences seen in Cochrane review not statistically significant; small randomized controlled trial showed dexamethasone
reduced admission rate in moderately ill patients; hypertonic saline—nebulizing epinephrine or albuterol in hypertonic
saline improves short-term response, compared to nebulization in regular saline (but hypertonic saline alone may cause
bronchospasm)
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| Recommendations: routine testing discouraged; clinical assessment of patient and response to management more important;
evidence-based practice guidelines improve efficiency and quality of care; management primarily consists of supportive
care and measures of nasal and airway clearance; albuterol safe and warranted in infants with bronchiolitis
(discontinue if child does not respond to first dose); nebulized epinephrine may help (but unavailable for outpatient management);
corticosteroids may have benefit in sicker patients; dexamethasone acceptable alternative to prednisone
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| Case: boy, 5 mo of age, presents with 2-day history of fever but appears well and hydrated; temperature 39.2°C, but no
source of fever identified after thorough examination; immunizations complete for age, including second dose of pneumococcal
vaccine (given 3 wk previously)
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| Incidence: source of fever unidentified in ≈20% of febrile children; some well-appearing children have serious occult bacterial
infection or urinary tract infection (UTI); age—groups based on risk and likely bacterial causes of infection; age
groups include neonates <28 days, infants 1 to 3 mo of age, and children 3 to 24 mo of age
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| Pneumococcal vaccine: prevaccine era—concern centered on children 3 to 24 mo of age; previous guidelines included
white blood cell (WBC) count to stratify risk groups; WBC count >15 cells/µL indicated high risk (6%-10%) for serious
bacterial infection; WBC count <15 cells/µL indicated low risk (outpatient management appropriate); coverage—
pneumococcal 7-valent conjugate vaccine (Prevnar) covers 7 strains of Streptococcus pneumoniae commonly responsible
for invasive disease in infants and children 3 mo to 3 yr of age; part of routine immunization schedule (since August
2000), given at 2, 4, and 6 mo of age, with booster given between 12 and 15 mo of age; ≈97% of isolates known to cause
invasive pneumococcal disease represented in vaccine; efficacy—in large northern California study conducted before
vaccine released, 97.5% of fully vaccinated children and 94% of children who received 1 dose protected against strains
covered by vaccine; vaccine 89.1% efficacious against all serotypes (ie, not just those represented in vaccine) in children
receiving 1 dose; studies conducted after licensure found 78% to 85% decrease in rate of invasive pneumococcal disease
in children <2 yr of age (vaccinated and unvaccinated populations); no documentation of increased prevalence of disease
from serotypes not covered by vaccine
|
| Management: assuming 90% efficacy of pneumococcal vaccine, children receiving 1 dose have <0.5% risk for serious bacterial
illness (SBI), regardless of WBC count; CBC unlikely to have significant impact on clinical management; empiric drawing
of CBC and blood culture not cost-effective if rate of SBI <0.5% as predicted for postvaccine population; efficacy of vaccine
in incompletely vaccinated children unclear; northern California study suggests immunity after 2 doses if sufficient time has
passed since second dose (for development of immunity); third dose given within 3 mo of second dose prevents dip in immunity;
3 doses appear to confer immunity similar to full series; South African study looking at similar vaccine showed 95% efficacy
after 2 doses; recommendations—immediately stabilize and treat ill or toxic-appearing febrile children, regardless of
age; consider using WBC count to stratify risk in children <4 mo of age or with <2 doses of pneumococcal vaccine; screen all
children with unexplained fever for UTI; consider children adequately vaccinated and at low risk ≥2 wk after second dose
(CBC not generally helpful and not likely to change management in these patients; screening for UTI still recommended); consider
age and other historical factors (eg, severity and duration of fever, presence of likely source, potential for follow-up)
when deciding whether to draw CBC in inadequately vaccinated children
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| Viral testing: positive viral diagnosis makes SBI and UTI much less likely; rapid viral tests help stratify risk for SBI; rapid
tests exist for RSV, adenovirus, parainfluenza, influenza, enterovirus, and rotaviruses; tests have higher specificity than
sensitivity; effect on management—reduces testing, hospitalization, and antibiotic use, without increasing number of missed
cases of SBI; prospective study—infants <90 day of age stratified as high- or low-risk using Rochester criteria (CBC;
WBC count; lumbar puncture [LP], when appropriate); viral panel performed on all children; low-risk infants remained at
low risk, regardless of results of viral panel (but risk even lower with positive viral test); positive viral test in high-risk infants
significantly reduced risk for SBI or UTI, from ≈16% to ≈5% (UTI more common; very low risk for bacteremia and
meningitis); risk for UTI remains appreciable in high-risk infants with positive viral test (especially with RSV); screening
for UTI recommended, especially in infants with high or persistent fever
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| MDI dosage: educating parents important; dose based on severity of symptoms; mild to moderate symptoms require only 1
to 2 puffs; although larger doses (as given in ED) safe, they may cause adverse effects (eg, hyperactivity, vomiting, tachycardia);
advice to parents—give child only as much medication as required to control symptoms; beware of adverse
effects at larger doses
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| Availability of corticosteroids: nebulized corticosteroids not as effective as systemic formulations; systemic corticosteroids
considered standard of care in acute setting
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| Dexamethasone dosage: studies looking at low doses (0.15 mg/kg and 0.3 mg/kg) in patients with croup have mixed results;
2 doses of 0.6 mg/kg equivalent to standard 5-day course of prednisone (established as efficacious); maximum
dose—2 doses of 16 mg, given 24 to 36 hr apart
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| Off-label use of IV dexamethasone: oral administration established as safe; writing protocol for pharmacy helpful; some
pharmacies package and label IV medication separately for oral use and administer with oral syringes
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| Ipratropium bromide (Atrovent): study showed reduced hospitalizations when given with albuterol for first 3 nebulized
treatments; no evidence of benefit after 3 treatments; speaker’s group often continues to administer drug q6h or q8h to in-
patients (safe and may reduce requirements for albuterol); no role in outpatient treatment of children with asthma
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| Levalbuterol (Xopenex): nonracemic form of albuterol (R isomer); 0.63 mg achieves same bronchodilation as 2.5 mg of
albuterol, with fewer adverse effects; however, most patients tolerate albuterol well, and expense limits use; note—
available only in nebulized form
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| Delivery of Atrovent: when administering bronchodilator with MDI and spacer, nebulizer sometimes used to deliver Atrovent;
not all patients require Atrovent (mostly used in patients who may require hospitalization); MDI formulation also
available
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| Multiple doses of bronchodilator: give 2.5 g over 5 min with nebulizer or 8 puffs using MDI with spacer; wait 20 to 30
min before administering subsequent dose
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Educational Objectives
| The goal of this activity is to facilitate diagnosis and improve efficiency and quality of management of common pediatric
emergencies. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss use of the metered-dose inhaler with spacer to treat acute exacerbations of asthma in children.
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| 2. Classify asthma by severity and initiate appropriate therapy for long-term management.
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| 3. Discuss the role of laboratory tests in the diagnosis of bronchiolitis and identify children who may benefit from medical
therapy.
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| 4. Discuss the impact of pneumococcal vaccine on the diagnosis and management of young children with unexplained fever.
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| 5. Use viral testing to stratify febrile children into low and high risk for serious bacterial illness.
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Discussed on This Program
Albuterol [AccuNeb, Proventil, Proventil HFA, Proventil Repetabs, Ventolin, Ventolin HFA, Volmax]
Dexamethasone (several trade names)
Ipratropium bromide [Atrovent]
Levalbuterol HCl [Xopenex, Xopenex HFA]
Pneumococcal 7-valent conjugate vaccine [Prevnar]
Prednisone (several trade names)
Racepinephrine (racemic epinephrine) [microNefrin, Nephron, S-2]
Suggested Reading
Bentur L, et al: Dexamethasone inhalations in RSV bronchiolitis: a double-blind, placebo-controlled study. Acta Paediatr
94:866, 2005; Berger WE: Paediatric pulmonary drug delivery: considerations in asthma treatment. Expert Opin Drug
Deliv 2:965, 2005; Blitz M, et al: Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst
Rev 19:CD003898, 2005; Boyd R, Stuart P: Pressurised metered dose inhalers with spacers versus nebulizers for beta-agonist
delivery in acute asthma in children in the emergency department. Emerg Med J 22:641, 2005; Christakis DA, et al:
Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics 115:878, 2005; Colmenares JP, et
al: Emergency department evaluation of febrile children after the introduction of Prevnar. Tenn Med 98:184, 2005; Cydulka
RK, et al: Inadequate follow-up controller medications among patients with asthma who visit the emergency department.
Ann Emerg Med 46:316, 2005; Ferris TG, et al: Are minority children the last to benefit from a new technology?
Technology diffusion and inhaled corticosteroids for asthma. Med Care 44:81, 2006; Hardasmalani MD, et al: Levalbuterol
verus racemic albuterol in the treatment of acute exacerbation of asthma in children. Pediatr Emerg Care 21:415,
2005; Kunkov S, et al: Predicting the need for hospitalization in acute childhood asthma using end-tidal capnography. Pediatr
Emerg Care 21:574, 2005; Mejias A, et al: Respiratory syncytial virus infections: old challenges and new opportunities.
Pediatr Infect Dis J 24:S189, 2005; Sekerel BE, et al: The effect of nebulized budesonide treatment in children
with mild to moderate exacerbations of asthma. Acta Paediatr 94:1372, 2005; Stoll ML, Rubin LG: Incidence of occult
bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a children’s
hospital emergency department and urgent care center. Arch Pediatr Adolesc Med 158:671, 2004; Zorc JJ, et al:
Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 18:417, 2005; Zorc JJ, et al: Clinical
and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics 116:644, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Marmor was recorded in San Francisco at Topics in Emergency Medicine, sponsored by University of California,
San Francisco, School of Medicine, Division of Emergency Medicine, and held October 24-27, 2005. The Audio-Digest
Foundation thanks Dr. Marmor and University of California, San Francisco for their cooperation in the production
of this program.
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