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Complications of Pregnancy

Acknowledgment We thank Dr. Sidhant Nagrani and Dr. Bisan Salhi for their contributions to previous editions of this chapter. Key Concepts Miscarriage is defined as the spontaneous termination of pregnancy before 20 weeks of gestational age. Approximately 25% of women experience some bleeding during pregnancy. Most miscarriages are due to uterine malformations or chromosomal abnormalities. Beta hCG discriminatory levels for detecting intrauterine pregnancy are usually considered…

Child Abuse

Physical Abuse Key Concepts The ultimate determination of whether abuse has occurred can take days or weeks. Emergency clinicians should focus on recognizing possible abuse, treating medical injuries, and establishing a safe disposition for the child. Completely undress infants and preverbal children for the physical examination; pay particular attention to the skin, ears, mouth and oral cavity, scalp, fontanel, and genitalia. Consider abuse routinely for sentinel…

Pediatric Drug Therapy

Key Concepts Awareness of differences in pediatric pharmacokinetics and specific drug toxicities is of critical significance for the safe and effective use of medications in children. Avoid prescription and over-the-counter (OTC) cough and cold medications in children because these agents have limited efficacy data and may cause harm. Counsel parents about the management of fever and appropriate indications and proper use of antipyretics. Perform a risk…

Pediatric Musculoskeletal Disorders

Key Concepts The pediatric physis is the weakest part of the bone and more likely to separate before adjacent tendon or ligament tears, occurring more frequently during periods of rapid growth. Displaced supracondylar fractures are at greater risk for neurovascular injury and compartment syndrome. A lateral elbow radiograph with an elevated fat pad is suspicious for occult fracture. Transient synovitis has a peak presentation between 3…

Pediatric Neurologic Disorders

Key Concepts Altered mental status in children has a varied spectrum of clinical presentations, and may include any of the following: altered level of consciousness, excessive sleepiness, irritability, lethargy, and abnormal behavior. A careful and detailed history is instrumental in determining whether an event was a seizure. Status epilepticus constitutes a neurologic emergency that carries high morbidity and mortality rates. Initial treatment is typically with IV…

Pediatric Genitourinary and Renal Tract Disorders

Foundations Genitourinary (GU) and renal tract emergencies in children are common. These issues span age and gender and have varying clinical presentations. Underlying pathology is due to both congenital and acquired disease. Careful history of present illness and family history can help guide a focused differential diagnosis. A complete physical is especially important in children who present with abdominal pain; in particular, a GU examination must…

Pediatric Infectious Diarrheal Disease and Dehydration

Key Concepts Identification of Pathogen Stool studies are not indicated in most uncomplicated cases of acute gastroenteritis (AGE). Exceptions are those cases in which specific treatment, specific prophylaxis, or health precautions are required, or in which the patient has systemic involvement, underlying medical complications, or dysenteric features. Antibiotics are not required for most cases of uncomplicated acute bacterial enteritis. Antibiotics are recommended routinely for C. difficile,…

Pediatric Gastrointestinal Disorders

Key Concepts Physiologic jaundice of the newborn and breast milk jaundice are the most common causes of jaundice in the neonatal period. Direct hyperbilirubinemia in infants is always pathologic and requires a detailed evaluation. Hypertrophic pyloric stenosis is associated with gradually progressive nonbilious emesis that becomes projectile. Hypochloremic-hypokalemic metabolic alkalosis is the classic electrolyte derangement associated with hypertrophic pyloric stenosis. Bilious vomiting in the neonate is…

Pediatric Cardiac Disorders

Key Concepts Consider a congenital heart defect in an infant with central cyanosis who does not respond to 100% supplemental oxygen (hyperoxia challenge). Neonates with ductal-dependent cardiac lesions typically present within the first 2 to 3 weeks of life with either acute cyanosis or shock. Prostaglandin E 1 (alprostadil, 0.05 to 0.1 μg/kg/min) can maintain a patent ductus arteriosus to supply mixed blood and temporize the…

Pediatric Lung Disease

Key Concepts Determining the causative agent of pneumonia by clinical presentation and radiographic findings is not reliable; empirical treatment is based on guideline recommendations and likely pathogens. Causative agents vary by age; viral agents predominate, especially in younger children, and Streptococcus pneumonia is the leading bacterial cause outside of the neonatal period. Infants and younger children with pneumonia may have subtle or nonspecific symptoms and signs…

Pediatric Lower Airway Obstruction

Asthma Key Concepts No single asthma score has been universally adopted to assess the degree of illness or treatment responses. However, most scores include some combination of respiratory rate, degree of wheezing, inspiratory-to-expiratory ratio, use of accessory muscles, and oxygen saturation. Chest x-ray (CXR) is not required for wheezing children, even for those who are febrile, are wheezing for the first time, or require hospitalization. CXR…

Pediatric Upper Airway Obstruction and Infections

Key Concepts Respiratory arrest precedes most pediatric cardiac arrests. Quick recognition of an airway problem and intervention in potentially life-threatening upper airway obstruction in children are critical. Retropharyngeal Abscess This is a potentially life-threatening emergency in young children with signs of upper airway obstruction or meningismus; a retropharyngeal abscess is often related to oral trauma. Retropharyngeal abscess is most frequently caused by Staphylococcus aureus, group A…

Pediatric Fever

Key Concepts Fever is the most common complaint among pediatric patients presenting to the emergency department (ED). Although rates of bacterial illness are lower since the advent of universal vaccination for Haemophilus influenzae type b and Streptococcus pneumoniae , serious bacterial infection (SBI) should be considered in the under-vaccinated or unvaccinated child. Viruses cause the vast majority of childhood febrile illnesses and are generally self-limited and…

Pediatric Trauma

Key Concepts Trauma is the leading cause of death in children in the United States. Avoid hypoxia and hypotension by early administration of oxygen and assisted ventilation, and fluid resuscitation with crystalloid at 20 mL/kg increments. Initiate transfusion of 10 mL/kg of packed red blood cells (pRBCs) if hypotensive or signs of hypovolemic shock after 40 mL/kg of crystalloid is infused. Key pediatric anatomic and physiologic…

Neonatal Resuscitation

Key Concepts Resuscitation should be anticipated for all deliveries; 10% of newborns will require some resuscitation, and 1% will require advanced life support interventions after birth. Predictable indications for resuscitation include hypoxia, hypothermia, hypoglycemia, hypovolemia, prematurity, maternal infection, and adverse effects of maternal medication. Drying, warming, positioning, and stimulating the infant are sufficient resuscitative measures for most deliveries. Adequate ventilation will reverse most bradycardia, while oxygenation…

Pediatric Resuscitation

Cardiac Arrest Key Concepts Unlike adults, most cardiac arrests in children arise from respiratory etiologies. Therefore, emphasis is first on oxygenation and ventilation. Detection of a child’s pulse may be difficult; if a brachial pulse is not definitively present after 10 seconds of palpation, initiate cardiopulmonary resuscitation (CPR). Hypotension is a late finding in pediatric shock and requires immediate intervention to prevent cardiac arrest. Progression from…

Pediatric Sedation and Analgesia

Key Concepts Patients of all ages experience pain, including infants, neonates, and premature babies. Oligoanalgesia, the inadequate treatment of pain, has many short-term and long-term consequences: worse patient outcomes, increase in patient’s pain threshold, and development of chronic pain. Pain management may include a combination of techniques: analgesics, topical anesthetics, local anesthetic injections, oral sucrose in infants, and nonpharmacologic interventions. Nonpharmacologic interventions to decrease pain or…

Pediatric Airway Management

Key Concepts Pediatric advanced airway management is a relatively rare skill to perform in most emergency departments (EDs), and skill maintenance is difficult based solely on clinical practice. There are several anatomic differences that impact pediatric airway management, and these occur mostly in the very young child (<2 years of age). Infants have a large occiput and a high, anterior airway, which impacts positioning during intubation.…

Care of the Pediatric Patient

Key Concepts Patterns of illness and injury vary by age, and a number of anatomic and physiologic characteristics affect the presentation and management of pediatric emergencies. A basic understanding of normal development will aid the emergency clinician in assessment of the pediatric patient. The pediatric assessment triangle (PAT) can be used as a tool for rapid evaluation of the patient’s overall status. Tachypnea in children should…

Sedative-Hypnotics

Acknowledgments We would like to acknowledge the valuable contributions of the previous edition authors Drs. Andrea Carlson and Leon Gussow. Key Concepts Supportive care, with a focus on respiratory depression, is the foundation of management of all sedative-hypnotic ingestions. Benzodiazepines are commonly used medications both medically and recreationally. Coingestions with other sedative-hypnotic agents can potentiate their neurologic and respiratory effects. Barbiturate medications are less commonly prescribed,…