1. Signs and symptoms of an Upper GI bleed in the pediatric patient
-most common presentation is hematemesis
-melena also common presentation
-many things mimic GI bleed -> food coloring, raw meats, swallowed blood from oropharynx
2. Differential diagnosis for acute pediatric upper GI bleed
-determine if variceal vs nonvariceal
-variceal bleed (uncommon but can be life threatening)-> portal HTN from congenital liver pathologies
-mucosal bleed -> gastritis, esophagitis, caustic ingestion, foreign body most common in pediatrics
3. ED diagnostic workup for an upper GI bleed in a pediatric patient
-CBC, BMP, LFT's, and Type/Cross essential to the workup
4. ED Management of Pediatric Upper GI bleed patient
-Place an NG tube
-Get GI, Surgery, and Interventional Radiology Involved early
-Octreotide and vasopressin are important treatments for variceal bleed
-For mucosal bleeds control acid production
- Neonate in respiratory distress: remember NRP!
- Neonate in respiratory distress with true unilateral absent breath sounds = Congenital Diaphragmatic Hernia??!!-> confirm with CXR
Congenital Diaphragmatic Hernia (CDH)
- Neonates likely have high risk for pulmonary hypertension!
- Do not give PPV -> worsens GI distention/lung compression = worsening pulmonary HTN
- In neonates intubate early to prevent hypoxia (hypoxia worsens pulmonary HTN) with low pressure vent settings
- Maintain systemic BP to reduce right to left shunting
- Older children with CDH, less likely to have significant pulmonary HTN, keep calm and try to avoid intubation
- Persistent/worsening cyanotic neonate - think cyanotic congenital heart defect -> Start Prostaglandins
- Remember Prostaglandins cause apnea, will likely need intubation
- Neonate in extremis = call for back-up early!
- severe onset of symptoms
- worsening clinical course
Abdominal Pain of Unusual Cause
PE vs Sepsis
• The pediatric airway has known unique challenges. Prepare yourself physically and cognitively!
• Maintain spontaneous ventilation if there is any doubt about obtaining successful advanced airway.
• Practice using airway equipment when you don't need it, so you are ready when you do need it.
Septic arthritis of the hip
-Most common hematongenous spread
- Up to 20% of patients with non-gonococcal septic arthritis will have 2 or more joints involved –> always do a full musculoskeletal exam!
- 50% will have positive blood cultures –> always obtain cultures.
- Risk factors: Extremes of age, hardware/recent instrumentation, skin infection, underlying arthritis, IV drug use
- You cannot rule out septic arthritis with inflammatory markers or any physical exam findings, so err on the side of obtaining joint fluid.
Pediatric septic arthritis vs. transient synovitis
- Kocher criteria can help differentiate: Temperature >38.5, WBC >12K, ESR >40, unable to bear weight.
Define status epilepticus:
Remember ABCs and supportive care in addition to treating seizures
Learn dosing for hypoglycemic seizure with dextrose
Learn dosing for hyponatremia seizure with 3% NaCl