3

Common PEM Problems

for the Emergency Medicine Resident

Brad Sobolewski, MD, MEd

Cincinnati Children's Hospital Medical Center Emergency Department Rotation Director

Febrile Infant

The Bottom Line

28 days old and under = full septic workup
29-60 days we can opt to exclude LP if baby is low risk

Fever defined as temperature

o
38 C

o
100.4 F

(rectal)

Viral URI Sx do NOT count as a fever source

H&P are not reliable to rule-out

serious bacterial infection (SBI)

12-28% of febrile neonates have SBI

UTIs (12-20%)

Bacteremia (3%)

Meningitis (<1%)

Other causes
Bacterial gastroenteritis

Gonococcal
keratoconjunctivitis

Omphalitis

Osteomyelitis

Peritonitis

Pneumonia

Septic joint

28 days
IV access

CBC, blood culture

Cath UA, urine culture

LP + CSF studies
Glucose if needed

Chest XRay if clinically warranted

Consider need for HSV testing

Enterovirus CSF PCR in the summer

Stool Culture if mucous or gross blood in the stool

Respiratory PCR and influenza

Lumbar puncture
LP success rate increases with early stylet removal and use of lidocaine

Family presence does not alter success rate

Residents get 2 attempts

Take a supervisor with you

Early stylet removal

CSF

d
o
o
Bl

Lumbar puncture

CSF Analysis
Tube 1 Culture and Gram stain

Tube 2 Glucose, protein

Tube 3 Cell count and dierential

Tube 4 Viral Studies or to be saved for further studies

Labs

Blood
WBC 5,000 or 15,000

Bands >1,500

Band:Neutrophil <0.2

Bands/Bands + Neutros

Urine
<10 WBC/hpf

Negative gram stain

CSF
0-28d - WBC <19/L

29-60d - WBC <9/L

Normal glucose or protein

Gram stain

Low Risk for Bacterial Meningitis

29-60 days old

Full-term (37 weeks gestation)

No prolonged NICU stay

No chronic medical problems

No systemic antibiotics within 72 hours

Well-appearing and easily consolable

No infections on exam

Blood and urine studies reassuring

LP

HSV?
Labs
HSV PCR in CSF and blood

HSV PCR of SEM lesions

Liver profile, BMP

Empiric Acyclovir
Strongly consider for ALL infants 21 days
and for infants 22 to 40 days with 1 of the
following:

Ill Appearing

Abnormal neurologic status, seizures

Vesicular rash

Hepatitis

Mom known to have primary HSV infection

at delivery

Antimicrobials
0-21d Ampicillin/Cefotaxime +/- Acyclovir

22-28d Ampicillin/Cefotaxime

29-56d Cefotaxime or Ceftriaxone (>6 weeks and no jaundice)

Additional Considerations
Add Vancomycin if

Ill Appearing

CSF

WBC elevated w/abnormal glucose or protein

Gram positive organism on Gram stain

What about?
Procalcitonin and CRP
do not improve confidence
to completely rule out SBI
at this time

Disposition
All babies under 28 days are admitted on empiric antibiotics
for 36 hours

Babies 29-60 days with normal CBC and urine can be

discharged home o antibiotics

You can get blood, urine and CSF on a baby 29-60 days and
D/C home if normal - but NO antibiotics!

Disposition
Babies discharged home must have PMD follow up within 24
hours

Also, trustworthy caregivers with reliable transportation

Always call the PMD

If you cant reach them - baby from out of town consider

admission

Bronchiolitis

Rare in the first month of life

Peak 2-5 months

90% of kids will have it by age 2

URI Symptoms
Rhinitis

LRTI Symptoms
Tachypnea

Cough

Wheezing

Crackles

Accessory muscle use

Nasal flaring

Fever in only 30%

RSV #1

If you think it is bronchiolitis you are

probably right!
Viral testing only if severe disease or concurrent septic workup

Getting a Chest Xray just to be sure increases your likelihood of

giving unnecessary antibiotics by 12%

If they have a fever

1/33 risk of UTI

More likely that it is d/t bronchiolitis alone or AOM

Therapies that help

Therapies that dont really help

Suctioning

Albuterol

Oxygen

Racemic epi

Hypertonic saline

Corticosteroids

CPT

Antibiotics (duh)

Infants at risk for rapid progression

Adjusted gestational age <42-44 weeks

<3 months old

Gestational age <34 weeks

Congenital heart disease

Respiratory rate 70

O2 sat <95%

Infants with apnea or

severe distress may
benefit from HFNC

Discharge Criteria
RR generally <70

O2 Sats >90% when awake

Adequate oral intake

Mild to moderate increased work of breathing

Reliable caretaker

Able to secure follow up

Resources
AAP Clinical practice guideline

PEMBlog Bronchiolitis 8-part series

Fussy Baby

<1% of Emergency Department visits

Excessive crying, irritability, screaming or fussiness

Very stressful for tired parents

Your goals

Perform a
thorough
H&P

Try to get
the baby to
stop crying

Head
Neuro exam mental status (must know development!)

Full fontanelle space-occupying lesion or infection

Hematoma or Ecchymosis Trauma

head circumference (hydrocephalus)

Eyes
Corneal abrasion

Eversion of eyelid for retained FB

Red eye and excessive tearing? Conjunctivitis, congenital glaucoma

Ears
AOM

Retained FB

Mouth
Stomatitis

Thrush

Dry mucous membranes

Lacerated lingual frenulum (?NAT)

adapted from PedEMMorsels - Sean Fox

Chest
Rib fractures

SVT

Congenital heart disease

Abdomen
UTI

Mass

Hepatomegaly

Intussusception

Appendicitis

Volvulus (bilious emesis)

Bowel Perforation

Hirschsprung Disease

chronic constipation and no meconium

in first 24 hours of life

GU
Testicular/Ovarian torsion

Incarcerated hernia

Anal fissure

adapted from PedEMMorsels - Sean Fox

Extremities
Hair tourniquet

Fractures

Sickle cell disease (dactylitis)

Septic joint

Post-vaccination (ex, DTaP especially)

Skin
Cellulitis

Eczema

Petechiae, purpura, etc.

Toxidromes

adapted from PedEMMorsels - Sean Fox

Colic
10-26% of infants

Can begin as early as

nd
2

week of life

Excessive crying for:

>3 hrs per day

>3 days per week

>3 weeks in duration

Peaks around

th
6 week

Should resolve by

Diagnosis of exclusion!

th
16

of life

week of life

Freedman, 2009 Pediatrics

Retrospective review of 237 afebrile <1 year olds with CC of crying, irritability,
screaming, colic, or fussiness

Did H&P or any testing contribute to diagnosis/etiology?

12 (5.1%) children had serious underlying etiologies, UTI n=3

Though 81 of 574 (14.1%) tests performed were positive only 8 (1.4%) of

diagnoses were assigned on the basis of positive tests

H&P suggested etiology in 66.3% of cases

Unwell appearance was associated with serious etiologies

Ocular fluorescein staining and rectal examination w/ hemoccult were

uncommon and all negative

Bottom line
If you and/or caregiver can calm the baby in the ED

and
H&P is normal the baby is probably fine

If you do any tests, consider U/A and culture

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