Introduction to Erythema Multiforme

Erythema Multiforme Minor
This condition is characterized by erythematous papules that evolve into target lesions with dusky centers. Some oral lesions may be present.
The most common precipitant is HSV infection. It may also be drug-induced.

Treatment

• Antihistamines provide symptomatic relief.
• Systemic steroids may be helpful if given early.
• Prophylactic acyclovir may be useful to prevent recurrent HSV-related disease.

Erythema Multiforme Major (Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis)
In Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), marked erythema or target lesions rapidly progress to blistering and epidermal sloughing.

Managing Acute Abdominal Pain in Children

Abdominal pain is one of the most common reasons for a parent to bring his or her child to medical attention. Evaluation of a “stomach ache” can challenge both parents and the physician.

Possible causes for a child’s abdominal pain range from trivial to life-threatening, with little difference in the child’s complaints. Fortunately, abdominal pain in a child usually improves quickly. Each parent or caregiver faces the difficulty deciding whether a complaint needs emergency care or not.

Abdominal pain is a common problem in children. Although most children with acute abdominal pain have self-limited conditions, the pain may herald a surgical or medical emergency.

Causes to be kept in MindAlthough many cases of acute abdominal pain are benign, some require rapid diagnosis and treatment to minimize morbidity. Numerous disorders can cause abdominal pain. The most common medical cause is gastroenteritis, and the most common surgical cause is appendicitis.

In the acute surgical abdomen, pain generally precedes vomiting, while the reverse is true in medical conditions. Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant. Signs that suggest an acute surgical abdomen include involuntary guarding or rigidity, marked abdominal distention, marked abdominal tenderness, and rebound abdominal tenderness.

The list that should be in mind while evaluating a child with abdominal is is as follows:

Medical causes

• Diabetic ketoacidosis
• Inflammatory bowel disease
• Acute adrenal failure
• Gastroenteritis
• Food Poisioning
• Urinary tract infection
• Hepatitis
• Sickle cell crisis
• Henoch-Schönlein purpura

Surgical Causes

• Acute appendicitis
• Bowel obstruction
• Intussusception/ volvulus
• Testicular torsion
• Meckel’s diverticulum

Others

• Infantile colic
• Functional pain

History and Physical Examination
In a child presenting with acute abdominal pain a complete history and detailed physical examination is important to reach a proper diagnosis and then appropriate management

Asthma – Management in Emergency Room

A child with acute attack of asthma will usually present with difficulty breathing, cough, wheezes and cyanosis.

Initial Assessment
Assess the Heart Rate, Respiratory Rate, O2 saturation, Peak expiatory flow rate, Use of accessory muscles, Pulsus paradoxus ( more than 20 mmHg difference in systolic B.P for inspiratory versus expiratory phase ) , Dyspnea, Alertness, Colour.

Initial Management

1. Give O2 to keep saturation > 95%.

2. Administer inhaled B- agonists: Nebulized albuterol 0.05 to 0.015 mg/kg/dose every 20 minutes or continuously depending on the condition.

3. Other nebulized bronchodilators that can be used include ipratropium bromide 0.25 to 0.5 mg.

4. If the air movement is poor or the patient is unable to cooperate with a nebulizer give epinephrine 0.01 ml / kg SC . It can be given every 15 minutes upto 3 doses.

5. Starting Steroids: If there is no response after one nebulized treatment or if the patient is steroid dependent or had a recent emergency depertment visit or an ICU care needed start prednisolone 2 mg/kg /day divided 6 hrly.

Hypothermia in Pediatric Practice

Hypothermia is defined as a core temperature of 35 C ( 95 F ) or less. It occurs when the body is no longer able to sustain normal body temperature. Onset of hypothermia depends on the imbalance between increased heat loss and decreased heat production.

Immediate Assessment and Questions

• What are the vital signs? Is there a Pulse?
• Is the patient breathing?
• What is the clinical setting? Very young children are susceptible to hypothermia as a result of environmental exposure.
• Any history of other medical problems like hypoglycemia, hypopituitarisim and hypoadrenalisim may present with hypothermia.
• Any possible source of infection. Septic patients may present with hypothermia.

Physical Examination

• Vital signs
• Measure core body temperature , pulse and B.P
• Volume status
• Volume status should be continuously monitored. Observe for signs of trauma or any continuing blood loss.

Neurological exam
Check mental status and perform a complete neurological exam if the patient is not comatose.

Workup

• CBC: To help rule out conditions such as sepsis and to determine Hb concentration and oxygen carrying capacity.
• Basic Metabolic panel: Provides clues to volume status, hypoglycemia and electrolyte disturbance.
• Urinalysis
• ABGs : Provides acid-base status a nd oxygenation status.
• Chest X-ray: To look for pulmonary edema or aspiration

Physiology of Hypothermia in childrenChildren have a higher surface area to mass ratio than adults and therefore cool faster and become hypothermic at an increased rate. Environmental factors like cold, wind and inadequate clothing can increase heat loss. Heat production can be affected by such factors as age, trauma and medical illness.

Stages of Hypothermia

1. Mild – Core temperature 32 to 35ºC (90 to 95ºF)
2. Moderate – Core temperature 28 to 32ºC (82 to 90ºF)
3. Severe – Core temperature below 28ºC (82ºF)

Management Of Anaphylaxis In Emergency Room

Definition of Anaphylaxis
Anaphylaxis is the clinical syndrome of immediate hypersensitivity. It is characterized by cardiovascular collapse, respiratory compromise and cutaneous and GI symptoms ( e.g urticaria, emesis )

Initial Management

1. ABC’s : Establish airway if necessary. Assess breathing. Supply with 100% oxygen with respiratory support as needed. Assess circulation and establish IV access. Place patient on cardiac monitor.

2. Epinephrine: Give epinephrine , 0.01 ml/kg (1:1000) intramuscular, maximum dose 0.5 ml. Repeat every 15 min as needed. The site of choice is lateral aspect of thigh due to its vascularity.

3. Albuterol: Give nebulized albuterol, 0.05 to 0.15 mg/kg in 3 ml normal saline solution ( quick estimate 2.5 mg for < 30kg and 5 mg for > 30kg ) every 15 min as needed.

4. Histamine 1- receptor antagonist: such as diphenhydramine, 1-2 mg/kg through IV.IM or oral route. Also consider a histamine -2 receptor antagonist.

5.Corticosteroids: helps prevent the late phase of allergic response. Administer methlyprednisolone in a 2 mg/kg IV bolus, then 2mg/kg per day IV or IM divided every 6 hrs or prednisone 2 mg/kg PO in a bolus once daily. Observe for 6 to 24 hrs for late phase symptoms depending on clinical condition and stability.

NICE indications for CT scan following traumatic head injury in children

NICE has proposed indications for CT scan following traumatic head injury in children in 2014. The indications are given below:

Any of:
• Suspicion of non-accidental injury
• Post-traumatic seizure
• Glasgow Coma Score (GCS) <14 on arrival at emergency department (<15 for <1 year of age)
• GCS <15 two hours after injury
• Suspected open or depressed skull fracture
• Evidence of basal skull fracture
• Focal neurological deficit
• Presence of bruise or swelling >5 cm in
diameter in children aged <1 year

More than one of:

Management Of Status Epilepticus In Children

Definition Of Status Epilepticus
Status Epilepticus is defined as ongoing seizure activity for greater than 20 minutes or repetitive seizures without return of consciousness for greater than30 minutes.

Any child presenting with status epilepticus is at a risk of irreversible brain injury and needs immediate management:

Initial Stabilization

1. The first priority of treatment is to ensure an adequate airway and to assess the cardiovascular status i.e look for ABC = airway, breathing and circulation.

2. Maintain an IV access.

3. Oxygen is administered and pulse oximetery observed.

4. ECG monitoring is done.

5. If violent muscle activity impairs ventilation, muscle paralysis and sedation should be instituted.

6. Immediate laboratory tests that need to be done include:

• Blood glucose
• Basic metabolic panel (sodium, calcium, magnesium)
• Antiepileptic drug levels
• Toxicology screening

Dehydration And Fluid Management In Children

Introduction
Total body fluid is higher in children than adults. At birth, the body is made up of 80% water. By adulthood it is only 55–60%. Water is distributed two thirds in the intracellular space and one third in the extracellular space (divided 75% interstitial and 25% intravascular). The distribution of water between these compartments depends on the pressure and osmotic gradients between them.

Dehydration
Dehydration is loss of water and electrolytes.

Causes Of Dehydration in Children: Children may become dehydrated from:
• Reduced oral fluid intake: reduced appetite due to illness, vomiting, sore throat
• Additional fluid losses: fever, diarrhea
• Increased insensible losses: increased sweating, tachypnoea
• Loss of the normal fluid-retaining mechanisms: capillary leak, burns, the permeable skin of premature infants, increased urinary losses secondary to renal disease.

Infants and young children are more prone to dehydration than older children and adults because:
• Their body is made up of more water
• They have a high surface area in relation to their height or weight (high surface area : volume
ratio)
• They have relatively high evaporative water losses
• They have a higher metabolic rate and so higher turnover of water and electrolytes
• They rely on others to give them fluids.