URTI in Pediatrics for emergency medicine .pptx

URTI

1. URTI in Pediatrics Hamza Aburayya PGY-1 Emergency Medicine Resident

2. Introduction Upper respiratory tract infection (URI), also known as “the common cold,” is a self-limited viral process with prominent URIs are the most common cause of human disease, as well as visits to emergency and primary care pediatricians Young children are at highest risk for frequent URI due to their lack of immunity from previous infection URIs occur throughout the year with peak incidence from fall through late spring The most associated etiology with colds are rhinoviruses

3. Pharyngitis

4. Etiology Many infectious agents can cause pharyngitis viruses being the most common Group A streptococcus (Streptococcus pyogenes) is the most common important bacterial cause of pharyngitis Many viruses cause acute pharyngitis. Some viruses, such as adenoviruses , are more likely than others to cause pharyngitis as a prominent symptom Rhinoviruses , are more likely to cause pharyngitis as a minor part of an illness that primarily features other symptoms, such as rhinorrhea or cough.

5. Clinical Manifestations Sore Throat Fever Rash Lymphadenopathy Dysphagia

6. Clinical Manifestations Strep. Pharyngitis: Pharynx is distinctly red The tonsils are enlarged and may be covered with a yellow, blood-tinged exudate. There may be petechiae on the soft palate and posterior pharynx and the uvula may be red stippled, and swollen Anterior cervical lymph nodes are enlarged and tender

7. Clinical Manifestations Viral Pharyngitis: Onset of viral pharyngitis is typically more gradual Pharynx is erythematous Symptoms more often include rhinorrhea, cough, and diarrhea. Conjunctivitis, coryza, or oral ulcerations also suggest a viral etiology.

8. Laboratory Evaluation The principal challenge is to distinguish pharyngitis caused by group A streptococcus from pharyngitis caused by viral organisms. A rapid streptococcal antigen test, a throat culture, or both should be performed to: The benefit from antibiotic therapy in children Improve diagnostic precision

9. Laboratory Evaluation WBC, ESR and CRP are not sufficient to distinguish streptococcal from nonstreptococcal pharyngitis, and these tests are not routinely recommended.

10. Treatment Most episodes of streptococcal pharyngitis resolve uneventfully over a few days. Early antimicrobial therapy accelerates clinical recovery by 24-48 hours. The major benefit of antimicrobial therapy is the prevention of acute rheumatic fever Management of viral pharyngitis consists of symptomatic therapies, reassurance and counselling Antihistamines and decongestants are not recommended for children younger than 6 years of age because of adverse effects and lack of benefits

11. Sinusitis

12. Etiology Sinusitis is a suppurative infection of the paranasal sinuses and most commonly occurs as a complication of an upper respiratory tract infection (URI) The maxillary and ethmoid sinuses are present at birth Sphenoid sinuses are present by 5 years of age Frontal sinuses begin to develop at 7 years of age Obstruction to mucociliary flow, such as mucosal edema resulting from a URI, impedes sinus drainage and predisposes to bacterial proliferation

13. Etiology The bacterial causes of most cases of acute sinusitis are: Streptococcus pneumoniae Nontypable Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus and anaerobes emerge as important pathogens in subacute and chronic sinusitis.

14. Clinical Manifestations The most common presentation of acute bacterial sinusitis is persistent rhinorrhea , nasal congestion, and cough , especially at night Symptoms should be persistent and not improving for >10 days to distinguish sinusitis from a URI Alternate presentations include high fever and purulent nasal discharge for at least 3 days or a biphasic illness where a patient has typical URI symptoms for up to a week

15. Clinical Manifestations Rhinorrhea Fever Cough Vomiting Headaches

16. Laboratory Evaluation Culture of the nasal mucosa is not useful. Sinus aspirate culture is the most accurate method of determining etiology but is not practical or necessary Routine imaging is not recommended in uncomplicated infections. Plain x-ray, CT, and MRI findings do not differentiate infection from allergic disease

17. Treatment Amoxicillin for 10-14 days can be used as first-line therapy of uncomplicated sinusitis in children. Broadening therapy to amoxicillin-clavulanate is appropriate if: There is no clinical response to amoxicillin within 2-3 days If risk factors for resistant organisms are present: Antibiotic treatment in the preceding 1-3 months Day care attendance Age <2 years Chronic sinusitis Eye swelling is present.

18. Otitis Media

19. Etiology Otitis media (OM) is a suppurative infection of the middle ear cavity. Bacteria gain access to the middle ear when the normal patency of the eustachian tube is blocked by upper airway infection or hypertrophied adenoids Bacteria are the most common pathogens in OM, most frequently as a co-infection with viruses. Viruses can be the sole pathogen in OM <20% The common bacterial pathogens are Streptococcus pneumoniae, nontypable Haemophilus influenzae , Moraxella catarrhalis, and, less frequently, group A streptococcus

20. Clinical Manifestations In infants, the most frequent symptoms of AOM are nonspecific and include fever, irritability, and poor feeding. In older children and adolescents, AOM usually is associated with fever and otalgia AOM also may present with otorrhea Signs of a common cold are often present

21. Clinical Manifestations Ear Pain Strabismus Abnormal Eye Movements Diarrhea Hearing Loss

22. Ear Exam Examination of the ears is essential for diagnosis and should be part of the physical examination of any child with fever With AOM, the tympanic membrane is often characterized by hyperemia rather than the normal pearly gray color, but may appear pink, white, or yellow depending on the degree of bulging The light reflex is lost There should be poor or absent mobility to negative and positive pressure

23. Laboratory Evaluation Routine laboratory studies, including CBC and ESR, are not useful in the evaluation of OM Tympanometry: Measurements of the resulting tympanogram correlate well with the presence or absence of middle ear effusion.

24. Treatment The recommended first-line therapy for most children meeting criteria for antibiotic therapy is amoxicillin 80-90 mg/kg/day in two divided doses Recommended next-step treatments include high-dose amoxicillin-clavulanate (amoxicillin 80-90 mg/kg/day), cefdinir, or ceftriaxone (50 mg/kg intramuscularly in daily doses for 3 days) Intramuscular ceftriaxone is especially appropriate for children with vomiting that precludes oral treatment

25. Complications Postauricular swelling and protrusion of the auricle are characteristic of mastoiditis Vestibular symptoms (e.g., dizziness, vertigo, balance and motor problems) with or without tinnitus or nystagmus may be related to labyrinthitis, mastoiditis, or cholesteatoma Cranial nerve palsies (e.g., facial nerve, abducens nerve) may be related to acute mastoiditis, petrositis , cholesteatoma, or intracranial complications Meningeal signs, cranial nerve deficits, and/or focal neurologic findings may be related to intracranial complications (e.g., meningitis, brain abscess , epidural or subdural abscess, lateral or cavernous sinus thrombosis)

26. Otitis Externa

27. Etiology Acute otitis externa is an infection of the external ear canal associated with diffuse inflammation and often significant edema Occurs in children between 7 and 12 years of age More common in the summer than in the winter The most common risk factor is hyperhydration and maceration of the epithelial layer lining the canal, often induced when a child is submerged during swimming (“swimmer’s ear”) The most common cause is Pseudomonas aeruginosa followed by Staphylococcus aureus and Staphylococcus epidermidis Polymicrobial infection is common

28. Clinical Manifestations Ear fullness and itching Pain is often severe and exacerbated by manipulation of the auricle as well as by any movement of the jaw A purulent and sometimes foul-smelling discharge Temporary hearing loss Rarely, posterior spread can involve the mastoid or can cause osteomyelitis of the skull Malignant otitis externa is osteomyelitis of the ear canal and should be suspected with the presence of fever >38.9°C, severe otalgia, and/or facial paralysis or meningeal signs.

29. Diagnostics Diagnosis is clinical According to the American Academy of Otolaryngology–Head and Neck Surgery Foundation , a diagnosis of otitis externa requires:

30. Treatment Analgesic therapy should be based on the severity of the pain. Ibuprofen or acetaminophen is sufficient to reduce pain in most cases Topical fluoroquinolone drops, such as ofloxacin or ciprofloxacin, instilled into the ear canal two to four times daily, are the standard treatment Do not give systemic antibiotics for uncomplicated cases of acute otitis externa, except?

31. Acute Mastoiditis

32. Etiology Acute mastoiditis is a bacterial infection of the mastoid Develops when inflammation and infection in the middle ear spread into the cells of the mastoid through the aditus ad antrum, develops as a complication of AOM The same bacterial organisms most commonly associated with AOM Incidence is highest in children younger than age 2 years Risk factors for acute mastoiditis include: Recurrent AOM Immunocompromise Presence of a cholesteatoma

33. Clinical Manifestations Signs and symptoms of AOM Erythema, edema, and/or tenderness of the mastoid area posterior to the auricle As the inflammation and infection in the mastoid progress, the auricle becomes visually protruded outward Advanced disease may cause palsies of the VI (abducens) or VII (facial) nerves Complications include subperiosteal abscess, facial nerve palsy, osteomyelitis of other parts of the skull, direct extension into the intracranial cavity (e.g., intracranial abscess, meningitis), venous sinus thrombosis.

34. Diagnostics The diagnosis is clinical Confirmation is by CT (with IV contrast) of the mastoid but is usually reserved for cases with suspected complications MRI may be preferred in children with suspected intracranial complications, but is usually only obtained after CT if more information is needed Laboratory tests rarely change outcome Consider blood cultures in children with fever Aspiration and culture of middle ear fluid by tympanocentesis are useful to identify the specific organism

35. Treatment Treatment for uncomplicated cases involves broad-spectrum IV antibiotics and drainage of middle ear and mastoid fluid Piperacillin-tazobactam plus vancomycin is an example of an appropriate regimen Antibiotic therapy can be narrowed once a specific organism is identified Drainage is usually accomplished by myringotomy with or without placement of tympanostomy tubes Mastoidectomy and more aggressive surgical intervention are typically reserved for cases in which there is no significant clinical improvement within 48 hours and for complications.

36. Croup

37. Etiology Croup, or laryngotracheobronchitis , is the most common infection of the middle respiratory tract Causes are parainfluenza viruses (types 1, 2, 3, and 4) and respiratory syncytial virus (RSV) During inspiration, the walls of the subglottic space are drawn together, aggravating the obstruction and producing the stridor characteristic of croup Most common in children 6 months to 3 years of age, with a peak in fall and early winter It typically follows a common cold

38. Clinical Manifestations Stridor is a harsh, high-pitched respiratory sound produced by turbulent airflow. It is usually inspiratory, but it may be biphasic and is a sign of upper airway obstruction Most common cause of infectious acute upper airway obstruction in pediatrics Signs of upper airway obstruction , such as labored breathing, cyanosis, and marked suprasternal, intercostal, and subcostal retractions, may be evident on examination

39. Clinical Manifestations Cough Barking Hoarseness Inspiratory stridor Low grade fever Apnea

40. Laboratory Evaluation Routine laboratory studies are not useful in establishing the diagnosis. Leukocytosis is uncommon and suggests epiglottitis or bacterial tracheitis Radiography is NOT necessary to confirm diagnosis Anteroposterior radiographs of the neck often show the diagnostic subglottic narrowing of croup known as the steeple sign

41. Treatment Oral or intramuscular dexamethasone for children with croup reduces symptoms and the need for hospitalization and shortens hospital stays. Dexamethasone (0.6-1 mg/kg) may be given once intramuscularly or orally Racemic epinephrine reduces subglottic edema by adrenergic vasoconstriction, temporarily producing marked clinical improvement. The peak effect is within 10-30 minutes, fades within 60-90 minutes A rebound effect may occur, with worsening of symptoms as the effect of the drug dissipates L-epinephrine (1:1000): 0.5 ml/kg (max 5 ml) RE (2.25%): 0.05 ml/kg (max 0.5 ml)

42. Indications to Hospitalize

43. Epiglottitis

44. Etiology Epiglottitis is a medical emergency because of the risk of sudden airway obstruction This illness is now rare and usually caused by group A streptococcus or Staphylococcus aureus or Haemophilus influenzae type B in unimmunized patients No seasonal predominance Most common between 2-6 years of age

45. Clinical Manifestations Abrupt onset - usual duration of illness before hospitalization < 24 hours Toxic appearance Stridor and labored respirations Fever - often > 39.0 Sore throat and reluctant to speak or swallow Aphonia, hoarseness, muffled voice Patients typically prefer sitting, often with the head held forward, the mouth open, and the jaw thrust forward (sniffing position)

46. Clinical Manifestations Cyanosis in later stages Drooling Tachycardia Tachypnea (but rarely > 40) Retractions

47. Clinical Manifestations Fever Drooling Toxic appearance Stridor Sniffing position Respiratory Distress

48. DO NOT! DO NOT UPSET THE CHILD DO NOT EXAMINE THE MOUTH DO NOT INSERT CANNULA UNTIL THE CHILD IS ANESTHETIZED

49. Laboratory Evaluation Labs may be obtained only after airway is secured CBC - elevated WBC with bandemia Blood cultures - positive 80 - 90% Lateral radiograph reveals thickened and bulging epiglottis (thumb sign) and swelling of the aryepiglottic folds The diagnosis is confirmed by direct observation of the inflamed and swollen supraglottic structures and swollen, cherry red epiglottitis Direct observation of the larynx should only be performed in the operating room with an anesthesiologist

50. Treatment Keep the child quite and avoid agitation Call anesthetist, ENT and consultant pediatrician Keep emergency trolley behind Oxygen may be given by mask Antibiotics: 3 rd generation cephalosporins (cefotaxime, ceftriaxone)

51. Bacterial Tracheitis

52. Etiology Bacterial tracheitis, also known as membranous laryngotracheobronchitis or bacterial croup, is an uncommon infection that can cause life-threatening upper airway obstruction The mean age of presentation is 5 to 8 years of age The most commonly isolated pathogen obtained from culture at bronchoscopy is S. aureus Other organisms include S. pneumoniae, Streptococcus pyogenes, Moraxella catarrhalis, H. influenzae, and oral anaerobes

53. Clinical Manifestations Bacterial tracheitis often develops secondarily after a viral upper respiratory tract infection, particularly influenza A A history of upper respiratory infection symptoms followed by sudden worsening with High fever Stridor (often biphasic), and Cough (which may be productive with thick sputum) Toxic appearance

54. Diagnostics Laboratory studies other than tracheal cultures (typically obtained during bronchoscopy) are of limited use Neck radiographs are not needed to make the diagnosis Bronchoscopy is the diagnostic method of choice in bacterial tracheitis

55. Treatment The management of tracheitis is similar to that of epiglottitis, with patients ideally going to the operating room for sedation, intubation, and bronchoscopy Administer empiric antibiotics in the ED to cover likely pathogens Appropriate choices include vancomycin or clindamycin plus a 3 rd generation cephalosporin Bronchoscopy may be therapeutic because the removal of purulent pseudomembranes improves tracheal toilet and may lessen upper airway obstruction

56. Peritonsillar Abscess

57. Etiology PTA AKA quinsy, is the most common deep neck infection and usually occurs in older children and teenagers PTAs are typically polymicrobial Most are unilateral, <10% are bilateral Predominant bacterial species are S. pyogenes (group A streptococcus), Staphylococcus aureus

58. Clinical Manifestations Drooling and a muffled, hot potato voice is common Unilateral sore throat (very bad) Severe respiratory distress is unusual Trismus (in two out of three patients) Bulging or asymmetry of the tonsils Deviation of the uvula away from the abscess side Throat pain may radiate to the ear

59. Diagnostics Clinical diagnosis Routine Labs are not needed Posterior pharynx ultrasonography can confirm the diagnosis and guide treatment A CT scan may be indicated if extension of infection is suspected If drainage performed in ED, send purulent material for gram stain and culture Any drainage effort should take great care to avoid puncture of the carotid artery

60. Treatment Treatment involves antibiotics and incision and drainage or needle aspiration Antibiotics alone are insufficient management for an abscess Empiric coverage includes amoxicillin-clavulanate (45 milligrams/kg per dose every 12 hours to a maximum of 875 milligrams per dose) or clindamycin (10 milligrams/kg per dose every 8 hours)

61. Retropharyngeal Abscess

62. Etiology The formation of a retropharyngeal abscess is believed to be secondary to suppuration of lymph nodes that have been seeded from a distant infection Localized penetrating trauma with subsequent invasion of this space by bacteria is another cause This most commonly occurs in children who fall with a stick or other similar object in their mouth Infection can also occur from traumatic esophageal instrumentation or ventral extension of vertebral osteomyelitis Retropharyngeal infection typically progresses from an organized phlegmon to a mature abscess.

63. Clinical Manifestations Minor upper respiratory infection or pharyngitis Fever is typically present Neck pain Odynophagia Dysphagia Trismus Drooling Neck swelling Neck stiffness, torticollis, and hyperextension The voice may be muffled Anterior cervical lymphadenopathy is common

64. Diagnostics Initial imaging includes a soft tissue lateral neck radiograph. The radiograph should be taken during inspiration with the neck extended to limit false-positive results The diagnosis of retropharyngeal abscess/cellulitis is suggested when the retropharyngeal space at C2 is twice the diameter of the vertebral body or greater than one half the width of the C4 vertebral body CT is helpful for diagnosing and defining the extent of the infection and surgical planning Unstable patients should be intubated before going to the radiology suite for CT scan

65. Treatment Carefully monitor and stabilize the airway Obtain IV or IO access Administer fluids, antibiotics, and CT contrast Retropharyngeal cellulitis and small, localized abscesses may be treated successfully with antibiotic therapy alone All other cases should undergo operative incision and drainage Initiate empiric antibiotic therapy in the ED with clindamycin (15 milligrams/kg per dose every 8 hours IV) or ampicillin-sulbactam (50 milligrams/kg per dose every 6 hours IV).

66. Complications Airway obstruction Spontaneous abscess perforation Mediastinitis Sepsis Aspiration Jugular venous thrombophlebitis/thrombosis, also known as Lemierre’s syndrome

67. References: Rosen's Emergency Medicine: Concepts and Clinical Practice, 10th Edition Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e Nelson Textbook of Pediatrics, 21st Edition UpToDate© AMBOSS illustrations American Academy of Pediatrics