“THE MISFITS”: A quick recall to critical diagnosis of pediatric emergency

 

Dr. Deviga T¹, Raghu V A²

College of Nursing, AIIMS Jodhpur, Rajasthan

 

ABSTRACT:

Emergency department (ED) physicians are facing challenge every day to recognize ill patients, diagnose life-threatening illness, and initiate treatment. Pediatric Emergency Medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of a wide variety of acute illnesses and injuries affecting infants, children and adolescents. Deaths of children in pediatric emergency department often occur within the first 24 hr of admission. Many of these deaths could be prevented by early identification, diagnosis and appropriate treatment upon arrival of sick children in pediatric emergency. This can be facilitated by rapid triage for all children in order to determine pediatric emergency. Most challenging task is to managing sick patients in the ED are neonates. Neonates often arrive at the ED with a nonspecific chief complaint or a history of symptoms that may or may not be benign. Hence, Health care providers who are working in ED should update the current information on pediatric emergency. The mnemonic "THE MISFITS" is helpful to quickly recall in diagnosing the common pediatric emergencies. This review article focuses mainly on early identification, diagnosis, and management of the more common neonatal emergencies.

 

 

INTRODUCTION:

Paediatric emergency medicine is the major branch of medicine concerned with the short-term and emergency treatment of children - neonates to adolescence. When children fall ill or are injured, they often need urgent or emergency assessment and treatment.¹ The neonatal and pediatric population provides a unique and difficult challenge for diagnosis and treatment in the emergency department, and a systematic approach is critical to allow for rapid diagnosis and treatment in the setting of a potentially sick neonate.⁴

 

The neonates who come to emergency department usually have vague and nonspecific symptoms. Signs are usually subtle and, even when recognized, may not be helpful in confirming a diagnosis. For example, respiratory distress may be due either to pulmonary or cardiac disease, generalized sepsis, abdominal pathology, or metabolic derangements.²

 

A study in a tertiary-care referral center, over a 12-month period revealed that 2100 out of a total of more than 39,000 visits were for infants less than 3 months of age. Complaints in neonates are usually not single but are often have complexes symptoms.³ one more study conducted in England and Wales shows that 25–30% of all visitors to emergency departments are children under 16 years old, approximating to 2 million children per year. In one UK city there are over 37000 attendances per annum to the pediatric Emergency Department out of the local population of approximately 100000 under 16 years old. ⁴

Pediatric emergency physician though a small group within the overall medical profession, play a key role in ensuring the health, safety, and wellbeing of children. A key aspect of the pediatric emergency physician role is coordinating the full range of health care professionals, and associated service providers, in their treatment and care of medical and surgical emergencies in pediatrics. The range of conditions present to emergency departments, including medical conditions from the child with collapse, convulsions or severe respiratory difficulties, to the child with a mild pyrexia or an upper respiratory tract infection. Similarly presentation with trauma crosses the whole spectrum from major, multiple traumas, to the most minor trauma requiring no treatment.⁴

 

Pediatric Children’s are classified based on presentation of symptoms to determine whether there is an urgent need for treatment, thus the child should take priority over other children who are already waiting. Triage is usually undertaken by a senior nurse, supported by decision-making algorithms. This review article focuses on the common pediatric emergency and a MISFITS acronym helps the pediatric emergency physician to diagnose emergency condition and start the life saving treatment as early as possible.

 

"THE MISFITS"

T-Trauma (Nonaccidental and accidental)

H-Heart disease/hypovolemia/hypoxia

E-Endocrine (congenital adrenal hyperplasia, thyrotoxicosis)

M-Metabolic (electrolyte imbalance)

I-Inborn errors of metabolism: Metabolic emergencies

S-Sepsis (meningitis, pneumonia, urinary tract infection)

F-Formula mishaps (under- or over dilution)

I-Intestinal catastrophes (volvulus, intussusceptions, necrotizing enterocolitis)

T-Toxins/poisons

S-Seizures

 

Trauma (accidental or non accidental)

The neonates with head trauma are difficult to evaluate. Trauma can be accidental as well as non accidental.  Approximately 30 % children visit the pediatric emergency with abusive head trauma. Studies reported that trauma may cause 70% of morbidity and 30% mortality in children.⁵ An infant with nonaccidental head trauma may only have subtle findings and cannot be detected eternally. The symptoms may be nonspecific with head injury. Early diagnosis of an occult head injury can prevent significant long-term morbidity.⁶

 

Diagnosis of neonates with a suspected accidental and non accidental trauma should include a computed tomography scan, ultrasound, or magnetic resonance imaging. If skull fracture is suspected, the skull x ray may be done. One study found that 37% of abused children less than 2 years of age had an occult traumatic head injury.

 

Emergency treatment of trauma in pediatric depend on presenting symptoms and immediate evaluation head injury is needed for specific treatment. Stabilization of the airway, breathing, circulation is done at the time of visit; bedside to this attention should be given to blood glucose evaluation, and appropriate temperature regulation. If there is bruising or a known intracranial bleed, then the laboratory evaluation should include a complete blood count, platelet count, prothrombin time and a partial thromboplastin time. Neuroimaging should be completed after stabilization.⁵ The child should be admitted and the injury reported to the appropriate authority for child abuse. A skeletal evaluation and ophthalmologic exam should be part of the hospital evaluation.

 

Heart Disease and Hypoxia:

a. Cyanotic Heart Disease:

The children with congenital heart disease usually have blue discoloration of the skin. Cyanosis is a pathologic process that requires immediate attention and evaluation. Cyanosis can also occur due to respiratory causes, infectious causes, central nervous system abnormalities and toxins but most common reason for cyanosis is cyanotic heart defect and so it should be considered at most. Congenital heart defects that present with cyanosis are Tetralogy of Fallot, Tricuspid atresia, Transposition of the great vessels, Total anomalous pulmonary venous return and Truncus arteriosus.

 

The cyanotic heart disease is difficult to diagnose in the newborn nursery due to patent ductus arteriosus (PDA). This will abnormal opening helps to maintain adequate oxygenated blood in systemic circulation. The PDA is anatomically closed by 2 weeks of age. So newborn requires radiological imaging studies to confirm the cyanotic heart disease.

 

The cause of cyanosis due to cardiac or noncardiac can be determined by providing 100% oxygen to baby. If the baby has cyanosis due to non cardiac causes, there is 10% increase in pulse oximetry value after providing 100% oxygen. If the baby has cyanotic heart disease there will be minimal changes in the pulse oximetry value. This can be also confirmed with a hyperoxia test, which involves an initial ABG analysis on room air and then a repeat ABG after 10 min of 100% oxygen given to baby. There should be only minimal change in PaO2 after 10 min of oxygen if the cause is cardiac

 

Monitor the BP of all four extremities carefully as a part of cardiac exam. In the physical examination, listen to normal and abnormal heart sound and heart rate. chest radiograph and electrocardiogram should be included in the evaluation. The important diagnostic tool for detecting heart defect is echocardiogram. Management of cyanotic heart disease at emergency department includes administration of prostaglandin E1 as a bolus of 0.05 mcg/kg IV and it is followed by an infusion of 0.05-0.01 mcg/kg/min IV. Patients who require transport to a facility for pediatric subspecialty care may require definitive airway management and oxygen administration prior to transportation.⁷

 

b. Acyanotic heart disease:

Usually children with acyanotic heart diseases present with symptoms of congestive heart failure. The most common acyanotic heart disease includes VSD, ASD and PDA. Addition to congenital acyanotic heart disease, there are other condition which may cause congestive heart failure in neonates. They are severe anemia, trauma, sepsis, supraventricular tachycardia and metabolic abnormalities. The classic symptoms for congestive heart failure include tachypnea, tachycardia, and hepatomegaly. The babies have history of poor or slow feeding, sweating or color change with feeding, and poor weight gain. The emergency management of these neonates includes stabilization of the ABC's, a Chest X ray, ECG, and laboratory evaluation including a CBC and serum electrolytes. An echocardiogram done to diagnose the heart defect and management usually includes furosemide (1.0 mg/kg IV) and inotropes include dopamine or dobutamine for cardiovascular support.⁷

 

c. Supraventricular Tachycardia:

Supraventricular tachycardia (SVT) is the most common neonatal dysrhythmia. Presenting complaints may range from tachycardia to poor feeding, irritability, heart failure, and shock ED management is dependent on the patient stability at presentation. In a stable neonate vagal manure is indicated, if not successful, administration of adenosine 0.1 mg/kg IV push is needed.   An unstable neonate is treated with synchronized cardioversion (0.5-1.0 J/kg). If both IV adinosin and cardioversion is not effective, amiodarone 5 mg/kg IV over 20-60 minutes may be administered. Alternatively, procainamide 15 mg/kg IV over 30-60 minutes may be administered. A 12-lead ECG should be obtained prior to and after conversion from SVT to normal sinus rhythm. This is a useful diagnostic tool for the cardiologists to help determine further management. A pediatric cardiologist should be consulted for further evaluation.

 

d. Bronchiolitis:

Bronchiolitis is responsible for 50% to 90% of neonatal admissions. Bronchiolitis is a viral lower-airway disease that is caused by respiratory syncytial virus 80% of the time, but other etiologies include adenovirus, influenza, or parainfluenza. Bronchiolitis is more common in the winter and spring seasons, but may present anytime. These patients may present with more classic symptoms that include rhinorrhea, cough, congestion, or significant respiratory distress and wheezing.

 

ED management is dependent on the presenting symptoms. Infants with severe, prolonged apnea accompanied by bradycardia and who are unresponsive to oxygen therapy and stimulation may require intubation. A fever or sepsis evaluation may often be part of ED management. Hospitalization should be considered for all neonates who are RSV-positive with a strong recommendation in all premature neonates and in all neonates with other comorbid conditions.⁸

 

e. Apnea:

Apnea is defined as a cessation of respiration for 20 sec or more and is associated with color change (cyanosis or pallor) or bradycardia. An ALTE (Apparent Life-Threatening event) is used to describe any event that is frightening to the observer and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, or gagging. Hospitalization may be appropriate for observation and monitoring.

 

Endocrine Emergencies:

a. Congenital Adrenal hyperplasia:

Endocrine emergencies in neonate include congenital adrenal hyperplasia and tyrotoxicosis. Congenital adrenal hyperplasia (CAH) is a group of inherited genetic disorders that affect the adrenal glands. CAH affects the production of steroid hormones: cortisol, which regulates your body's response to illness or stress; mineralocorticoids, such as aldosterone, which regulate sodium and potassium levels; and androgens, such as testosterone, which are sex hormones. In many cases, CAH results in deficiency of cortisol and overproduction of androgen. If CHA is not diagnosed at the time of birth with the help of blood investigation, the patient may present with symptoms of vomiting, hypoglycemia, or even shock. The most common cause of CAH is a deficiency in the 21-hydroxylase enzyme.

 

Management includes stabilization of the ABC's, a bedside blood glucose measurement, and serum electrolytes. The electrolyte abnormalities may include hyponatremia and hyperkalemia. Hypotension that is unresponsive to fluids or inotropes should be suspected for CAH. The patient should be treated with hydrocortisone 25-50 mg/m² IV. It is important to treat the hypoglycemia. Usually hyperkalemia in these patients will respond to fluid therapy but if the patient is has ECG changes, then calcium chloride, sodium bicarbonate, insulin and glucose may be necessary. These patients usually require pediatric critical care management and endocrine consultation.⁹

b. Thyrotoxicosis:

Fetal and neonatal hyperthyroidisms are usually produced by transplacental passage of thyroid-stimulating immunoglobulins. Most commonly, the thyroid-stimulating immunoglobulins are a component of active maternal Graves' disease. Often children present to the ED with symptoms such as poor feeding, failure to thrive, tachycardia, irritability, hyperthermia, vomiting, diarrhea, jaundice, thrombocytopenia, respiratory distress, heart failure and shock. Evaluation should include thyroid functions tests. Treatment after stabilization will include propranolol 0.25 mg/kg IV for the tachycardia, and propylthiouracil 1.25 mg/kg IV. Endocrine consultation and admission to a pediatric hospital is recommended.⁹

 

Metabolic abnormalities:

The most common metabolic emergency is due to alteration in electrolytes and blood glucose. Often the child visit emergency department with hypoglycemia and other common electrolyte imbalance include metabolic acidosis and alkalosis, hyponatremia and hypocalcemia. Usually vomiting, alterations in neurologic status and feeding difficulties are the most prominent features of metabolic emergencies. Stabilize the child. Treatment of hypoglycemia includes blood glucose monitoring and IV 10% dextrose administration. Treat metabolic acidosis with sodium bicarbonate. Administration of normal saline and calcium carbonate is needed in hyponatremia and hypocalcemia.

 

Inborn Errors of Metabolism:

Inborn Errors of Metabolism comprise a group of disorders in which a single gene defect causes a clinically significant block in a metabolic pathway. During the neonatal period, inborn errors of metabolism mostly present with an overwhelming illness that requires prompt diagnosis and both supportive and specific treatments. Inborn errors of metabolism symptoms often unrecognized because they are uncommon and require a high level of genetic test for diagnosis. Presenting symptoms may be subtle and nonspecific symptoms include poor feeding, vomiting, failure to thrive, tachycardia, tachypnea, or irritability. Occasionally the diagnosis may be more apparent and include symptoms of seizures, lethargy, hypoglycemia, apnea, temperature instability, and acidosis. Physical exam findings are usually normal.

 

Initial management should include stabilization of the ABC's and a bedside blood glucose evaluation. Laboratory evaluation should include a CBC, serum electrolytes, pH, lactate, ammonia, liver function tests, and urinalysis for reducing substances and ketones. The complete evaluation should also include blood and urine for organic and amino acids. These patients usually require fluid resuscitation, IV dextrose to prevent further catabolism, and admission to a pediatric hospital with a genetics consultation.¹⁰

 

Neonatal sepsis:

Neonatal sepsis is a systemic infection occurring in infants at ≤28 days of life and is an important cause of morbidity and mortality of newborns.¹¹ Mortality from neonatal sepsis may be as high as 50% for infants who are not treated. Infection is a major cause of fatality during the first month of life, contributing to 13-15% of all neonatal deaths.¹²

 

Neonatal sepsis may be categorized as early-onset or late-onset. Of newborns with early-onset sepsis (less than 72 hr), 85% present within 24 hours, 5% present at 24-48 hours, and a smaller percentage present within 48-72 hours. Onset is most rapid in premature neonates. Early-onset sepsis is associated with acquisition of microorganisms from the mother. The microorganisms most commonly associated with early-onset neonatal sepsis includes ¹³ : GBS, E coli, Coagulase-negative Staphylococcus, H influenzae, L monocytogenes. Late-onset neonatal sepsis, appears after 72hr of life. The infection is often transmitted through the hands of the care providers. Organisms that have been implicated in causing late-onset neonatal sepsis includes: Coagulase-negative staphylococci, S aureus, E coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinentlytobacter, Anaerobes. Neonatal sepsis commonly manifests as pneumonia, septicemia or meningitis.¹⁴

 

The manifestations of neonatal sepsis are often vague and ill defined. The signs and symptoms or focal signs of infection, including temperature instability, hypotension, poor perfusion with pallor and mottled skin, metabolic acidosis, tachycardia or bradycardia, apnoea, respiratory distress, grunting, cyanosis, irritability, lethargy, seizures, feeding intolerance, abdominal distention, jaundice, petechiae, purpura, and bleeding. No investigation is required as a prerequisite to start treatment in clinically obvious case. Blood culture, total leukocyte count, absolute neutrophil count, immature to total neutrophils ratio, CRP and micro ESR constitutes a useful sepsis screen for clinically doubtful cases. Sepsis screen is considered positive if two of these parameters are positive.¹⁵

 

Institution of prompt treatment is essential for ensuring optimum outcome of neonates with sepsis who often reach the health care facilities late and in a critical condition. Supportive care and antibiotics are the two equally important components of treatment. It should be realized that antibiotics take at least 12 to 24 hours to show any effect and it is the supportive care that makes the difference between life and death early in the hospital course.¹⁵.

 

Formula MISHAPS:

The inappropriate mixing of water and powdered formula or overdilution of concentrated liquid or premixed formula may result in life-threatening electrolyte disturbances or failure to thrive. Hyponatremia may present as seizures and requires recognition of an electrolyte abnormality and immediate correction to stop the seizure.¹⁶

 

Intestinal conditions:

Vomiting in the neonatal period should always prompt the consideration of a pathologic process. It may be difficult to differentiate a life-threatening cause from a mild viral gastroenteritis or even severe gastroesophageal reflux. The initial symptoms may be nonspecific and the history may not be helpful in a neonate who has not developed a normal pattern. Bilious emesis is always concerning and should always initiate a pediatric surgery consultation.

 

a. Volvulus:

Midgut volvulus is a condition in which the intestine has become twisted as a result of malrotation of the intestine during fetal development. Malrotation occurs in 1 out of 5000 live births and is usually diagnosed in the first month of life. The presenting symptoms include bilious emesis and poor feeding, or lethargy and shock in more advanced presentations. An upper gastrointestinal study with contrast is the gold standard for confirming the diagnosis. The principles of management are to treat haemodynamic instability with prompt intravenous fluid resuscitation, nasogastric tube decompression, and immediate paediatric surgical referral for definitive surgery. The curative surgical treatment is a Ladd’s procedure, which involves untwisting the intestine, division of any congenital bands, and widening the mesentery to result in the bowel being in a “safe” non-rotated position. ¹⁷

 

b. Necrotizing entercolities:

Necrotising enterocolitis (NEC) is now the most common gastrointestinal emergency occurring in neonates. Prematurity and low birth weight are the most important risk factors. ² NEC does not occur in utero. Colonisation of the gut with either commensal or pathogenic bacteria may affect maturation of the innate immune system. The manifestations are abdominal distension with increasing gastric aspirates, visible intestinal loops, altered stool pattern, bloody mucoid stool and bilious vomiting. Associated features are bradycardia, lethargy, shock, apnoea, respiratory distress, temperature instability.

 

Early recognition of NEC and vigorous medical management has reduced the need for surgery. Intravenous fluids, total parenteral nutrition and IV antibiotics for 10-14 days: Ampicillin/gentamicin or cefotaxime. Plus metronidazole or clindamycin. Nasogastric or orogastric tube to decompress the bowel with low intermittent orogastric suction.  Antifungals should be considered for babies who have recently been on lengthy courses of antibiotics or are not responding to antibiotic treatment. Surgery if a deteriorating or perforated/necrotic bowel is suspected.¹⁸

 

c. Pyloric stenosis:

Hypertrophic pyloric stenosis is very rare during the newborn period. Here we present a full term male neonate with abundant hematemesis 12 hours after birth which interrupted oral feeding. Bleeding subsided within three days after conservative measures, and oral feeding was restarted but not tolerated. The vomiting was effortless and nonbilious. An upper gastrointestinal series revealed gastric dilatation and partial obstruction of the gastric outlet. HPS was found by laparotomy on the fourth day and Fredet-Ramstedt pyloromyotomy relieved the gastric emptying. This is one of the few cases of HPS present at birth, which was diagnosed and surgically treated early, and we suggest a congenital etiology in previously reported cases of HPS.¹⁹

 

The classic physical exam findings of a palpable "olive" structure in the right upper quadrant and visible peristaltic waves may be present. Diagnosis is confirmed with an ultrasound that reveals a thickened and lengthened pylorus. If an upper GI study is performed, a "string sign" will be visible. Although surgical management is the standard, reports of pharmacologic management with IV atropine followed by oral atropine show satisfactory results.²⁰

 

Toxics in neonates:

Acute lead poisoning in children is uncommon and is generally observed in patients who have been exposed to high concentration of lead from folk remedies, lead containing paint chips or foreign bodies or from intrauterine exposure. Acute lead encephalopathy is most severe presentation of lead poisoning and has been reported to occur after use of lead containing eye cosmetic, kohl on the umbilical stump of newborns. Treatment for lead poisoning includes supportive measures and chelating agents. The chelating agents are intravenous calcium disodium edetate (EDTA), oral dimercaptosuccinic acid (DMSA) and intramuscular dimercaprol (BAL). BAL is used only when there is severe toxicity as in lead encephalopathy.²¹

 

Neonates are also at great risk to develop drug toxicities because of immaturity of their drug metabolism and disposal mechanism. These limitations determine the efficacy and/or safety of a therapeutic or inadvertent drug exposure. the net diagnosis required serum level determination, we could not postpone the immediate therapeutic measures in the presence of a reliable history of drug exposure and a wrong written dose on a prescription, accompanied with the typical clinical sign and symptoms, for most offending agent, qualitative measurement is not possible or likely to change the decision for treatment. More, the better education of medical professional and parents are required to avoid neonatal drug toxicities. ²²

 

Seizures:

Neonatal seizures require urgent treatment to prevent brain injury. Seizures with hypoglycemia or hypoxia are detrimental to the brain! Abnormal, repetitive and stereotypic behaviours of neonates should be suspected and evaluated as possible seizures. Polygraphic video–EEG recording of suspected events is probably mandatory for an incontrovertible seizure diagnosis. Confirmation of neonatal seizures should initiate urgent and appropriate clinical and laboratory evaluation for the aetiological cause and treatment. Family and prenatal history is important. A thorough physical examination of the neonate should be coupled with urgent and comprehensive biochemical tests for correctable metabolic disturbances. Although rare, severe inborn errors of metabolism should be considered for diagnosis and treatment. Initial treatment with phenobarbital should be considered. If seizures persist, phenytoin should be added. Persistent seizures may require the use of an intravenous benzodiazepine, such as lorazepam or midazolam.²³

 

CONCLUSION:

Neonatal physiological immaturity is the important concept for many health issues. Hence thorough assessment and quick action is required in all newborn to identify and treat the critically ill neonate. More, successful emergency treatment outcome depends on open communication and effective teamwork between health care workers.

 

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Received on 08.11.2019         Modified on 31.12.2019

Accepted on 14.01.2020      ©A&V Publications All right reserved