Common

 Pediatric  Illnesses  in  the  

ER  &  Urgent  Care  
Jawanner  L.  Davis  
DNP,  ACNP-­‐BC,  FNP-­‐C  
Emergency  Medicine  
 ObjecHves  
v IdenHfy  and  discuss  common  pediatric  illnesses  
treated  in  the  ED  &  Urgent  Care  seLng  
v Describe  and  evaluate  management  of  common  
pediatric  illnesses  in  the  ED  &  Urgent  Care  seLng  
v Explore  key  pearls  and  relevant  evidence  based  
treatment  guidelines  for  common  pediatric  
illnesses  in  the  ED  &  Urgent  Care  seLng  
v IdenHfy,  discuss,  and  review  pearls  &  piOalls  for  
common  pediatric  illnesses  
 Disclosures:  None  

The  content  of  material  presented  in  

this  CE  ac8vity  will  not  include  
discussion  of  unapproved  or  
inves8ga8onal  uses  of  products  or  
devices  
 The  Sick  Child  
•  Preparedness  
–  EducaHon  of  staff  
–  Normal  range  of  vital  signs  
–  VaccinaHon  Status  
•  ABCs    
–  Airway,  Breathing,  CirculaHon  
–  IV  or  Intraosseous  lines  as  indicated  
–  Prompt  evaluaHon  of  eHology  in  emergent  cases  
 Common  Cold  

Fever  

Sore  
Cough  
Throat  

FaHgue   CongesHon  

Nasal    
Discharge  
 Common  Cold  
§  Also  referred  to  as  “URI”  
§  Viruses  are  most  common  cause  
§  Last  up  to  14  days  
§  AnHbioHcs  not  needed  
§  Noted  wheeze  is  normal  
§  Causes  for  concern:  stridor  when  child  at  rest/calm,  
signs/symptoms  of  pneumonia,  general  danger  signs,  
symptoms  ongoing  past  14  days  
§  DifferenHal  Dx:  RhiniHs,  SinusiHs,  LaryngiHs,  BronchiHs,  
BronchioliHs/RSV,  Influenza,  InfecHous  Mononucleosis  
 Common  Cold:  
Tests/MedicaHons  
§  Swabs  for  RSV,  Influenza  
 
§  Blood  draw  for  Mono  
§  Nebulizer  treatments/Inhaler:  
 -­‐Albuterol  nebulizer  (0.63mg,  1.25mg,  2.5mg)/3ml  
     -­‐Albuterol  inhaler  (90mcg/spray  MDI)  >4  years    of  age  
 -­‐Duoneb-­‐ipratropium  bromide/albuterol    (0.5mg/
2.5mg/3ml  neb)  
§  Tamiflu    
§  Oral  Steroids  
–  Prenisolone  (0.12-­‐2  mg/kg/d)  divided  qd-­‐qid  x5  days  
–  Orapred  (0.14-­‐2  mg/kg/d)  divided  qd-­‐qid  x5  days  
–  Decadron  0.08-­‐0.3  mg/kg/day  divided  q6-­‐12h  
§  Weight  based  Tylenol  and/or  Ibuprofen  
 Common  Cold:  
Treatment  
§  SymptomaHc  treatment  
§  Tylenol  and/or  ibuprofen  
§  Humidifier/warm  cloths  
§  MucolyHcs    
§  HydraHon  
§  NutriHon  
§  Monitor  
§  Follow  up  with  primary  care  provider  
Tamiflu  Dosage  
Conjunc'vi's  
Ø Most  cases  are  viral  
Ø Itching,  redness,  tearing  
Ø Viral:  Adenovirus  most  
common,  consider  HSV  
infecHon  
Ø Bacterial:  Staph  most  
common,  consider  if  
contact  lenses  in  place;  
chlamydia,  &  gonococcal  
 ConjuncHviHs:  
Treatment  
•  Erythromycin:  
 (0.5%  ophthalmic  ointment)  q4h  x7-­‐10  days  
•  Gentamicin  :  
 (0.3%  ophthalmic  ointment,  soluHon)  1-­‐2gn  x7d  
•  Chlamydia:  
 Erythromycin  (50mg/kg/day)  po  divided  q6h  x14d  
•  Gonococcal-­‐-­‐-­‐Rocephin  IV  x7  days  
•  F/U  with  PCP  and  optometrist  
•  Worsening  symptoms  occur  such  as  worsening  pain,  
acute  visual  change,  photophobia  
Open  Wide…Please!!!!!  

PHARYNGITIS  
 PharyngiHs  
q Acute  &  Viral  
q 90%  sore  throat  and  fever  cases  are  related  to  
viral  infecHons  
q 10%  are  Group  A  streptococcal  
q Peak  ages  4-­‐11  
q Peak  months  January-­‐May  
q DifferenHal  Diagnosis:  GABHS,  Mononucleosis,  
Gonococcal  pharyngiHs,  EpigloLHs,  
Retropharyngeal/Peritonsillar  abscess,  Cervical  
lymphadeniHs,  GERD  
 PharyngiHs:  
Symptoms  
Sore  
Fever  
Throat  

Red  
Exudate  
Pharynx  

Tonsil  
Headache   Enlargement  

VomiHng  
Palate  
&    
Petechiae  
Diarrhea  
 PharyngiHs:  
Treatment  
•  SymptomaHc  Care  
•  Rapid  Strep  Test  with  culture,  CBC,  Mono    
•  Penicillin  VK(  50-­‐70mg/kg/d  in  3  divided  doses)  
•  Bicillin  LA  (0.6  units  IM  <27kg  or  1.2  units  IM  >27kg)  single  dose  
•  Rocephin  (50  mg/kg)  IM  x1  dose  
•  Amoxicillin  (50  mg/kg/d)  daily  dose  x10  days  
•  Azithromycin  (12  mg/kg)  daily  x5  days  
•  Keflex  (25-­‐50  mg/kg/d)  in  3-­‐4  divided  doses  x10  days  
•  Steroids:    
–  Prenisolone  (0.12-­‐2  mg/kg/d)  divided  qd-­‐qid  x5  days  
–  Orapred  (0.14-­‐2  mg/kg/d)  divided  qd-­‐qid  x5  days  
–  Decadron  0.08-­‐0.3  mg/kg/day  divided  q6-­‐12h  
•  Tylenol/Ibuprofen  
•  ENT  Referral  
 Careful  InjecHng!  

Infants  <18  months  

 Vastus  lateralis  muscle  
Children  >18  months  and  walking  
 Deltoid  muscle  (C)  
 Ventrogluteal  site    (E)  
 Dorsogluteal  site-­‐not  recommended  <3  years  (D)  
 Vastus  lateralis  muscle  (B)  
   
 Otalgia  
•  Otalgia  is  defined  as  ear  pain.  Two  separate  
and  disHnct  types  of  otalgia  exist.  Pain  that  
originates  within  the  ear  is  primary  otalgia;  
pain  that  originates  outside  the  ear  is  referred  
otalgia.    
•  Typical  sources  of  primary  otalgia  are  external  
oHHs,  oHHs  media,  mastoidiHs,  and  auricular  
infecHons.    
Otalgia  
 Acute  OHHs  Media  (AOM)  
vs  
OHHs  Media  with  Effusion  (OME)  
 
 Acute  OHHs  Media  
•  35%  Viruses  
•  Common  between  ages  6-­‐36  months  
•  Fever  common  
•  URI  usually  coexist,  however  AOM  should  not  
correlate  with  source  of  fever  
•  80%  of  the  Hme,  anHbioHcs  resolve  AOM  within  1  
week  
•  No  anHhistamines,  decongestants,  or  steroids  
due  to  unproven  effecHveness  
 
 Always  ExcepHons…  
There  are  instances  where  a  bulging  tympanic  
membrane  is  absent  and  child  sHll  has  AOM:  
I.  AcHve/acute  draining  to  ear  (otorrhea)  
II.  Semicolor  shaped  accumulaHon  at  the  margin  of  
the  tympanic  membrane  
III.  Redness  of  the  tympanic  membrane  doesn’t  
confirm  AOM.  Is  it  unilateral?  
IV.  Immobility  of  the  tympanic  membrane  need  not  
be  absolute  
 What  do  I  treat  with?  
•  High  dose  amoxicillin  overcomes  drug  resistance  
•  Auralgan  ear  drops  for  otalgia  in  nonperforated  TM  
•  Amoxicillin  80-­‐90  mg/kg  TID  x10  days  (1st  line)  
•  AugmenHn  80  mg/kg  TID  x10  days  (had  amoxicillin  in  
the  last  30  days  or  have  an  oHHs/conjuncHviHs  combo)  
•  Azithromycin  10  mg/kg  Day  1,  then  5  mg/kg  x4  days  
•  Rocephin  50  mg/kg  IM  x1  dose  
•  Septra  0.4  mg/kg  BID  7-­‐10  days  
 OHHs  Media  with  Effusion  
v Acute  fullness  in  the  ear  
v Opacified  and  poorly  mobile  tympanic  membrane  in  
the  neutral  or  retracted  posiHon  
v Tympanocentesis  treatment  of  choice  due  to  reducing  
pressure  caused  by  thick  mucoid  fluid  
v The  major  pathogen  in  AOM,  Streptococcus  
pneumoniae,  is  infrequently  recovered  when  
tympanocentesis  is  performed  for  OME  
v A  child  who  is  fussy  or  can  report  “pain,”  doesn’t  
support  a  diagnosis  of  AOM,  so  treat  accordingly.  
NOTE:  No  anHbioHcs  for  OME,  procedural  
improvement  as  first  line  
OHHs  Externa  
   *Inflamma3on  of  the  external  auditory  canal  
 OHHs  Externa:  
Treatment  

Clean    
Ear  Canal  
Treat  diabeHcs  
with  po  Cipro   Irrigate  

Use  Wick  if     Pain  

needed   Management  

Oral    
AceHc  Acid  2%  
AnHbioHcs  

CorHsporin  oHc  
Ofloxin  drops   soluHon  drops  
or  suspension    
World  of  Rashes  
World  of  Rashes  
 Rashes:  
Facts  
ü  Can  originate  from  a   ü  Vaccines  are  aiding  in  
drug/medicaHon,   decreasing  incidence  of  
infecHous  culprit,  or   diseases  in  relaHon  to  
allergic  reacHon   rash  manifestaHon  
ü  Everyone  has  different   ü  Some  rashes  will  
rash  presentaHon,  with   disappear  without  
similarity  commonly   treatment,  however  TIME  
noted   and  SEVERITY  are  
ü  History  during   significant  
assessment  highly   ü  Viral  vs  Bacterial    
important     ü  Fungal  idenHficaHon  
perHnent  
 What  do  I  do?  
•  Thorough  history  
•  Assessment  
•  Red  Flags  
•  MedicaHons  
•  Monitor  
•  Recheck/Reevaluate/Follow  UP  
 Roseola  
Ø Also  referred  to  as  “Viral  Exanthem”  
Ø Affects  children  3  years  of  age  and  younger  
Ø Abrupt  fever  (3-­‐7  days),  inflamed  TM,  faHgue  
Ø Red  Flag-­‐-­‐-­‐-­‐-­‐-­‐febrile  seizures    
Ø AnHpyreHcs  (Tylenol  15mg/kg  or  Ibu  10mg/kg)  
Ø HydraHon  
 
 Hand-­‐Foot-­‐Mouth  Disease  
•  Affects  infants  and  children  <5  years  of  age  
•  Coxsackievirus  A16  is  the  most  common  cause  of  
hand,  foot,  and  mouth  disease  in  the  United  
States  
•  Prodrome  period  (fever,  malaise,  sore  throat,  and  
poor  appeHte),  followed  by  herpangina  in  oral  
cavity  aver  2nd  day  of  fever  
•  Rash  appears  within  1-­‐2  days  on  palms  of  hand  
and  soles  of  feet  
•  SymptomaHc  treatment    
 ImpeHgo  
o  Bacterial  skin  infecHon  from  either  Staphylococcus  
aureus  or  Streptococcus  pyogenes  
o  Face  and  extremiHes  MOST  common  involved  sites  
o  Honey-­‐colored  crusted  erosions  
o  Keflex  (25mg/kg/day)  divided  into  2  doses  x10  days  
o  Topical  Bactroban  Hd  x10  days  
o  Proper  hand  washing  
o  Return  to  school  24  hours  aver  starHng  anHbioHcs  
 Dermatophyte  InfecHon:  
Tinea  
•  Tinea  CapiHs,  Tinea  Corporis,  Tinea  Cruris,    
       Tinea  Pedis,  Tinea  Unguium  (onychomycosis)  
•  CapiHs-­‐  Griseofulvin  (20mg/kg/d)  single  dose  or  
divided,  for  6-­‐8  weeks  
•  Corporis/Pedis/Cruris-­‐  Lamisil  (soluHon  or  spray),  
Loprox  (cream  or  loHon),  Nizoral  (cream)  bid  or  
QD  in  15g,  30g,  60g  
•  Unguium-­‐  Oral  terbinafine  (260mg/d,  6  weeks  for  
fingernails  and  12  weeks  for  toenails)  or  topical  
nail  lacquer  

 
Candidiasis  
 Candidiasis  
•  Caused  by  yeast  like  fungus,  Candida  albicans  
•  Normal  flora,  however,  epidermis  invasion  occurs  with  
moisture,  darkness,  and  warmth…produces  
overgrowth  
•  Pediatric  most  common  sites  are  oral  cavity  and  diaper  
area  
•  Oral  origin  referred  to  as  thrush  
•  Oral  area  treatment:  NystaHn  oral  suspension  (100,000  
U/ml)  qid  x10  days  
•  Diaper  area  treatment:  NystaHn  cream  (100,000  units/
g)  with  each  diaper  change  x3  days  
 
Wait,  My  Child  Won’t  Sleep  Because  
Of……..  
 Pinworms  
q Prevalence  highest  in  preschoolers  and  in  school-­‐
age  children  
q White,  threadlike  worm  for  which  humans  are  
the  ONLY  hosts  
q Female  deposit  eggs  on  perianal  skin  and  then  
die  
q Perianal  pruritus  with  excoriaHon  common  
q Treatment:  transparent  tape  for  kids  under  2  
years  of  age  or  Pyrantel  pamoate  (>2  years  of  
age),  11mg/kg  x1  dose,  may  repeat  in  2  weeks  
 
FYI…..  
 Pearls  for  PracHce  
v  Fever  is  not  dangerous  in  of  itself  unless  greater  than  or  equal  to  
105  degrees  or  coexisHng  with  other  acute  vs  prolonged  symptoms  
v  Viruses  are  the  most  common  cause  of  fever  
v  History  and  physical  are  your  friend  and  will  aid  in  differenHal  
diagnosis  along  with  treatment  plan  
v  Tylenol  and/or  ibuprofen  are  necessary  (at  correct  dosages)  
v  Reassessment  and  idenHfy  primary  care  provider  
v  VaccinaHons  are  necessary  
v  AnHbioHcs  are  not  ALWAYS  the  answer  
v  Infants  that  won’t  stop  crying  during  exam  MAY  warrant  a  more  
serious  illness  
v  Parent/caretaker  involvement  
That’s  a  WRAP….  
 References  
•  Casey,  J.  &  Pichichero,  M.  (2015).  Acute  O88s  Media:  Update  2015.  
Retrieved  from  hnp://
contemporarypediatrics.modernmedicine.com/contemporary-­‐
pediatrics/news/acute-­‐oHHs-­‐media-­‐update-­‐2015?page=full  
•  Correll,  D.  (2011).  The  Nurse  Prac88oner  Prac8ce  Guide:  For  
Emergency  Departments,  Urgent  Care  Centers,  and  Office  Prac8ces.  
Jackson,  TN:  Acute  Care  Horizons  
•  Hay,  W.,  Levin,  M.,  Sondheimer,  J.,  &  Deterding.R.  (2009).  Current  
Diagnosis  &  Treatment:  Pediatrics.  McGraw-­‐Hill  
•  Uphold,  C.  &  Graham,  M.  (2003).  Clinical  Guidelines  in  Family  
Prac8ce.  Gainesville,  Florida:  Barmarrae  Books  
•  World  Health  OrganizaHon.  (2012).  Pocketbook  of  Hospital  Care  for  
Children:  Guidelines  for  the  Management  of  Common  Childhood  
Illnesses.  Retrieved  from  hnp://apps.who.int/iris/bitstream/
10665/81170/1/9789241548373_eng.pdf    
ANY  QUESTIONS?!?!?!