Pediatric emergency medicine trisk 571

child should arouse a strong suspicion of pneumonia. Localized findings, more often seen in the child older than 1
year, include inspiratory rales, decreased breath sounds (sometimes the only abnormality), and less often, dullness
to percussion. Patients with lower lobe pneumonia may present with abdominal pain; occasionally, the abdominal
findings in pulmonary infections mimic appendicitis. With upper lobe pneumonia, the pain may radiate to the
neck, causing meningismus; the diagnosis of pneumonia must, therefore, be considered in the child with nuchal
rigidity and normal CSF.
Triage considerations: Children with fever and respiratory distress should be evaluated for pneumonia, despite
the recognition that only a minority of febrile infants and children with respiratory distress will harbor a bacterial
pathogen. Some children with pneumonia will require supplemental oxygen, more advanced airway support,
and/or fluid resuscitation.
Clinical assessment: The diagnosis often is made by chest radiograph, which can be falsely negative in
dehydrated or neutropenic children. While there are no pathognomonic findings to differentiate viral from bacterial
pneumonia, certain patterns in radiographic findings are of use to the PEM clinician. A lobar consolidation is
assumed to be of bacterial origin, needing treatment with antibiotics, whereas a minimal, diffuse interstitial
infiltrate in a previously healthy toddler suggests a viral infection that can be managed with symptomatic therapy
or, in an adolescent, Mycoplasma pneumoniae, calling for treatment with azithromycin. Bilateral involvement,
pleural effusion, and pneumatoceles indicate more severe disease.
Further laboratory studies are obtained only on specific indications. A WBC count may be helpful in
differentiating viral from bacterial disease or in assessing the likelihood of bacteremia in the young child. The rate
of occult pneumonia in children with leukocytosis >20,000/mm3 remains 10% to 15% in the post-pneumococcal
conjugate vaccine era. Procalcitonin has been used to stratify the risk of bacterial pneumonia in adults. Blood
cultures rarely alter management in nontoxic, previously healthy children and are more likely to result in detection
of contaminants than pathogens.
The most common complication of pneumonia is dehydration due to decreased intake and increased insensible
losses; this is particularly true for young children. Rarely, extensive pulmonary involvement compromises
ventilation, leading to respiratory failure. ABGs should be considered for any child with significant respiratory
distress or transcutaneous oxygen saturation below 90%. The most common causes of parapneumonic effusions
are pneumococcus and staphylococcus. Bacteremia may result in additional foci of infection, including meningitis,
pericarditis, epiglottitis, and septic arthritis.
Management: First, the PEM clinician should consider whether or not the child is a candidate for outpatient
therapy ( e-Table 94.7 ). Professional societies have formulated consensus guidelines on which children can be

classified as moderate or severe pneumonia and may benefit from intensive care unit care ( e-Table 94.8 ).
Second, the PEM clinician needs to consider whether a child requires antibiotic therapy. The Infectious Diseases
Society of America recommends that antibiotics are not routinely required in preschool-aged children with
pneumonia who will be managed as outpatients, as the vast majority have viral etiologies. This is a strong
recommendation based on high-quality evidence. Empiric antibiotic management is reviewed in Table 94.14 .
Immunocompromised children should receive broad-spectrum antibiotics, including pseudomonal coverage. The
management of children with complicated pneumonia is described elsewhere in the sections on empyema and lung
abscess. Standard precautions should be utilized for children with suspected community-acquired pneumonia.

Other Respiratory Tract Infectious Emergencies
Tracheitis
Bacterial tracheitis is predominantly caused by S. aureus in the post-Hib vaccine era in children without
tracheostomies. It can mimic the presentation of epiglottitis (see above) with a rapid course. While children present
with fever and stridor, they are more toxic appearing than children with croup and are in more respiratory distress.
Radiographs may reveal tracheal narrowing and direct laryngoscopy may demonstrate a pseudomembrane. The
first step in management is to secure the airway; the emergency medicine physician should anticipate that
intubation may be difficult; if anesthesiologist or otolaryngology support is available at a facility, consideration
should be given to having them at the bedside prior to intubation being attempted. Broad-spectrum antibiotics
(e.g., vancomycin and ceftriaxone) should be started and the child should be admitted to an intensive care unit.
Tracheitis is commonly considered in children with tracheostomies who present with increasing tracheostomy
secretions. Recognizing that tracheostomy tubes rapidly are colonized with oral and respiratory flora, the diagnosis


of tracheitis should not rest on culture results alone. Rather, clinicians should obtain a Gram stain and viral testing
in addition to bacterial culture. Standard precautions should be used.
Empyema
Empyemas are purulent pleural effusions that can complicate pneumonia. Empyemas are most commonly seen
with S. aureus and pneumococcal pneumonia and increasing incidence rates of staphylococcal pneumonia have
been seen in the post-Prevnar era. Gram-negative pathogens should be suspected in immunocompromised hosts,
neonates, and patients with indwelling chest tubes. The most common symptoms are fever, shortness of breath, and

pleuritic chest pain. The most common examination finding is tachypnea; auscultation can reveal rales or
decreased breath sound. Pleural friction rubs are rarely heard in young children. Chest radiography demonstrates
blunting of the costophrenic angle. A decubitus or cross-table lateral radiograph can be performed to see if the
fluid is free-flowing. Ultrasonography can be very useful to determine if sufficient fluid is present for
thoracentesis; for older children, a decubitus fluid layer at least 1 cm thick is considered sufficient to attempt
thoracentesis. CT allows for better differentiation between an empyema and lung abscess. Thoracentesis for pleural
fluid can be sent for cell count and differential, lactate dehydrogenase (LDH), protein, glucose, and pH in addition
to Gram stain and cultures. Cultures that should be obtained include aerobic, anaerobic, and acid-fast cultures.
Adenosine deaminase (ADA) should be sent from the pleural fluid if tuberculosis is suspected. The pleural fluid
parameters that help differentiate causes of pleural effusion are reviewed in
e-Table 94.9 . Some children with
empyema will need video-assisted thoracoscopic surgery with debridement; this has been shown to decrease
hospital length of stay and fever duration. Empiric antibiotic therapy should target pneumococcus, S. aureus, and
GAS. For mildly ill patients, ampicillin and azithromycin treatment for community-acquired pneumonia may be
appropriate. For children with risk for staphylococcal disease (e.g., history of staphylococcal disease, presence of
pneumatocele), combination therapy with clindamycin and a third-generation cephalosporin is reasonable.
Critically ill children should be treated with vancomycin and a third-generation cephalosporin. Anaerobic coverage
should be considered for neonates, immunocompromised hosts, associated neck infections (especially with jugular
thrombophlebitis), and patients with indwelling chest tubes. Standard precautions are recommended for children
with empyema unless tuberculosis is suspected (in which case, airborne precautions should be used) or unless the
child has draining skin lesions (in which case contact precautions should be utilized).


TABLE 94.14
MANAGEMENT OF UNCOMPLICATED COMMUNITY-ACQUIRED PNEUMONIA IN PREVIOUSLY
HEALTHY CHILDREN a
Age

Outpatient

Inpatient b

Other considerations

Neonates

N/A

Ampicillin + thirdgeneration
cephalosporin

Consider empiric influenza antiviral therapy
in children with moderate–severe
pneumonia during influenza season, even
if rapid influenza diagnostic test results
are negative (these tests are insufficiently
sensitive to guide empiric therapy)

Infants

Amoxicillin

Ampicillin

Preschool aged

Amoxicillin

Ampicillin

School aged

Amoxicillin +
macrolide

Ampicillin +
macrolide

Adolescents

Amoxicillin +
macrolide

Ampicillin +
macrolide

The IDSA guidelines state that
antimicrobial therapy may not be
required routinely for preschool-aged
children with community-acquired
pneumonia, as the majority will have a
viral etiology. Laboratory parameters or
radiographic findings might help
determine need for antibiotics

a Based

upon the 2011 Infectious Diseases Society of America and the Pediatric Infectious Diseases Society guidelines for the management of
community-acquired pneumonia in children. Clin Infect Dis 2011;53(7):e25. Management for children with complicated pneumonia (e.g., empyema,
lung abscess) is discussed elsewhere. Unimmunized children should have a third-generation cephalosporin added to ampicillin, for coverage of H.

influenzae type B.
b Vancomycin or clindamycin should be added if there is clinical, laboratory, or radiographic reason to suspect staphylococcal pneumonia; critically ill
children should be treated with broad-spectrum antibiotics for pneumonia (e.g., vancomycin and cefotaxime), given that rates of resistant pneumococci
are increasing in many industrialized nations.
N/A, not applicable.

Lung Abscess
Most lung abscesses are polymicrobial and caused by aspiration of oral flora, especially in patients with underlying
neurologic disorders. The predominant anaerobes are Bacteroides, Peptostreptococcus, and Prevotella. Anaerobes,
S. aureus, pneumococcus, and nontypeable H. influenzae are the most common pathogens identified in otherwise
healthy children. Fungal pathogens and Pseudomonas should be considered in immunocompromised children. M.
tuberculosis will be discussed separately in the section on travel medicine. The most common symptoms are fever,
cough, shortness of breath, and chest pain. Symptoms have often been present for up to 2 to 3 weeks before the
child is recognized to have a lung abscess; as a consequence, weight loss is seen in some children, whereas it is an
uncommon occurrence for children with community-acquired pneumonia. Auscultation of the lungs is often
nonfocal, particularly in young children. The diagnosis usually is made by chest radiograph, which can show a
thin- or thick-walled cavity with an air–fluid level. Intrathoracic adenopathy can be found in more subacute causes
of lung abscess (e.g., tuberculosis, fungal). CT can be of use if operative intervention is planned to better delineate
the anatomy. Leukocytosis with a neutrophilic predominance is common; blood cultures are positive in 10% to
15% of cases. Gram stain of the sputum is rarely useful unless the abscess has ruptured into a bronchus and is
communicating with the airway. Percutaneous aspiration or bronchoscopy is more sensitive in yielding a
microbiologic diagnosis. Empiric antibiotic coverage should target S. aureus, pneumococcus, and anaerobes.
Clindamycin and cefotaxime is one such regimen, with the advantage that it can be readily converted from a
parenteral regimen to oral equivalents. However, for toxic-appearing children, or in regions where cephalosporinresistant pneumococci or clindamycin-resistant staphylococci are commonly seen, vancomycin should be included


in the initial regimen. Standard precautions should be used for patients with lung abscesses unless tuberculosis is
suspected (in which case, airborne precautions should be implemented).
Pertussis
Pertussis (whooping cough) is caused by Bordetella pertussis or Bordetella parapertussis (the latter being the

cause of kennel cough in dogs). There were an estimated 19,000 cases in 2017, with approximately 80% occurring
in children (and almost 10% occurring in infants younger than 6 months). A similar clinical syndrome can be
caused by adenovirus or Chlamydia trachomatis in infants. There are three clinical stages. The first symptoms are
indistinguishable from a viral URI. This catarrhal phase, characterized by a mild cough, conjunctivitis, and coryza,
lasts for 1 to 2 weeks. An increasingly severe cough heralds the onset of the second stage (paroxysmal), which
continues for 2 to 4 weeks. After a prolonged spasm of coughing often involving 10 or more coughs in succession,
the sudden inflow of air produces the characteristic whoop (young infants lack the ability to generate sufficient
negative inspiratory pressure and may, therefore, not whoop). During episodes, children can appear to choke,
become cyanotic, and appear anxious. Post-tussive emesis is common. When not coughing, the child has a
remarkably normal history and physical examination, except for an occasional subconjunctival hemorrhage. Young
infants can exhibit apnea unrelated to coughing paroxysms. During the third stage (convalescent), the intensity of
the cough wanes. At times, pertussis may present as a chronic cough without other signs of infection. The fatality
rate for pertussis is approximately 1% for patients in the first month of life and 0.3% for those between age 2 and
12 months. Complications often occur during the paroxysmal stage. The most immediately life-threatening
complication is complete obstruction of the airway by a mucous plug, leading to respiratory arrest. Secondary
bacterial pneumonia occurs in 25% of children with pertussis and accounts for 90% of the fatalities. Seizures are
seen in 3%, and encephalitis in 1%. Sudden increases in intrathoracic pressure can cause intracranial hemorrhages,
rupture of the diaphragm, and rectal prolapse.
The white blood count often is elevated, at times with a leukemoid reaction (the latter more common in infants
over 6 months of age) and a lymphocytic predominance. Chest radiographs often are normal. The diagnosis is by
PCR of nasopharyngeal secretions. Early treatment can reduce symptoms and shorten the clinical course although
it is unclear if antibiotics influence course during paroxysmal phase (does still reduce transmission); however, it is
important to start antibiotic treatment when pertussis is suspected and prior to confirmatory testing. The preferred
treatment is azithromycin (10 mg/kg daily for 5 days in infants <6 months of age and 10 mg/kg daily on the first
day (maximum: 500 mg), followed by 5 mg/kg for the subsequent 4 days for older children, maximum 250 mg).
Erythromycin (40 mg/kg/day divided every 6 hours × 14 days, maximum dose: 2 g/day) can also be utilized,
though the more frequent dosing interval and longer treatment duration are associated with reduced adherence.
Household and close contacts (even if fully immunized) require chemoprophylaxis with azithromycin. Contacts
who are not fully immunized should also receive a booster dose of the vaccine (DTaP for children <7 years of age,
TDaP for children 7 years and above). Receipt of the acellular pertussis vaccine does not obviate the need for

postexposure prophylaxis (PEP) for healthcare workers, so strict use of droplet precautions (gloves, mask) is
needed for any provider caring for a child with suspected pertussis.

CARDIAC INFECTIOUS EMERGENCIES
Kawasaki Disease
See also:
Chapter 86 Cardiac Emergencies
Chapter 101 Rheumatologic Emergencies
CLINICAL PEARLS AND PITFALLS