Pediatric emergency medicine trisk 2281 2281

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