Pediatric emergency medicine trisk 2683 2683

Children with leukocoria should have an urgent ophthalmologic examination to
help differentiate retinoblastoma from other possible etiologies such as congenital
cataract, coloboma, idiopathic retinal detachment, and others. Direct extension via
the optic nerve into the meninges and spinal fluid is a possible but unlikely
complication of the tumor. Presentations are usually local and therefore cured by
enucleation, but systemic chemotherapy, intra-arterial (ophthalmic artery)
chemotherapy, cryotherapy, laser therapy, and insertion of radioactive plaques are all
being explored to preserve vision. Management of retinoblastoma hinges on the
probability of useful vision in the affected eye. Ophthalmology should be consulted
early to determine if the patient’s visual acuity has already been affected by the mass
and to plan the urgency of examination under anesthesia. Management of
intraorbital tumors may be possible on an outpatient basis, in conjunction with an
experienced pediatric ophthalmologist, if the mass is unlikely to affect vision
quickly or if vision is already profoundly impaired in the affected eye.
Management of other head and neck tumors can sometimes occur on an outpatient
basis, in conjunction with a pediatric oncologist and a specialist, such as an oral
surgeon or otorhinolaryngologist with expertise in the anatomic region of the tumor.
However, specific symptoms such as uncontrolled pain, difficulty maintaining
hydration, TLS, or any evolving threat to the airway require inpatient management.

TUMORS OF THE THORAX
Goals of Treatment
The most critical decision making and care in the ED is the differentiation of
emergent from nonemergent tumors of the thorax. This difference is frequently
driven by tumor location (see Fig. 124.11 in Thoracic Emergencies chapter).
CLINICAL PEARL AND PITFALLS
Children with anterior mediastinal mass must be managed with the utmost
caution. Prevention of respiratory failure is critical, as these masses may
be located below the carina, rendering even intubation ineffective.

Current Evidence

Thoracic tumors can be caused by a number of childhood cancers. While
hematologic malignancies are common, embryonal neoplasms such as
neuroblastoma, sarcomas such as primitive neuroectodermal tumor (PNET), and
carcinomas can also present in the chest. In general, there are no specific
predisposing conditions or factors.