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  Sometimes, a lab result or radiograph will indicate need for emergent directed treatment (eg, foreign body). It is extremely important to frequently reassess the patient after each treatment to determine response and make decisions for further management. Clinical status can change very quickly in patients with respiratory distress (Figure 49-5). TREATMENT Croup. Administer humidified oxygen, and all patients should get dexamethasone 0.6 mg!kg/dose (max 16 mg) intramuscular (IM) or by mouth (PO) regardless of the RESPIRATORY DISTRESS severity. If there is stridor at rest, give racemic epinephrine 0.5 mL of 2.25% solution in 3 mL of normal saline (NS) via a nebulizer. Foreign body aspiration. Definitive management is to remove in the operating room by laryngoscopy or bronchoscopy. In the setting of critical airway obstruction or impending/actual respiratory arrest, attempt to force the foreign body out with back blows or chest or abdominal thrusts depending on the age and size of the

  Soft tissue neck radiograph may reveal a thumbprint sign of epiglottitis (Figure 49-3), the steeple sign of croup, or a widened retropharyngeal space seen in retropharyngeal abscess (Figure 49-4). Neck computed tomography may be required for definitive diagnosis of retropharyngeal abscess or other deep space infections of the neck causing airway obstruction. RESPIRATORY DISTRESS .&. Figure 49-2. Bi lateral decubitus chest x-rays in a patient showing right-sided air trapping. Note that on the left lateral decubitus view (A) the left lung is compressed as expected. However, when the child is placed right-side down (B), the right lung remains relatively hyperinflated. This child was taken to the operating room, where a peanut was found in the right mainstem bronchus. Electrocardiogram may reveal decreased QRS amplitude (pericardia! effusion), electrical altemans (severe pericardia! effusion or cardiac tamponade), conduction delay (myocarditis), or ST segment and T wave changes (peri

  Pneumonia incidence varies inversely with age, whereas the etiology changes based on the season and age of the patient. Important secondary causes of respiratory distress include congenital heart disease, cardiac tamponade, myocarditis/pericarditis, tension pneumothorax, central nervous system infection, toxic ingestion, peripheral nervous system disease (eg, Guillain-Barre syndrome, myasthenia gravis, botulism), metabolic disorders ( eg, diabetic ketoacidosis), hyperammonemia, and anemia. CLINICAL PRESENTATION ..,._ History Initial treatment may be required for stabilization before a complete history and physical examination can be performed. Ask for a description of respiratory problems, including onset, duration, and progression of symptoms. Keep in mind that respiratory distress can present as difficulty with feedings in infants and decreased activity or feeding in toddlers. Inquire about precipitating or exacerbating factors. Ask if there was any recent history of choking, as th

   It accounts for 10% of pediatric visits to the ED, 20% of pediatric admissions, and 20% of deaths in infants. Respiratory distress can potentially lead to respiratory failure (the inability of oxygen ­ ation and ventilation to meet metabolic demands) and should be recognized and treated promptly. Several anatomic and physiologic characteristics put pediatric patients at higher risk for respiratory compro ­ mise. Infants <4 months of age are obligate nose breathers. Nasopharyngeal obstruction significantly increases the work of breathing. The location of the narrowest part of the airway, where a foreign body is likely to lodge, differs in adults (vocal cords) and children (cricoid cartilage). The diameter of the pediatric airway is a third that of adults. Narrowing of the airway leads to a greater relative increase in resistance to airflow ( 1-mm occlusion decreases crosssectional diameter by 20% in adults vs. 75% in children). Abdominal musculature is a primary contributor to res

  Age Qual ifications Physical Examination Lab values to determine low-risk stratification Treatment for High risk patients Treatment for Low risk patients Study outcome statistics Rochester Criteria <60 days Term infant No perinatal antibiotics No underlying disease Not hospitalized longer than the mother at birth Well-appearing No ear, soft tissue, or bone infection WBC >5,000 and <15,000/�L Absolute band count <1,500/�L UA <10 WBC/HPF Hospital admission Empiric antibiotics Home No antibiotics Follow-up required Sensitivity 92% Specificity 50% PPV 1 2.3% NPV 98.9% Philadelphia Protocol 29-60 days Not specified Well-appearing Unremarkable exam WBC <15,000/�L Band-neutrophil ratio <0.2 UA <1 0 WBC/HPF Urine Gram stain negative CSF <8 WBC/�L CSF Gram stain negative Chest radiograph: no infi ltrate (if done) Hospital admission Empiric antibiotics Home No antibiotics Follow-up required Sensitivity 98% Specificity 42% PPV 1 4% NPV 99.7% Boston Criteria 28-89 days

  as a single generalized tonic-clonic seizure that lasts < 1 5 minutes in children aged 6 months to 6 years with no resulting focal neurologic deficits. These seizures occur in the setting of fever in previously healthy children with no history of epilepsy or signs of central nervous system ( CNS) infection. Three percent to 5% of all children will have a simple febrile seizure. A source should be investigated for a patient presenting with a simple febrile seizure, but an extensive work-up is usually not indicated. A febrile seizure is considered complex if it has focal features, lasts longer than 15 minutes, or occurs more than once in 24 hours. A more extensive work-up including laboratory studies, imaging, and lumbar puncture should be strongly considered in those presenting with complex febrile seizures. ..... Physical Examination Vital signs and general appearance should always be e valuated before proceeding with the remainder of the physical exam. Heart rate can be elevated