UMEM Educational Pearls - Pediatrics

Category: Pediatrics

Title: Rheumatic Fever

Keywords: Rheumatic Fever, Jones Criteria, Heart Disease, Salicylates, Chorea (PubMed Search)

Posted: 11/9/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Rheumatic Fever

  • Significant cause of cardiovascular morbidity in developing countries and still present in the USA, although declining in incidence.
  • American Heart Association update of the Jones Criteria (1992):
    • Major Criteria
      (1)    Carditis (of any of the layers of the heart)
      (2)    Polyarthritis
      (3)    Subcutaneous Nodules
      (4)    Erythema Marginatum
      (5)    Chorea
    • Minor Criteria
      (1)    Arthralgia (not a criterion if polyarthritis is present)
      (2)    Fever
      (3)    Elevated acute-phase reactants (ESR, CRP)
      (4)    Prolonged P-R interval
  • Diagnosis made by presence of TWO MAJOR or ONE MAJOR PLUS TWO MINOR.
  • Diagnosis can also be made with presence of chorea and documented strep pharyngitis.
  • Acute Management
    • Treat the Infection
      (1)    Penicillin (Pen V for 10 days or Pen G IM)
    • Alleviate Symptoms
      (1)    Salicylates are particularly effective for migratory arthritis
      (2)    High Dose ASA (80-100mg/kg/Day for several weeks, and then taper)
      (3)    NSAIDs for those who cannot tolerate ASA
      (4)    Steroids reserved for moderate to severe carditis.

Category: Pediatrics

Title: Childhood Heart Transplantation

Keywords: Heart Transplantation, Rejection, Syncope, Chest Pain (PubMed Search)

Posted: 11/2/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Children s/p Heart Transplantation – Rejection

  • Children need heart transplantation for complex congenital heart defects (hypoplastic left heart syndrome is most common) or dilated cardiomyopathies.
  • Signs of Acute rejection
    • Chest Pain is uncommon
    • Common presentions: fever, myalgias, and vomiting.
      • ECG may show a decreased R wave amplitude and an increased QRS duration.
    • Labs are most often NOT diagnostic in acute rejection.
      • Troponin and CK levels may or may not be elevated.
      • Elevated LFTs are concerning for right heart failure.
    • Echo – Diastolic dysfunction is the earliest change seen in acute rejection
  • Signs of Chronic Rejection
    • Clinical symptoms often related to the accelerated atherosclerosis
    • “Silent” ischemia or infarction – decreased exercise tolerance or malaise
    • Syncope

Woods, WA. Care of the Acutely Ill Pediatric Heart Transplant Recipient. Pediatric Emergency Care. 23(10):721-724, October 2007.

Category: Pediatrics

Title: Severe Asthma in Pediatrics

Keywords: Severe Asthma, Refractory to standard therapy, intubation, atrovent, magnesium, noninvasive ventilation, heliox, ketamine, singulair (PubMed Search)

Posted: 10/26/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Severe Asthma in Pediatrics (Using “the kitchen sink” when all else fails)

Every effort should be made to avoid intubating an asthmatic pt.  Here are some possible options to consider:

  • Atrovent - Multiple doses should be preferred to single doses of anticholinergics. The available evidence only supports their use in school-aged children with severe asthma exacerbation. (reference #1)
  • Magnesium - Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma (based on 5 adult and 2 pediatric studies)
  • Noninvasive ventilation - The application of NPPV in patients suffering from status asthmaticus, despite some interesting and very promising preliminary results, still remains controversial. (only one trial met criteria.  No pediatric studies)
  • Heliox – No good evidence to support its use, but it is relatively safe to use, provided the patient doesn’t need more than 30% FiO2 (70%Helium)
  • Ketamine – Cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing children to the risks associated with mechanical ventilation.
  • Singulair - Intravenously administered montelukast, in addition to standard therapy, provided rapid benefits and was well tolerated among patients with acute asthma. (Study population 15yrs – 54yrs).


  • References:
  1. Plotnick LH, Ducharme FM. Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000060.
  2. Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD001490.
  3. Ram FSF, Wellington SR, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004360.
  4. Rodrigo, GJ. et al. Use of Helium-Oxygen Mixtures in the Treatment of Acute Asthma. Chest. 2003;123:891-896. 2003
  5. T. Kent Denmark, Heather A. Crane, Lance Brown. Ketamine to avoid mechanical ventilation in severe pediatric asthma. Journal of Emergency Medicine. Volume 30, Issue 2. pages 163-166


Category: Pediatrics

Title: Pediatric Septic Shock

Keywords: Sepsis, Shock, Tachycardia, Hypotension (PubMed Search)

Posted: 10/19/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Pediatric Septic Shock

  • Sepsis is the most common cause of pediatric deaths worldwide.
  • Recognition is paramount!  Delayed Dx = Higher Mortality
    • Hypotension is a late finding. 
    • Look for other signs of End Organ Hypoperfusion
      • Prolonged Cap Refill, Change in MS
      • Tachycardia, Tachypnea
      • Elevated Lactate / unexplained metabolic acidosis
  • Management strategy is similar to that of adults
    • Get access (Don’t forget your I/O’s if necessary)!
    • Fluid Resuscitation is the most important aspect of the management
      • Get 20-60ml/kg infused within the first 15 minutes
      • Children with septic shock who get >40ml/kg before the first hour have increased survival compared to those who do not.
        • They may require 60-200ml/kg over the first few hours.
    • Get your Abx on board quickly
    • Currently there are Protocols that are based on the Adult Surviving Sepsis Campaign.

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.  Pediatr Crit Care Med. 2005 Jan;6(1):2-8.

Category: Pediatrics

Title: Foreign Bodies

Keywords: Foreign Body, Button Battery, Heliox, Respiratory Distress (PubMed Search)

Posted: 10/12/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Foreign Bodies
•    No object should be left in the esophagus for >24 hrs
•    Unusual FB’s:
        ==>    Very Sharp or pointed objects may perforate the GI tract and should be removed endoscopically.
        ==>    Long objects (>6cm) or wide (>2cm) objects may not pass and should  be remove  endoscopically.
•    Button Batteries
        ==>    9% of cases involve more than one battery (x-ray mouth to anus)
        ==>    Hazards:
                    (1)    Heavy metal leakage (Mercury) – low risk but real
                    (2)    Electrical Discharge (Local tissue injury)
                    (3)    Pressure Necrosis
                    (4)    Leakage of Corrosives
        ==>    85% Pass without symptoms
                    (1)    No intervention if pass the esophagus and pt is without symptoms

•    Consider Heliox as a temporizing measure in children with respiratory distress, while awaiting endoscopy/bronchoscopy.

Category: Pediatrics

Title: Concussions (Pediatric Sports Medicine)

Keywords: Concussion, Second Impact Syndrome, Sports Medicine (PubMed Search)

Posted: 10/5/2007 by Sean Fox, MD (Updated: 2/23/2024)
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  • Symptoms
    • HA, Dizziness, Confusion, Tinnitus, Nausea, Vomiting, Vision changes
  • 3 grades of Concussions
    • Grade 1 = transient concussion symptoms.  No amnesia.  No LOC. 
    • Grade 2 = transient concussion symptoms with amnesia.  No LOC.
    • Grade 3 = + LOC of any durations
  • Return to Play Guidelines 
    • (there is no consensus statement. What follows is based on the most conservative approach)
    • Grade 1: Remove from game, Examine q 5 min.
      Return to game when asymptomatic for 20 minutes.
    • Grade 2: Remove from game until asymptomatic for 1 week.
    • Grade 3: ED evaluation.  No contact sports for 1 month once asymptomatic for 2 weeks. 
      • These apply to first concussions.  Increase concern with 2nd concussion.
  • Second-Impact Syndrome
    • Occurs when a player returns to contact sport before symptoms of 1 concussion have fully  resolved.
    • Even a minor blow to the head can result in loss of brain’s autoregulation of blood flow.  
      • Leads to vascular engorgement and subsequent herniation.

Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med 1990;87:4.

Category: Pediatrics

Title: Growth

Keywords: Growth, Failure to thrive, Weight Gain (PubMed Search)

Posted: 9/28/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Growth An infant with failure to thrive will first demonstrate poor weight gain. ==> With continued insult, there will be reduced height/length growth and then, finally, reduced head circumference growth. After birth, infants will normally loose weight initially (particularly breastfed infants). Infants should regain their birth weight by 2 weeks of life. For the first 3 months, infants should gain ~30 grams a day (~1 oz / day). By 6 months, they should have doubled their weight. By 12 months, they should have tripled their weight. By 24 months, they should have quadrupled their weight.

Category: Pediatrics

Title: Henoch-Schonlein Purpura

Keywords: Henoch-Schonlein Purpura, abdominal pain, Vasculitis, Nephritis (PubMed Search)

Posted: 9/21/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Henoch-Schonlein Purpura HSP is a small vessel vasculitis ==> Related to IgA nephropathy; however, IgA nephropathy more often involves young adults and predominantly affects the kidneys. Generally, HSP is a benign, self-limited disease. Pt s are NOT TOXIC appearing. ARENA (common symptoms) ==> Abdominal Pain and Vomitting (85%) +/- Bloody Stools ==> Rash (95-100%) ==> Edema (20-50%), peripheral or scrotal ==> Nephritis ==> Arthritis / Arthragias (60-80%) particularly of knees and ankles Steroids are controversial no definitive controlled trials demonstrate their efficacy.

Category: Pediatrics

Title: Supracondylar Fractures

Keywords: Humeral Fracture, Supracondylar Fracture, radius fracture, Compartment Syndrome (PubMed Search)

Posted: 9/14/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Supracondylar Fractures Most common elbow fracture in childhood. Mechanism: Hyperextension (FOOSH) 90-95% Flexion (Fall on Flexed Elbow) 5-10% Posterior Fat Pad suggests intra-articular effusion and fracture. Complications = Ulnar, Median, and Radial nerve injuries, brachial artery injury, Volkmann s ischemic contracture, COMPARTMENT SYNDROME Associated Distal radius Fracture in ~5% of cases Palpate the wrist! Attempts in the ED at partial reduction leads to increase soft tissue injury and swelling, which will complicate the definitive reduction in the OR.

Category: Pediatrics

Title: Arnold-Chiari (Chiari II) Malformation

Keywords: Arnold-Chiari (Chiari II) Malformation, Stridor, Sycope, Respiratory Distress, Weakness, Herniation (PubMed Search)

Posted: 9/7/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Arnold-Chiari (Chiari II) Malformation Arnold-Chiari malformation = herniation of cerebellar tissue and the medulla downwards through the foramen magnum into the upper cervical spinal canal causing compression of the upper segments of the spinal cord. Two distinct ages are identified with Chiari II malformations: infants and adolescents ==> Infants often present with Respiratory Distress, Inspiratory Stridor, and/or apnea. -- These herald impeding brainstem compromise. ==> Older children more often present with syncopal episodes or muscle weakness. Chiari Malformation needs to be considered in all children with myelomeningocele, Down s Syndrome, Hydrocephalus, Sacral Dimple, or other neurologic abnormalities presenting with respiratory distress. ==> Myelomeningocele is associated with Chiari Malformation and hydrocephalus in 80-90% of cases. Recognition is critical, since movement of the head and neck can lead to further compression of the CNS structures. Rath GP, Bithal PK, Chaturvedi A: Atypical Presentations in Chiari II Malformation. Pediatric Neurosurgery 2006;42:379-382

Category: Pediatrics

Title: Congenital Heart Disease

Keywords: Pediatric Congenital Heart Disease, Hyperoxia test, Prostaglandin E, Shock, CHF (PubMed Search)

Posted: 8/31/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Congenital Heart Disease Clinical signs and symptoms of pediatric congenital heart disease are often subtle ==> Often misdiagnosed with respiratory illness or sepsis Can progress to CHF and shock ==> CHF in infants = tachypnea, tachycardia, and hepatomegaly (classic triad) -- JVD, Peripheral Edema, rales are UNCOMMON (unlike adults) Hyperoxia Test Is the etiology of the cyanosis cardiac or noncardiac? ==> If pulmonary disesase is the cause, 100% FiO2 will increase PaO2 to ~150mmHg and increase the Pulse Ox by ~10%. ==> If Heart Defect is the cause, there will be minimal improvement in condition and values. PGE1 administration ==> Used to reopen or maintain patency of ductus arteriosus until definitive intervention. ==> Consider it in a neonate presenting in shock (possibly undiagnosed ductal dependent lesion). ==> Side effects are hypotension, bradycardia, seizures, and APNEA. ==> Either intubate before or be prepared to intubate.

Category: Pediatrics

Title: Lead Poisoning

Keywords: Lead Poisoning, Toxicology, Plumbism, CaEDTA, BAL, DMSA, Lead Lines, Basophilic Stippling (PubMed Search)

Posted: 8/24/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Lead Poisoning In Baltimore, 4.6% of kids screened had high lead levels in 2006 Plumbism presents often with vague and nonspecific symptoms; however, have high index of suspicion if: ==> Listlessness, clumsiness, or loss of developmental skills, ==> Recurrent or intermittent abdominal pain, vomiting, and constipation ==> Afebrile Convulsions ==> Resides in a house built before 1950 ==> Family history of elevated lead ==> History of Pica ==> Iron Deficiency Anemia ==> Evidence of neglect/abuse Lead Level will not come back in a timely fashion to help direct care, therefore, presumptive Chelation may be warranted. Evidence to Support Lead Posioning: ==> Micorcytic Anemia ==> Elevated Erythrocyte Protoporphyrin ==> Basophilic stippling of erythrocytes ==> Glycosuria, aminoaciduria (from development of Fanconi s Syndrome) ==> Radiopaque flecks on AXR ==> Lead Lines (dense metaphyseal bands on knee and wrist x-rays) Chelation with CaEDTA, BAL, or DMSA depending on level and symptoms.

Category: Pediatrics

Title: Neonatal Hypoglycemia

Keywords: Hypoglycemia, Neonate, Glucagon, Dextrose (PubMed Search)

Posted: 8/18/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Pediatric Hypoglycemia Hypoglycemia = <45mg/dL in symptomatic neonate; = <35mg/dL in asymptomatic Symptoms = jitteriness, tachycardia, apnea, cyanosis, tachypnea, hypotonia, temperature instability, lethargy, irritability, or abnormal cry. (almost anything!) - So check the Sugar EARLY Fasting (often from gastroenteritis and dehydration) - the most common etiology of ketotic hypoglycemia in nondiabetic kids Glucagon has diagnostic and therapeutic role If it improves hypoglycemia, then glycogen stores are sufficient. Remember to draw extra tubes for future endocrine work-up PRIOR to giving dextrose! Rule of 50 For neonates: 5ml/kg of D10; For children: 2ml/kg of D25. - 5x10=50, 2x25=50 Claudius, I., C. Fluharty, and R. Boles, The emergency department approach to newborn and childhood metabolic crisis. Emerg Med Clin North Am, 2005. 23(3): p. 843-83.

Category: Pediatrics

Title: Pseudosubluxation

Keywords: Pseudosubluxation, swischuk Line, Hangman's Fracture, Cervical Injury (PubMed Search)

Posted: 8/10/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Pseudosubluxation Refers to the normal mobility of the cervical vertebrae, IN FLEXION, which may appear pathologic Distinguishing between Pseudosubluxation and Pathologic - The displacement should only occur in flexion (Not extension) (1) most pediatric c-spine films are in flexion due to the relatively larger occiput - Swischuk Line (1) Line that is drawn from anterior aspects of C1 to C3 spinous processes (2) This line should be within 2 mm of the anterior aspect of the C2 spinous process - Spinal-Laminar Line (1) The line drawn connecting the lamina of C1, C2, and C3 should remain intact even in flexion If you suspect that the misalignment represents pseudosubluxation, than you can reposition in extension; if it resolves, it is consistent with pseudosubluxation. But be careful, if mechanism warrants it, obtain CT to r/o hangman s fracture instead. Anterior displacement of C2 in children: physiologic or pathologic. LE Swischuk. Radiology. Vol 122(3) 1977. p 759-763.


0708102139_Swischuck Line.ppt (518 Kb)

Category: Pediatrics

Title: Painless Neck Masses

Keywords: Neck Mass, thyroglossal duct cyst, Second Brachial Cleft Cyst, ectopic Thyroid tissue (PubMed Search)

Posted: 8/3/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Painless Neck Masses Thyroglossal Duct Cyst = most common congenital midline mass ==> Concern that it may be ectopic thyroid tissue ==> Painless ==> Elevates with the tongue during swallowing (It is attached to the base of the tongue) ==> Requires ultrasound. Thyroid Scan if thyroid is abnormal. ==> Tx; Sistrunk procedure excsion of cyst and and mid-portion of the hyoid bone (not removing the portion of the hyoid leads to high rate of recurrence). Second Branchial Cleft Cyst = Most common branchial anomaly (90%) ==> Painless fluctuant mass in the anterior triangle ==> Arise due to failure of the embryonic branchial cleft to obliterate. ==> Ultrasound or CT may be useful to define mass and for pre-operative evaluation. Both are mostly asymptomatic, but may cause symptoms due to compression of local structures. Both may become infected secondarily, at which time they will no longer be painless. Treat with Abx if infected. Surgical excision should be delayed until active infection is resolved.

Category: Pediatrics

Title: Hirschsprung Disease

Keywords: GI, Hirschsrung Disease, Constipation (PubMed Search)

Posted: 7/26/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Hirschsprung Disease Is the absence of parasympathetic ganglion cells in the rectum and colon. May present in neonates or young children. Consider it in any child with constipation, bilious emesis, delayed passage of meconium (after the first 48-72 hrs), abdominal distension, or enterocolitis. Classic physical finding: tight anal sphincter, empty rectal vault, followed by an explosive bowel movement (due to releasing the pressure by loosening the anal sphincter). Definitive Dx made by rectal biopsy. May be complicated by bacterial overgrowth causing enterocolitis.

Category: Pediatrics

Title: Nursemaid's Elbow

Keywords: Nursemaid's Elbow, Radial Head Subluxation (PubMed Search)

Posted: 7/20/2007 by Sean Fox, MD (Updated: 2/23/2024)
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Nursemaid's Elbow PRESENTATION ==> Radial head subluxation is VERY common; most often seen in ages of 1-4 yrs. ==> Arm is held close to the body, elbow flexed and forearm pronated. MANAGEMENT ==> If the history and physical are classic, no X-rays are needed. Obtain x-rays if there is pain to palpation of long bones (rule out Monteggia fx) or the story is not classic. ==> Hold elbow at 90 degrees, then firmly supinate and simultaneously flex the elbow. ==> Place thumb over region of radial head and apply pressure as you supinate. May also need to extend elbow to help screw radial head back in place. POST-REDUCTION ==> Immobilation is not necessary for 1st episode ==> If delayed reduction (>12 hours), place in long arm posterior splint in full supination and elbow @90 degrees

Category: Pediatrics

Title: Bronchiolitis

Keywords: Bronchiolitis, Bronchodilators, Steroids, Supplemental Oxygen (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/13/2007) (Updated: 2/23/2024)
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Bronchiolitis The most common lower respiratory infection in infants Diagnosis is based on clinical history and physical. No lab test is useful. Management - Bronchodilators should not be used routinely. They can be continued if the pt has a positive response after a trial. - Corticosteroids have not been found to be of benefit. - Antibiotics should not be used, unless indicated for other reasons. - Ribaviran has not demonstrated any benefit. - Use Supplemental oxygen if the patient is persistently sat'ing <90%. Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793

Category: Pediatrics

Title: Inborn Errors of Metabolisn

Keywords: Inborn Errors of Metabolism, Hypoglycemia, organomegaly (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 2/23/2024)
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Inborn Errors of Metabolism For the child with neurologic abnormalities, vomiting, acidosis, hypoglycemia, organomegaly, or cardiopulmonary arrest remember to consider Inborn Errors of Metabolism (IEM) on your DDx. There are over 300 disorders of the various biochemical pathways, and while the individual incidence for each disorder may be rare, the collective incidence for IEM is 1-2 / 1,000 births. Treat dehydration and hypoglycemia promptly but FIRST, draw EXTRA blood samples (at UMMS, two adult Green Tops and one adult Red Top) in addition to the basic labs. ==> Once you begin therapy to correct the acid/base disturbance, hypoglycemia, and dehydration the abnormal metabolites present in their serum will be reduced and possibly confound the diagnosis. ==> Draw the extra blood, before your give the NS bolus or the Dextrose! ==> Basic Labs (1) ABG, BMP, Ammonia, U/A are helpful immediately (2) CBC, Blood and Urine Cultures (look for concurrent infection, possibly the inciting event) (3) Urine Reducing Substances, serum organic acids, urine and serum amino acids are also useful

Category: Pediatrics

Title: Bacterial tracheitis

Keywords: Bacterial tracheitis, stridor, croup, epiglottitis (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 2/23/2024)
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Bacterial Tracheitis Considered bacterial tracheitis in a patient who has fever, stridor, and symptoms that do not respond to therapy for croup (racemic epinephrine and steroids). The epidemiology of acute infectious upper airway disease in pediatrics has been altered with immunization against Haemophilus influenza- b and the widespread use of corticosteroids for the treatment of viral croup. Bacterial Tracheitis has replaced epiglottitis and croup as the most common cause of acute respiratory failure. One study found it to be 3 times more likely to cause respiratory failure than croup and epiglotittis combined. The mortality rates had been reported as high as 18% to 40%. Hopkins, A., et al., Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics, 2006. 118(4): p. 1418-21.