Vital Signs

• Rapid Assessment and Vital Signs
• Fluid Resuscitation and Urine Output

HEENT

• Pediatric Dental Chart

Abdomen

• Acute Appendicitis Pediatric Pearls

Neurology

• BRUE Clinical Practice Guidelines
• Pediatric Head CT Algorithm
• Seizures (Status Epilepticus) 2016

Pain Management

• Pain-free ED

Respiratory

• Bronchiolitis Pediatric Pearls
• Croup Pediatric Pearls
• Pediatric RSI guidelines 2016
• RSV Pediatric Pearls

Sepsis

• Fever Work Up and Management in Infants

MedStar Pediatric Emergency Medicine Clinical Practice Council

Responsiveness: GCS, tone, activity
Airway: Patent, maintainable with positioning, unmaintainable
Breathing: Respiratory rate, work of breathing, color, breath sounds, pulse ox
Circulation: Heart rate, capillary refill time, skin color and temp, central vs peripheral pulses, LOC

[table class=”table-striped”]
Age, Wt (kg),HR,RR,SBP
Newborn, 3.5,130,40,70
3 mo,6,140,30,80
6 mo, 8,130,30,80
1 yr, 10,120,26,90
2 yr, 12,115,26,90
3 yr, 15,110,24,90
4 yr, 17,100,24,90
6 yr, 20,100,20,95
8 yr, 25,90,20,95
12 yr, 40,85,20,105
[/table]

*Hypotension= Systolic BP less than or equal to 70 + (2 x age in years over 1 year)

~For kids <10kg:
100 mL/kg/day

~For kids >10kg:
4 mL/kg /hr for the first 10 kg
2 mL/kg/hr for the next 10 kg
1 mL/kg/hr for every kg >20 kg

Normal 1-2 mL/kg/hr
Minimum 0.5-1 mL/kg/hr

Anatomy: The appendix arises from the cecum, which is located in the right lower quadrant of the abdomen in the majority of children.

It may lie in the upper abdomen or on the left side in children with congenital abnormalities of intestinal position, situs inversus totalis, and after repair of diaphragmatic hernia, gastroschisis, and omphalocele.

• Anorexia
• Periumbilical pain (early)
• Migration of pain to the right lower quadrant (often within 24 hours of onset of symptoms)
• Vomiting (typically occurring after the onset of pain)
• Fever (commonly occurring 24 to 48 hours after onset of symptoms)
• Right lower quadrant tenderness
• Signs of localized or generalized peritoneal irritation such as:
  • Involuntary muscle guarding with abdominal palpation
  • Positive Rovsing sign (pain in the right lower quadrant with palpation of the left side)
  • Obturator sign (pain on flexion and internal rotation of the right hip, which is seen when the inflamed appendix lies in the pelvis and causes irritation of the obturator internus muscle)
  • Iliopsoas sign (pain on extension of the right hip, which is found in retrocecal appendicitis)
  • Rebound tenderness (elicited by the examiner placing steady pressure with his or her hand in the right lower quadrant for 10 to 15 seconds and then suddenly releasing the pressure; a positive finding consists of increased pain with removal of pressure)

[table class=”table-striped”]
Item,Score (Point)
Anorexia,1
Nausea or vomiting,1
Migration of pain,1
Fever >38°C (100.5°F),1
Pain with cough\, percussion or hopping,2
Right lower quadrant tenderness,2
White blood cell count >10\,000 cells/microL,1
Neutrophils plus band forms >7500 cells/microL,1
Total,10 Points
[/table]

C: Centigrade; F: Fahrenheit.

● A PAS ≤2 or 3 suggests a low risk for appendicitis. Children with a PAS score in this range may be discharged home as long as their caretakers understand that persistent pain or additional symptoms warrant repeat evaluation.
● A PAS ≥7 or 8 indicates a high risk for appendicitis. Children with a PAS score in this range warrant surgical consultation or urgent imaging depending upon local guidelines. It is unclear if the PAS alone can be used to determine the need for appendectomy, because the number of patients with high scores who do not have appendicitis varies widely.

● A PAS of 3 to 6 or 7 is indeterminate for appendicitis. The best approach is not clear. Options include surgical consultation, diagnostic imaging, serial abdominal examinations while being observed in the hospital, or a combination of these approaches depending upon local resources.

The frequency of appendicitis in several studies varies by PAS as follows:
●PAS ≤2 to 3 – 0 to 2 percent
●PAS 3 to 6 – 8 to 48 percent
●PAS ≥7 – 78 to 96 percent

1) Recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE).
2) Provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder.
3) Provides management recommendations, or key action statements, for lower-risk infants.

In the absence of identifiable risk factors, laboratory studies, imaging studies, and other diagnostic procedures are unlikely to be useful or necessary in infants considered “low risk”.

The ALTE literature supports that infants presenting with a lower-risk BRUE do not have an increased rate of cardiovascular or other events during admission and hospitalization may not be required, but close follow-up is recommended.

[table]
Age,Symptom,Treatment
.< 2 yr [attr rowspan=2],GCS = 14 or signs of altered mental status, CT Head
GCS = 15 but “not acting like self”
History of LOC > 5 sec
Scalp hematoma
Severe mechanism of injury, Observer vs Head CT
>2 yr [attr rowspan=”2″],GCS=14 or AMS or basilar skull fracture,CT Head
History of LOC\, vomiting\, headache\, OR severe mechanism of injury,Observe vs Head CT
[/table]

– ABCDE, oxygen, monitors
– IV access, glucose check
– Brief H&P
– Initial Labs: CBC, CMP, Mg, Phos, HCG, Tox, Med levels

– IF IV ACCESS OBTAINED: Lorazepam (Ativan) 0.1mg/kg IV (max 4mg)
– IF NO IV ACCESS: Midazolam (Versed) 0.3mg/kg Buccal/IM/IN (max 10mg)
or Diazepam (Valium) 0.5mg/kg Rectal (max 20mg)
– second dose of Lorazepam 0.1mg/kg IV (max 4mg)

**SECOND MEDICATION:
-Levetiracetam (Keppra) 50mg/kg IV (max 2500mg)
or Fosphenytoin 20mg/kg IV

**THIRD MEDICATION:
-Fosphenytoin 20mg/kg IV
or Valproate 40mg/kg IV
or Levetiracetam 50mg/kg
-Notify PICU and Neurology (4th Medication Recommendations)

**SECOND/THIRD MEDICATION CHOICE:
-If on Levetiracetam <80mg>80mg/kg/day:
2nd med Fosphenytoin, 3rd med Valproate
– If on Phenytoin:
2nd med Levetiracetam, 3rd med Valproate
*If patient received a benzo dose prior to arrival, consider advancing to a 2nd agent after the first lorazepam dose

Source: http://www.chop.edu/clinical-pathway/status-epilepticus-clinical-pathway (accessed 6/27/16)

Goal: To improve pain control and decrease anxiety for our patients in the pediatric emergency department during minor painful or stressful procedures.
Note: This protocol is not meant to address procedural sedation.

For painful procedures:
1. Topical anesthetics should be applied in anticipation of a painful procedure, as appropriate (see below).
2. Systemic (oral, intranasal, or parenteral) analgesia and/or anxiolysis should be provided prior to the painful procedure as appropriate (see below).
3. During the procedure:

• One dedicated person (Registered Nurse (RN), Multifunction Technician, Child Life), if available, to provide procedural support to child: distraction (toys, books, music, bubbles), relaxation (guided imagery, positive touch).
• Encourage parent interaction (if appropriate).

4. After the procedure: Help child regroup, calm, recover.

**Please note that EMLA, LMX-5, LET, Pain Ease, Sweet Ease, and Acetaminophen and Ibuprofen are part of nurses’ advanced treatment protocols, and can be administered by the RN according to the protocol.**

Triage RN, RN Responsibilities:
Prior to an anticipated painful procedure, the RN should place a topical anesthetic: LET prior to laceration repair, EMLA or LMX-5 prior to IV placement if time permits or prior to incision and drainage of an abscess, Pain Ease prior to IV catheter placement or venipuncture if there is not enough time for placement of EMLA or LMX-5.

Physician, Physician Assistant (PA) Responsibilities:
If a topical anesthetic has not already been placed by RN in advanced triage, the physician or PA will consider topical anesthetic prior to a painful procedure: LET prior to laceration repair, EMLA or LMX-5 prior to incision and drainage of an abscess, Pain Ease prior to IV catheter placement or venipuncture if the IV catheter is needed quickly.

[table class=”table-striped table-col-border”]
In anticipation of:,EMLA,LMX-5,LET,Pain Ease
IV placement / venipuncture, ✔ (if time permits)[attr colspan=”2″],,✔
Laceration Repair,,,✔,
Abscess (I & D),✔,✔,,
Lumbar puncture, IM shots, arterial puncture,✔,✔
Abrasion,,,✔,✔
Onset to peak effect:,60 min.,30 – 60 min.,30-60 min.,immed.
Notes,, Use for ≥ 2 yrs of age,,Not Sterile
[/table]

• Behavioral distraction (age-appropriate toys in our age-based procedural pain kits, iPad applications).
• Cognitive strategies (breathing exercises, relaxation training).
• Physical strategies (comfort positioning, heat/cold therapy, massage).

• For mild pain, the RN should administer Acetaminophen 15 mg/kg/dose PO/PR every 4 hours as needed for mild pain or Ibuprofen 10 mg/kg/dose PO every 6 hours as needed for pain.
• Ibuprofen is preferred for musculoskeletal pain.
• Ibuprofen is contraindicated for use in patients < 6 months old.

Note: PA’s are encouraged to follow the same protocol, and the attending physician should be made aware when giving non-topical pharmacologic analgesics.

For moderate to severe pain, the following oral narcotics are available in the Pyxis:
Hydrocodone/Acetaminophen

• 1-0.2 mg/kg/dose of hydrocodone (0.2-0.4 mL/kg of elixir) PO every 4 hours prn moderate to severe pain.
• Available as hydrocodone 7.5mg/ acetaminophen 500mg per 5mL liquid.

Oxycodone

• 05-0.15 mg/kg/dose every 4 hours prn moderate to severe pain.
• Maximum dose: 5mg/dose.
• Available as oxycodone 5mg/5mL oral solution or as a 5 mg immediate release tablet.

Oxycodone-APAP

• For adolescent/adult or >50 kg: One (1) tablet every 4 hours prn moderate to severe pain.
• Available as oxycodone 5mg / acetaminophen 325 mg tablets.

Acetaminophen/codeine

• 5-1 mg/kg/dose of codeine (0.2-0.4 mL/kg of elixir) PO every 4 hours prn moderate to severe pain.
• Available as codeine 12 mg and acetaminophen 120 mg per 5 mL oral solution, or as 30 mg tablets.
• Can also be dosed by age:
  • 3-6 years: 5 mL (12 mg codeine + 120 mg acetaminophen) PO every 6 hours prn moderate to severe pain.
  • 7-12 years: 10 mL (24 mg codeine + 240 mg acetaminophen) PO every 6 hours prn moderate to severe pain.
  • ≥12 years: 15 mL (36 mg codeine + 360 mg acetaminophen) PO every 4 hours prn moderate to severe pain.
• Caution:
  • Life-threatening adverse events and death have occurred in certain children who received codeine after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome. These children had evidence of being “ultra-rapid metabolizers” of substrates of cytochrome P450 2D6, including codeine.
  • If prescribing codeine-containing drugs, use the lowest effective dose for the shortest period of time on an as-needed basis (i.e., not scheduled around the clock).
  • Do not use in children < 3 years old.

Intranasal fentanyl is available as a needleless analgesic that can be delivered via the mucosal atomization device (MAD).

• The starting dose is 1.5 mcg/kg (max 50 mcg).
• Onset of action: 5 minutes. Duration: 30-60 minutes.
• As with all opiates, may need to titrate to effect.
• When ordering intranasal medications, the licensed independent provider must write out the word “intranasal” and cannot abbreviate “IN” to avoid any medication errors.

Examples of painful procedures for which intranasal fentanyl would be appropriate: incision and drainage, wound-dressing/ packing changes, laceration repair, burn debridement/dressings, other minor procedures.

Ketorolac (Toradol)

• 5 mg/kg/dose up to 30 mg IV every 6 hours prn moderate to severe pain.
• Approved for age >2 years old.
• **Do not give if ibuprofen or another NSAID has been given in the last 6 hours**

Morphine

• 1-0.2 mg/kg/dose every 3 hours prn severe pain.
• Adolescent and adult standard starting dose: 2-5 mg/dose every 2-6 hours prn severe pain.
• May give higher doses in patients with developed tolerance from long-term use.
• Titrate to effect.

Hydromorphone

• 01 mg/kg/dose every 4 hours prn severe pain.
• Adolescent and adult dose: 0.3-1 mg/dose every 4-6 hours prn severe pain.
• **Use with caution in infants and young children and do not use in neonates (age < 1 month) due to potential CNS effects.**

**Intent is anxiolysis with maintenance of consciousness. Obtained when a single drug is given at a low to moderate dose. If more than one agent is given (i.e. benzodiazepine and a narcotic) then this is considered moderate sedation, and the procedural sedation guidelines for monitoring should be followed.**

Indications: Consider using an agent for anxiolysis for procedures such as: lumbar puncture, CT scan for young/anxious children, foley catheter placement, foreign body removal, pelvic exam.

Lorazepam (Ativan). Standard dose for anxiolysis: 0.05 mg/kg dose every 4-8 hours PO, maximum dose: 2 mg/dose. Onset of action: 20-30 minutes. Duration of action: 6-8 hrs.

Midazolam (Versed). Standard dose for age >6 months: 0.25-0.5 mg/kg/dose PO x1, maximum dose: 20 mg. Onset of action: 10-30 min; Duration: 1-2 hours.

• Younger patients (6 months – 5 years) may require higher total doses of 1mg/kg/dose, whereas older patients (6-15 yrs) may require only 0.25 mg/kg/dose. Use 0.25 mg/kg/dose for patients with cardiac or respiratory compromise, concurrent CNS depressive drug, or high-risk surgery.
• Use lower doses when given in combination with narcotics.
• Has rapid and predictable onset of action, a short recovery time. Causes amnesia. Results in mild depression of hypoxic ventilatory drive.
• Contraindicated in neonates (age < 1 month).
• Causes respiratory depression, hypotension, and bradycardia.

• The dose of intranasal midazolam is 0.2-0.4mg/kg (max 10 mg) to be given via the mucosal atomization device (MAD).
• Onset of action is 10-15 minutes. Duration is 60 minutes.
• Nasal burning may occur with intranasal midazolam and may last 30 seconds.
• When ordering intranasal medications, the licensed independent provider must write out the word “intranasal” and cannot abbreviate “IN” to avoid any medication errors.

IV Lorazepam (Ativan).

• Dose: 0.05 mg/kg/dose every 4-8 hrs, max dose 2 mg/dose.
• May also be given IM at same dose.
• Onset of action: IV: 1-5 minutes, IM, 30-60 minutes. Duration: 6-8 hrs.

IV Midazolam (Versed)

• Standard dose:
  • For ages 6 months to 5 yrs is 0.05-0.1 mg/kg/dose; initial dose up to 2 mg, with a max total dose of 6 mg. A total dose up to 0.6 mg/kg may be necessary for desired effect.
  • For ages 6-12 yrs, standard dose is 0.025-0.05 mg/kg/dose. Initial dose up to 2 mg, with a max total dose of 10 mg. A total dose up to 0.4 mg/kg may be necessary for desired effect.
  • For adolescents >12 yrs, use adult dose of 0.5-2 mg/dose. Usual total dose 2.5-5 mg; max total dose 10 mg.
• Dose should be given over 2-3 minutes.
• May repeat doses prn in 2-3 minute intervals.

• Cardiorespiratory monitoring should be used when a single IV or intranasal agent (i.e. either a benzodiazepine or a narcotic) is being used.
• If multiple agents are being used (i.e. a benzodiazepine in combination with a narcotic), then this is considered moderate sedation, and the procedural sedation guidelines for monitoring should be followed.

• Administer 0.2-0.5 mL (equivalent to 1-2 drops or 1 pacifier dip) of Sweet Ease by mouth via pacifier.
• May repeat every 30 seconds for a maximum of 2 minutes.
• Indications: procedures such as heel sticks, immunizations, venipuncture, IV line insertion, arterial puncture, insertion of a foley catheter and lumbar puncture in neonates and infants.
• Age: Strongest evidence for infants 0-1 month but some studies show efficacy up to 12 months.

The following set of guidelines applies for children 1 to 23 months of age.

Croup (laryngotracheitis) is a common illness responsible for up to 15 percent of emergency department visits due to respiratory disease in children in the United States.

Croup symptoms usually start like an upper respiratory tract infection, with low-grade fever and coryza followed by a barking cough and various degrees of respiratory distress. In most children, the symptoms subside quickly with resolution of the cough within two days.

Croup is usually caused by viruses, which are detected in up to 80 percent of patients. The most common cause is parainfluenza virus. The table below displays the most common viruses associated with croup, as well as their frequency, severity, and peak time of presentation.

[table class=”table-striped”]
Etiology,Frequency,Severity,Peak Incidence
Parainfluenza virus types 1 to 3 (type 1 is most common),Frequent,Variable (usually severe with type 3 virus),Winter and spring
Enterovirus,Occasional to frequent,Usually mild,Fall
Human bocavirus,Occasional to frequent,Usually mild,Spring and fall
Influenza A and B viruses,Occasional to frequent,Variable (severe with influenza A virus),Winter
Respiratory syncytial virus,Occasional to frequent,Mild to moderate,Winter
Rhinovirus,Occasional to frequent,Usually mild,Fall
Adenovirus,Occasional,Mild to moderate,Winter
[/table]

Equipment, personnel, monitors,
Prepare for difficult airway( video assist, LMA available)

FiO2 via 100% nonreabreather for 2-3 min. Avoid positive pressure bag-valve-mask unless necessary. Consider additional oxygen via nasal cannula during intubation @ 15L/min HFNC or 5L/min.

Adequate volume resuscitation
Vagolytics – Atropine consider for all children < 1 year (laryngoscopy induced bradycardia), children <5 receiving first dose of succinylcholine, older children receiving second dose of succinycholine, patients experiencing bradycardia prior to intubation

ICP Protection -Lidocaine

Analgesia (only if indicated. Can be used for pain and sedation. Not first choice)

Normotensive
Propofol, Etomidate

Hypotensive
Ketamine, Etomidate
Avoid: propofol, versed (↓BP)

Septic Shock
Ketamine.
Caution: Etomidate(adrenal suppression) propofol(↓BP), versed (↓BP)

Status Asthmaticus
Ketamine, etomidate

Status Epilepticus
Propofol, midazolam
Caution: Etomidate

Head Injury/Increased ICP
Etomidate (unless sz), propofol
Caution: Ketamine

Optional step. No proven benefit in preventing gastric aspiration.

None – may consider no neuromuscular blockade in first attempt with anticipated difficult airway
Succinycholine – IDEAL AGENT unless contraindications. Rapid acting and short duration.
Rocuronium – CAUTION w difficult airway or inexperience 2/2 long duration

Clinical and
ETCO2 and
pulsox and
CXR – ideal=2cm above carina

(ETCO2 either capnogrophy or colorimetric CO2 detector; use peds device <15 kg, use adult device> 15kg: not accurate if low pulm blood flow (ie cardiac arrest)

Place NG or OG if not done already

continuous pulsox
continuous capnography
mechanical ventilation
ABG

Sedation (and analgesia if needed)
Propofol infusion, diazepam, fentanyl
If long acting paralytics are needed
Vecuronium, pancuronium Avoid: Succinycholine

[table class=”table-striped”]
Drug,Induction Dose,Time of Onset,Duration ,Comment
Premedications (when needed)[attr colspan=”5″ style=”background:#ccc”]
Atropine, 0.01-0.02mg/kg IV\, max 0.5mg (can be given IM 0.02mg/kg), Within seconds,>30 minutes,Give 1-2 minutes prior to any sedative or paralytic
Lidocaine,1-2mg/kgIV,1-3 minutes,30 minutes,Give 2-5 minutes prior to intubation to pts with ↑ ICP
Sedatives [attr colspan=”5″ style=”background:#ccc”]
Etomidate,0.2-0.4 mg/kg IV,Within seconds,10-15 minutes,Favorable side effect profile; min CV effects. decreases ICP/IOP; may cause myoclonus Avoid in suspected septic shock (adrenal suppression). ↓ seizure threshold in pts with known seizure d/o
Ketamine,1-3mg IV (Can be given IM 2-4mg/kg),1-2 minutes,10-15 minutes,Preserves airway reflexes and resp drive; bronchodilator; + analgesia
Caution in ICP and ocular pressure and HTN (evidence not strong); increases secretions; rare instances of laryngospasm
Propofol,1-2 mg/kg IV bolus (up to 3mg/kg/min in age 6 mos-5 years),Within seconds,10-15 minutes,Neuroprotective effect. Suppresses seizure activity.
Significant myocardial depressant; ↓BP; ↓resp drive; met acidosis;
Consider other options in patients with hx anaphylaxis to egg/soy
Versed,0.1-0.3mg/kg IV max single dose 10mg, 2-5 min,15-30 minutes,Anticonvulsant properties Consider more favorable agents first Respiratory depression\, myocardial depression\, ↓BP. Avoid in hemodynamically unstable patients.
Neuromuscular blockade [attr colspan=”5″ style=”background:#ccc”]
Succinycholine,1-2 mg IV (Can be given IM 4mg/kg), 20-60 seconds, 4-6 minutes, Most widely used 2/2 short brief Duration
Bradycardia especially with repeated doses(extreme cases asystole) –atropine premedication in patients < 5years; transient muscle fasciculations\, which may be important in pts with ↑ICP or ↑ocular pressure\, transient ↑K+ in healthy patients; potentially life-threatening ↑K+ in at-risk patients
Strictly Avoid: pre-existing hyperkalemia\, crush injury\, multsytem trauma\, burns >48hr\, denervating neurologic disorders; skeletal myopathies; malignant hyperthermia
Do not use for maintenance paralysis
Caution: Increased ICP or IOP
Rocuronium, 0.6mg-0.9mg/kg, 30-60 seconds, 30-60 minutes, Long duration = caution with difficult airway or inexperience.
Succinycholine is usually better choice. Rarely ↑HR\, ↑BP
Post Intubation [attr colspan=”5″ style=”background:#666;color:white”]
Sedatives (post intubation) [attr colspan=”5″ style=”background:#ccc”]
Propofol,Continuous sedation
10-240 micrograms/kg/min (0.6 – 15mg/kg/hour),,,Neuroprotective effect. Suppresses seizure activity.
Significant myocardial depressant; ↓BP; ↓resp drive; met acidosis;
Consider other options in patients with hx anaphylaxis to egg/soy
Fentanyl,1-3mcg/kg IV,1-2 minutes,30-40 minutes,May cause chest wall rigidity; may also cause ↑ ICP; may ↓BP. Consider safer more effective options for sedation.
Diazepam, 0.1-0.2 mg/kg max 4mg, 2-3 minutes, 30-90 minutes,
Paralytics (post intubation) [attr colspan=”5″ style=”background:#ccc”]
Vecuronium,0.1-0.3mg/kg IV,2-5 min,30-60 minutes,Primarily used for maintenance paralysis
Pancuronium,0.1mg/kg,1-5min,120-150 min,Primarily used for maintenance paralysis
[/table]

[table class=”table-striped table-col-border”]
Source,Well appearing and Low Risk²,Ill appearing or High Risk³ after initial labs
No Source,Full sepsis workup⁴\, LFTs\, CXR⁵ only if resp sx abx\, consider acyclovir⁶\, admit, Full sepsis workup\, LFTs CXR only if resp sx abx\, plus acyclovir\, admit
Bronchiolitis\, RSV\, Flu\, or other virus positive⁷,Full sepsis workup\, LFTs CXR only if resp sx abx\, consider acyclovir\, admit [attr colspan=”2″]
UTI⁸,Full sepsis workup\, LFTs CXR only if resp sx abx\, consider acyclovir\, admit [attr colspan=”2″]
[/table]

[table class=”table-striped table-col-border”]
Source,Well appearing and Low Risk,Ill appearing or High Risk after initial labs
No Source,Full sepsis workup\, CXR only if resp sx abx\, admit, Full sepsis workup\, +/- LFTS CXR only if resp sx abx\,consider acyclovir\, admit
Bronchiolitis\, RSV\, Flu\, or other virus positive,Full sepsis workup\, +/- LFTS CXR only if resp sx abx\,consider acyclovir\, admit[attr colspan=”2″]
UTI,Full sepsis workup\, CXR only if resp sx abx\, admit [attr colspan=”2″]
[/table]

[table class=”table-striped table-col-border”]
Source,Well appearing and Low Risk,Ill appearing or High Risk after initial labs
No Source, Urine⁴\, blood⁴\,
If Low risk\, no abx\, discharge and ensure follow-up
Admit if SBI – and refer to High Risk section, Full sepsis workup\, admit\, abx
Bronchiolitis\, RSV\, Flu\, or other virus positive, Urine\, blood\, If Low risk\, no CSF\, no abx\, discharge and ensure follow-up.
Admit if SBI– and refer to High Risk section
Or admit if needed for bronchiolitis with no abx, Full sepsis workup\, admit\, abx
UTI,Full sepsis workup\, admit\, abx[attr colspan=”2″]
[/table]

[table class=”table-striped table-col-border”]
Source,Well appearing and Low Risk,Ill appearing or High Risk after initial labs
No Source, Consider urine (see risk factors⁹), Treat per established clinical guidelines
Bronchiolitis\, RSV\, Flu\, or other virus positive, Consider urine (see risk factors), Treat per established clinical guidelines
UTI8,Consider initial IV treatment:
Infants < 6 months of age
Moderate / Severe Dehydration
Vomiting\, inability to tolerate oral fluids\, antibiotics
Concern for follow-up[attr colspan=”2″]
[/table]

[table]
0-21 days,Ampicillin/Cefotaxime (alt: Amp/Gent) +/-Acyclovir, GBS\, enterococcus\, GNRs\, HSV\, Listeria
22-28 days,Ampicillin/Cefotaxime (alt: Amp/Gent), GBS\, enterococcus\, GNRs\, Listeria
29-56 days,Cefotaxime (alt: Ceftriaxone ),Late GBS\, Pneumococcus

[/table]

Consider Vancomycin ((MRSA, resistant pneumococcus) if

• Ill Appearing
• Gram positive organism on Gram stain of blood or CSF
• CSF WBC > 8 and abnormal glucose or protein

Well appearing infants with no clinical concern for HSV and Blood, Urine, CSF Cultures NEGATIVE and
UA NORMAL

Discharge after 24 hours of negative cultures if: CSF Profile NORMAL, CSF Gram Stain NEGATIVE HSV CSF PCR NEGATIVE, if sent or Enterovirus Meningitis positive

Discharge after 36 hours of negative cultures if:
Uninterpretable LP/Bloody tap
PCR studies pending or not sent

For Ill appearing patients, other concerns, or other positive results, follow established guidelines

• Ill appearing or toxic at any age
• At risk medical conditions (oncology, sickle cell, etc)
• Incomplete Immunizations

In general well appearing infants without risk factors are at low risk for bacteremia

¹Fever – documented / history of rectal / axillary temperature ≥ 38°C (100.4) in the ED, at home, or referring MD’s office

² Low risk Criteria
29-56 days old
Full-term (≥37 weeks gestation)
No prolonged NICU stay
No chronic medical problems
No systemic antibiotics within 72 hours
Well-appearing and easily consolable
No infections on exam
Blood:
WBC ≥ 5,000 and ≤ 15,000
Band to neutrophil ratio < 0.2
(Bands/bands + neutrophils)
Urine:
WBC < 10 /HPF
Negative Gram stain
Chest x-ray (if obtained):
No infiltrate

³High Risk
Do not meet the low risk criteria
If data is incomplete (urine or blood could not be obtained)

⁴ Labs
Blood – CBC with diff. Blood culture. LFTs if < 21 days or 0-28 days or up to 28 days if indicated for HSV suspicion
Urine –Cath UA w/ micro (at MFSMC= urinalysis complete) plus Urine culture
CSF – culture and gram stain (tube 1), protein and glucose (tube 2), Cell count and diff (tube 3), Viral studies or save (HSV PCR 0-28 days, Enterovirus PCRbetween June and November or CSF pleocytosis)
Respiratory Viral Panel for all admitted 0-56 day old patients year round
Full Sepsis workup = all of the above.
Blood culture bottles are placed in the main incubator at MFSMC at the time they are logged in by the main lab into medconnect. The machine reads every 10 minutes. A negative culture is real time

⁵ Consider CXR
Concern for bacterial pneumonia
Suspected HSV infection with respiratory symptoms
Suspected Chlamydia or Pertussis

⁶ When to consider HSV
Consider empiric HSV testing and treatment
Infants Option A – ALL < 21 days
Option B – < 21 days plus any of the following.
Mom had active primary HSV at delivery
Skin vesicles
Seizures, abnormal neurologis status
Elevated Liver Enzymes
CSF Pleocytosis – (especially if also CSF RBCs)
Infants 22—40 days and one of:
Ill Appearing
Abnormal neurologic status, seizures
Vesicular rash
Hepatitis
Mom known to have primary HSV infection at delivery
Infants 22-28 days
Additional:
For concern or dx of HSV, additional w/u includes
SEM (Skin, Eye, Mouth)
Add swabs from conjuctiva, buccal mucosa, rectum and any vesicular lesions
Disseminated Disease
Add BMP, LFTs, PT/PTT, type and screen, chest x-ray

⁷ Bronchiolitis
29-60 days with clinical bronchiolitis (with or without RSV) are at significantly lower risk for bacteremia and meningitis, but 3-5% rate of UTI

⁸ UTI
29- 60 days -positive bacteremia risk. Rare meningitis (usually ill appearing)

⁹ UTI risk factors ages 2-24 months (risk increases w number of risk factors
-Girls– non-black, T >39 C, Fever > 2 days, no other source, < 12 months, prior UTI -Male – Uncircumcised, non –black, T >39 C, Fever > 24 hours, no source, < 6 months, prior UTI

¹⁰ Byington et al.
Admitted culture negative infants at LR for SBI or at HR who test positive for a viral pathogen are eligible for dc at 24 hours. All other culture-negative infants are eligible for the same at 36 hours. Result: decr LOS, decr ABX use, decr cost with no change in readmission rate and no cases of missed SBI after hospital discharge.