2/1/2013 Case #1: Polka dot Jane Pale, Bleeding, and Febrile: Heme-Onc Emergencies in Kids 3 yo spots on her legs x 1 week, gum bleeding and epistaxis Recent viral illness Judith R. Klein, MD, FACEP PE: vs nl; bruises, petechiae, Assistant Professor of Emergency Medicine no splenomegaly UCSF-SFGH Department of Emergency Medicine Labs: Plts 20K, other cell lines normal What happened to the Bleeding in kids platelets? Let’s talk bleeding: -Deep (muscles/joints): factor prob DESTRUCTION PRODUCTION -Mucocutaneous (gums, nose): platelet prob Hx : meds, recent infxn, family hx ITP Bone marrow PE : VS, ill?, splenomegaly ITP problem: ITP Labs : CBC/smear, PT/PTT, fibrinogen, -infiltration Medications (heparin) d-dimer, lytes -aplasia HUS Rare in kids <150K platelets abnormal DIC Case #2: Pale, bleeding and Immune thrombocytopenic purpura: ITP feverish Age 2-4 yrs; 80% resolve in 6 mos 2 yo with pallor and low grade Sudden bleeding/bruising post viral fever x 10 days. Blood on toothbrush x 1 month Treatment: admit/heme consult! PE: P120, BP 90/50, T 38.0 >30K/mild bleeding : observe blood at gums, pale, diffuse LAN, spleen tip palpable <20K or significant bleeding : -IVIG, steroids (BM biopsy) Labs: Hb 6, Plt 20, WBC 120K; -ICH or life-threatening hemorrhage? blasts on smear platelet transfusion/splenectomy 1
2/1/2013 Hyperleukocytosis Leukemia in the ED Most common CA in kids: 75% ALL WBC>100,000-->hyperviscosity -->sludging-->CNS/lungs most affected Differential: -Virus (EBV/parvovirus) Tx: oncology ASAP for leukopheresis -Autoimmune (HUS) and/or immediate chemo -BM failure (aplastic anemia) Beware transfusions-->can worsen Workup: smear, lytes, Ca, viscosity problem PO4, uric acid, T/S, PT/PTT, BCx/Abx if T>38.3, CXR, EKG More bad news..... Case #3: He looks like Shrek Ca 6.5, PO4 7 , uric acid 10 15 yo no 1 o care large LN in and K 7.5!! K+ neck bigger x 2 weeks; face PO 4 Tumor lysis syndrome --> fatter; dry cough at night arrhythmias/renal failure Uric Acid PE : VS wnl, nl resp status, 5 cm neck LN firm, painless; facial Treatment: plethora -Hydration -Hyperkalemia/hypocalcemia tx Labs : mild anemia, nl lytes/ -Hyperuricemia uric acid, CXR mediastinal *Alkalinization? Allopurinol? Rasburicase? mass/tracheal deviation -Hemodialysis Isolated lymph node Lymphoma in kids enlargement #1: Lymphadenitis- try antibiotics, consider MRSA #3 cause of CA in kids after Hx of cat scratch? TB? Monospot? leukemia and brain CA. Recheck 1 week: bigger, firm, fluctuant, diffuse-->more Hodgkins>>NHL aggressive work-up: US, CXR, CBC, FNA biopsy Very curable, but initial presentation may be life- threatening 2
2/1/2013 Mediastinal masses: Case #4: Hot Tot disasters waiting to happen.... 3 yo with AML with T101 x 2 days; rhinorrhea/mild cough; last chemo 5 days; Imm UTD PE: T 100 P120 RR 30 O 2 96%; mod mucositis, nl CRT, CVL site #1 problem: airway clean SVC syndrome Labs: WBC 1.8, ANC 350, PLT 40 Management: -AVOID SEDATION -Oncologist for further imaging (CT/MR) and emergent chemo/radiation/steroids Admit them all? Fever/neutropenia in kids Definition: Not all fever/neutropenia alike -T>101 or >100.4 x 2; oral or ax -ANC<500mm 3 Mortality: 80% to 1-3% Many causes of neutropenia Risks of admitting: -nosocomial infection Bugs involved: -kids/parents hate it -10-30% ID’d: rest idiopathic -$$$ -90% bacterial (skin, resp, GI) -Viral (HSV, VZV, RSV, flu): less common Risks of not admitting: -Fungal: prolonged neutropenia/steroids -overwhelming sepsis Risk profile The Science? Higher risk: -<1 year old Gupta, 2009: -Lower/longer neutropenia -123 episodes: 88 pts 2-15 years -Focal infection -Criteria: no focal infxn or sepsis, no -Severe mucositis other reasons for inpt, brief -VS abnl/shock/organ failure low ANC, no hx fungal infxn -Indwelling device: CVL -CRP>90, PLT<50 Augmentin/oflox po vs. CTX/amikacin IV Lower risk: No difference in fever resolution, -T<39; no focal infection no mortality -no sx except fever SMALL study Gupta, Ped Hemat Oncol 2009. 3
2/1/2013 More science on fever and Fever/neutropenia bottom line neutropenia Agyeman: Predicting bacteremia Admit unless pediatric oncologist directs 423 episodes fever/16% bacteremia otherwise or patient in clinical trial 100% sensitivity if any one: Hb>9, Plt<50, shaking chills, other other reason for admit Derivation only; needs validation Agyeman, Ped Infec Dis J 2011 Fever/neutropenia: Case #5: My bones ache management Workup: 15 yo with SCD/asthma -All: CBC, BCx, UA,*CXR c/o leg, back, chest pain. -Sx dependent: chem 7, nasal wash Mild cough. (rsv, flu), throat cx, skin swabs PE: T 38.2, RR 18, O 2 96% Treatment : chest: few wheezes; legs/back - Neutropenic precautions! hypesthetic -Abx for G+/G-/pseudomonas: ceftazidime, cefipime, imipenem, zosyn Labs: Hb baseline, retics>10% -Add vancomycin if CVL CXR.... -G-CSF: no evidence of mortality benefit -Hydrocortisone: only if on steroids or pituitary abnl Pain crisis Pain crisis management Duration: 3-7 days PO or IVF to euvolemia Most common complication of SCD -3x more admit 25-29 yrs vs. <4 yrs Pain meds: NSAIDs, opiates, PCA D/C: oral pain meds RTC not prn Low back>long bones> abd/chest Steroids?: NO, shorter episode but PE: 20% fever, usually normal rebound pain common Red flags : HA, CP, abd pain, Nitric oxide? No benefit in 150 pt RCT* jaundice, vomiting, neuro sx, focal bone ttp/edema, fever Redding-Lallinger, Curr Prob Ped Adolesc Health Care 2006 *Gladwin , JAMA 2011 . 4
2/1/2013 Acute chest: management What about that CXR? Acute chest definition: new Pain management infiltrate + CP, T, O 2 , RR, cough, or wheezing Oxygen/incentive spirometry* Pneumonia vs acute chest? Abx: cephalosporin (CTX)+macrolide Pathophysiology/risks: Bronchodilators prn -pain crisis (necrotic BM)-->fat embolism pRBC: if deteriorating; to Hb 10 only -sedation/splinting-->hypoventilation -asthma (RR 6-8)* Future: NO? steroids? *Knight-Madden, Thorax 2005. *Bellet, NEJM 1995. Bacterial infection and Case #9: Hot sickler SCD 5 mo old SCD and T 39 x 2 days. Most common cause of death No other sx; no sick contacts. Nl po and UOP. Pathophysiology: functional asplenia Immuniz-UTD; on PCN Bugs: Pneumococcus , Salmonella, Staph , PE: T 39.1, RR 30, O 2 98% E. coli , Strep. appears well, nl CRT, no resp distress. No bone ttp. No rash. Highest risk: <12 mos up to 3 years SCD: 300-600x risk of Pneumococcus (IPD) PCN prophylaxis: reduce IPD by 84% Impact of vaccinations Work-up: fever and SCD Vaccines: H.flu and PCV-13 Fever: T>38 if <6 mo; >38.5 if >6 mo McCavit 2011: 3x risk of Hx: Immuniz? Pcn? Focal sx? hospitalizations post PCV-7 Workup: CBC, retics, BCx; Adamkiewicz 2008: 68% risk of +/- : UA/UCx, CXR, LP IPD post PCV-7. Abx: ceftriaxone for all; +/- vanco McCavit, Ped Blood Ca 2011 Adamkiewicz, Pediatrics 2008 5
2/1/2013 In a nutshell Fever/SCD: disposition? Bruising and low platelets? Think ITP but admit them to rule Admit: out bad things -all <6 mos - >6 mos if toxic, other SCD Not just platelets low? Bone marrow problem/cancer complic, T>40, WBC <5 or >30, Hb<5 Mediastinal mass? Beware of sedation Discharge: Admit febrile neutropenic kids. Period. -return 24 hrs for re-check -repeat abx until Cx (-) x 48 hours and afebrile SCD and pain? May be just a pain crisis, but look at end -reliable pt organs SCD and fever? It may not be a virus! 6
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