Pediatric emergency medicine trisk 104

ischemic stroke due to vertebral artery dissection is traumatic in half of cases and often presents with ataxia, headache, vomiting, cranial nerve deficits, and hemiparesis Rarely, cerebral sinovenous thrombosis can manifest with isolated cerebellar venous infarction On rare occasions, ataxia can be part of the initial clinical manifestations of opsoclonus-myoclonus syndrome, often associated with neuroblastoma FIGURE 15.1 Acute ataxia diagnostic pathway MANAGEMENT CONSIDERATIONS Posterior fossa masses and cerebellar edema due to stroke or cerebellitis may manifest with signs of ICP, often associated with ataxia, altered mental status, and other neurologic signs In these instances, consideration of the increased ICP must be foremost Deferring LP in a child with concern for increased ICP is imperative to prevent herniation and its potential morbidity and mortality If there is any concern clinically for a mass, hemorrhage, or other space occupying CNS lesion, imaging should precede LP If a child is found to have increased ICP, treatment with hypertonic saline or mannitol and other acute neurologic precautions should be undertaken (see Chapter 97 Neurologic Emergencies ) Consultation with neurology and/or neurosurgery may be warranted Treatment for GBS or its variants is mostly supportive, and in up to 10% to 20% of cases may require ventilator support Children with reduced vital capacity (≤20 mL/kg) generally progress to respiratory failure This needs to be evaluated early in the emergency department through pulmonary function testing (in cooperative children) and close clinical monitoring for fatigue and other clinical signs of impending failure Most children will recover with immunomodulatory therapy (intravenous [IV] immunoglobin, or plasma exchange [PLEX] in more severe cases), however, recovery times vary and can take months to a year in some patients Definitive treatment will require collaboration with critical care and neurology Randomized trials for the treatment of ADEM are lacking, but general consensus indicates that high-dose IV methylprednisolone (30 mg per kg per day, maximum 1,000 mg per day) should be initiated early and given for days, usually followed by an oral taper over to weeks IV Ig (2 g per kg over to days) is often considered as a second-line agent in cases poorly responsive to steroids PLEX is reserved for refractory and particularly severe cases Prompt initiation of treatment usually results in excellent outcome, with full recovery in the majority of cases within days or weeks Suggested Readings and Key References Caffarelli M, Kimia AA, Torres AR Acute ataxia in children: a review of the differential diagnosis and evaluation in the emergency department Pediatr Neurol 2016;65:14–30 Thakkar K, Maricich SM, Alper G Acute ataxia in childhood: 11-year experience at a major pediatric neurology referral center J Child Neurol 2016;31(9):1156– 1160 CHAPTER 16 ■ BREAST LESIONS JONATHAN ORSBORN, RAKESH D MISTRY INTRODUCTION Most breast lesions in children and adolescents are benign and self-limited, and patients and their families will generally benefit from reassurance that neoplastic diseases of the breast are extremely rare in all pediatric age groups This chapter focuses on the diagnostic approach to the variety of breast lesions, and discusses the management of common etiologies that pediatric emergency physicians are likely to encounter DIFFERENTIAL DIAGNOSIS Breast lesions in children are typically divided into the following categories: infections, benign cysts or masses, malignant masses, abnormal nipple secretions, lesions associated with pregnancy and lactation, and miscellaneous causes, including both anatomic and physiologic entities ( Table 16.1 ) A complete history and physical examination narrow the differential diagnosis and usually provides sufficient information to guide management With few exceptions, most breast lesions require little diagnostic testing in the emergency department (ED) and typically can be managed with supportive care and occasionally, outpatient referral to an appropriate specialist The commonly encountered disorders ( Table 16.2 ) are almost always benign, but consideration must be given to potentially life-threatening processes ( Table 16.3 ) Breast Infections Infection in the breast may take the form of a mastitis, cellulitis, or abscess The incidence of breast infection occurs bimodally, with the early peak in the neonatal age group and the later, more common, peak in postpubertal females Neonatal breast infection (mastitis neonatorum) most frequently presents in the first few weeks of life, commonly resulting from infection of the already enlarged breast bud produced by intrauterine maternal estrogen stimulation As a result, mastitis neonatorum is more likely to occur in full-term, as opposed to premature infants The most common infecting organism is Staphylococcus aureus in >75% of cases, although gram-negative enterics, anaerobes, group A or group B streptococci may be isolated More recent studies have demonstrated an increased incidence of community-associated methicillin-resistant S aureus (CA-MRSA) The clinical presentation of neonatal breast infection is characterized by local signs of inflammation, such as edema, erythema, and warmth Fever is present in just 22% to 38% of cases Traditionally, the evaluation of even well-appearing infants with neonatal mastitis included blood, urine, and potentially CSF cultures; however, there is scant evidence supporting this degree of diagnostic workup There is growing evidence that demonstrates little correlation between blood, urine, or CSF cultures and causative organisms of mastitis or breast abscess Therefore, for well-appearing infants with localized mastitis, one may consider culture of purulent discharge, if present, and forgoing further evaluation for invasive infection Empiric antibiotic coverage for S aureus including CAMRSA active agents should be initiated Infants managed as outpatients require strict return precautions and close follow-up with PCP Although uncommon in neonatal mastitis, infants with signs of systemic illness have potential for invasive infections, including bacteremia, osteomyelitis, and pneumonia Therefore, a complete sepsis evaluation is indicated For hospitalized infants, initial ED therapy consists of empiric broad-spectrum intravenous antibiotic for S aureus , streptococcal organisms, and gram-negative enterics These antibiotic regimens include vancomycin plus a third-generation cephalosporins for gram-negative coverage Subsequent antibiotic therapy is guided by culture and sensitivity results If there is concern for breast abscess, incision and drainage should be done by a surgeon to minimize harm to developing breast tissue Breast infection in postpubertal females is classified as lactational or nonlactational Nonlactational mastitis/breast abscess is rare but can develop in the central or peripheral regions of the breast from introduction of skin bacteria into the ductal system Infections in the central region of breast, proximal to the nipple, are more likely in the setting of obesity, nipple piercings, or poor hygiene, while peripheral mastitis is more likely to be associated with trauma or systemic illness Other predisposing factors for mastitis include previous radiation therapy, foreign body, sebaceous cysts, hidradenitis suppurativa, and trauma to the periareolar area Signs and symptoms of infection include local erythema, warmth, pain, and tenderness and purulent nipple discharge Systemic signs, including fever, are less commonly present Organisms commonly implicated in this age group include both methicillin-sensitive and resistant S aureus, streptococcal species, Enterococcus, Pseudomonas species, and anaerobic organisms such as Bacteroides species Recommended treatment for mastitis in the postpubertal female includes initiation of anti-staphylococcal oral antibiotic therapy and warm compresses Instruct patients to keep the area clean and dry, to wear a clean cotton bra, and to ... rare in all pediatric age groups This chapter focuses on the diagnostic approach to the variety of breast lesions, and discusses the management of common etiologies that pediatric emergency physicians... diagnosis and evaluation in the emergency department Pediatr Neurol 2016;65:14–30 Thakkar K, Maricich SM, Alper G Acute ataxia in childhood: 11-year experience at a major pediatric neurology referral...early in the emergency department through pulmonary function testing (in cooperative children) and close clinical