Rosen & Barkin's 5-Minute Emergency Medicine Consult (556 page)

• General (in all ages):
  
  • Cough
    
  • Rales
    
  • Fever
    
  • Hypoxia
    
  • Tachycardia
    
  • Tachypnea, retractions, grunting
    
  • Rash (up to 10% of cases); usually maculopapular
    
  • Nonspecific symptoms of toxicity
    
  • Pulmonary exam:
    
    • Decreased breath sounds, ventilation
      
    • Dullness to percussion
      
    • Wheezing, ronchi, rales
      
• Infants <6 mo:
  
  • Altered behavior: Listless, irritable
    
  • Apnea (esp. RSV in premature infants)
    
  • Conjunctivitis (
    Chlamydia
    <1 mo old)
    
  • Cyanosis
    
  • Grunting
    
  • Poor feeding
    
  • Temperature instability (hypothermia/hyperthermia)
    
  • Vomiting, often with coughing
    
  • Cough
    
  • Nasal congestion
    
  • Nasal flaring
    
  • Wheezing
    
  • Staccato cough (
    Chlamydia
    )
    
• Children >5 yr:
  
  • Pleuritic chest pain
    
  • Productive cough
    
  • Rigors, chills
    

• Immunization history
  
• Past medical history include immune status
  
• Exposures
  
• Progression of signs and symptoms
  

• Pulmonary exam may be helpful, particularly in children >5 yr.
  
• Peripheral and central cyanosis should be assessed.
  
• Evidence of respiratory compromise, distress, failure
  

• Pulse oximetry
  
• Chest radiograph:
  
  • Gold standard for diagnosis
    
  • Should be ordered for patients with signs of lower respiratory tract infection and patients <36 mo old with marked leukocytosis or neutrophilia (WBC >15,000 or absolute neutrophil count [ANC] >9,000).
    
  • Much overlap between viral and bacterial findings
    
  • Viral and
    M. pneumoniae
    tend to show interstitial infiltrates, often perihilar and peribronchial.
    
  • Bacterial pneumonias may show focal lobar consolidation, focal alveolar infiltrates, and possibly effusion or pneumatocele.
    
  • Round pneumonia pathognomonic of
    S. pneumonia
    
  • Lateral decubitus films may aid in demonstrating effusion.
    

• CBC with differential:
  
  • Patients with bacteremia tend to have leukocytosis with left shift.
    
  • Sensitivity and specificity are poor.
    
  • Patients with WBC ≥20,000 or ANC >9,000 are at increased risk of pneumococcal bacteremia.
    
  • B. pertussis
    usually has elevated WBC with lymphocytosis.
    
• Blood culture:
  
  • Low yield (<10–20%)
    
  • Recommended in children <36 mo
    
  • Probably worthwhile in toxic patients requiring hospitalization
    
• Arterial blood gas may be useful in determining degree of respiratory insufficiency in critically ill patients.
  
• Electrolytes to exclude syndrome of inappropriate antidiuretic hormone secretion and in hypotensive children
  
• Sputum for Gram stain and culture may be obtained in older children with suspected bacterial infection.
  
• Mycoplasma
  IgM or cold agglutinin titers:
  
  • Useful if suspecting this organism
    
  • More likely positive with severe illness
    
• Nasopharyngeal washes for direct fluorescent antibody and culture:
  
  • Identify RSV,
    C. trachomatis,
    and
    B. pertussis
    infections
    

Chest radiographs are still the imaging modality of choice:

• Posteroanterior and lateral films should be obtained whenever possible.
  
• CT provides additional detail and better identification of underlying lung pathology but adds little as an initial testing modality.
  

Pleural fluid (if present) for culture, Gram stain, protein, glucose, and cell counts

• Reactive airway disease (asthma, bronchiolitis [age <2 yr])
  
• Aspiration:
  
  • Gastroesophageal reflux
    
  • Vascular ring
    
  • H-type tracheoesophageal fistula
    
  • Foreign body
    
  • Hydrocarbon
    
• Congestive heart failure
  
• Congenital:
  
  • Cystic fibrosis
    
  • Sequestered lobe
    
  • Congenital lobe absence
    
  • Hemangioma
    
• Neoplasm
  

TREATMENT

• Pulse oximetry
  
• Administer high-flow oxygen for respiratory distress.
  
• IV fluids (0.9% normal saline [NS] 20 mL/kg initial bolus) for volume depletion, hypotension
  
• Support and intubation for respiratory failure
  

• If moderately or severely ill:
  
  • Secure airway, as appropriate; intubate for clinical respiratory failure. Children with severe sepsis or septic shock benefit from aggressive airway management.
    
  • High-flow oxygen
    
  • IV hydration (0.9% NS 20 mL/kg initial bolus) and resuscitation if in shock or hypovolemia
    
• Monitor
  
• Ongoing pulse oximetry
  
• Arterial blood gas if inadequate ventilation
  
• Check bedside glucose in severely ill-appearing infants and toddlers:
  
  • If hypoglycemic, administer glucose D25 at 2 mL/kg IV for toddlers or D10 at 5 mL/kg IV for neonates.
    

• Continue pre-hospital and initial stabilization therapy.
  
• Early antibiotic therapy should be broad enough to address local resistance patterns in your area.
  
• Often have concurrent reactive airway disease that needs specific treatment with bronchodilator (albuterol or levalbuterol)
  
• Perform thoracentesis if pleural effusion is compromising respiratory function or for diagnostic tests.
  

• Empiric therapy with oral antibiotics for most well-appearing children ≥6 mo:
  
  • Infants <2 mo:
    
    • Outpatient treatment generally not recommended unless child has no respiratory distress or associated conditions or issues.
      
  • Children 3 mo–5 yr:
    
    • Amoxicillin
      
    • Amoxicillin—clavulanate
      
    • Trimethoprim—sulfamethoxazole
      
    • Erythromycin—sulfisoxazole
      
    • Macrolide (azithromycin or clarithromycin)
      
  • Children 5–18 yr:
    
    • Macrolide (azithromycin or clarithromycin)
      
• Initiate IV antibiotic therapy for moderate to severely ill children who require admission:
  
  • Neonate:
    
    • Ampicillin, and cefotaxime or gentamicin
      
    • Azithromycin for suspected
      C. trachomatis
      or
      B. pertussis
      pneumonia
      
  • Infants 1–2 mo:
    
    • Ampicillin and cefotaxime
      
    • Azithromycin or erythromycin for suspected
      C. trachomatis
      or
      B. pertussis
      
  • Children ≥3 mo:
    
    • Cefotaxime, cefuroxime, or ceftriaxone
      
    • Vancomycin for suspected or confirmed penicillin-resistant
      S. pneumoniae
      
    • Macrolide (i.e., azithromycin) for suspected
      M. pneumoniae
      
    • Clindamycin if group A strep suspected in patient with severe disease
      
• Unusual organisms require specific therapy in coordination with infectious disease consultation.
  
• Albuterol (0.5% solution or 5 mg/mL): Nebulizer 0.015 mg (0.03 mL)/kg per dose up to 5 mg per dose q10–20min as needed; metered dose inhaler (with spacer; 90 mg per puff) 2 puffs q10–20min up to total of 10 puffs
  
• Amoxicillin: 80 mg/kg/24 h q12h PO
  
• Amoxicillin–clavulanate: 30 mg/kg/24 h q12h PO
  
• Ampicillin: 100–150 mg/kg/24 h q6h IV
  
• Azithromycin: 10 mg/kg/24 h daily for 1 day, then 5 mg/kg/24 h daily for 4 days
  
• Cefotaxime: 50–75 mg/kg/24 h q8h IV, max. 2 g q8h
  
• Ceftriaxone: 100 mg/kg/24 h q12–24 h IV, max. 2 g q12h
  
• Cefuroxime: 100 mg/kg/24 h q8h IV, max. 2 g q8h
  
• Clarithromycin: 15 mg/kg/24 h q12h PO, max. 500 g q12h
  
• Clindamycin 30–40 mg/kg/24 h q6–8h IV
  
• Erythromycin–sulfisoxazole: 40 mg/kg/24 h as erythromycin q8h PO, max. 2 g/d
  
• Gentamicin: 5–7.5 mg/kg/24 h q8–12h IV
  
• Trimethoprim–sulfamethoxazole: 8–10 mg/kg/24 h as TMP q12h PO
  
• Vancomycin: 10–15 mg/kg/24 h q8–12h IV; max. 1,000 mg
  

FOLLOW-UP

• Toxic appearance
  
• Respiratory distress or failure
  
• Dehydration/vomiting
  
• Apnea
  
• Infants <2 mo
  
• Infants <6 mo with lobar pneumonia
  
• Hypoxia (O
  ₂
  saturation <92% on room air [sea level])
  
• Pleural effusion
  
• Poor response to outpatient oral therapy
  
• Immunocompromised children
  
• Concern about noncompliant parents
  

• Most cases are mild and can be discharged home if no evidence of hypoxia, significant work-of-breathing, dehydration, vomiting, or noncompliance.
  
• Ensured follow-up within 1–2 days
  

Respiratory failure, effusion, toxicity

Clinical resolution should be ensured through follow-up.

• Early, aggressive airway management for patients with severe sepsis and septic shock
  
• Delays to antibiotic therapy should be avoided.
  
• Discharged patients should have clear evidence of good support, follow-up, and lack of toxicity.
  
• Local patterns of drug resistance should be known and empiric therapy should take these resistance patterns into consideration.
  

• Cevey-Macherel M, Galetto-Lacour A, Gervaix A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines.
  Eur J Pediatr
  . 2009;168(12):1429–1436.
  
• Kronman MP, Hersh AL, Feng R, et al: Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007.
  Pediatrics
  2011;127:411–418.
  
• Michelow IC, Olsen K, Loranzo J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.
  Pediatrics
  . 2004;113(4):701–707.
  
• Murphy CG, van de Pol AC, Harper MB, et al. Clinical predictors of occult pneumonia in the febrile child.
  Acad Emerg Med
  . 2007;14(3):243–249.
  
• Shah SS, Dugan MH, Bell LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia.
  Pediatr Infect Dis J.
  2011;30:475–479.