# Clinical Cases: Pediatric Emergencies

## Case 1: Bronchiolitis - The Wheezing Infant

### Patient Demographics
- **Age:** 4 months
- **Sex:** Female
- **Accompanied by:** Mother

### Chief Complaint
"She's breathing really fast and won't eat."

### History of Present Illness
Mother brings her 4-month-old daughter for evaluation of respiratory distress. Illness began 3 days ago with rhinorrhea and mild cough. Over the past 24 hours, infant has developed increased work of breathing, wheezing audible without stethoscope, and poor feeding (taking only 50% of usual bottle volumes). Mom reports fewer wet diapers today. Older sibling (3 years) had a "cold" last week.

### Initial Assessment

**Pediatric Assessment Triangle (PAT):**
- **Appearance:** Alert but tired-appearing, consolable
- **Work of Breathing:** Increased - subcostal retractions, nasal flaring
- **Circulation:** Slightly pale, cap refill 2 seconds

**ESI Level:** 2 - Respiratory distress in young infant

**Vital Signs:**
- Heart rate: 168 bpm
- Respiratory rate: 68 breaths/min
- SpO2: 89% on room air
- Temperature: 38.2C (100.8F) rectal
- Weight: 5.8 kg (25th percentile)
- Blood pressure: Not initially obtained

### Primary Survey (Pediatric Approach)

**Airway:**
- Patent, no stridor
- Copious nasal secretions

**Breathing:**
- Tachypneic (RR 68, normal for age <60)
- Subcostal and intercostal retractions
- Nasal flaring present
- Diffuse expiratory wheezes and crackles bilaterally
- Prolonged expiratory phase

**Circulation:**
- Tachycardic (appropriate for age and fever)
- Capillary refill 2 seconds
- Slightly mottled extremities

**Disability:**
- Alert, tracking, appropriate interaction
- Normal fontanelle (soft, flat)
- Normal tone

**Exposure:**
- No rashes
- No signs of abuse/neglect

### Respiratory Distress Assessment

**Severity Indicators:**
| Finding | This Patient | Concern Level |
|---------|-------------|---------------|
| SpO2 on room air | 89% | Moderate-Severe |
| Respiratory rate | 68 | Moderate |
| Retractions | Subcostal, intercostal | Moderate |
| Nasal flaring | Present | Moderate |
| Feeding | 50% of normal | Moderate |
| Mental status | Tired but alert | Mild-Moderate |

### Secondary Survey

**SAMPLE History:**
- Symptoms: Cough, rhinorrhea, respiratory distress, poor feeding, decreased urine output
- Allergies: None known
- Medications: None
- PMH: Full-term, healthy, no prior hospitalizations
- Last Meal: Attempted bottle 2 hours ago, took 30mL
- Events: Sick contact (sibling)

**Birth/Developmental History:**
- Born at 39 weeks, uncomplicated delivery
- Birth weight 3.2 kg
- Up to date on immunizations
- Meeting developmental milestones
- No prior wheezing episodes

**Risk Factors for Severe Bronchiolitis:**
- Age <12 weeks: No (4 months)
- Prematurity: No
- Chronic lung disease: No
- Congenital heart disease: No
- Immunodeficiency: No
- Neuromuscular disease: No

### Physical Examination

**HEENT:**
- Copious clear nasal discharge
- Oropharynx mildly erythematous
- TMs normal bilaterally
- Fontanelle soft, flat

**Respiratory:**
- Tachypneic with retractions
- Diffuse wheezes and crackles
- Good air entry bilaterally
- No focal findings

**Cardiovascular:**
- Tachycardic, regular rhythm
- No murmur
- Pulses 2+ throughout

**Abdomen:**
- Soft, non-tender
- No hepatosplenomegaly

**Skin:**
- Mildly dry mucous membranes
- Skin turgor slightly decreased

### Diagnostic Testing

**Point-of-Care:**
- Respiratory viral panel (nasal swab): RSV positive
- Glucose: 78 mg/dL

**Labs (not routinely indicated, obtained due to severity):**
- CBC: WBC 11.2, Hgb 11.8
- BMP: Na 136, K 4.8, HCO3 22, Glucose 82

**Chest X-ray:** Hyperinflation, perihilar infiltrates, no focal consolidation (classic bronchiolitis pattern)

### Diagnosis

**Acute bronchiolitis** secondary to Respiratory Syncytial Virus (RSV)

### Management

**Evidence-Based Bronchiolitis Treatment:**

**What DOES work:**
1. **Supplemental oxygen:** Nasal cannula at 1L/min, goal SpO2 >90%
2. **Nasal suctioning:** Bulb suction before feeds and PRN
3. **Hydration:** IV fluids initiated (D5 1/2 NS at maintenance rate)
4. **Monitoring:** Continuous pulse oximetry, respiratory assessment

**What does NOT work (avoid routinely):**
- Bronchodilators (albuterol) - no proven benefit in bronchiolitis
- Corticosteroids - no benefit
- Antibiotics - unless bacterial superinfection
- Chest physiotherapy - no benefit

**Trial of Bronchodilator:**
- One-time albuterol trial considered
- If clear response, may continue; if no response, discontinue
- This patient: No significant response to albuterol trial - discontinued

### Clinical Course

**First 6 hours:**
- SpO2 92-94% on 1L NC
- Respiratory rate decreased to 54
- Tolerated 60mL formula by mouth
- Fewer retractions

**Admission Criteria (met by this patient):**
- Age <12 months with significant respiratory distress
- Hypoxia requiring supplemental oxygen
- Inadequate oral intake
- Apnea history (not present here)
- High-risk underlying conditions (not present)

### Disposition
- Admitted to pediatric floor
- Weaned oxygen over 48 hours
- Improved feeding
- Discharged home day 3
- Return precautions provided
- Follow-up with pediatrician in 2-3 days

### Teaching Points

1. **RSV is the most common cause:** Peak age 2-6 months; almost all children infected by age 2
2. **Diagnosis is clinical:** Viral testing confirms etiology but doesn't change management
3. **Supportive care is mainstay:** Oxygen, suction, hydration - no specific treatment
4. **Bronchodilators generally don't work:** Unlike asthma, bronchiolitis involves inflammation and mucus, not bronchospasm
5. **Admission criteria:** Hypoxia, poor feeding, young age, high-risk conditions
6. **Natural history:** Typically worsens days 3-5, then improves; full recovery 2-3 weeks
7. **Prevention:** Palivizumab (RSV antibody) for high-risk infants; hand hygiene critical

### Clinical Image
![Chest X-ray Bronchiolitis](case_01_image.jpg)

**Image Description:** Pediatric chest radiograph demonstrating hyperinflation of the lungs with flattened diaphragms, perihilar infiltrates, and peribronchial thickening consistent with acute viral bronchiolitis.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Jeremy Jones. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/bronchiolitis-2

---

## Case 2: Febrile Infant - The 28-Day-Old with Fever

### Patient Demographics
- **Age:** 28 days
- **Sex:** Male
- **Accompanied by:** Both parents

### Chief Complaint
"He feels warm and isn't acting right."

### History of Present Illness
Parents bring their 28-day-old son for evaluation of fever. Temperature at home was 38.4C (101.1F) rectal. Infant has been less interested in feeding today, taking only 50% of usual volumes. Parents note he seems "fussy" and not easily consoled like usual. No cough, congestion, or diarrhea. No sick contacts. Parents are first-time parents and appropriately concerned.

### Initial Assessment

**Pediatric Assessment Triangle:**
- **Appearance:** Irritable when examined, settles briefly with mother
- **Work of Breathing:** Normal respiratory effort
- **Circulation:** Pink, well-perfused

**ESI Level:** 2 - Febrile neonate requires immediate evaluation

**Vital Signs:**
- Heart rate: 172 bpm
- Respiratory rate: 42 breaths/min
- SpO2: 98% on room air
- Temperature: 38.6C (101.5F) rectal
- Weight: 4.2 kg

### Critical Concept: The Febrile Neonate (<28 days)

**Why the concern?**
- Immature immune system
- Risk of serious bacterial infection (SBI): 10-15%
- Includes: UTI, bacteremia, meningitis
- Pathogens: Group B Strep, E. coli, Listeria, HSV

**This baby is 28 days old - at the upper limit of "neonate" but still HIGH RISK**

### Primary Survey

**Airway:** Patent, crying
**Breathing:** Normal rate and effort
**Circulation:** Well-perfused, strong pulses
**Disability:** Irritable but consolable, normal tone, normal fontanelle
**Exposure:** No rashes, no petechiae

### Secondary Survey

**SAMPLE History:**
- Symptoms: Fever, irritability, decreased feeding
- Allergies: None
- Medications: Vitamin D drops
- PMH: Full-term (39 weeks), uncomplicated SVD, no NICU stay
- Last Meal: 3 hours ago, took 45mL (usually 90mL)
- Events: Fever noted 4 hours ago

**Birth History:**
- GBS status: Negative
- ROM: 8 hours before delivery
- Maternal fever: None
- Apgars: 8, 9

**Detailed Physical Exam:**

**General:** Intermittently irritable, settles with consoling
**HEENT:**
- Fontanelle soft, flat
- TMs normal
- No conjunctivitis
- Mucous membranes moist

**Neck:** Supple, no meningismus (difficult to assess in neonates)

**Cardiovascular:**
- Tachycardic (appropriate with fever)
- No murmur
- Strong pulses, cap refill 2 seconds

**Respiratory:**
- Clear breath sounds
- No distress

**Abdomen:**
- Soft, non-distended
- No masses
- Normal umbilicus (no erythema, discharge)

**GU:**
- Uncircumcised male
- No scrotal swelling

**Skin:**
- No rashes
- No vesicles (HSV concern)
- No petechiae

**Neurological:**
- Normal tone
- Symmetric movements
- Strong suck reflex

### Diagnostic Workup - Febrile Neonate Protocol

**Required Studies:**
1. **CBC with differential:** WBC 18,400 with 68% neutrophils, 4% bands
2. **Blood culture:** Obtained before antibiotics
3. **Urinalysis and urine culture:** Catheterized specimen - UA positive (>10 WBC/hpf, positive LE)
4. **Lumbar puncture:**
   - CSF WBC: 4 cells/μL (normal <20)
   - CSF protein: 85 mg/dL (normal for age)
   - CSF glucose: 48 mg/dL (serum 72) - ratio normal
   - Gram stain: No organisms
   - CSF culture: Sent
   - HSV PCR: Sent

5. **Metabolic panel:** BMP normal
6. **Inflammatory markers:** Procalcitonin 0.8 ng/mL

### Diagnosis

**Urinary tract infection** in febrile neonate
- High risk for bacteremia/urosepsis
- Most common source of SBI in febrile infants

### Management

**Empiric Antibiotics (given before culture results):**
- Ampicillin 50 mg/kg IV q8h (Listeria coverage)
- Cefotaxime 50 mg/kg IV q8h (broad GN coverage, good CSF penetration)
- Acyclovir 20 mg/kg IV q8h (HSV coverage - given any febrile neonate with irritability)

**Note:** Acyclovir started empirically given irritability; will discontinue if HSV PCR negative and clinically improving

**Supportive Care:**
- IV fluids
- Antipyretics (acetaminophen 15 mg/kg PR)
- Continuous monitoring

### Culture Results (48 hours)

- **Blood culture:** Negative
- **Urine culture:** E. coli >100,000 CFU/mL (confirms UTI)
- **CSF culture:** Negative
- **HSV PCR:** Negative

### Antibiotic Adjustment
- Discontinue ampicillin (no Listeria)
- Discontinue acyclovir (HSV negative)
- Continue cefotaxime, transition to ceftriaxone
- Total IV antibiotic course: 7 days (given age)

### Disposition
- NICU/Pediatric floor admission
- Complete IV antibiotic course
- Renal ultrasound: Normal (no structural abnormality)
- Voiding cystourethrogram: Deferred to outpatient (will need given age and UTI)
- Discharged day 7, follow-up with pediatrics and urology

### Teaching Points

1. **Fever in neonate = sepsis workup:** Full evaluation including LP mandatory in <28 days
2. **Don't miss HSV:** Acyclovir empirically if irritability, seizures, vesicles, or CSF pleocytosis
3. **UTI most common SBI:** Catheterized specimen required; bag specimens unacceptable
4. **Blood culture before antibiotics:** But don't delay antibiotics for LP if patient unstable
5. **Ampicillin + cefotaxime (or gentamicin):** Standard empiric regimen for neonatal sepsis
6. **Ceftriaxone avoided in neonates:** Risk of bilirubin displacement; use cefotaxime instead
7. **Follow-up imaging:** UTI in young infant requires renal US; VCUG to evaluate for vesicoureteral reflux

### Clinical Image
![Lumbar Puncture Position - Pediatric](case_02_image.jpg)

**Image Description:** Illustration demonstrating proper positioning for lumbar puncture in an infant, with the baby held in lateral decubitus position with hips and knees flexed, spine curved, while an assistant stabilizes the patient and monitors for respiratory compromise.

**Attribution:** Image from Wikimedia Commons, Infant lumbar puncture positioning. Public domain. Source: https://commons.wikimedia.org/wiki/File:Lumbar_puncture_infant.jpg

---

## Case 3: Pediatric Dehydration - The Vomiting Toddler

### Patient Demographics
- **Age:** 18 months
- **Sex:** Male
- **Accompanied by:** Father

### Chief Complaint
"He can't keep anything down and seems really tired."

### History of Present Illness
Father brings 18-month-old son for evaluation of vomiting and lethargy. Illness began 36 hours ago with non-bloody, non-bilious vomiting (8-10 episodes). Diarrhea began 24 hours ago (watery, no blood, 6 episodes). Child has refused to drink and has had only 2 wet diapers in the last 24 hours (usually 6-8). Older sister had similar symptoms last week. Father reports child has become increasingly tired and "floppy."

### Initial Assessment

**Pediatric Assessment Triangle:**
- **Appearance:** Lethargic, poor eye contact, minimal response to stimulation
- **Work of Breathing:** Normal
- **Circulation:** Pale, mottled extremities, cap refill 4 seconds

**ESI Level:** 2 - Moderate-severe dehydration with lethargy

**Vital Signs:**
- Heart rate: 168 bpm
- Respiratory rate: 28 breaths/min
- SpO2: 99% on room air
- Temperature: 37.4C
- Blood pressure: 82/48 mmHg (low for age)
- Weight: 10.2 kg (baseline 11.5 kg per father)

**Weight Loss Calculation:**
(11.5 - 10.2) / 11.5 = 11.3% weight loss = SEVERE dehydration

### Dehydration Assessment

| Feature | Mild (3-5%) | Moderate (6-9%) | Severe (>10%) | This Patient |
|---------|-------------|-----------------|---------------|--------------|
| Mental status | Normal | Irritable/lethargic | Lethargic/obtunded | Lethargic |
| Thirst | Normal | Thirsty | Drinks poorly | Refuses fluids |
| Heart rate | Normal | Increased | Markedly increased | 168 (increased) |
| Pulses | Normal | Normal/decreased | Weak | Weak |
| Breathing | Normal | Normal | Deep | Normal |
| Eyes | Normal | Slightly sunken | Deeply sunken | Sunken |
| Tears | Present | Decreased | Absent | Absent |
| Mucous membranes | Moist | Dry | Parched | Parched |
| Skin turgor | Normal | Decreased | Tenting | Tenting |
| Cap refill | Normal | 2-3 seconds | >3 seconds | 4 seconds |
| Urine output | Normal | Decreased | Minimal/none | 2 diapers/24hr |

**Assessment: SEVERE dehydration (>10%)**

### Primary Survey

**Airway:** Patent
**Breathing:** Normal rate and effort
**Circulation:** Tachycardic, hypotensive, delayed cap refill, weak pulses - **SHOCK**
**Disability:** Lethargic but responds to painful stimuli, GCS 12 (E3V4M5)
**Exposure:** Sunken eyes, dry mucous membranes, tenting skin

### Immediate Resuscitation

**IV Access:**
- Peripheral IV attempted x2 - unsuccessful (poor veins)
- IO access placed in proximal tibia

**Fluid Resuscitation:**
- Normal saline 20 mL/kg bolus (200 mL) over 20 minutes
- Reassess after each bolus

**Response to First Bolus:**
- HR: 152 (improved)
- BP: 88/54 (improved)
- Cap refill: 3 seconds (improved)
- Mental status: More alert

**Second Bolus:**
- Additional NS 20 mL/kg given
- Continued improvement in perfusion

### Secondary Survey

**SAMPLE History:**
- Symptoms: Vomiting, diarrhea, lethargy, decreased urine output
- Allergies: None
- Medications: None
- PMH: Healthy, immunizations up to date
- Last Meal: Small amount of water this morning, vomited
- Events: Sick contact (sibling with gastroenteritis)

**Physical Examination (After Initial Resuscitation):**

**General:** More alert, still appears ill

**HEENT:**
- Sunken eyes (improving)
- Dry mucous membranes
- No oral lesions

**Cardiovascular:**
- Tachycardic, improved perfusion
- Strong central pulses, weak peripheral

**Abdomen:**
- Soft, mildly distended
- Hyperactive bowel sounds
- No tenderness

**GU:**
- Dry diaper

**Skin:**
- Tenting improved
- No rashes

**Neuro:**
- More interactive
- Age-appropriate responses

### Diagnostic Testing

**Point-of-Care:**
- Glucose: 68 mg/dL (low normal, give dextrose-containing fluids)
- Urine: Unable to obtain (minimal output)

**Labs:**
- BMP: Na 148, K 3.2, Cl 118, HCO3 16, BUN 32, Cr 0.8
- Glucose: 72
- VBG: pH 7.28, pCO2 28

**Interpretation:**
- Hypernatremic dehydration (Na 148)
- Hypokalemia (K 3.2)
- Metabolic acidosis with respiratory compensation
- Elevated BUN/Cr ratio (prerenal azotemia)

### Diagnosis

**Acute viral gastroenteritis** with severe hypovolemic shock and hypernatremic dehydration

### Management

**After Resuscitation Phase:**
1. **Maintenance + Deficit Replacement:**
   - Fluid: D5 0.45% NS with 20 mEq/L KCl
   - Calculate 48-hour correction (hypernatremia correction)
   - Goal: Lower Na by max 0.5 mEq/L/hour (risk of cerebral edema if too fast)

2. **Monitoring:**
   - Strict I/O
   - Serial electrolytes every 4-6 hours initially
   - Daily weights
   - Neuro checks (for cerebral edema)

3. **Nutrition:**
   - NPO initially, then advance diet slowly
   - Oral rehydration when tolerating

### Clinical Course

**At 12 hours:**
- HR: 120, BP: 94/58
- Na: 145 (appropriate rate of decline)
- Tolerating small amounts of Pedialyte
- Voiding

**At 24 hours:**
- Na: 142
- Tolerating regular diet
- Active, playful

### Disposition
- Admitted for IV rehydration
- Transitioned to oral fluids at 24 hours
- Discharged home at 36 hours
- Education on oral rehydration for gastroenteritis
- Return precautions provided

### Teaching Points

1. **Assess dehydration severity:** Clinical signs correlate with fluid deficit; weight loss is gold standard if known
2. **Don't delay IV/IO for lab results:** Shock requires immediate fluid resuscitation
3. **20 mL/kg boluses:** Repeat and reassess until perfusion improves
4. **Hypernatremic dehydration:** Common in young children; correct slowly to avoid cerebral edema
5. **Oral rehydration:** First-line for mild-moderate dehydration; ondansetron may help success
6. **IO access:** Don't hesitate if IV difficult; especially in decompensating child
7. **Most gastroenteritis is viral:** Antibiotics rarely indicated; supportive care is mainstay

### Clinical Image
![Clinical Signs of Dehydration](case_03_image.jpg)

**Image Description:** Comparison images demonstrating clinical signs of dehydration in pediatric patients, including sunken eyes, decreased skin turgor (tenting), and dry mucous membranes. These findings help clinicians estimate the degree of dehydration.

**Attribution:** Image from Wikimedia Commons, Signs of dehydration. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Dehydration_signs.svg