Tiny Things That Crawl Should Scare You Dan O’Donnell, M.D.

Objectives Create anxiety and fear among EMS providers Overview of common low acuity pediatric complaints that can have very bad outcomes –ALTE –Febrile Infant –Ingestions

Case 1 EMS called to “the projects” for a “blue child.” You arrive to find a 2 month old male crying in mom’s arms. You are told the child was found blue in the crib but began crying quickly there after. Exam is unremarkable (lungs clear, no cyanosis) Vitals are “normal” (SpO2 94%) Mom would rather take the child herself. SOR?

ALTE Apparent Life Threatening Event “An episode that is frightening to the observer and that is characterized by some type of apnea, color and muscle tone change or some type of choking and gagging.”

Apparent Life Threatening Event Previous (and inappropriate) terms: Previous (and inappropriate) terms: - “near-miss SIDS” - “near-miss SIDS” - “aborted SIDS” - “aborted SIDS” Refers to any combination of presentations Refers to any combination of presentations - pallor - pallor - cyanosis - cyanosis - hypotonia or hypertonia - hypotonia or hypertonia - apnea - apnea - bradycardia - bradycardia -Caregiver often responds by performing CPR -Caregiver often responds by performing CPR

Apnea “Pathologic apnea” - respiratory pause of more than 20 seconds or with associated cardiac arrhythmias, pallor, hypotonia, or cyanosis Respiratory pause of less than 15 seconds may be normal at any age Breath Holding

ALTEs (Apparent Life Threatening Events) History of Infants with Unexplained ALTEs History of Infants with Unexplained ALTEs - apnea82% - apnea82% - pallor70% - pallor70% - limpness60% - limpness60% - cyanosis48% - cyanosis48% - pallor and limpness47% - pallor and limpness47% - “lifelessness”41% - “lifelessness”41% - coldness16% - coldness16% - not clear if breathing14% - not clear if breathing14% - stiffness11% - stiffness11% - staring / rolling eyes10% - staring / rolling eyes10% - shallow breathing4% - shallow breathing4%

ALTE All patients with suspected ALTE need to be transported for full evaluation –Monitoring – cardiac / oximetry –Oxygen –Supportive care and treat other conditions –No IV usually required Large workup and 50% will have no diagnosis Most will be admitted for observation and evaluation

What about our case? Even if you forget everything else …this kid is 2 months old! Good luck with SOR if under 90 days old If you think they need to go give the phone to mom.

Please Take These Kids Seriously

Case 2 Friday night dispatch to a 4 week old with recent runny nose. He was crying a little more tonight so mom checked his temp… Physical Exam: Well looking, taking a bottle, mild congestion Your experienced partner takes mother aside and begins discussing getting appointment with primary pediatrician. What do you think?

The Febrile Infant Most separate out infants <90 days What is a fever? –100.4 F (38 C) How do you take it? Parents are usually right What needs to be done with this kid?

The Septic Workup

What about this… Fever in this age group is concerning for more serious illness. 305 kids <60 days –83.8% viral –Meningitis / Bacteremia –UTI –Etc. This is many times an automatic admit

Case 3 2 year old female at grandma’s house found with med bottle in hand and one tablet in mouth. Lucky for everyone the script had just been filled and there is only one pill missing Well looking playful child What would you like to do next?

Questions The usual AMPLE / OPQRST What medication? How many mg? How long ago?

Medications That Can Kill A Toddler With One Tablet Or Teaspoon Koren G, et al. Journal of Toxicology. Clinical Toxicology 1993;31(3):407-13

Some Numbers 40% of total exposures in 2000 were 2 y/o or younger 40% of fatalities were caused by a short list of medications

Drugs Iron Tricyclic Antidepressants Anti-psychoticsAnti-MalarialsAnti-arrhythmias Calcium Channel Blockers Narcotics Oral Hypoglycemic

Some Names You Should Know AmitriptylinImipramineDiltiazemVerapamilTheophyllineCodeineHydrocodoneMethadoneGlipizideGlyburide

A Special Word on Iron Number one killer in toddlers More than one dose Remember prenatal vitamins

Don’t Forget What You Already Know! Ethylene Glycol Requires very little to be fatal

Methanol Also very little to be toxic Drink packaging has changed over past few years.

Recap Remember ALTE (Apparent Life Threatening Event) – –Less than one with any worrisome history –Blue, Choking, Floppy, etc Fever in kids <90 days can be big deal There are many medications that can kill a 10 kg toddler with a single dose