pediatric vaccination

TSK: Chief Complaint “2 y/o with fever and runny nose x6 hours”

Cranquis: … so this virus will probably stop causing fevers within the next 2 days, and as long as he keeps drinking liquids meanwhile, he’ll be just fine.

Mom: BUT YOU’RE GOING TO GIVE HIM ANTIBIOTICS FOR THE INFECTION RIGHT.

Cranquis: Well, if there were any signs of bacterial infection on his exam, I would definitely do that. But this is a viral infection, and viruses just giggle when they see antibiotics.

Mom: NO YOU GUYS HAVE STRONGER ANTIBIOTICS THAT KILL ALL THE VIRUSES TOO AND YOU’RE GOING TO GIVE HIM SOME BECAUSE I AM SICK AND TIRED OF HIM GETTING VIRUSES EVER SINCE HE STARTED DAYCARE 6 MONTHS AGO.

Cranquis: That’s the unfortunate nature of daycare – kids share all their viruses around a lot. On the plus side, he’ll have a much healthier immune system by the time he starts school and–

Mom: HE WON’T EVEN SURVIVE TO START SCHOOL AND WHEN HE DIES BECAUSE OF THIS VIRUS IT’S GOING TO BE YOUR FAULT FOR NOT GIVING HIM ANTIBIOTICS. THERE HAS TO BE SOMETHING YOU CAN DO TO KEEP HIM FROM GETTING VIRUSES.

Cranquis: Well, funny you should mention it, because I noticed he hasn’t had a flu shot yet, and the flu is a virus that could actually kill him, so a flu shot could help keep him from getting a deadly virus.

Mom: I’M NOT PUTTING THOSE CHEMICALS IN HIS BODY HE NEEDS TO FIGHT IT OFF ON HIS OWN.


…and some people say that if you put your ear up to the door of Urgent Care Exam Room 4 today, you can still hear this conversation taking place on an infinite loop until the eventual heat-death of the universe…

Croup vs. Epiglottitis (Peds.)

Pediatrics (neonates to school age; adolescence is another topic) is probably my least favorite specialty to deal with and they are one of the hardest to help at times with all the elements that go with the patient. Whether it is dealing with the sick child or the distraught parents, we must sift through the physical findings and the information from the parents to understand what is going on. This gets especially sticky when it comes to some upper airway complications in the younger group.

Two very common upper airway problems in the younger populations include Croup and Epiglottitis. Both can be dangerous, but require different management when treatment is concerned. This article will give you a brief overview of the pathophysiology, signs and symptoms, treatments, and key points to remember.

Croup

Pathophysiology: Commonly a viral infection (RSV, adenovirus, influenza A and B, etc.) of the upper respiratory system for ages 6 to 36 months. Major inflammation has occurred in the larynx, trachea, bronchi, bronchioles, and lung parenchyma; causing obstruction of the airway. As the swelling progresses supraglottic the patients with begin show signs of respiratory distress. Further along, the patient’s lower airway may begin to begin having atelectasis, due to the lack of air keeping the alveoli open.

Croup is a slow progression of inflammation. Noticing early that the patient has upper respiratory issue is key in the management. Due to the smaller airway of children, we must not hesitate to seat

Signs and Symptoms: The most common sign of croup will be the seal like bark with inspiratory stridor. With this means that the patient is in respiratory distress and quickly heading to failure. If you hear the seal like bark, check the lower lung fields for crackles, because possible atelectasis may have begun.

Commonly more serious during night, awakening them from sleep. Other signs to know include:

  • Tachypnea
  • Retractions
  • Cyanosis
  • Shallow respirations
  • Fever

Treatment: Emergency treatment for croup is a humidified air and a dose of corticosteroids. If in further destress, racemic epinephrine will assist with edema. ETCO2 and O2 readings will help determine if there is retention of gasses, which may lead to acidosis. ABGs will be needed to confirm this as well.

Usually, patients will be able to return home to be monitored. Family should watch for difficulty breath and be using humified air. Antipyretics will assist in keeping fevers down as well.

Epiglottitis

Pathophysiology: Influenza type B, streptococcus pneumoniae or aureus may cause epiglottitis. The epiglottis is a small flap above the glottic opening, which is used to prevent foreign objects entering the trachea. When the epiglottis is infected, with will swell, narrowing the airway for the patient. Increased work of breathing may occur and soon my might have a patient in respiratory failure.

Epiglottitis is a more acute problem, with sudden onset and quick changes to mentation form the restriction of airflow.

Signs and symptoms: As the epiglottis swells, the child may begin to develop stridor. When stridor occurs, we must ask the question is this an object or is this medical. Other signs that might point you towards epiglottitis will be:

  • Sore throat
  • fever
  • Odynophagia
  • Drooling
  • Irritability
  • Cyanosis
  • Tripoding or nasal flaring

Treatment: The most important thing with these patients is to ensure they have an airway. Do not try and examine the patient, especially if you are a paramedic on scene (Load and go). When gathering a medical history, it is especially important to ask for vaccination in the pediatric population. Today, Influenza vaccinations are given to children, but we do have a set population now that do not vaccinate their children. X-rays of neck will be done and a visual examination may be performed. Keep the patient calm at this time, further agitation may cause the airway to swell more.

Patient will commonly receive an antibiotic, such as ceftriaxone, to help with the bacteria. ET tubes may be places in severe cases and usually remain for 24 to 48 hours. Trachostomes may be required, if a ET tube cannot pass the glottic opening.

Key Points

  • Both Croup and Epiglottitis can be dangerous to pediatric patients. If you have a child that has stridor and any signs of distress, they will need immediate attention.
  • Out of hospital, assume epiglottitis and rule it out when you can. This load and go for you
  • Croup X rays may show steeple sign, but epiglottitis won’t

Written by: MEDDAILY

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luckystarsmd  asked:

Hi Wayfaring! Obviously, you are pro-vaccines, and I am too. It drives me crazy when I hear about parents refusing vaccination on faulty premises. There is a post going around tumblr about a pediatrician refusing to treat unvaccinated patients. I understand the risks these unvaccinated patients pose to other patients, but do you think doctors have an ethical obligation to these kids (who didn't choose to not vaccinate themselves)? Would you ban unvaccinated kids from your future practice?

I have a hard time with this concept, and my opinion goes back and forth. 

My office has taken the stance that we will accept children of anti-vax parents because they do need healthcare (and several other pediatricians in the area won’t take them), but we will discuss vaccination with them at every well child visit and make them sign refusals of vaccinations each time they turn them down. 

I have 2 patients who are unvaccinated or under-vaccinated because their parents don’t want to expose them to “chemicals”. One agreed to take some vaccinations once I showed her the labels on the bottles and proved that they did not contain mercury or thimerosol. There are few things that patients do that make me truly angry, but not vaccinating is one of them. It is very close to child abuse in my book.

Ultimately my goal is to take care of patients. If I refuse to see a patient because their family members are unreasonable, I’m not helping the patient. It think that’s what my office is getting at with their policy. However, I still wonder if there should be a “non-vaccinated” waiting area for those patients who come in for sick visits so that they do not infect other people in the waiting room.  

This is a discussion that I’m going to have to have with my future partners in a few months when I start my new job. 

Photo by Armelle Vanderhaghen/MSF

 In this picture MSF staff are removing medical supplies from a recently arrived cargo plane in Paoua. These supplies and the work performed by Médecins Sans Frontières are essential for a country that has been racked by violence since 2012.

   MSF has been performing medical treatment at a hospital in Paoua, Central African Republic since 2006.  Our activities include emergency care, routine vaccination, surgeries, pediatrics, obstetrics/maternity, and HIV-AIDS tuberculosis treatment.