Pediatric emergency medicine trisk 0404 0404
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those available over the counter, and poisons available in the household may be
important in treating an older child. Finally, obtaining a detailed social history
may provide information that is pertinent to the care of the child.
Is There an Underlying Cause?
A careful physical examination identifies many treatable acute illnesses that can
cause apnea. One clue to serious systemic disease is abnormal body temperature,
including fever or hypothermia. Tachypnea may suggest either a respiratory or a
metabolic problem. Signs of shock should prompt consideration of potential
underlying etiology, including sepsis or hypovolemia from occult trauma.
Evaluation of the nervous system should include notation of mental status,
palpation of the fontanelles, and funduscopic examination. Dysmorphic features
might suggest an underlying congenital abnormality. Bruising may be indicative
of nonaccidental trauma. However, an entirely normal physical examination
provides no reassurance that the described event was clinically insignificant and
will not recur.
For the child with a diagnosis of BRUE and considered to be lower risk ( Table
14.2 ), it is recommended that minimal testing be done. Engaging caregivers and
utilizing a family-centered approach can help guide management, disposition, and
follow-up. Resources such as cardiopulmonary resuscitation (CPR) training
classes can be provided. Further testing should be guided by the history and
physical examination. A 12-lead EKG looking for dysrhythmias may be ordered.
Laboratory testing is not routinely performed, but may be indicated for specific
clinical concerns. Pertussis testing might be considered when there is an
appropriate history or possible exposure. For other potential diagnoses, tests to
consider in the ED include a measurement of blood glucose and serum
electrolytes. Any indication that the infant could have a serious infection should
be pursued with cultures of blood, urine, and cerebrospinal fluid. Urine and blood
for toxicologic analysis should be obtained from patients who may have been
exposed to toxic substances or medications. Noninvasive pulse oximetry is
adequate to identify hypoxemia, and significant metabolic acidosis will be
identified through analysis of serum electrolytes. The arterial or venous blood gas
examination does not serve as a screening test for a serious event and should only
be obtained on the basis of specific indications. Radiologic studies (such as of the
lateral neck, chest, abdomen, or neuroimaging) should be performed as indicated
by the history and physical examination.
The tasks of the emergency physician faced with a young patient who has had
an apneic episode are to identify whether he or she should be hospitalized and to
treat underlying conditions. If a careful history and physical examination suggest
