Pediatric emergency medicine trisk 0562 0562
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Sickle cell anemia may cause swollen and painful digits in young children,
referred to as dactylitis (see Chapter 93 Hematologic Emergencies ).
Thrombophlebitis or deep venous thrombosis rarely occurs in the prepubertal
child but may affect adolescents; inherited hypercoagulable states, weightlifting,
indwelling catheters, and the use of oral contraceptive pills predispose patients to
this condition. Evaluation of these patients should include an ultrasound of the
venous system of the affected limb and a thorough laboratory evaluation.
Superior vena cava syndrome is a medical emergency caused by obstruction of
blood flow through the vessel, resulting from compression from a tumor,
thrombosis, or neoplastic invasion. This usually presents with shortness of breath
and swelling to the head, neck, or upper extremities, often with some degree of
cyanosis or plethora.
GENERALIZED EDEMA
Generalized edema, with an otherwise normal examination, occurs most
commonly in patients with renal disease, particularly nephrotic syndrome (see
Chapter 100 Renal and Electrolyte Emergencies ). The initial diagnosis is based
on significant proteinuria (3+ or >200 mg/dL on a urinalysis). A urinalysis should
therefore be included early in the evaluation of any pediatric patient presenting
with generalized edema. The presence or absence of urine red blood cells, white
blood cells, or casts in the urine, along with further laboratory testing including
chemistries, albumin, total protein, complement, and triglyceride levels may help
to confirm the diagnosis. Various factors, including the presence of hypertension
or significant fluid collections in the pleural or peritoneal spaces, must be
considered to determine the appropriate initial management of these patients.
Other forms of renal disease or vasculitis, including glomerulonephritis,
hemolytic uremic syndrome, or Henoch–Schönlein purpura (HSP) may cause
generalized edema. In the child with HSP, the swelling primarily affects the lower
extremities, where the purpuric rash predominates, or is isolated to specific joints
when arthritis is present. The purpuric rash, despite normal platelet count and
coagulation studies (consistent with a vasculitis), is usually, but not universally,
present.
The evaluation of the child presenting with generalized edema must also
include a complete and thorough cardiovascular examination. Patients with CHF,
pericarditis, myocarditis, or cardiomyopathy may present with edema, but these
children will often have additional signs and symptoms. An edematous child
presenting with a gallop, tachycardia, tachypnea, inspiratory crackles, or
