Pediatric emergency medicine trisk 1718 1718
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The most common pathogen causing mediastinitis is Staphylococcus aureus.
Approximately 50% of patients with mediastinitis will have concurrent
bacteremia.
When an infection is suspected, CBC, erythrocyte sedimentation rate (ESR),
urinalysis, urine culture, and blood and wound cultures should be obtained.
Concern for sepsis, endocarditis, or mediastinitis warrants prompt treatment with
empiric broad-spectrum IV antibiotics. Judicious fluid resuscitation for septic
shock depends on the heart disease. Give aliquots of 10 mL/kg crystalloid for
fluid resuscitation in patients with poor ventricular function, volume overload,
pulmonary overcirculation, or significant AV valve regurgitation. Reassess
frequently for signs of CHF. In all surgical complications, cardiothoracic surgery
and cardiology should be consulted.
Cardiac Transplantation. Pediatric heart transplant patients presenting to the ED
require special consideration. Concerns following transplant include rejection,
infection, nonadherence, cardiac allograft vasculopathy (CAV), and issues arising
from long-term immunosuppression.
Rejection, infection, and CAV may all present in a similar fashion. Pediatric
transplant patients with these conditions present with subtle complaints including
tachycardia, tachypnea, lethargy, irritability, abdominal pain, nausea, vomiting,
and/or poor feeding. Abdominal pain is frequently endorsed in pediatric patients
with rejection or symptomatic CAV. Atypical chest pain may also be a sign of
CAV and rejection (chest pain can occur as some patients partially reinnervate
over time). Low-grade fever, malaise, and heart failure symptoms may also be
present. Arrhythmias and conduction disturbances may be a sign of rejection or
coronary artery vasculopathy. Physical signs may include jugular venous
distension, hepatomegaly, new murmur, and a gallop.
Infections are a threat to the immunocompromised transplant patient.
Prophylaxis against fungal (nystatin), cytomegalovirus (CMV) (ganciclovir,
especially in CMV + donor), and protozoal trimethoprim-sulfamethoxazole
(TMP–SMX) infections is used after transplant. In the first month following
transplant, the greatest risk of infection is bacterial or fungal. In the second
month, CMV and other viruses pose the greatest threats.
Long-term immunosuppression increases the transplant recipient’s risk for
posttransplant lymphoproliferative disorder/malignancy, hypertension, and renal
failure. In the adolescent age group, nonadherence is a leading cause of late
rejection and death. Adherence to the medical regimen should be asked of all
adolescent patients presenting to the ED. The transplanted patient should be
