Pediatric emergency medicine trisk 4092 4092
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Clinical Considerations
Clinical Recognition. Empyema is most common in children 2 to 9 years of age,
though children under 2 years tend to have the highest mortality. The clinical
presentation varies based on when in the disease course the child is evaluated.
Presentation with a pneumonia that fails to improve after about 48 hours of
appropriate antibiotic treatment should lead to the consideration of a complication
like empyema. High fever is common, as are the symptoms of pneumonia: cough,
pleuritic chest pain, malaise, and shortness of breath. Children are typically ill
appearing and may demonstrate tachypnea, respiratory distress, and hypoxia.
Examination findings may include rales, decreased breath sounds on the affected
side, and dullness to percussion.
Please refer to the Community Acquired Pneumonia Clinical Pathway at
. Plain radiographs of the chest should be obtained. Different guidelines
in the United States and the United Kingdom propose either decubitus films or
ultrasound to delineate if the fluid in the pleural space layers. Children with a
moderate (i.e., opacification of more than ¼ of the thorax) to large (i.e.,
opacification of more than ½ of the thorax) effusion should undergo ultrasound to
better characterize the fluid. Ultrasound has several advantages over CT including
lack of radiation, no need for sedation, earlier detection of septae and loculations,
as well as superior ability to describe the nature of the fluid collection.
Furthermore, it can be a helpful therapeutic adjunct to help with chest tube
placement when necessary.
Management. Unlike in uncomplicated pneumonias, children with empyemas are
more likely to be bacteremic and they should all have a blood culture drawn in
order to help direct antimicrobial therapy. Empyema in healthy children may
respond to prolonged IV antibiotic therapy and chest tube drainage, if the fluid is
thin and not loculated. Initial antibiotics should be broad spectrum and based on
local resistance patterns and can be narrowed later if a pathogen is identified.
Coverage for MRSA is often included in initial antibiotic selection. If a patient
fails to respond to this management, loculation of thick purulent material should
be suspected. In such cases, both thoracostomy drainage with the addition of
fibrinolytic agents and VATS have been shown to be effective in hastening
recovery and reducing morbidity. Choice of therapy is often dictated by regional
expertise. Regardless of treatment modality, early surgical consultation is
warranted for significant empyemas.
