1. A 14 month old child is brought into the ED for fevers, vomiting, diarrhea x 4 days. Stools are watery and nonbloody. The infant appears nontoxic and well hydrated. The patient attends day care. What is the most likely diagnosis?

a) Campylobacter
b) Rotavirus
c) Shigella
d) Salmonella
e) Norwalk virus

2. A 3 year old child is brought into the ED for vomiting, bloody diarrhea, and abdominal pain. Patient had symptoms of gastroenteritis 12 days ago, and fully recovered. The patient has low grade fever and hematuria. You astutely suspect Hemolytic Uremic Syndrome. You would expect all these additional findings EXCEPT:

a) Petechiae
b) Hypertension
c) Elevated LDH
d) Prolonged PTT
e) Decreased haptoglobin

3. A 2 year old child is brought to the ED after an episode of vomiting. The mother found the child with an empty bottle of chewable vitamins with iron, and mom says she estimates the child must have eaten at least 25 Flintstones Gummies six hours ago. After vomiting, the child seems much better, and is comfortable in ED with normal vitals. You should tell the parents:

a) The child will be fine, the danger period has passed
b) The child needs gastric lavage
c) The child needs activated charcoal
d) An XR should be obtained; if no pill fragments, they can be reassured.
e) The child is in the danger phase and needs very close monitoring and admission.

 

Answers:

1. B

Rotavirus is the most likely cause of severe diarrhea in children. Lasts 5-7 days, associated with vomiting, fever, nonbloody diarrhea. Adenovirus is the second most likely cause of viral diarrhea in children. Norwalk virus causes epidemic gastorenteritis in older children, usually in the winter, with symptoms lasting <3 days, with fever and myalgias and mild GI symptoms. Campylobacter jejuni , Salmonella, Shigella, C. Dificile, and Yersinia enterocolitis are common organisms that cause bacterial gastroenteritis.

2. D

HUS is characterized by nephropathy, migcroangiopathic hemolytic anemia, thrombocytopenia. Patients can develop HTN, petechiae, easy bruising, hepatosplenomegaly, proteinuria, edema, hyponatremia, hypocalcemia. Coag studies tend to be normal.

3. E

Stages of Iron Poisoning

Stage

Time

Description

1

Within 6 h

Vomiting, hematemesis, explosive diarrhea, irritability, abdominal pain, lethargy

If toxicity is severe, tachypnea, tachycardia, hypotension, coma, metabolic acidosis

2

6–48 h

Up to 24 h of apparent improvement (latent period)

3

12–48 h

Shock, seizures, fever, coagulopathy, metabolic acidosis

4

2–5 days

Liver failure, jaundice, coagulopathy, hypoglycemia

5

2–5 wk

Gastric outlet or duodenal obstruction secondary to scarring

3g is the lethal dose for a 2 year old patient. Do not rely on the absence of pill fragments to guide treatment. Lavage needs to be done within 1-2h of ingestion, and activated charcoal is not effective. Involve poison control early. In late stages, treatment will include chelating agents ( IV deferoxamine ), and dialysis.

References:

Adapted from Pediatric Emergency Medicine, Just the Facts. 2004

Pediatric Iron Toxicity http://emedicine.medscape.com/article/1011689-overview#showall