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Most common bacterial etiology of acute otitis media
- Streptococcus aureus g+ cocci, grapelike clusters, falcultative anerobic
- Streptococcus pneumoniae g+ diplococci, aerotolerant anaerobe
- Haemophilus influenzae g- rod, aerobic or falcultative anaerobic
- Moraxella catarrhalis g- diplococci, aerobic
- Pseudomonas aeruginosa g- rod, aerobic
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Otitis media definition, acute vs chronic
- inflammation of middle ear space
- acute < 2 - 3 weeks
- chronic > 3 months
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Most common surgery for children in US
tympanostomy tubes - 1-2mm tubes of teflon, silicone, polyethylene and stainless steel or titanium to allow drainage
- 2 million yearly
- Out patient procedure
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tympanocentesis should be considered in children who
fail treatment after 10 to 28 days
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Most common complication of tympanostomy surgery
AOM with otorrhea - acute purulent discharge
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Recommended treatment of AOM by CDC, WHO, AAFP, AAP
1st line -- standard dose amoxicillin x 5 to 7 days
- If child is <24 mo, attends day care or has been tx'd within 30 days then
- 1st line - high dose amoxicillin x 10 days
-
Antibiotic approved for the middle ear that are not ototoxic
- ofloxacin (fluoroquinolone)
- ciprofloxacin (fluoroquinolone)/dexamethasone
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Which is louder inspiratory or expiratory breath sounds and why
inspiratory are louder because the airway become progressively smaller as air comes into the lung causing turbulence
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tracheal breath sounds
- very loud
- relatively high pitched
- inspiratory sound length = expiratory sound length
- not routinely auscultated
-
vesicular breath sound
- major normal breath sound
- heard over majority of lung
- soft low pitch
- inspiratory sound length > expiratory sound length
-
bronchial breath sounds
- very loud
- high pitched
- gap between inspiratory and expiratory phase
- expiratory sound length>inspiratory sound length
- heard over manubrium
- indicate consolidation (solid/liquid is present where air was)
-
bronchovesicular breath sounds
- intermediate intensity and pitch
- inspiratory sound length = expiratory sound length
- heard over 1st and 2nd ICS and between scapula (mainstem bronchi)
- indicate consolidation
-
Decreased or absent breath sounds occur in
- ARDS
- Emphysema
- Pleural effusion
- Pneumothorax
-
Absent breath sounds occur in
atelectasis
-
bronchial breath sounds in abnormal locations indicate
- consolidation
- test for egophony and whispered pectroliloquy
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crackles
- discontinous
- nonmusicle
- brief
- more common on inspiration
- may be classified as fine or course
-
fine crackle sound
- high pitched
- soft
- very brief
-
course crackles sound
- low pitched
- loud
- less brief
-
crackles may be normal in what situations
- anterior lung bases after
- maximal expiration
- prolonged recumbency
-
crackles are mechanically caused by
- small airways opening during inspiration and collapsing during expiration
- incompletely closed airways during expiration
- bubbles through secretions
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Conditions in which crackles are heard
- ARDS
- asthma
- bronchiectasis
- chronic bronchitis
- consolidation
- early CHF
- pulmonary edema
- interstitial lung disease
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Wheeze are
- continuous
- high pitched
- hissing
- heard on expiration (sometimes on inspiration)
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Wheezes are mechanically caused by
- air flow through airways narrowed by
- secretions
- foreign bodies
- obstructive lesions
-
listen for changes in wheezes and crackles after
deep breath or cough
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may indicate if one or both air ways are involved
monophonic wheezes vs. polyphonic wheezes
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Weezing may be present in what conditions
- asthma
- chronic bronchitis
- COPD
- CHF
- pulmonary edema
-
Rhonchi are
- low pitched
- continuos
- musical sounds (similar to wheeze)
- imply obstruction of larger airway
-
Stridor is
- inspiratory musical wheeze
- loudest over trachea during inspiration
- suggests obstruction of trachea or larynx --> EMERGENCY
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Pleural Rub
- creaking or brushing sound
- discontinuous or continuous
- usually localized over a particular site in chest wall
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Pleural rub is caused by
imflammed or roughened pleural surfaces rubbing against each other
-
Pleural rub is heard in
- pleural effusion
- pneumothrax
-
mediastinal crunch
- hamman's sign
- crunches and crackle synchronized to heart beat (not respiration)
- heard best in left decubitus position
- EMERGENCY
-
mediastinal crunch indicates
pnumomediastinum
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McCaig and Hughes study from 1992 showed that AOM usually resolves without treatment in
7 days
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Required to make a proper diagnosis of AOM
- pneumatic otoscopy showing decreased movement of TM +
- unilateral abnormal TM --> bulging, erythematous or cloudy
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estimated of URTI in preschool and school aged children per year
3 to 8 URTI / year
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5 to 10% of children with URTI will develop
sinus infection as a complication of a antecedent viral infection
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bacteria that cause sinusitis
- streptococcus pneumonia
- haemophilus influenzae
- moraxella catarrhalis
- (same bacteria as with AOM)
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duration of symptoms of rhinosinusitus
7 days
-
diagnosis of sinusitis in children
- persistence of nasal purulence > 10 to 14 days +
- daytime cough
- commonly following a URTI
- less common
- fever 39 or greater
- malodorous breath
- HA
- facial pain or swelling
- periorbital swelling
- sore throat
-
tx for sinusitis
1st line - normal dose amoxicillin
- in high risk individuals such as those listed in AOM
- high dose amoxicillin x 7 - 10 days
- amoxicillin-clavulanate
- cefuroxime axetil
Macrolids for individuals with penicillin allergies
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most common cause of sore throat
- adenovirus
- EBV
- parainfluenza
- RSV
- herpes simplex
- influenza A
and
non-beta hemolytic streptococcus
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most common cause of streptococcal pharyngitis
streptococcus pyogenes or GABHS
-
streptococcal pharyngitis peak seasons
winter and spring
-
tx of acute streptococcus pharyngitis prevents
- rheumatic fever
- peritonsillar abscess
- toxic shock syndrome
-
streptococcal pharyngitis diagnosis
- rapid antigen test
- throat culture
-
to assure an accurate rapid strep test
swab the tonsils and do not touch other parts of the pharynx
-
tx for streptococcal pharyngitis
penicillin V 250 mg BID or TID x 10 days, 500mg for adults
for penicillin allergy --> macrolides (erythromycin)
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most common bacteria causing UTI
E. coli
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UTI in infants is a common cause of
children that present with other conditions and fever may have a UTI as well
-
Diagnosis of UTI
- gold standard - urine culture obtained by suprapubic aspiration
- + urinalysis (to speed results and avoid renal scaring from polynephritis)
- s/s
- fever > 2 days
- vomiting
- diarrhea
- irritabiltiy
- flank and suprapubic tenderness
- malodorous urine
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Risk factors for UTI in infants
- white race
- < 12 mo
- > 39 degree C for > 2 days
- no source of fever
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UTI treatment
- often resistant to trimethoprim-sulfamethoxazole and ampicillin
- if treatment does not appear to be working
- tx with 3rd generation cephalosporin, hydration, observation
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