B E R KOW I T Z S PEDIATRICS Carol D. Berkowitz, MD, FAAP 6th Edition A PRIMARY CARE APPROACH B E R KOW I T Z S PEDIATRICS A PRIMARY CARE APPROACH AAP 6th Edition Berkowitz B E R I T Z S Edited by Carol D. Berkowitz, MD, FAAP The reference of choice for pediatricians, residents, medical students, and pediatric nurse practitioners, the newly revised and expanded sixth edition provides clear, practice-oriented guidance on the core knowledge in pediatrics. Edited by a leading primary care authority with more than 100 contributors, this edition provides comprehensive coverage of hundreds of topics ranging from temper tantrums and toilet training to adolescent depression and suicide. More than 155 (including 5 brand-new) clinical chapters review pertinent epidemiology and patho­ p hysiology and then give concise guidelines on what symptoms to look for, what alternative diagnoses to consider, what tests to order, and how to treat your patient. This is an ideal reference for pediatricians, family physicians, medical students, residents, residency program directors, physician assistants, pediatric nurse practitioners, and nurses and perfect for use in continuity clinics. This new edition brings you state-of-the-art expertise and insight by Carol D. Berkowitz, MD, FAAP, past president of the American Academy of Pediatrics. She is currently executive vice chair in the Department of Pediatrics at Harbor-UCLA Medical Center and distinguished professor of clinical pediatrics at the David Geffen School of Medicine at B E R KOW I T Z S PEDIATRICS A PRIMARY CARE APPROACH 6th Edition 9 781610023726 90000 ISBN 978-1-61002-372-6 For other pediatric resources, visit the American Academy of Pediatrics at shop.aap.org. New in the sixth edition y All chapters have been reviewed and updated to address current issues. y Five new chapters, including Health Systems Science, Social Determinants of Health: Principles, and Adverse Childhood Experiences: Trauma-Informed Care. y A newly created Instructor’s Guide includes advice on how to best sequence topics in ­ c ontinuity clinics and provides answers to the text case study questions with an emphasis on applying chapter concepts and critical thinking to the case study. y Case study questions have been enhanced and resources have been revised. y This edition is completely reorganized into 15 parts using a systems-based approach. Other AAP resources related to this title New! Berkowitz’s Pediatrics Instructor’s Guide SECTION I PRIMARY CARE: SKILLS AND CONCEPTS Chapter 78: head trauma 18 19 An epidural hematoma is a collection of blood that accumulates between the skull bone and the tough outer covering of the brain (ie, dura mater). UCLA. PEDIATRICS These are often the result of tears in the middle menin- geal artery caused by skull fractures. KOW Classically, patients have initial LOC followed by a lucid interval and then rapid deterioration sec- ondary to brain compression. On CT, an epidural hematoma appears as a large collection of blood with convex borders next to the skull (Figure 78.2A). Surgical evacuation is required in most cases. The subdural hematoma accumulates between the dura and the underlying brain tissue. These are associated with skull fractures and contusions. On CT, they appear to have a crescent-shaped bor- der (Figure 78.2B). Large subdural hematomas usually require sur- gical evacuation. In infants and young children, these are often the result of nonaccidental trauma. Diffuse axonal injury (DAI) involves extensive damage to the axo- nal white matter of the brain that results from shearing forces that typically occur with rapid acceleration or deceleration of the brain (Figure 78.2C). The child with DAI may have normal or nonspecific CT findings. Selected References Atabaki SM, Stiell IG, Bazarian JJ, et al. A clinical decision rule for cra- nial computed tomography in minor pediatric head trauma. Arch Pediatr Adolesc Med. 2008 162(5):439–445 PMID: 18458190 https://doi.org/10.1001/ archpedi.162.5.439 Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg. 2001 36(8):1107–1114 PMID: 11479837 https://doi.org/10.1053/ jpsu.2001.25665 Bruce DA. Head trauma. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins 2005 Crompton EM, Lubomirova I, Cotlarciuc I, Han TS, Sharma SD, Sharma P. Meta- analysis of therapeutic hypothermia for traumatic brain injury in adult and pedi- atric patients. Crit Care Med. 2017 45(4):575–583 PMID: 27941370 https://doi. org/10.1097/CCM.0000000000002205 Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K Children’s Head Injury Algorithm for The Prediction of Important Clinical Events Study Group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 91(11):885–891 PMID: 17056862 https://doi.org/10.1136/adc.2005.083980 Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 80(24):2250–2257 PMID: 23508730 https://doi.org/10.1212/ Pathophysiology Children have significant anatomic differences from adults that pre- dispose them to head trauma and certain types of intracranial injury. They have a higher center of gravity, an increased head to body ratio, and weaker neck muscles compared with adults. Additionally, children have thinner cranial bones and less myelinated brain tis- sue, which predisposes them to intraparenchymal injuries. Whereas adults are more likely to have focal intracranial hematomas, chil- dren are more likely to develop diffuse cerebral edema. Cerebral edema can disrupt cerebral blood flow, resulting in ischemic injury. Normally, blood flow to the brain is maintained at a constant rate by the process of autoregulation. A complete blood cell count and serum electrolyte panel should be performed for all pediatric patients with significant head trauma. Eating With severe brain injury, auto- regulation is disrupted and blood flow to the brain is determined by cerebral perfusion pressure (CPP), which is a measure of the mean arterial pressure (MAP) less ICP (CPP = MAP ICP). Cerebral blood flow is therefore compromised when the MAP is too low (ie, hypotension) or the ICP is too high (ie, cerebral edema). Several of the management strategies in children with severe brain injuries focus on maintaining MAP and reducing ICP however, control of CPP after head can be quite difficult. Children have a greater capacity for recovery than adults this is especially true for infants and very young children, whose open sutures and fontanels permit expansion of the skull in response to edema and blood. In head trauma, primary and secondary brain injury can occur (Figure 78.1). Primary injury is the structural damage that occurs to the cranium and its contents at the time of injury. Secondary injury is damage to the brain tissue after the initial event. Such damage may result from hypoxia, hypoperfusion, hypercapnia, hyperther- mia, and altered glucose or sodium metabolism. The main treat- ment strategies for patients who have sustained head trauma focus on the prevention of secondary brain injury. Primary brain injury can be prevented only through education and safety, such as advo- cating for wearing helmets in appropriate situations. Differential Diagnosis minor head trauma in a child can result in skull fracture or intracranial injuries. Most skull fractures are simple and linear. Other fracture types are comminuted, diastatic, basilar, and depressed. A comminuted fracture is one involving multiple skull fragments. A diastatic fracture is one with a wide separation at the fracture site. Disorders Basilar fractures occur at the base of the skull and often have characteristic findings on physical examination (ie, bilateral peri- orbital ecchymosis [ie, raccoon eyes], hemotympanum, postauric- ular ecchymosis [ie, Battle sign]). In a depressed fracture, fragments of the skull are displaced inward, potentially damaging intracra- nial structures. Head trauma may result in concussion, mild traumatic brain injury, or intracranial hemorrhage. A concussion is defined as a trauma-induced impairment of neurologic function. This may occur with or without a loss of consciousness (LOC). Neurologic exami- nation is usually normal, but the patient may experience somatic symptoms (eg, headache), physical signs (eg, LOC, amnesia), behav- ioral changes, cognitive impairment, or sleep disturbances. Some of these minor and subtle neurologic sequelae can last for months after the injury (ie, postconcussion syndrome). Most resolve within a relatively short period, typically 7 to 10 days however, with more severe trauma the symptoms can last longer. Laboratory Tests A complete blood cell count and serum electrolyte panel should be performed for all pediatric patients with significant head trauma. Bedside glucose monitoring should be performed in any child with a head injury with an altered level of consciousness. Toxicology eval- uation may be indicated in the adolescent who appears to be intox- icated or has an altered level of consciousness. The infant or child with an intracranial hemorrhage should undergo screening coag- ulation studies (ie, prothrombin time, activated partial thrombo- plastin time) as well as a type and screen test or crossmatch, should surgery be required. Imaging Studies In cases of acute pediatric blunt or penetrating trauma, a noncon- trast CT of the head is currently the diagnostic study of choice. It is quite sensitive for the detection of acute hemorrhage and skull frac- ture. It can also provide additional information on the severity of injury, indicating increased ICP, cerebral edema, or pending herni- ation. Among the findings on CT that indicate severe brain injury are the shift of midline structures, effacement of the sulci, ventric- ular enlargement or compression, and loss of normal gray/white matter differentiation. An emergent head CT is warranted for any child with altered mental status, a GCS below 14, penetrating trauma, or focal neuro- logic deficit. The question of which children with minor head trauma should undergo CT was evaluated in a study of 17,000 children from the Pediatric Emergency Care Applied Research Network (PECARN) database. In this study, a decision rule was retrospectively derived and then prospectively validated as a method to identify children at very low risk for intracranial injury. These criteria can be found in Box 78.3. If a child is otherwise healthy and meets these criteria, the risk of intracranial injury is extremely low and the child can be safely discharged from the ED or clinic with anticipatory guidance and return precautions. Neither CT nor a period of observation is required. It should be noted that this decision rule was validated as “rule out” only and meant to identify the child at very low risk. That is, not meeting all the criteria does not mean CT is warranted. A cerebral contusion is a bruise of the brain tissue and typically occurs with a more severe injury, such as a high-speed motor vehi- cle crash. A contrecoup contusion may be sustained when the brain strikes the skull on direct impact, bruising 1 portion of the brain, with resulting injury to the side of the brain on rapid deceleration. Clinical manifestations depend on the location of the contusion but often include altered mental status, excessive sleepiness, confusion, and agitation. Small intraparenchymal hemorrhages and swelling of the surrounding tissues are often seen on computed tomography. CASE RESOLUTION The case scenario involves a young child with a significant mechanism of injury, brief LOC, and a depressed, altered mental status. Initial physical findings prompt suspicion of a depressed skull fracture and overlying soft tissue injury. Appropriate diagnostic tools after evaluation of airway, breathing, and circula- tion are cranial CT followed by admission for observation, monitoring, and serial neurologic examination. Surgical repair of the skull fracture may be necessary. Figure 78.1. Functional anatomy of the brain and surrounding structures with sites of pathology. 1, Caput succedaneum. 2, Subgaleal hematoma. 3, Cephalhematoma. 4, Porencephalic or arachnoid cyst. 5, Epidural hematoma. 6, Subdural hematoma. 7, Cerebral contusion. 8, Cerebral laceration. (From Tecklenburg FW, Wright MS. Minor head trauma in the pediatric patient. Pediatr Emerg Care. 1991 7[1]:40–47, with permission from Wolters Kluwer Health.) Table 78.2. Modified Glasgow Coma Score for Younger Children Elements Points 1. Eye opening a. Spontaneous 4 b. To command 3 c. With pain 2 d. No response 1 2. Verbal response a a. Coos and babbles 5 b. Irritable cry 4 c. Cries to pain 3 d. Moans to pain 2 e. None 1 3. Motor response a. Normal spontaneous movement 6 b. Withdraws to touch 5 c. Withdraws to pain 4 d. Abnormal flexion 3 e. Abnormal extension 2 f. None 1 Maximum score 15 a Assessment of verbal response is modified in children. 15 CHAPTER 64Even CASE STUDYinjury A 16-year-old girl is brought to the office by her mother because the mother feels that her daughter is too thin and always appears tired. The mother reports that her daughter does not eat much at dinner and generally says she is not hungry. Recently, the girl bought diet pills that were advertised online. The teenager claims that she has not taken the pills, so she does not understand why her mother is so upset. She says she feels fine and considers herself healthy because she has recently become a vegetarian. The girl is a 10th-grade student at a local public school and attends classes regularly, although her friends are occasionally truant. She is involved in the drill team, swim team, and student council. She has many friends who have “nicer” figures than she does. Neither she nor her friends smoke tobacco or use drugs, but they occasionally drink alcohol at parties. The girl is not sexually active and denies a history of abuse. Her menstrual periods are irregular, with the last occurring approximately 3 months prior to this office visit. She currently lives with her mother, father, and 2 younger siblings. Although things are “OK” at home, she thinks her parents are too strict and do not trust her. They have just begun to allow her to date, but she dislikes that she has a curfew. The physical examination is significant for a thin physique, and vital signs are normal. On the growth chart, her weight is at the 15th percentile and her height is at the 75th percentile her body mass index (BMI) is 17 (10th percentile). Her weight at a previous visit was at the 40th percentile. The remainder of the physical examination is unremarkable. Questions 1. What are the common characteristics of disordered eating in adolescents? An adolescent may have an atypical presentation for eating disorder and may not display a blatant refusal to eat but rather may exhibit subtle characteristics of disordered eating, such as constant dieting, obsession with a certain physical exercise, or irregular menstruation. The patient with eating disorder also may present with general complaints related to weight loss and nutritional or volume deficiencies, such as fatigue or syncope. Such a patient also may exhibit minimal weight gain according to standard growth charts or a delay in the onset of puberty or progression of pubertal development. 2. What are the important historical points to include when interviewing the patient with suspected eating disorder? Which teenagers are considered at risk? When interviewing the patient with suspected eating disorder, the history should address specific issues related to changes in food preferences (eg, vegetarian, vegan, low-fat diet), eating behaviors, dieting, calorie counting, weight history, exercise routine, and body image concerns. Inquiries should also focus on symptoms associated with complications of eating disorders, such as dysphagia secondary to esophagitis from recurrent vomiting, constipation from fluid restriction, and muscle weakness associated with emetine toxicity from chronic ipecac use (although ipecac is less readily available, so its effects are seen less frequently), as well as a detailed menstrual history. Particular attention should be paid to the adolescent’s overall functioning at home, with friends, and at school the presence of other comorbid psychiatric disorders (eg, depression, anxiety) and a history of suicidal ideation or sexual and/or physical abuse. Out-of-control behavior as a result of substance use also should be assessed. 3. How is the diagnosis of anorexia nervosa and bulimia nervosa made? Diagnostic criteria for anorexia nervosa (AN) include restriction of energy intake relative to requirements intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly Student worksheets corresponding to each chapter’s case study questions are available online in a user- friendly format so they can be completed to prepare for discussions.
Next Page