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PEDIATRIC EmergEnCy medicinE PRACTICE AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE s EBMEDICINE.NET April 2011 An Evidence-Based Volume 8, Number 4 Assessment Of Pediatric Author Wesley Eilbert, MD, FACEP Associate Clinical Professor, Department of Emergency Medicine, Endocrine Emergencies University of Illinois College Of Medicine at Chicago, Chicago, IL Peer Reviewers It’s 2:30 am on a slow Thursday night when the triage nurse Laura K. Bachrach, MD brings in an ill-appearing, tachypneic, and febrile 2-year-old Professor of Pediatrics, Stanford University School of Medicine, Stanford, CA; Lucile Packard Children’s Hospital at Stanford, with markedly delayed capillary refill. As you are listening to Stanford, CA inspiratory crackles in the child’s left lung, you notice that her Ara Festekjian, MD, MS medications list includes hydrocortisone and fludrocortisone. Division of Emergency Medicine, Childrens Hospital Los Angeles, Los Angeles, CA; Assistant Professor Of Pediatrics, Keck School Of You ask the child’s mother about these uncommon medications, Medicine Of The University Of Southern California, Los Angeles, CA and she informs you that her daughter has congenital adrenal Martin I. Herman, MD, FAAP, FACEP hyperplasia. As you struggle to recall the specifics of this rela- Attending, Department of Pediatric Emergency Medicine, Sacred Heart Children’s Hospital, Pensacola, FL; Professor of Pediatrics, tively rare condition, the nurse asks you whether this diagnosis Department of Pediatrics, Florida State University College of is going to change the management of this critically ill child. Medicine, Pensacola, FL CME Objectives Most emergency clinicians are quite comfortable treat- Upon completion of this article, you should be able to: ing diabetic ketoacidosis (DKA) in children, but other 1. Cite the presentation, evaluation, and treatment of adrenal insufficiency in children. rarer endocrine disorders in this population are likely 2. Cite the presentation, evaluation, and treatment of to cause anxiety in even the most well-read emergency pheochromocytoma in children. 3. Cite the presentation, evaluation, and treatment of disorders clinician. In addition to their complex pathophysiolo- involving antidiuretic hormone (ADH) in children, including gies, these disorders present with an array of nonspecific diabetes insipidus and the syndrome of inappropriate complaints — the most ominous of which is an altered antidiuretic hormone (SIADH). 4. Cite the presentation, evaluation, and treatment of mental status. This issue of Pediatric Emergency Medicine hypothyroidism and hyperthyroidism in children. Practice reviews the diagnosis and management of these Date of original release: April 1, 2011 Date of most recent review: March10, 2011 uncommon disorders, which, if left untreated, can cause Termination date: April 1, 2014 significant morbidity. Medium: Print and Online Method of participation: Print or online answer form and evaluation Prior to beginning this activity, see “Physician CME Information” on page 27. AAP Sponsor Michael J. Gerardi, MD, FAAP, Alson S. Inaba, MD, FAAP, Brent R. King, MD, FACEP, FAAP, Christopher Strother, MD FACEP PALS-NF FAAEM Assistant Professor,Director, Martin I. Herman, MD, FAAP, FACEP Clinical Assistant Professor of Pediatric Emergency Medicine Professor of Emergency Medicine Undergraduate and Emergency Attending, Department of Pediatric Medicine, University of Medicine Attending Physician, Kapiolani and Pediatrics; Chairman, Simulation, Mount Sinai School of Emergency Medicine, Sacred Heart and Dentistry of New Jersey; Medical Center for Women & Department of Emergency Medicine, Medicine, New York, NY Children’s Hospital, Pensacola, FL; Director, Pediatric Emergency Children; Associate Professor of The University of Texas Houston Adam Vella, MD, FAAP Professor of Pediatrics, Department Medicine, Children’s Medical Pediatrics, University of Hawaii Medical School, Houston, TX of Pediatrics, Florida State Assistant Professor of Emergency Center, Atlantic Health System; John A. Burns School of Medicine, Robert Luten, MD Medicine, Pediatric EM Fellowship University College of Medicine, Department of Emergency Honolulu, HI; Pediatric Advanced Pensacola, FL Professor, Pediatrics and Director, Mount Sinai School of Medicine, Morristown Memorial Life Support National Faculty Emergency Medicine, University of Medicine, New York, NY Editorial Board Hospital, Morristown, NJ Representative, American Heart Florida, Jacksonville, FL Association, Hawaii and Pacific Michael Witt, MD, MPH, FACEP, Jeffrey R. Avner, MD, FAAP Ran D. Goldman, MD Ghazala Q. Sharieff, MD, FAAP, FAAP Island Region Professor of Clinical Pediatrics Associate Professor, Department FACEP, FAAEM Medical Director, Pediatric Andy Jagoda, MD, FACEP and Chief of Pediatric Emergency of Pediatrics, University of Toronto; Associate Clinical Professor, Emergency Medicine, Elliot Hospital Medicine, Albert Einstein College Division of Pediatric Emergency Professor and Chair, Department Children’s Hospital and Health Center/ Manchester, NH of Medicine, Children’s Hospital at Medicine and Clinical Pharmacology of Emergency Medicine, Mount University of California, San Diego; Montefiore, Bronx, NY and Toxicology, The Hospital for Sick Sinai School of Medicine; Medical Director of Pediatric Emergency Research Editor Children, Toronto, ON Director, Mount Sinai Hospital, Medicine, California Emergency Lana Friedman, MD T. Kent Denmark, MD, FAAP, New York, NY FACEP Mark A. Hostetler, MD, MPH Clinical Physicians, San Diego, CA Fellow, Pediatric Emergency Tommy Y. Kim, MD, FAAP Medical Director, Medical Simulation Professor of Pediatrics and Gary R. Strange, MD, MA, FACEP Medicine, Mt. Sinai School of Center; Associate Professor of Emergency Medicine, University Assistant Professor of Emergency Professor and Head, Department Medicine, New York, NY Emergency Medicine and Pediatrics, of Arizona Children’s Hospital Medicine and Pediatrics, Loma of Emergency Medicine, University Loma Linda University Medical Division of Emergency Medicine, Linda Medical Center and of Illinois, Chicago, IL Center and Children’s Hospital, Phoenix, AZ Children’s Hospital, Loma Loma Linda, CA Linda, CA Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Eilbert, Dr. Bachrach, Dr. Festekjian, Dr. Herman, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support. Abbreviations Part I. Adrenal Insufficiency ACTH: Adrenocorticotropic hormone Critical Appraisal Of The Literature ADH: Antidiuretic hormone BUN: Blood urea nitrogen literature search was performed using Ovid CAH: Congenital adrenal hyperplasia A MEDLINE® and PubMed. Keywords included CNS: Central nervous system adrenal insufficiency, congenital adrenal hyperplasia, CSW: Cerebral salt wasting 21-hydroxylase deficiency, and stress-dose corticosteroids. DKA: Diabetic ketoacidosis Similar searches were performed in the Cochrane GI: Gastrointestinal Database of Systematic Reviews and the National ED: Emergency department Guideline Clearinghouse. EMS: Emergency Medical Services Most of the literature on pediatric adrenal FSH: Follicle-stimulating hormone insufficiency published within the past 20 years ICU: Intensive care unit has addressed its 2 main causes: congenital adrenal IM: Intramuscularly hyperplasia and adrenal suppression due to chronic IV: Intravenously corticosteroid use. Unfortunately, most of these LH: Luteinizing hormone articles are case series or observational studies, with MMI: Methimazole few clinical trials. Within the last decade, adrenal PO: “per os” by mouth insufficiency in critically ill children has become a PTO: Propylthiouracil hot topic, resulting in some well-designed studies SIADH: Syndrome of inappropriate antidiuretic that are covered in this article. hormone T : 3 Triiodothyronine Anatomy, Epidemiology, And T4: Thyroxine tid: “ter in die” three times a day Pathophysiology TRH: Thyrotropin-releasing TSH: Thyroid-stimulating hormone Acute adrenal insufficiency occurs when the adrenal cortex fails to produce enough cortisol in response to stress, which is often triggered by infection or trauma. Patients classically present with inappropri- ate and rapid decompensation in the presence of a stressor, but in some cases, symptoms develop with Table Of Contents no obvious inciting event.1 The most common cause Part I. Adrenal Insufficiency ....................................2 of acute adrenal insufficiency in North America is Part II. Pheochromocytoma .....................................5 the sudden discontinuation of or noncompliance Part III. Disorders Involving Antidiuretic with medication or emesis in patients who are on Hormone .................................................................7 long-term glucocorticoid therapy.2 Adrenal insuffi- Part IV. Thyroid Disorders ..................................... 11 ciency also occurs in patients receiving such therapy Cost- and Time-Effective Strategies ......................15 who are subjected to stressors such as sepsis, trau- Clinical Pathway For Assessment And ma, or surgery. Although it is seen most commonly Management Of Adrenal Insufficiency ............16 in patients who are taking long-term oral glucocorti- Clinical