3a paeds Flashcards
What treatment do most resp tract infections need?
nothing as most are self limiting
what is Croup and Sx?
An upper respiratory tract infection causing oedema in the larynx and a barking cough
Common causes of Croup?
parainfluenza virus
(Respiratory Syncytial Virus (RSV))
What age group are typically affected by croup?
6 month - 2 years
Tx croup?
(O2 if needed)
oral dexamethasone
What is epiglottitis?
inflammation of epiglottis
EMERGENCY!!!
Causative organism of epiglottitis?
haemophilus influenza type B
(H.influenzae B)
Now immunised against in UK
most susceptible to epiglottitis?
4-6 years old, but can affect all ages
Sx epiglottitis?
ACUTE onset, high fever, painful throat
DROOLING
Tripod position, sat forward with a hand on each knee
Tx epiglottitis?
Do not lie patient down
Do not distress patient or parent
Get a senior and secure airway
once airway is secure
IV antibiotics (e.g. ceftriaxone)
Steroids (i.e. dexamethasone)
Whooping cough
LRTI
Prolonged cough + fever for >2 weeks
Primary vaccinations completed @ 4 months
14 days erythromycin/7 days clarithromycin
What is bronchiolitis
Inflammation and infection in the bronchioles
RSV invades nasopharyngeal epithelium → increased mucus production → bronchial obstruction
Causative organism of bronchiolitis
Respiratory syncytial virus (RSV)
RFs for bronchiolitis?
prematurity, CF, immunodeficiency
Sx bronchiolitis?
winter months,
coryza/rhinitis/stuff nose
Followed by fever + dry cough, progressive dyspnoea
Tx bronchiolitis
Often nothing
O2, NGT, CPAP (continuous positive airway pressure)
Wheeze
A whistling sound caused by narrowed airways, typically heard during expiration
Stridor
A high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup
Grunting
Caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
What is pneumonia?
Infection of the lower respiratory tract and lung parenchyma which leads to
consolidation
What is consolidation in relation to respiratory disease
Air-filled spaces of the lung are filled with the products of disease
Common causes of pneumonia
Can be bacterial or virus
viral = RSV
Neonates: Group B Strep,
Infants: Strep pneumoniae=pneumonitis
School age: Strep pneumoniae=pneumonitis
Sx Pneumonia
Cough (typically wet and productive)
High fever (> 38.5ºC)
Can get some symptoms secondary due to sepsis Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
ix pneumonia
Mainly via clinical signs
CXR helpful but not necessary
Tx pneumonia
neonates - board spec IV Abx
usually amoxicillin but local guidelines
O2 if needed
what is asthma
Chronic inflammatory disease of airways with REVERSIBLE airway obstruction
Atopy
Asthma + Eczema + Hay fever
sx asthma
wheeze, dry cough, SoB, chest tightness
worse at cold, allergy, exercise and night
Asthma diagnosis
normally not before 3
history and examination
peak flow diary, spirometry with reversibility test
tx asthma step 1
short-acting beta-2 agonist inhaler (e.g. salbutamol)
tx asthma step 2
a regular low dose corticosteroid inhaler (beclomethasone)
tx asthma step 3
a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response
tx asthma step 4
Titrate up the corticosteroid inhaler to a medium dose. Consider adding:
Oral leukotriene receptor antagonist (e.g. montelukast)
inhaled long acting muscarinic antagonist (i.e. tiotropium)
tx asthma set 5
Add the one you didn’t add out of
Oral leukotriene receptor antagonist (e.g. montelukast)
inhaled long acting muscarinic antagonist (i.e. tiotropium)
For asthma before adding a new drug what must you check
Inhaler use and check with parents and child compliance
moderate acute asthma Sx and stats
breathless, but NOT distressed. O2 <92%, Peak expiratory flow rate >50% predicted
severe acute asthma Sx and stats
some signs of distress. Too breathless to talk/feed, tachypnoea, tachycardia, O2<92%, PEFR 33-50% predicted
life threatening acute asthma Sx and stats
silent chest, confusion, normal pCO2, PEFR <33% predicted
moderate asthma tx
Inhaled SABA 10 puffs, PO prednisolone, reassess in 1h
severe / life-threatening acute asthma tx
High flow O2 if sats <92%
SABA + SAMA (10 puffs, repeat every 20-30 min)
IV hydrocortisone
Otitis media
An infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (ear drum) and the inner ear.
3 bones of the middle ear
Malleus
Incus
stapes
Why are ear infections common
The bacteria enter from the back of the throat through the eustachian tube. A bacterial infection of the middle ear is often preceded by a viral upper respiratory tract infection
Sx otitis media
ear pain, reduced hearing in the affected ear and URTI sx
ix otitis media
otoscope shows a tympanic membrane that is red and inflamed
not grey and shiny
Tx otitis media
most self limiting
Abx if bad
What is glue ear
otitis media with effusion
occurs when Eustachian tube is blocked
Glue ear ix
Dull tympanic membrane (with air bubbles)
Tx glue ear
Grommet
What are grommets
Tiny tubes inserted into the tympanic membrane allow fluid out
fall out on their own
How is hearing checked
screening at birth?? and school??
First poo name
meconium
how long is normal for first poo
48 hours
secondary causes of constipation (7)
Hirschprung’s disease
Cystic fibrosis
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Cows milk intolerance
Not passing meconium
Hirschsprung’s disease
tx constipation
idiopathic constipation can be diagnosed clinically, once red flags have been
considered.
Correction of any reversible contributors e.g. high fibre diet, good hydration
Laxatives: Movicol is first line
Why is GORD so common in infants
immaturity of the lower oesophageal sphincter
sx of GORD
failure to thrive
chronic crying
difficulty feeding
ix GORD
rule out UTI
Tx GORD
usually resolved within a year
Gaviscon
thickened formula
PPI trial for 4 weeks
what is the pyloric sphincter
ring of smooth muscle between the stomach and the duodenum
What is pyloric stenosis
Hypertrophy and therefore narrowing of the pylorus
cause of projectile vomiting in pyloric stenosis
peristaltic waves trying to force food into duodenum become more powerful
eventually ejects food into oesophagus
features of pyloric stenosis
Projectile vomiting + not keeping down food
presents in first few weeks
failure to thrive
large olive in upper abdomen
blood gas pyloric stenosis
Blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid
Dx pyloric stenosis
abdo USS
tx pyloric stenosis
laparoscopic pyloromyotomy
Incision in the smooth muscle of the pylorus to widen the canal
viral causes of diarrhoea in children
Rota virus
Tx gastroenteritis
infection control
microscopy, culture and sensitivities
Fluids
what is coeliac
autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine
autoantibodies in coeliac
anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA)
specific problem in coeliac
atrophy of intestinal villi specifically jejunum
Sx coeliac (7)
asymptomatic
failure to thrive
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
genetic association in coeliac
HLA-DQ2
Tx coeliac
REMAIN EATING GLUTEN
check for specific antibodies
Endoscopy and intestinal biopsy show:
Crypt hypertrophy
Villous atrophy
IBD
Chrons and Ulcerative colitis
Inflammation of GI tract. periods of exacerbation and remission
simulation day notes
puerperium in obs notes
what is biliary atresia
narrowing or absent bile duct
leads to cholestasis
how does biliary atresia present
Jaundice for >14 days
due to increased conjugated bilirubin
(conjugated bilirubin is secreted from bile duct)
Mx biliary atresia
Kasai procedure
(surgery)
Intestinal obstruction Sx
vomiting (often bilious (green))
absolute constipation
abdo pain
distention
Common caused of intestinal obstruction in kids (4)
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Intussusception
Dx intestinal obstruction
abdo xray
showing dilated loops of bowel
Mx intestinal obstruction
Nil by mouth
paediatric surgery unit
inserting a nasogastric tube to help drain the stomach
IV fluids
what is Hirschsprung’s disease
A congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum
what is the myenteric plexus (Auerbach’s plexus)
The enteric nervous system.
function of enteric nervous system
stimulating peristalsis of the large bowel (gut motility)
Pathophysiology of Hirschsprung’s disease
absence of parasympathetic ganglion cells
causing constant constriction of large bowel
lack of motility and bowel distention
presentation of Hirschsprung’s (5)
Delay in passing meconium (more than 24 hours)
Chronic constipation since birth
Abdominal pain and distention
Vomiting
Poor weight gain and failure to thrive
What is Hirschsprung-Associated Enterocolitis
inflammation and obstruction of the intestine
life threatening and can lead to toxic megacolon and perforation of the bowel
urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel
Mx Hirschsprung’s
Abdominal xray incase of HAEC
Rectal biopsy is used to confirm the diagnosis
Definitive management is by surgical removal of the aganglionic section of bowel
what is Intussusception
One piece of the bowel telescopes inside another leading to ischaemia and bowel
obstruction
Most common in the distal ileum at the ileocecal junction
Epidemiology of Intussusception
most common in boys
3 months to 3 years
Most commonly < 1
Most common cause of obstruction in neonates
presentation of Intussusception (6)
Severe, colicky abdominal pain
Pale, lethargic and unwell child
“Redcurrant jelly stool”
Right upper quadrant mass on palpation. This is described as “sausage-shaped”
Vomiting
Intestinal obstruction
Mx Intussusception
Dx via ultrasound
Air enema
Surgical resection
most common appendicitis age
10-20
Where does pain start in appendicitis
central abdominal pain
where does pain move to in appendicitis
right iliac fossa
where is tender in appendicitis
McBurney’s point
1/3 the distance from the ASIS to the umbilicus
What is Rovsing’s sign
In appendicitis palpation of the LIF causes pain in the RIF
features of appendicitis
Loss of appetite
N+V
Rovsing’s sign
Guarding on abdominal palpation
features of peritonitis secondary to Appendix rupture
Rebound tenderness
Percussion tenderness
Differentials of appendicitis
Ectopic Pregnancy
ovarian cysts
Meckel’s Diverticulum
Tx appendicitis
Laparoscopic appendectomy
two types of cows milk allergy
IgE mediated - reaction in 2hours
non IgE mediated - reaction slowly over several days
presentation of cows milk allergy
Symptoms when breast milk ->formula
D+V
Abdo pain
bloating
Rash
swelling
Mx cows milk allergy
breast feeding mothers avoid cows milk
special formula
wait until they outgrow it
Cystitis
inflammation of the bladder
Sx UTI young children (6)
Very general
Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
Sx UTI older children
Fever
Suprapubic pain
Vomiting
Dysuria
Urinary frequency
Urine dipstick
Nitrites - bacteria
Leukocytes - WBCs
Protein - nephrotic syndrome
glucose - diabetes
Ketones - DKA?
Mx children under 3 months with a fever
All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone)
Abx for UTI in kids
LOCAL GUIDLINES
Trimethoprim
Nitrofurantoin
Recurrent UTI ix
Ultra sound to check for underlying cause or renal damage
Vulvovaginitis
Inflammation and irritation of the vulva and vagina
3-10
Why is vulvovaginitis less common after puberty
Oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection.
Mx vulvovaginitis
Good toilet hygiene
Keeping the area dry
nocturnal enuresis
bed wetting
normal when v young
can be underlying problems
Nephrotic syndrome science
Basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine.
nephrotic syndrome presentation
Frothy urine
Generalised oedema
Pallor
Nephrotic syndrome triad
Low serum albumin
High urine protein content (>3+ protein on urine dipstick)
Oedema
most common cause of nephrotic syndrome
minimal change disease
minimal change diagnosis
Urinalysis will show small molecular weight proteins and hyaline casts
renal biopsy will be normal
Mx minimal change disease
high dose corticosteroids (i.e. prednisolone).
Nephritic syndrome
nephritis/inflammation of kidneys
Sx nephritis syndrome
Reduction in kidney function
Haematuria: invisible or visible
Proteinuria: although less than in nephrotic syndrome
Common causes of nephritic syndrome
Post-streptococcal glomerulonephritis
IgA nephropathy (Berger’s disease)
post strep glomerular nephritis
1-3 weeks after a B-haemolytic streptococcus (tonsillitis)
Immune complexes get lodged in the glomeruli and cause inflammation and
AKI
IgA nephropathy (Berger’s disease)
Related to an IgA vasculitis
IgA deposits in the nephrons of the kidneys causing inflammation
post strep glomerular nephritis Mx
evidence of recent strep
conservative management
diuretics if oedema
IgA nephropathy (Berger’s disease) Mx
supportive treatment of the renal failure and immunosuppressant medications such as steroids
Haemolytic Uraemic Syndrome causes
Thrombosis in small blood vessels throughout the body
Triggered by Shiga toxins from E. coli or Shigella
Haemolytic uraemic syndrome triad
Microangiopathic haemolytic anaemia
Acute kidney injury
Thrombocytopenia (low platelets
Haemolytic uraemic syndrome presentation
Diarrhoea that turns bloody at day 3ish
Haemolytic uraemic syndrome Mx
Stool culture is used to establish the causative organism
Hospital admission and supportive management
2 types of polycystic kidney disease
Autosomal recessive polycystic kidney disease (ARPKD)
Autosomal dominant (ADPKD)
Autosomal dominant usually shows up later in life
Polycystic kidney disease presentation
Oligohydramnios and polycystic kidneys seen on antenatal scans
oligohydramnios = lack of amniotic fluid
What is Potter syndrome
Underdeveloped ear cartilage, low set ears, a flat nasal bridge and abnormalities of the skeleton.
and Pulmonary hypoplasia
Due to the lack of amniotic fluid
Tx Polycystic kidney disease
Breathing support due to pulmonary hypoplasia
Dialysis
Liver failure due to congenital liver fibrosis
WIlms tumour
Tumour in kidneys usually under 5
movement of the testes
Develop in the abdomen move through the inguinal canal into the scrotum
Normally reach scrotum prior to birth
risks of undescended testes
most spontaneously descend
Testicular torsion, infertility, cancer
if not done by 6 months surgery (Orchidopexy) considered and done before 1 year
Hypospadias
A congenital condition affecting babies from birth and diagnosed on examination
Opening of the urethra is in wrong place
hydrocele
fluid within the tunica vaginalis that surrounds the testes
soft + non tender
Light on it causes it to light up
Mx Ultrasound
