7. Practical Skills in Paediatrics Flashcards
Describe the checklist approach to acute paediatric assessment?
ABCD E-NT Temperature Tummy DEFG (blood glucose)
Other exams (neuro etc) as indicated
What is the typical presentation of nephrotic syndrome?
Anorexia,
GI disturbance,
Hx recent infections,
Irritability
Oedema (periorbital, genital),
Ascites
Oliguria.
What is an important consideration in a child presenting with peripheral oedema?
May be Dehydrated
Esp in nephrotic syndrom since onset acute.
What shows on laboratory testing in nephrotic syndrome?
URINE
Hyperalbuminuraemia
Proteinuria (300+)
BLOOD
Hyperlipidemia
Hypoalbuminaemia (so total low Ca2+);
Urea and creatinine usually normal.
What is the diagnostic criteria for nephrotic syndrome?
In order to establish the presence of nephrotic syndrome, laboratory tests should confirm the existence of
(1) nephrotic-range proteinuria,
(2) hypoalbuminemia,
(3) hyperlipidemia.
Therefore, initial laboratory testing should include the following:
Urinalysis
Urine protein quantification
Serum albumin
Lipid panel
What is the Tx for Nephrotic Syndrome?
Prednisolone 60mg/m2/day (max 80mg) for 6 weeks Stop Slowely (40mg/m2/48h for ≥6 weeks. 90% respond in 8 weeks.)
If not responding to steroids/recurrence then consider diuretics. Furosemide slow IV/PO + spironolactone.
What are the common causes of dehydration in children?
Infectious- Viral/ Bacterial gut organisms Urinary tract infection Bronchiolitis Diabetic Ketoacidosis (DKA) High output ostomy Insensible losses (especially neonates)
What symptoms may point to a Dx other than Gastroenteritis in a child with nausea and vomitting?
Temp ≥38 if <3mths or ≥39 if older. SOB Tachycardia Altered Conscious State Neck Stiffness Bulging Fontanelle? Non blanching rash Blood/mucous in stool Severe or Localised Abdo Pain Abdominal Distension or Rebound Tenderness
What are the symptoms of dehydration in the newborn/infant?
Prolonged Cap Refill (sternum 5s, normal = 2s return)
Eyes Sunken + Tearless
Tachycardia
Hypotension
Peripheral Vasoconstriction
Weight Loss
Sunken Fontanelle
Reduced LOC
Dry Mucous Membranes
How would you quickly assess dehydration in child?
Dry Mucous Membranes Very Dehydrated = Skin Turbor (firm when pinched) Lethary Less Wet Nappies (From mother) BP Drop (Late sign – Acute!) HR+RR Increase Cap Refill (Sternum)
How is dehydration classified?
Mild: Just clinically detectable (3%)
Moderate: Dry mucous membranes, reduced skin turgor (5%)
Severe: As above with sunken eyes, poor capillary return + shock may be severely ill with poor perfusion, thready rapid pulse (8%)
(Don’t use an estimation of greater than 8%. NB: 8% dehydrated = water deficit of 80mL/kg)
What is the Mx for dehydration?
Oral rehydration solution – most GE can be managed with little and often appropriate oral fluids
Naso-gastric – an alternative to oral…
IV fluids – Need to treat shock
What is the Tx for shock from dehydration?
If shocked or severe dehydration give a bolus.
Normally 20/mL kg of 0.9% Normal saline
Except in DKA (10mk/kg), heart failure or any surgical patient
If low sugar 2.6mmol/L then need to give a bolus of 10% dextrose 2ml/kg
What are the daily fluid requirements for infants and children?
100 ml/kg/day for first 10 kg
+50 ml/kg/day for the second 10kg
+20 ml/kg/day for each kg thereafter
What are the clinical features of DKA?
Polyuria
Polydipsia
Polyphagia (hunger)
Weight Loss
Kussmaul Respirations
Ketotic Breath
Signs of Shock
How is DKA diagnosed?
Requires the combination of
- Hyperglycaemia (≥11mmol/L)
- Acidosis (venous pH <7. 1
Describe the Management of DKA?
ABCDE
Consider securing airway (OrPhar+100%o2/intubate)
Rapidly confirm diagnosis: with history, finger-prick glucose + ketones; venous blood gas; urine dip for ketones/glucose.
- Assessment of dehydration
Degrees of dehydration- mild, moderate, severe
GCS (True common rare <10%) - IVF resuscitation
Bolus
Maintenance (100, 50, 20)
Correction - Complications
Electrolyte imbalance
Cerebral Oedema
Fluid Management in DKA requires special considerations, what are they?
The objective is to restore sugar levels using insulin.
However it must be done slowly to avoid cerebral oedema.
As sugar comes down acidosis and ketones will correct.
Bicarb is superfluous except in severe shock.
Potassium should not be given until the child passes urine.
Blood should be repeated every hour.
How do we calculate the fluid to be given in DKA?
Hourly rate = (48h maintenance + deficit – fluid already given) ÷ 48
What is the bolus?
10ml per kg normal 0.9% saline
What is the maintenance fluid?
100ml/kg for 1st 10kg
50ml/kg for 2nd 10kg
20 ml/kg for 3rd 10kg
PER 24 HOURS (x2 or oxford 48 hour calculation)
How do we correct?
Minus any fluid already given as resuscitation fluid.
What are the symptoms of Cerebral Oedema?
Headache Irritability Cranial nerve palsy Seizure Abnormal posturing Papilloedema
Bradycardia
Hypertension
Irregular respirations
What is the treatment?
Call your senior
Exclude hypoglycaemia
Mannitol 0.25–1.5g/kg IVI or NaCl 2.7% 5mL/kg
Restrict IV maintenance fluids by 1⁄2 and replace
deficit over 72h
Move to PICU and do CT
Treat sepsis vigorously
Lecture: Elevate head, Reduce fluids, Mannitol, Anaesthetics, Neuroimaging- CT Brain, PICU
Outline the Stepwise approach in asthma treatment?
Step 1 = Mild Intermittent = Inhaled Short Acting Beta-Agonist As Req
Step 2 = Regular Preventer Therapy = Add Inhaled Corticosteroid or LRA.
Step 3 = Initial Add-On Therapy = Consider Addition of Leukotriene Receptor Agonist. If already on LRA’s consider addition of corticosteroids
Step 4 = Referral to respiratory physician.
