AHN 548 Unit 2 Flashcards
Unit 2
What is autosomal dominance
mutation has occurred in 1 gene of an allelic pair and that the presence of this new gene produces enough of the changed protein to give a different phenotypic effect
characteristics of autosomal dominant inheritance (4)
- trait appears with equal frequency in both sexes, 2. at least 1 parent must have the trait unless a new mutation has just occurred, 3. when homozygous individual is mated to a normal individual, all offspring will carry trait. if heterozygous individual is mated to a normal individual, 50% of offspring will show trait, 4. if the trait is rare, most persons demonstrating it will be heterozygous
characteristics of autosomal recessive inheritance (5)
- characteristic will occur with equal frequency in both sexes. 2. for characteristic to be present, both parents must be carriers of recessive trait. 3. if both parents are homozygous for the recessive trait, all offspring will have it. 4. if both both parents are heterozygous for recessive trait, 25% of offspring will have it. 5. frequent occurrence of individuals with rare recessive characteristics, consanguity is often present
x linked recessive, what is it
occurs when gene on x chromosome undergoes mutation and the new protein formed as a result of this mutation, is incapable of producing a change in phenotype characteristic in the heterozygous state
x linked recessive characteristics (4)
- condition occurs more commonly in males than in females. 2. if both parents normal and an affected male is produced, it must be assumed that the mother is a carrier of the trait. 3. if father is affected and an affected male is produced, the mother must be at least heterozygous for the trait. 4. female with trait may be produced in 2 ways: may inherit a recessive gene from both her mother and father (father is affected and mother is heterozygous), may inherit recessive gene from 1 of her parents and may express the recessive characteristic as a function Lyon hypothesis
examples of autosomal dominant conditions and traits (11)
cataracts, color blindness (yellow blue), deafness, Huntington’s chorea, keloid formation, marfans syndrome, mitral valve prolapse, muscular dystrophy, pectus excavatum, von willebrand, wolff-parkinson-white syndrome
examples of autosomal recessive conditions (9)
albinism, total color blindness, cystic fibrosis, deafness, galactosemia, glaucoma, phenylketonuria, sickle cell anemia, tay Sachs disease
ABCDE of primary survey if trauma (what do these letters stand for)
airway, breathing, circulation, disability (Neuro), exposure
CAB meaning for patients that are apneic or have agonal breaths
chest compressions, open the airway, provide two rescue breaths
airway : primary survey
failure to maintain airway most common cause of preventable death; give all pts high flow 02 at 100%, apply manual stabilization of neck then apply collar
signs of pneumothorax
asymmetric breath sounds, trachael deviation, cyanosis, bradycardia
How to evacuate tension pneumothorax
insert large bore catheter over needle assembly attached to a syringe through 2nd intercostal space, midclavicular line. withdraw air
tx for pneumothorax and hemothorax
place chest tube in 4th or 5th intercostal space in anterior axillary line. insert over rib to avoid neurovascular bundle. connect to water seal
tx for open pneumothoraces
treat temporarily with petroleum gauze tapped on 3 sides to create flap
when does child need endotrachael intubation
Glasgow less than 9 (decreased loc), need for prolonged ventilation, severe head trauma, or impending operative intervention
airway route of choice for children
orotrachael intubation, no need for cervical manipulation
contraindication for nasotracheal intubation
midfacial injury
risk associated with use of LAM ( laryngeal mask airway
risk for aspiration, shouldn’t be used for prolonged definitive airway management
external hemorrhage control
direct pressure, only use hemostats on scalp
signs of cardiac tamponade
s/p penetrating or blunt injury. signs: shock, pulseless electrical activity, narrowed pulse pressure, distended neck veins, hepatomegaly, muffled heart sounds
diagnostic and tx for cardiac tamponade
ultrasound, pericardiocentesis and rapid volume infusion
treatment for poor perfusion
rapid infusion of normal saline or LR at 20ml/kg of body weight. if no improvement after 2 boluses, give 10 ml/kg of RBCs
assessment of Neuro deficit
assess pupils, level of consciousness, use AVPU or Glasgow
maintaining body temp in child with injuries
hyperthermia compromises outcomes in children with acute brain injuries
signs of urethral transection
blood at meatus or in scrotum, or displaced prostate. foley is CONTRAINDICATED
urine output for children with foley
1 ml/kg/h
AMPLE for obtaining history
allergies, medications, past medical hx/ pregnancy, last meal, events/ environment leading to injury
skin physical assessment for injured child
search for lacs, hematoma, burns, swelling, bruising, remove foreign body. ask about tetanus vaccination
head physical assessment for injured child
check for hemotympanum, clear or bloody cerebrospinal fluid leak from nares. battle sign ( hematoma over mastoid). raccoon eyes sign of basilar skull fx. look for wounds, foreign body. CT scan
sign of basilar skull fx.. what vaccine to give
raccoon eyes. consider pneumococcal vaccine
spine exam of injured child
check for spine pain with palpation. obtain xray…if child is obtunded still wait for child to awaken before clearing spine
seat belt sign
abdomen pain and tenderness with linear contusion across abdomen. increases risk of intra abdominal injury
x linked dominant definition
mutation will produce a protein when present in heterozygous state, sufficient to cause change in characteristic
characteristics of x linked dominant
- characteristic occurs with same frequency in males and females, 2. affected male mated to normal female will produce characteristic in 50% of offspring, 3. affected homozygous female mated to normal male will produce characteristics in all offspring, 4. heterozygous female mated to normal male will produce characteristic in 50% of offspring, 5. occasional heterozygous females may not show the dominant trait on the basis of the Lyon hypothesis
polygenic inheritance def and examples
inheritance of single phenotypic feature as a result of the effects of many genes. examples : cleft lip, club foot, meningomyelocele, dislocation of hip
mitosis
division of somatic cells
prophase
chromosome filaments shorten, thicken, and become visible. 2 long parallel spiral strands lying adjacent to one after. stands begin to unwind, nuclear membrane disappears
metaphase
2nd phase of mitosis, formation of spindle and lining up of chromosomes in pairs
anaphase
3rd phase of mitosis, centromere divides and each daughter chromatid goes to 1 of poles of the spindle
signs of pelvic fx
pain, crepitus, abnormal motion. foley insertion contraindicated
tx goals for acute head injury in children
aggressively treat hypotension to optimize cerebral perfusion, provide supplemental o2 to keep above 90%, achieve eucapnia (end tidal co2 35-45 mm hg), avoid hyperthermia, minimize painful stimuli
tx of choice for acute seizures in children in hospital
fosphenytoin or levetiracetam
most common head injury in children
traumatic brain injury
head injury symptoms
non specific, headache, dizziness, n/v, disorientation, amnesia, slowed thinking, preservation
AVPU
alert, responsive to voice, responsive to pain, unresponsive
Glasgow coma scale
score 3 to 15, under 8 indicates cns depression requiring positive pressure ventilation
imaging for head injury
CT
head injury differential diagnosis
cns infection, toxicological ingestion, inborn errors of metabolism
risks associated with open head injury, precautionary tx
risk for infection due to direct contamination. allow entry portal for streptococcus pneumoniae. give pneumococcal vaccination
early symptoms of acute intracranial hypertension
ams, headache, vision changes, vomiting, gait difficulties, pupillary abnormalities, PAPILLEDEMA, stiff neck, cranial nerve palsies, hemiparesis
late signs of acute intracranial hypertension
Cushing triad (bradycardia, hypertension, irregular respirations
diagnostics for acute intracranial hypertension
consider CT before lumbar puncture due to risk of herniation
ICP tx in children
intubate, give sedative and paralytic. maintain pco2 between 35 and 40, give mannitol. elevate HOB, keep head midline, consult neurosurgery
s/p concussion in children
no sports until symptom free at rest and with exercise without medication use. usually 1 to 2 weeks
superficial thickness burns
painful, dry, red, hypersensitive. ex:sunburn
superficial partial thickness burns characteristics
red, blister
deep partial thickness burn characteristic
pale, edematous, blanch with pressure, decreased sensitivity to pain
full thickness burns
white or black, dry, depressed, leathery, no sensation
deep full thickness burns
most severe, burn down to muscle and bone
compilation of severe burns
contracture, compartment syndrome, renal failure secondary to myoglobinuria from rhabdomyolisis
major burn category areas
hands, feet, face, eyes ears, perinuem
what types of burns are counted when calculating % body surface area
partial and full thickness. NOT superficial
tx for superficial and partial thickness burns
Pain control, saline irrigation, application of antibiotic ointment and nonadherent dressing (petroleum gauze). leave small blisters intact. drain larger blisters or leave intact, then protect with bulky dressing. reexamine in 48 hours.
home tx for superficial and partial thickness burns
cool compress, hydrocodone or oxycodone
oral or nasal burn/ inhalation injury actions and considerations
establish artificial airway. singing of oro or nasophharynx needs immediate intubation. consider toxicity from carbon monoxide, cyanide, or other combustion products. place ng tube and foley
fluid resuscitation for full thickness and deep burns
fluid needs are based on weight and percentage of BSA. parkland formula for fluid therapy is 4 mL/kg/% bsa burned for 1st 24 hours with half administered in 1st 8 hours along with maintenance rates. urine output should be 1 to 2 mL/kg/hr
admission for children with burns
burns greater than 10% BSA/ inhalation injuries/ abuse should be admitted. admission warranted for adequate pain control. burns greater than 20% or full thickness greater than 2% should be admitted to children’s center or burn center with burn specialist
burn prognosis
the greater the surface area and depth of burn the greater the risk of long term morbidity and mortality .
electrical burns in children: what to expect
children awake and alert at time of eval after electrocution, ecg not necessary. exposure to high voltage current causes “locking on” effect causing tetany. Can cause extensive nerve and muscle injury, fxs, and cardiac arrhythmias
heat cramps
brief severe cramps of skeletal or abdominal muscles following exertion. core temp is normal or slightly elevated. No lab eval indicated
heat exhaustion
pt sweats and have varying degrees of sodium and water depletion. core temp normal or slightly increased. weakness, fatigue, headache, disorientation, pallor, thirst, nausea, muscle cramps, possible shock.
heat stroke
life threatening, neuro dysfunction. same symptoms as great exhaustion but severe cns dysfunction is hallmark. incoherent/ combative. severe cases include vomiting, shivering, coma, seizures, nuchal rigidity and posturing.
diagnosis of heat stroke
rectal temp above 40.6 C (105 F)
severe complications of heat stroke
cellular hypoxia, enzyme dysfunction and disrupted cell membranes lead to global end organ derangement. may develop rhabdomyolysis, myocardial necrosis, electrolyte abnormality, acute tubular necrosis, renal failure, hepatic degeneration, acute respiratory distress, DIC
heat stroke differential diagnosis
viral gastroenteritis, sepsis, neuroleptic malignant syndrome, malignant hyperthermia, anticholinergic poisoning
heat cramps tx
get out of heat, remove clothing, rest, rehydrate with electrolyte solution
heat exhaustion tx
iv fluid rehydration
heat stroke tx
address ABCs and give o2, place monitor, rectal temp, foley and ng tube. give iv fluids isotonic crystalloid for hypotension, give diazepam for comfort, central venous pressure monitoring. active cooling (stop at 39 C or 102 F to prevent shivering) admit pt PICU
heat stroke labs
cbc, electrolytes, glucose, creatinine, pt and put, creatine kinase, liver function test, abg, urinalysis, serum calcium, magnesium and phosphate
prognosis for heat cramps, heat exhaustion and heat stroke
heat cramps and heat exhaustion: full recovery; heat stroke: risk of end organ damage…but should recover fully
hypothermia
core temp under 35 C (95 F), usually related to water submersion
hypothermia symptoms
peripheral vasoconstriction, cool mottled skin, shivering, temp falls, heart rate slows, mental status declines. severe cases mimic death: pale, cyanotic, pupils fixed or dilated, muscle rigidness , may not have palpable pulses. HR of 4 -6 beats per min may be adequate perfusion due to lowered metabolic needs in severe hypothermia. don’t call death until unresponsive after rewarmth and resuscitation efforts
causes of hypothermia besides cold exposure and who’s at risk
sepsis, metabolic derangement, ingestion, cns disorder, endocrinopathies. neopates, trauma victims, and chronically disabled most at risk.
labs and imaging for hypothermia
cbc, electrolytes, coagulation studies, glucose, and blood gas studies, cxr
hypothermia tx
may go into asystole or v give, start cpr, defibrillation and epi won’t work until pt is rewarmed. cover with blankets, warm bath immersion, watch for afterdrop (drop in temp after rewarming). extensive warming is warmed 02,warm crystalloid fluids, warm peritoneal and pleural lavage
hypothermia prognosis
may have cns anoxic injuries and lung injury
risk factors for submersion injury
epilepsy, alcohol, lack of supervision
submersion injury symptoms
cough, nasal flaring, grunting, retraction, wheezes, cyanosis. child rewarmed but remains apneic and pulseless will probably not survive or will have severe Neuro deficits
imaging for submersion injury
cxr and ct brain
submersion injury complications and prognosis
anoxia from laryngospasm or aspiration leads to irreversible cns damage after 4 to 6 minutes. protection from anoxia only occurs if child falls through ice or directly into icy water
options for laceration repair
staples, sutures, tissue adhesive (never use on highly contaminated wound like a bite)
laceration tx
give pain medication, irrigate with normal saline or tap water, debride tissue, remove foreign material, closure, antibiotic ointment, tetanus shot
infection from dog bites
dogs may carry pasteurella canis, pasteurella multocida, and streptococci staphylococci. treat with amoxicillin and clavulanic acid
complications of dog bites
scarring, infection, cns infection, septic arthritis, osteomyelitis, endocarditis, sepsis, posttraumatic stress
complications of cat bite
tenosynovitis, septic arthritis, cellulitis
cat scratch disease findings
papule, vesicle, or pustule at site of inoculation. hallmark of csd is regional lymphadenitis
cleaning of cat puncture wounds
high pressure irritation contraindicated since it may force bacteria deeper. soak in dilute providone iodine solution for 15 minutes. give tetanus shot, DO NOT close wound
infection from cat wound
p multocida is most common pathogen in cats. give first line amoxicillin and clavulanic. admit pt if infected wound is hand or foot
absorption rates in order
iv, inhalation, sublingual, IM, subq, nasal, oral, rectal, dermal
body burden
total amount of drug or toxin within body and may be useful to determine dose absorbed from ingestion
blood levels in poisoning
Don’t go by blood levels. treat symptoms
high risk ingestant
caustic solutions, hydrogen fluoride, drugs of abuse, or medications such as calcium channel blocker, opiod, hypoglycemic, and antidepressant. and also if poisoning was intentional
skin burn from contaminant tx
flood with sterile saline solution or water
emesis and lavage in Peds pt
don’t use in routine management of poisoning
charcoal use in peds
shouldn’t be used routinely, never give to those with ams who can’t protect airway. repeat 4 to 6 hours until passed through rectum. DON’T use for ingestion of heavy metals, hydrocarbons, caustic, and solvent ingestions
charcoal dosage peds
1 to 2 g/kg (max 100 g) per dose. repeat dose for slow passage agents, but DON’T repeat sorbitol or saline cathartics (would cause fluid loss and electrolyte imbalances)
use of cathartics in peds
don’t improve outcome and should be avoided
whole gut lavage in peds
orally administered, non absorbable hypertonic solution (golytely). use with poisoning with sustained release preparations, mechanical movement of items through bowel (like cocaine packets) and poisoning with substances poorly absorbed by charcoal (like lithium and iron). contraindications in those with intestinal blockage
alkaline diuresis for enhanced excretion
used for tx of salicylate toxicity and to prevent methotrexate used on substances whose pK8 is less than 7.5. sodium bicarb used. observe for hypokalemia.
hemodialysis for peds poison treatment
used when potentially life threatening toxicity is caused by dialyzable drug and cannot be treated by conservative means, or there renal failure or insufficiency, or marked hyperosmolality or severe acid base or electrolyte disturbances not responding to therapy
poisoning by Tylenol/paracetamol tx
abnormalities in liver function may not show for 72 to 96 hrs. treat with acetylcysteine (acetadote) oral or IV. get blood levels 4 hours after ingestion
acetylcysteine dosage for over 40kg
over: IV administered as loading dose of 150mg/kg administered or 15-60 minutes, followed by infusion of 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours
alcohol/ethanol consumption in children
children show change in sensorium with blood levels as low 10 to 20 mg/dL and should be seen immediately. intoxication increases risk of subarachnoid hemorrhage
alcohol/ethanol consumption tx
manage hypoglycemia and acidosis. start IV drip of d5w or d10w if bg less than 60. death is usually because of resp failure. in severe cases, cerebral edema may occur
amphetamine acute poisoning symptoms
common poisoning because diet pills and it’s use in adhd medication. anxiety, hyperactivity, hyperpyrexia, diaphoresis, htn, abd cramps, n/v, and inability to void urine, hyponatremia and seizures. severe cases lead to rhabdomyolysis and toxic psychosis
chronic amphetamine use symptoms
high tolerance, hyperactivity, disorganization, and euphoria followed by exhaustion, depression, and coma lasting 2 to 3 days. psychosis
amphetamine tx
benzodiazepine (lorazepam) titrated in small increments. give droperidol or haldol for extreme hallucinations or agitation. control hypertherrmia. psych treatment as well
local anesthetics (lidocaine) poisoning symptoms
cns stimulation, acidosis, delirium, ataxia, shock, convulsions and death. can cause fetal death
local anesthetic poisoning tx
if swallowed, clean mucous membranes, give 02. treat methemoglobinemia with methylene blue 1% over 5 to 10 minutes to relieve cyanosis. treat acidosis with sodium bicarb. treat seizures with benzos. treat bradycardia with atropine. give fat emulsion therapy for cardiac arrest
antihistamines and cold med toxicity symptoms
excitement, hallucinations, delirium, ataxia, tremors, convulsions followed by cns depression, resp failure, or cardio collapse. dry mouth, fixed dilated pupils, flushed face, fever
antihistamines and cold med toxicity tx
benzos (ativan) to control seizure and agitation. physostigmine to reverse symptoms. treat dysrhythmia and hypotension with normal saline and a vasopresser
arsenic poisoning, commonly found in
fruit tree, insecticide, and tobacco spray. seafood exacerbates concentration.
arsenic poisoning acute symptoms
abdomen pain, vomiting, watery and bloody diarrhea, cardi collapse, paresthesia, neck pain, garlic breath
arsenic poisoning chronic symptoms
anorexia, generalized weakness, giddiness, colic, abdomen pain, polyneuritis, dermatitis, nail changes, alopecia, anemia
barbiturate poisoning symptoms
confusion, poor coordination, coma, miotic or fixed dilated pupils, resp depression, resp acidosis, atelectasis, hypotension
benzo poisoning symptoms
cns depression, lethargy without hemodynamic compromise in small amounts, large overdose can cause resp and cardiac depression
barbiturate and benzo tx
maintain airway, treat hypotension, urinary alkalinization , charcoal. flumazenil for cns and resp depression
beta blocker and calcium channel blocker toxicity symptoms
bradycardia, hypotension, heart block, dysrhythmia, cns depression
beta blocker and calcium channel blocker toxicity tx
iv fluid (isotonic), give around for bradycardia, give calcium and glucagon . if still hypotensive give vasopressor (dopamine, norepinephrine)
carbon monoxide poisoning symptoms
non specific, headache or flulike symptoms, confusion, unsteadiness, coma. permanent cardiac, liver, or cns damage may occur.
carbon monoxide poisoning lab findings
proteinuria, glycosuria, elevated serum amniotransferase
carbon monoxide poisoning tx
give 02 immediately (hyperbaric too)
acids poisoning where are they found, symptoms
metal, toilet bowl cleaners, batteries. symptoms coagulative necrosis. burns skin and mucous membranes. hydrofluoric acid can cause penetrating burn for hours or days and cause life threatening hypocalcemia
alkali poisoning examples and symptoms
more severe reaction than acid. results in liquefactive necrosis. burns skin and mucous membranes. ex. Clorox, drano, purex
acid and alkali poisoning tx
emetics and lavage are CONTRAINDICATED. wash burned areas with copious amounts of warm water. irritate eye for 20 minutes. may need intubation. treat hydtofluoric burns with calcium glyconate gel or infusion
cocaine poisoning
tachycardia, hyperpnea, htn, stimulation of cns followed by coma seizures, hypotension, and resp depression. may have dysrhythmias
tx for cocaine toxicity
charcoal for body stuffers and whole bowel irrigation for body packers. treat seizures and agitation with lorazepam
symptoms of overdose of cyclic antidepressants
sudden onset coma within 1 to 2 hours. convulsions, hypotension, dysrhythmia
tx and diagnostic of overdose of cyclic antidepressants
charcoal and benzos, ecg, sodium bicarb for reverse ventricular dysrhythmia and qrs changes. physostigmine contraindicated. give dopamine or norepinephrine for hypotension
tx for lomotil toxicity
pulse of monitoring, give naloxone hydrochloride for respiratory depression
5 stages of iron toxicity
- hemorrhagic gastroenteritis (30 to 60 minutes after ingestion) associated with shock, acidosis, coagulation defects, and coma, lasts for 4 to 6 hours 2. phase of improvement, lasts 2 to 12 hours. 3. delayed shock (12 to 48 hours after ingestion) metabolic acidosis, fever, leukocytosis, coma. 4. liver damage, hepatic failure. 5. residual pyloric stenosis (4 weeks after ingestion)
urine after iron toxicity
red color prior chelation, means iron over 350 mg/dL
iron toxicity tx
gastric lavage and whole bowel irrigation. deferoxamine for chelating iron, contraindicated in patients with renal failure unless on dialysis. fast infusion can cause hypotension, flushing, urticaria, tachycardia and shock
lead poisoning (plumbism) symtoms
vague, weakness, irritability, weight loss, vomiting, personality change, ataxia, constipation, headache, colicky abdomen pain. late manifestations: developmental delays, convulsions, coma, increased icp (medical emergency)
lead poisoning labs and findings
cbc, serum ferritin. glycosuria, proteinuria, hematuria, and aminoaciduria. may have normocytic slightly hypochromic anemia. csf pressure and protein is elevated.
lead poisoning tx
succimer used in asympyomatic children with blood lead over 45 mcg/dl. dimercaprol and calcium sodium edetate in symptomatic children with blood level over 70. treat encephalopathy with anticonvulsants. give diet high in calcium and phosphorus
metatarsus adductus signs
Inward deviation of the forefoot. Most common foot abnormality. Angulation occurs at the base of the 5th metatarsal causing prominence of this bone. Could be caused by intrauterine positioning . associated with hip dysplasia
metatarsus adductus tx
Fully flexible deformity requires no treatment, but if the deformity is rigid and cannot manipulated past the midline it is worth while to perform serial casting.
club foot (talipes equinovarus) signs
Plantar flexion of the foot at the ankle joint, inversion deformity of the Heel, and medial deviation of the forefoot. associated with spine problems
club foot tx
Manipulation of the foot to stretch the contracted tissues on the medial and posterior aspect followed by casting to hold the correction. Serial casting performed weekly for 6 to 8 weeks. if severe percutaneous Achilles tenotomy is performed.
flat foot signs
Flat foot is normal in infants. make sure heel cord is not too short and infant has arch when sitting in non weight bearing position. rule out tarsal coalition/fusion
flat foot tx
No treatment indicated unless there is calf or leg pain. Supportive shoe can be use
talipes calcaneovalgus signs
Excessive dorsiflexion at the ankle and eversion of the foot. Usually due Intrauterine position
talipes calcaneovalgus tx
Passive exercises common stretching the foot into a plantar flexion Should resolve by age 3 to 6 months
cavus foot signs
Unusually high longitudinal arch of the foot. usually will have a claw toe as well. could be associated with poliomyelitis, diastematomyelia. will have pain
cavus foot tx
othotic to realign the foot. Surgery may be necessary to lengthen the contracted extensor and flexor tendons and to release the plantar fascia and other tight plantar structures
bunion (hallux valgus) sign
most common forefoot abnormality. Lateral deviation of the great toe associated with prominence over the head of the 1st metatarsal. Painful with shoe wear
bunion tx
surgery after bones are completely mature in adulthood
genu varum signs and tx
means bowleg. normal from infancy to age 3. associated with blount dz. may need brace or osteotomy
genu valgum
means knock knee, from age 4 to 9 is normal
tibial torsion
internal rotation of of tibia. normal from birth to 16 months. usually resolves spontaneously.
femoral anteversion
causes toeing beyond age 2 to 3. should resolve spontaneously. encourage activities like skating
developmental dysplasia of hip signs and diagnosis
will feel slipping of joint when performing ortolani sign. may also be able to easily dislocate with barlow sign. Can only abduct up to 60 °. galeazzi sign: uneven knees, lower knee is dislocated hip. will have painless limp when walking. may waddle of both hips displaced.
hip dysplasia tx
can be reversible if fixed in first few weeks of life. most undergo spontaneous correction by 2 to 6 weeks of age. use pavlik harness in first few weeks of life. DON’T do forced and extreme reduction…can lead to necrosis of femoral head. if severe will need closed reduction and then spica cast.
torticollis signs
occurs usually due to injury to sternocleidomastoid muscle during delivery. may follow uri or mild trauma in kids. head will tilt to the side opposite of affected muscle
torticullis tx
need passive stretching in 1st year of life. surgery may be needed to release muscle.
scoliosis signs
lateral curvature of spine and rotation of vertebrae. waistline asymmetry and deformity of rib cage. most common in girls (develops around age 8 to 10) and usually idiopathic.
scoliosis signs
lateral curvature of spine and rotation of vertebrae. waistline asymmetry and deformity of rib cage. most common in girls (develops around age 8 to 10) and usually idiopathic.
scoliosis tx
bracing can be used on curvature 20 to 40°. surgical correction needed over 40°. need rods and fusion
marfan syndrome
connective tissue disorder. unusually long fingers and toes (arachnodactyly), hypermobility of joints, subluxation of ocular lenses (or other eye probs), high arched palate, possible to have scoliosis, pectus carinatum, aortic aneurysms
marfan syndrome tx
supportive. manage bp. restrict physical activity. may need bracing
osteogenesis imperfecta signs
genetic connective tissue dz. have multiple and recurrent fractures. may be autosomal dominant (1-5) or autosomal recessive ( 6-11). fx may happen intrauterine. may have dwarfism. blue sclerae, thin skin, hyeperextensive joints. cardio and resp probs
osteogenesis imperfecta tx
surgical tx of long bones. rods placed for fx prevention. usually wheelchair bound by adulthood. biphosphates used for fx prevention
ankle sprains signs and tx
happens due to forceful inversion or eversion, causing tearing of lateral or medial ligaments. tx: immobilization with splint and rest ( use crutches). may do functional rehab
knee sprains signs and tx
pulling of collateral and cruciate ligaments…umcommon. tx: refer to specialist if edema present
internal derangement of knee
clicking or locking of knees can be heard. get stress films
back sprains
unusual in kids but may occur in trauma. cause lateral and midline pain. check differential of kidney issues, infection and tumors.
contusions
muscle contraction with hematoma cause charley horse. tx: ice, compression, rest. no exercise for 5 to 7 days . may use heat after initial healing
osteochondroma
most common benign bone tumor in kids. pain free mass. capped with cartilage. result from defect of growth plate and grow during childhood. near metaphyseal region of long bones. tx: should be excised if it affects function or causes deformity
baker cyst
herniation of synovium of knee joint into popliteal region. self limiting. may aspirate mucinous fluid to diagnose
ganglion cyst
smooth small cystic mass connected by a pedicle to the joint capsule usually on dorsum of wrist. self limiting
legg calve perthes
occurs between age 4 and 8. vascular supply to proximal femur is interrupted. pain, limp. on imaging will see effusion of joint, widening of joint space. tx: protect joint by minimizing impact
Concussion: what is is?, symptoms?
occurs when direct blow to body or head translates forces in to the brain, causing transient alteration of neuro function. Confusion, headache, visual disturbance, posttraumatic amnesia, balance problems
What to do after concussion
don’t leave pt alone in initial hours, only do CT if pt deteriorates, symptoms resolve in 7-10 days. need physical an cognitive rest for 1 to 2 days. Don’t return to play until 24 hours asymptomatic
Fracture of clavicle
caused by trauma or fall on outstreched hand, tx: pain control, apply sling and swathe. then early progressive rehab is important. no contact sports for 8-12 weeks. only surgery needed for open fractures or those with neurovascular compromise
acromioclavicular separation
injury from fall on shoulder. acromioclavicular joint capsule tearing. there will be soft tissue swelling and tenderness, positive cross arm test. tx: rest and immobilization in sling with progressive rehab and return to activity in 1 to 6 weeks.
fx of humerus
injury from significant fall on outstreched arm or shoulder, severe pain, swelling, and deformity. assess brachial plexus and radial nerves. apply sling for 4-6 weeks followed by return to play in 8 to 12 weeks
acute traumatic anterior shoulder instability
Injury with an abducted and externally rotated arm. pt has severe pain and mechanical block to motion. some pts will spontaneously reduce but most need closed reduction. don’t need sling. may reoccur
Rotator cuff injury
usually due to repetitive overuse and tissue failure. usually tendonitis and bursitis. present with pain in anterior and lateral shoulder. rehab of injury needed
Little league shoulder
participate in throwing sport, overuse injury (age 11-14). pain in lateral aspect of humerus with throwing. swelling around shoulder. xray may show widening and sclerosis. tx: rest from throwing, PT for rehab
epicondyle apophysitis/little league elbow
participate in throwing sport, overuse injury (age 9-12). pain in medial elbow. Tx: complete rest from throwing activities, restricted throwing for up to 6 weeks
distal phalanx injury
splint for 3 to 6 weeks or until pt is pain free. surgical k wire can be used for reduction. may have nail bed injury
distal interphalangeal injury
ball handling sports, forced flexion against actively extending finger. present with flexion contracture, inability to extend distal phalanx. tx: splinting for 4 weeks for fx and 6 to 8 weeks for tendon repair
thumb injury
skier’s thumb, injury to ulnar collateral ligament from forced abduction of the thumb MCP. need thumb spica cast 4 to 6 weeks. need surgery if severe
hand fxs
check fingers for growth plate involvement, rotation and displacement. if stable, splint for 3 to 4 weeks and buddy taped for immediate return to sports. all other should be referred to ortho surgeon. boxer fx needs hand based casting for 4 weeks
wrist injury
distal and radial injuries require casting for 3 to 6 weeks in short or long arm cast, torus or buckle fxs may be placed in rigid brace for 3 to 4 weeks
hamstring strain
mechanism is forced knee extension. pain with tearing or popping sensation in posterior leg, common in athletes. pain occurs with knee flexion against resistance, ice and apply compression. crutches may be needed
jumper’s knee
from repetitive loading of quadriceps during running and jumping. tenderness over patellar tendon. need PT, ice and activity modification
Osgood-Schlatter Disease
insidious onset of activity related anterior knee pain in teens. swelling and pain over tibial tubercle. caused by recurrent traction on tibial tubercle apophysis (growth plate). irregular ossification on xray. typically resolves spontaneously as bones mature, pain control with nsaids
Meniscal injury
medial or lateral knee pain, joint line tenderness. feeling of locking or knee giving way. tx: need surgery, need 6 weeks of crutch training, return to sports in 3 to 4 months
Red eye
causes: trauma, foreign body, infection, allergy, conjunctivitis
tearing
in infants can be due to nasolacrimal obstruction. associated with glaucoma, photophobia and blepharospasm
purulent discharge from eye
associated with bacterial conjunctivitis.
watery discharge from eyes
occurs with viral conjunctivitis.
mucoid discharge from eyes
allergic conjunctivitis or nasocrimal obstruction, will contain eosinophils
photophobia
aversion to light, happens with corneal abrasions, foreign bodies, and iritis may squint one eye. present in infants with glaucoma, albinism, aniridia, and retinal dystrophies
leukocoria
white pupil, present in retinoblastoma, retinopathy, pupillary membrane, cataracts, retinal detachment, toxocara infection and retinal dysplasia. need immediate optho consult
refractive errors: whos at risk
heriditary, marfan, down syndrome.
myopia
nearsightedness, objects at far distance are blurry, onset around age 8. may squint. tx: glasses
hyperopia
farsightedness, hard to focus on near objects. significant can cause cross eyes (esotropia) and amblyopia
astigmatism
person has two planes of focus. all objects blurred. causes amblyopia. treated with glasses
age norms for vision testing
6 weeks: eye to eye contact slow follow movement, 3 months: fixing and following for 2 to 3 feet distance, 6 months: interest in objects across the room, 2 to 3 year use allen and lea symbols with familiar pictures, 4 years old: tumbling e game and tell orientation of E or snellen chart.
visual acuity age norms
less than 2 vision 20/60 or beter, 3 year old 20/40-20/30, 4 year old 20/30 to 20/25, 5 and older 20/20
absent red reflex differentials
cataract, large refractive error, tumor, strabismus
removal of FB on eye
give topical anesthetic, remove foreign body with irrigation or cotton applicator. give ophthalmic antibiotic
corneal abrasion
sudden and severe eye pain, decreased vision, tearing, eyelid edema, redness. tx: ophthalmic antibiotic ointment. no patch needed
penetrating injury to eye
emergency, sudden ocular pain, vision prb, irregular pupil,
6 cardinal positions of gaze
medial rectus, superior rectus, superior oblique, lateral rectus, inferior rectus, inferior oblique
wood lamp in eye exams
turns epithelial defects yellow green. herpes lesions look branchlike,
Hordeolum (Stye)
Patho: Staph. Localized tender, red, warm papule on upper or lower eyelid. Tx: Warm compresses. Topical
abx (bacitracin or erythromycin). If no improvement in 48 hours, consider referral for incision and drainage.
Chalazion
Obstruction of meibomian glands with inflammation and granuloma formation. May follow an internal stye. Hard eyelid nodule, upper or lower, with localized redness. Minimal to no tenderness. May have distorted vision due to compression on cornea.
Tx: Eyelids crubs with baby shampoo, warm
compresses, and topical antibiotic ointment (bacitracin or EES). If doesn’t resolve, refer to
ophthalmology for incision and curettage and/or
corticosteroid injection.
Blepharitis
Patho: Bacterial overgrowth (usually staphylococcus).
Meibomian gland obstruction may occur. Common chronic inflammatory condition of eyelid margins causing irritation and redness, and sometimes dry eyes, conjunctivitis, eyelid ulcerations, or eyelid scaling. Tx: Eyelid scrubs with baby shampoo, warm
compresses, and topical antibiotic ointment
Dacrocystitis
Infection of the lacrimal sac. Usually unilateral. Acute: redness near tear duct, tender, swelling pain, purulent discharge expressed. Tx: systemic antibiotics. Warm
compresses. Surgical relief after acute resolution. Chronic: tearing and discharge. pus expressed. tx: surgery
ptosis
eyelid drooping. need surgery for mod to severe
viral conjunctivitis
caused by adenovirus, Usually bilat with copious watery discharge. Sometimes associated with URI symptoms. tx: No antibiotics needed. Secondary
bacterial conjunctivitis is not uncommon and
often sulfonamide eye drops are prescribed to
prevent. Cold compresses. Hygiene education
bacterial conjunctivitis
if caused by Staphlococci, streptococci, Haemophilus,
Pseudomonas, and Moraxella: will have Copious purulent discharge and mild discomfort. self limiting in 10 to 14 days but can take Topical abx to clear in 2-3 days. If caused by Gonococcal & Trachoma (chlamydial): will have Infected genial secretions.
Copious purulent discharge. Tx: Systemic abx
Allergic conjunctivitis
• Patho: Atopic. Allergic rhinitis, dermatitis, or asthma will usually co-exist. Signs: Seasonal, Itching, tearing, redness, and stringy discharge. Large cobblestone
papillae are noted on the upper tarsal conjunctiva in the vernal form. tx: Topical histamine H1-receptor antagonist or topical mast cell stabilizers are
recommended. Adding oral antihistamine may be needed
nasoclacrimal duct obstruction
tearing and mucoid drainage from affected eye especially in the morning, erythema and conjunctivitis. tx: massage nasolacrimal sac to empty debris. may need surgical tx
glaucoma
caused by increased ICP, can cause vision loss due to optic nerve injury and corneal scarring. signs: tearing, photophobia, corneal clouding. will have sudden eye pain. will need sx and med to decrease icp
viral keratitis
painful red eye. branchlike pattern under woodlamp. caused by herpes and adenovirus affecting cornea. tx with topical antifungals. give systemic meds to newborns like acyclovir
cataracts
signs: leukocoria, poor fixation, strabismus or nystagmus. abscence of red reflex. should be removed prior to six weeks of age
retinoblastoma
most commonprimary intraocular malignancy of childhood. usually seen before age 3. will have leukocorria. could cause death. tx: chemoreduction and radiotherapy
retinal detachement
seen in marfan syndrome. symptoms: floaters, flashing lights, loss of visual field, abnormal or absent red reflex, tx: surgical
diabetic retinopathy
higher risk with type 1 and insulin dependent diabetes, , blurred vision, myopia, cataracts. tx pan retinallaser photocoagulation or vitreoretinal surgery.
papilledema
increased icp, can be caused by tumor or hydrocephalus, ophthalmoscopy will reveal elevated disc and vessel tortuosity. tx: corticosteroid or carbonic anhydrase inhibitor. may need shunt
Amblyopia
“lazy eye”, tx: patch good eye to strengthen bad eye
Estropia (Cross-eyed)
tx with surgery between 6 months and 2 years old. accomadative may use bifocals and rehab
Extropia (Wall-eyed)
tx with sx, orthoptic exercises , patching, and occasionally glasses
Cyanotic Presentations in infants
Etiology: transposition of the great vessels, total anomalous pulmonary venous return, truncus arteriosus (some types), tricuspid atresia, and pulmonary atresia or critical pulmonary stenosis.
S/S: Early cyanosis often without initial respiratory distress
Testing: ABG, CXR, EKG, and Echo
Acyanotic Presentations in infants
Etiology: Left-side outflow obstruction, left-to-right shunting VSD
S/S: Dependent on etiology, peripheral pulses diminished or absent
Testing: Echo
Pulmonary HTN in infants
Etiology: Many. Pulmonary vascular vasoconstriction, smooth muscle development, or decreased area of exchange due to meconium aspiration syndrome, hyaline membrane disease, perinatal depression, neonatal sepsis, chronic intrauterine hypoxia, pulmonary hypoplasia etc…
S/S: Respiratory distress with poor response to O2, cyanosis, patent ductus arteriosis or foamen ovale by echo
Treatment: Ventilation, IV fluids, systemic pressors, nitric oxide, ECMO
S1, S2, S3 and S4
S1- sound of AV valve closure; S2-sound of semilunar valve closure, splitting varies with respiration; S3- rapid left ventricular filling,disappears when going from supine to sitting or standing; S4- atrial contraction and increased atrial pressure, not normal, happens in noncompliant ventricle, diastolic dysfunction
cardiac defects associated with down syndrome
AVSD, atrioventricular septal defect
cardiac defects associated with turner syndrome
Bicuspid aortic valve, coarctation, dilated aortic root, htn
cardiac defects associated with Noonan syndrome
dysplastic pulmonic valve, HCM
cardiac defects associated with Williams-Beuren syndrome
supravalvular aortic stenosis, PPS, Coronary ostial stenosis
cardiac defects associated with Marfan Syndrome
MVP, MR, dilated aortic root
cardiac defects associated with fetal alcohol syndrome
VSD, ASD
cardiac defects associated with MAternal rubella Loeys-Dietz Syndrome
PDA, PPS, Aneurysmal PDA, dilated aortic root, tortuous arteries throughout the body
Systolic murmurs
MR. PASS: Mitral Regurgitation, Physiologic (also known as functional, systolic flow murmur, a heart murmur heard in the absence of cardiac abnormality), Aortic Stenosis, Systolic; MVP: Mitral Valve Prolapse
Diastolic murmurs
MS. ARD: Mitral Stenosis, Aortic Regurgitation Diastolic
Resting heart rate for < 1 month
80-160
Resting heart rate for 1-3 months
80-200
Resting heart rate for 2-24 months
70-120
resting heart rate 2-10 years
60-90
blood pressure checks in extracardiac examination
do BP in every extremity, low BP in lower extremities suggests coarctation of aorta
cyanosis of extremities
results from increased concentration of reduced hemoglobin in blood. bluish skin color, low cardiac output, hypothermia. look for bluish mucous membranes
clubbing of fingers and toes
associated with severe cyanotic congenital heart dz. appears after age 1. can occur with endocarditis, chronic liver dz, IBS, chronic pulmonary dz, and lung abscess
edema on extracardiac exam
in dependent areas means elevated right BP seen with tricuspid valve pathology or heart failure
extracardiac exam of abdomen
hepatomegaly is cardial sign of rt heart failure. splenomegaly may be present in pts with long standing HF and infective endocarditis. ascites feature of rt HF
dextrocardia
heart on rt side of chest, severe when other organs aren’t reversed as well.
D transposition of great arteries on CXR
egg on string
tetralogy of fallot on CXR
boot shaped heart
unobstructed total anomalous pulmonary venous drainage on CXR
Snowman
obstructed total anomalous pulmonary venous drainage on CXR
small heart with congested lungs
coarctation
figure 3 sign + rib notching
Transesophageal echocardiography
test for heart disease, under general anesthesia
Transthoracic echocardiogram
pt must be still for 30 minutes, at each transducer a beam is swept through the heart and a 2 dimensional image appears. gives info on structural detail and intracardiac blood flow and pressure gradients.
MRI in infants
useful in imaging thoracic vessels to eval structure and blood flow. helpful in diagnosing MArfan, Turner and Loeys-dietz syndrome
During ABG testing
Lung disease responds well to 100% 02, heart disease does not
Cardiac cath
tests oximetry, shunts, cardiac output, pressures, vascular resistance
atrial septal defect
opening in atrial septum permitting shunting of blood between atria, widely split S2, RV heave, ejection murmur at pulmonary area, frequently asymptomatic. Xray shows enlarged heart, ECG shows right heart deviation. tx: surgical or catheterization closure
ventricular septal defect
most common congenital heart malformation, clinical features are failure to thrive, tachypnea, and diaphoresis with feeds. lt to rt shunt with normal pulmonary vascular resistance. may cause eisenmenger syndrome. tx: diuretics and systemic afterload reduction, may need sx treatment to place patch
Atrioventricular defect
common in infants with down syndrome, incomplete fusion of embryonic endocardial cushions. symptoms such as failure to thrive, tachypnea, diaphoresis with feeding, recurrent bouts of pneumonia. tx: surgery is required before 1st year of life
Patent Ductus Arteriosis
continuous murmur, bounding peripheral pulses. signs:failure to thrive, tachypnea, diaphoresis with feeding. lt to rt shunt, imaging will show enlarged lt atrium and ventricle, ecg may be normal. tx: indomethecin given to close PDA in preterm infants. otherwise sx needed
pulmonary valve stenosis
cyanosis and high incidence of right sided HF. dilated pulmonary artery on CXR. tx: recommened for pts with systemic or suprasystemic rv pressure. done with percutaneous balloon valvuloplasty
Coarctation of the aorta
absent or diminished femoral pulses, blowing systolic murmur in back or left axilla. lt ventricular enlargement on Xray. tx: surgical corrective repair
Aortic stenosis
harsh systolic ejection murmur at upper right sternal border, thrill in carotid arteries, systolic click at apex, dilation of ascending aorta on CXR. tx: percutaneous balloon valvuloplasty in symptomatic patients
Mitral Valve Prolapse
midsystolic click, late systolic whooping or honking murmur, overdiagnosed, symptoms: chest pain, palpitations and dizziness. common in marfan, loey-dietz, and ehlersddanslo syndroms. tx: propanolol
tetralogy of fallot
hypoxemia spells during infancy, rt sided aortic arch, ejection murmur at upper left sternal border. right ventricular outflow tract obstruction. Hgb, hematocrit, and RBCs will be elevated. tx: palliative care vs total correction through open heart sx
transposition of great arteries
cyanotic newborn without resp distress, more common in males, neonates usually large and profoundly cyanotic without resp distress tx: corrective surgery with arterial switch operation
Kawasaki dz
leading cause of heart dz in children, manage with IVIG and high dose aspirin
pulmonary htn
subtle with symtpoms of dyspnea, fatigue, chest pain and syncope. rare, progressive and often fatal dz without tx. tx:use cardic cath for data, give vasodilators like nifidepine or diltiazem. if unresponsive give prostanoids, endothelin antagonist or phosphodiesterase 5 inhibitors
x linked recessive conditions (8)
color blindess (red green), diabetes insipidus, gout, hemophilia A, hemophilia B, hypothyroidism, immunodificiency, muscular dystrophy
neural tube dz ex
anencephaly, spina bifida, meningomyelocele
neural tube dz maternal testing
maternal serum drawn at 16 to 20 weeks gestation. if elevation over 2.5 of st deviation of the mean , do amniocentesis for AFP along with US
false positive on neural tube
due to innacurate dating of of gestational age, multiplegestation, fetal demise, dying fetus, or structural abnormalities. do repeat
trisomy 21
most common trisomy responsible for down syndrome,
