BASIC - PAEDIATRICS Flashcards
1
Q
Name of NSAIDs?
A
Ibuprofen
2
Q
Indications of NSAIDs?
A
- PRN for mild-to-moderate pain
- Regular treatment of pain related inflammation
3
Q
Mechanism of NSAIDs?
What is the selective cox inhibitor?
A
- Inhibit synthesis of prostaglandins from arachidonic acid by inhibiting cyclooxygenase (COX)
- COX-1 stimulates prostaglandin synthesis essential to preserve gastric mucosa, maintain renal perfusion (by dilating afferent glomerular arterioles) and inhibit thrombus formation at the vascular endothelium
- COX-2 expressed in response to inflammatory stimuli stimulates production of prostaglandins that cause inflammation and pain
- Therapeutic benefits of NSAIDs are principally COX-2 inhibition and adverse effects by COX-1 inhibition
- Selective COX-2 inhibitors (e.g. etoricoxib) developed to reduce the adverse effects
4
Q
SE of NSAIDs?
A
- GI toxicity
- Renal impairment
- Increased risk of MI/CVA
- Fluid retention
5
Q
Interactions of NSAIDs?
A
- GI Ulceration o Aspirin, corticosteroid - GI bleeding o Anticoagulants, SSRIs, venlafaxine - Renal Impairments o ACEi, diuretics
6
Q
Contraindications of NSAIDs?
A
o Severe renal impairment
o Heart Failure
o Liver failure
7
Q
Caution of NSAIDs in prior?
A
o Peptic ulcer disease
o GI bleeds
o CVD
8
Q
Prescription of NSAIDs?
A
- Available as tablets, suspensions, gels, suppositories, injectable
- Acute pain treatment should be stopped when resolved
- Taken with food to minimise GI upset
9
Q
What to warm patients on NSAID use?
A
- Warn patients that the most common side effect is indigestion and advise them to stop treatment and seek medical advice if this occurs
10
Q
Communication when on NSAIDs?
A
- For patients with acute pain, explain that long-term use, e.g. beyond 10 days, is not recommended due to the risk of side effects
- Advise patients requiring long-term treatment (particularly if they have renal impairment) to stop NSAIDs if they become acutely unwell or dehydrated to reduce the risk of damage to the kidneys
11
Q
What other drug should be considered?
A
- Can use gastroprotection for patients at increased risk
12
Q
What is the general dose for NSAIDs in children?
A
3-4 times a day, maximum dose 30mg/kg/day
13
Q
What is the dose of NSAIDs for children 10-11 years and 12-17 years?
A
o For Child 10–11 years
300 mg 3 times a day; maximum 30 mg/kg per day; maximum 2.4 g per day.
o For Child 12–17 years
Initially 300–400 mg 3–4 times a day; increased if necessary up to 600 mg 4 times a day
14
Q
Indications for paracetamol?
A
- 1st line analgesic for acute and chronic pain
- Antipyretic
15
Q
Mechanism of paracetamol?
A
- Weak cyclooxygenase (COX) inhibitor, involved in prostaglandin metabolism
- Increase pain threshold and reduce (PGE2) concentrations in thermoregulatory region, controlling fever
- Specifically, COX-2 isoform (inflammation) rather than COX-1 isoform (protecting gastric mucosa, regulating renal blood flow and clotting)
16
Q
SE of paracetamol?
Describe mechanism of overdose and treatment?
A
- Few side effects
o Metabolised by CYP450 enzymes to toxic N-acetyl-p-benzoquinone imine (NAPQI) which is conjugated with glutathione before elimination
o NAPQI accumulation causes hepatocellular necrosis
o Treated with acetylcysteine
17
Q
Interactions of paracetamol?
A
- CYP450 inducers increase the rate of NAPQI production and risk of liver toxicity after paracetamol overdose
18
Q
Dose reduction of paracetamol?
A
- Dose reduced in liver toxicity
19
Q
Caution of paracetamol?
A
o Chronic excessive alcohol use
o Malnutrition
o Low body weight
o Hepatic impairment
20
Q
Prescription of paracetamol?
A
- Oral paracetamol can be purchased in retail outlets7
- Regular administration or PRN
- Available as tablets, caplets, capsules, soluble tablets or oral suspensions
- IV is possible
21
Q
Communication to patient of paracetamol?
A
- Effects should be felt around half an hour after taking it
- Warn them not to exceed the recommended maximum daily dose because of the potential risk of liver poisoning
- Advise them that many medicines purchased from the chemist (e.g. cold and flu preparations) contain paracetamol
- Warn them to check the label
22
Q
General dosage of paracetamol in children 10-15 years and 16-17 years?
A
o Child 10-15 years
480-750mg every 4-6 hours, max 4 doses
o Child 16-17
0.5-1g every 4-6 hours, max 4 doses
23
Q
Indication for oxygen?
A
- Hypoxaemia
- Accelerate reabsorption in pneumothorax
- Reduce half-life of carboxyhaemoglobin in carbon monoxide
24
Q
Mechanism for oxygen?
A
- Supplemental oxygen therapy increased the PO2 in alveolar gas, driving more rapid diffusion into blood
- Increases delivery of oxygen to the tissues
- In pneumothorax, oxygen reduces nitrogen fraction in alveolar gas to accelerate nitrogen diffusion out of body
- Oxygen competes with CO to bind with haemoglobin and thereby shortens the half-life of carboxyhaemoglobin
25
SE of oxygen?
- Discomfort of facemask
| - Dry throat
26
Any interactions in oxygen?
None
27
Contraindications of oxygen?
- Caution in Type 2 Respiratory failure (COPD)
| - Avoid around naked flames, heat sources or smoking
28
Prescription of oxygen?
Different deliveries for different indications?
Doses?
- Target oxygen saturation 94-98%
- Initial delivery device, use reservoir (non-rebreathe) mask in critical illness, use nasal cannula for everyone else
- Reservoir mask allows highest oxygen concentration and flow rate should be 15L/min
- Nasal cannula delivers variable oxygen concentrations between 24-50% at flow rates of 2-6L/min
29
Communication in oxygen?
- Should be kept in place continuously but may briefly be removed for eating and drinking
30
Monitoring of oxygen?
o SpO2 monitoring
| o ABG
31
Names of common beta-2 agonists?
- Short-Acting
o Salbutamol, Terbutaline
- Long-Acting
o Salmeterol, formoterol
32
Indications of beta-2 agonists?
- Asthma – short acting as step 1, long-acting as step 3 (must be given with inhaled corticosteroids)
- Hyperkalaemia – nebulised salbutamol (in addition to insulin, glucose, calcium gluconate) in emergency treatment
33
Mechanism of beta-2 agonists?
What happens in high doses?
Specific long acting SE?
- Beta2-receptors found in smooth muscle of bronchi, GI tract, uterus, blood vessels
- Stimulation of GPCR leads to smooth muscle relaxation – improves airflow
- Stimulate Na/K/ATPase pump causing K+ to move into cells – treat hyperkalaemia in addition to insulin
34
SE of beta-2 agonists?
- ‘Fight-or-flight’ effects
o Tachycardia, palpitations, anxiety, tremor
- Gluconeogenesis, may increase serum glucose
- High doses
o Serum lactate levels increased
- Long-acting
o Muscle cramps
35
Interactions of beta-2 agonists?
- Beta-blockers reduce effectiveness
- Hypokalaemia
o Concomitant use with theophylline, corticosteroids
36
Contraindications of beta-2 agonists?
- Long-acting only prescribed in asthma with inhaled corticosteroid
o As associated with increased asthma deaths
37
Caution of beta-2 agonists?
o CVD – tachycardia promote angina, arrhythmias
o Hypokalaemia
o Diabetes
38
Prescription of beta-2 agonists?
- PRN prescription
o Use 2 puffs every 4 hours, up to 10 if needed
o If more, then hospital
- Can be administered aerosol (MDI), dry powder, nebulised, in combination with steroid (Symbicort, Seretide)
- Spacer provided to improve airway deposition and treatment efficacy
39
Communication of beta-2 agonists?
- Medicine will make their airways relax and therefore improve their breathing
- Treats the symptoms, not the disease
- Clear on how and when to take the inhaler (e.g. for acute symptoms, pre-emptively before exercise or regularly for long-acting medication)
40
Monitoring of beta-2 agonists?
- Monitored via peak expiratory flow rate (PEFR)
41
Name of antimuscarinics?
Ipratropium, tiotropium, glycopyrronium
42
Indications of antimuscarinics?
- Acute exacerbation (short-acting)
| - Added in step 4 of chronic asthma (long-acting)
43
Mechanism of antimuscarinics?
- Bind to muscarinic receptor, competitive inhibitor of acetylcholine
- Stimulation of muscarinic receptor causes ‘rest and digest’ effects
- Blockage has opposite effects:
o Reduced smooth muscle tone
o Reduced secretions
o Relaxation of pupillary constrictor and ciliary muscles – pupil dilatation and preventing accommodation – blurred vision
44
SE of antimuscarinics?
- Little systemic absorption
| - Blurred vision, urinary retention, constipation, dry mouth
45
Interactions of antimuscarinics?
- None
46
Cautions of antimuscarinics?
o Angle-closure glaucoma
| o Arrhythmias
47
Contraindications of antimuscarinics?
o Hypersensitivity to atropine or derivatives
48
Prescription of antimuscarinics?
- Short-acting used QDS or PRN
- In acute asthma
o 0.25mg in 4mL saline
o Every 20-30 mins for 1st 2 hours then every 8 hours if needed
- Can be inhaled or nebulised liquid
49
Communication of antimuscarinics?
- Treatment to make their airways relax, which should therefore improve their breathing
- Treats the symptoms, not the disease
- Ensure they are clear on how and when to take the inhaler (e.g. for acute symptoms, pre-emptively before exercise or regularly for long-acting medication)
- Discuss possible side effects, such as dry mouth, and advise them to chew gum or suck sweets or bottle of water
50
Monitoring of antimuscarinics?
- Monitor PEFR
51
Names of inhaled corticosteroids?
Beclomethasone (Clenil Modulite 50mcg lower-potency, Clenil 200mcg)
52
Indications of inhaled corticosteroids?
Step 2 of therapy in chronic asthma – not controlled by short-acting B2 agonists
53
Mechanism of inhaled corticosteroids?
- Pass through plasma membrane and activate receptor which:
o Upregulation of anti-inflammatory proteins
o Downregulates pro-inflammatory interleukins, cytokines, chemokines
- Effects
o Reduces mucosal inflammation
o Widens the airways
o Reduces mucus secretion
54
SE of inhaled corticosteroids?
- Occur locally in the airway
o Oral candidiasis
o Hoarse Voice
- Few systemic effects unless at very high dose which may cause adrenal suppression, growth retardation and osteoporosis
55
Interactions of inhaled corticosteroids?
- None
56
Contraindications of inhaled corticosteroids?
- Caution of long-term high-dose corticosteroids as potential for growth suppression
57
Prescription of inhaled corticosteroids?
```
- Inhalation of powder (circle one)
o Child 5-11 years
100-200mcg BDS
o Child 12-17 years
200-400mcg BDS, can be increased
- Inhalation of aerosol (normal puffer)
o Child 12-17 years
50-200mcg BDS, can be increased to 400mcg
- Prescribe brand name
- May need steroid card
- Drugs are delivered in aerosol (metered dose inhaler [MDI]) or dry powder form
```
58
What should be prescribed with inhaler?
- Spacer with metered dose inhalers improves airway deposition and treatment efficacy and reduce oral adverse effects
- Inhaler and technique should be checked and corrected at every consultation
59
Communication of inhaled corticosteroids?
- Explain that you are offering a steroid inhaler to ‘dampen down’ inflammation in the lung
- Reassure them that hardly any of the steroid is absorbed into the body so, except in very high-dose treatment, there are unlikely to be any serious side effects (or weight gain)
- Advise them to rinse their mouth and gargle after taking the inhaler to prevent development of a sore mouth or hoarse voice
- Show your patient how to use the device
60
Monitoring of inhaled corticosteroids?
- Review after 3–6 months
61
Name of osmotic laxatives?
Lactulose, Macrogol (Movicol), phosphate enema
62
Indications of osmotic laxatives?
Constipation and faecal impaction – 1st line Movicol in paediatrics
Bowel preparation prior to surgery or endoscopy
Hepatic encephalopathy
63
Mechanism of osmotic laxatives?
- Osmotically active substances (sugars/alcohol) that remain in gut lumen
- Hold water in stool
- Maintain volume and stimulate peristalsis
- Lactulose
o Reduces ammonia absorption by increasing gut transit rate and acidifying stool
o Inhibits proliferation of ammonia-producing bacteria
o Useful in hepatic encephalopathy
64
SE of osmotic laxatives?
- Flatulence
- Abdominal cramps
- Nausea
- Diarrhoea
- Phosphate enema
o Local irritation, electrolyte disturbances
65
Interactions of osmotic laxatives?
- Effects of warfarin may be slightly increased
66
Contraindications of osmotic laxatives?
o Intestinal obstruction (risk of perforation)
67
When would you use phosphate enema in caution?
o Heart failure, ascites, electrolyte disturbances
68
Prescription of osmotic laxatives?
- Orally used prescribed regularly
- May take a few days for an effect to be seen, as need to pass through GI tract
- Phosphate enema PRN or once only
- Taken with or without food
- Can have solutions which can be diluted in another liquid (squash) to improve compliance
- Enemas administered with patient lying on side and stay in position for a few minutes
69
Communication of osmotic laxatives?
o Explain treatment with a laxative
o Will hopefully make their stool softer and easier to pass
o To work, it requires them to drink plenty of water: they should aim to have at least 6–8 glasses of liquid per day
o Mention that side effects can occur, but these may get better over time
o Advise that the dose should be adjusted to maintain comfort
o If regularly passing >2/3 soft stools per day, dose should be reduced, or stopped
70
Name of stimulant laxatives?
Senna, Bisacodyl, glycerol suppositories
71
Indications of stimulant laxatives?
Constipation – 2nd line in paediatrics
| As suppositories for faecal impaction
72
Mechanism of stimulant laxatives?
- Stimulant laxatives increase water and electrolyte secretion from the colonic mucosa
- Increasing volume of colonic content and stimulating peristalsis
- Direct pro-peristaltic action, although the exact mechanism differs between agents
o Bacterial metabolism of Senna in intestine produces metabolites that have a direct action on the enteric nervous system, stimulating peristalsis
o Rectal administration of glycerol suppositories, provokes a similar but more localised effect and can be useful to treat faecal impaction
o Docusate sodium has both stimulant and faecal softening actions
73
SE of stimulant laxatives?
- Abdominal pain/cramps
- Diarrhoea
- Prolonged use
o Melanosis coli (reversible pigmentation of intestinal wall)
74
Interactions of stimulant laxatives?
- None
75
Contraindications of stimulant laxatives?
o Intestinal Obstruction
o Haemorrhoids
o Anal Fissures
76
Prescription of stimulant laxatives?
- Regular oral administration, usually BDS
| - When rectal, PRN or once only
77
Communication of stimulant laxatives?
- Explain offering treatment with a laxative that will help stool to pass
- As with other laxatives, ensuring good oral fluid intake will also help, 6–8 glasses of liquid per day
- Stimulant laxatives do not work immediately and may need a few doses before a sustained effect is noticed
- Dose can be adjusted if necessary to maintain comfort
- If they are regularly passing >2/3 soft stools per day, dose should be reduced or stopped
- Mention side effects but these may get better over time
78
Name of emollients?
Aqueous cream, liquid paraffin
| Examples - E45, Aveeno (colloidal oatmeal)
79
Indications of emollients?
- Topical treatment for all dry or scaling skin disorders
| - Used alone or in combination with topical corticosteroids in the treatment of eczema
80
Mechanism of emollients?
- Emollients replace water content in dry skin
- Contain oils or paraffin-based products that soften skin and reduce water loss by protecting against evaporation
- Many preparations used as soap substitute (as soap is drying to the skin) and also bath or shower emollients
81
SE of emollients?
- Greasy on skin but this is part of therapeutic effect
| - Exacerbate acne and folliculitis by blocking pores and hair follicles
82
Interactions of emollients?
- Space out topical emollients – usually apply emollient 15 minutes before application of steroid cream
83
Contraindications of emollients?
- Fire hazard when oil content high
84
Properties of different types of emollients?
```
- Properties
o Emulsions of oil and water to make creams, lotions and ointments
o Lotions (less oil, more water) and creams (50% oil and water) spread further
o Ointments (80% oil, 20% water) are more occlusive and potent
- If find greasy and unpleasant, consider a cream or lotion instead of ointment and apply more often
```
85
Directions for emollients?
- Directions
o Applied BDS/TDS in active disease
o Give sufficient supply for frequent use
o Continue after improvement to prevent recurrence
o Apply emollients in the direction of hair growth
86
Communication of emollients?
- Encourage use as often as possible
87
Names of topical corticosteroids?
| Potency of each example?
Mild – Hydrocortisone 0.5-2.5%
Moderate – Eumovate (Clobetasone butyrate 0.05%)
Potent – Betnovate (betamethasone valerate 0.1%)
Very Potent – Dermovate (Clobetasol propionate 0.05%)
88
Indications of topical corticosteroids?
- Inflammatory skin conditions, e.g. eczema, psoriasis where emollients are ineffective
89
Mechanism of topical corticosteroids?
- Upregulate anti-inflammatory genes and downregulate pro-inflammatory genes (e.g. cytokines, tumour necrosis factor alpha)
- Suppression of circulating monocytes and eosinophils
- Increased gluconeogenesis from increased circulating amino and fatty acids, released by catabolism of muscle and fat
- Mineralocorticoid effects, stimulating Na+ and water retention and K+ excretion in the renal tubule
- Because topical, effects limited to site – need prolonged use of potent topical steroids for systemic effects
90
SE of topical corticosteroids?
- Skin thinning
- Telangiectasia
- Contact dermatitis
- When used on face:
o Perioral dermatitis
o Exacerbate acne
- Rarely, systemic effects:
o Adrenal suppression
o Immunosuppression
o Diabetes
o Osteoporosis
91
Interactions of topical corticosteroids?
- None when topical
92
Contraindications of topical corticosteroids?
- Contra-indications
o Infection present
- Avoid potent on face and course should be short
93
Prescription of topical corticosteroids?
- Use as mild as possible for as short a time
- < 2 weeks (1 week for facial lesions)
- Prescription
o Name, strength, formulation, amount
- BDS applied thinly on affected area
- Wash hands after application
94
Communication of topical corticosteroids?
- Warn them of the risk of skin damage if the treatment is applied to the wrong areas or for too long
- BNF advise finger-tip of cream or ointment should cover two palms worth
95
Indications of benzylpenicillin?
- Meningitis - 1st line community
| - CAP – Secondary Care Neonates
96
Indications of amoxicillin?
- CAP – Primary Care 1st line
- CAP – Secondary care Children
- HAP – IV amoxicillin
- UTI - < 3months IV
- UTI - > 3months oral
- Otitis Media
97
Indications of co-amoxiclav?
- Alternatives in CAP and HAP
- >3 months UTI and pyelonephritis
- Otitis Media
98
Indications of tazocin?
- HAP >5 days in hospital
99
Indications of ampicillin?
- < 3 months UTI
100
Indications of phenoxymethylpenicillin?
- Tonsillitis
101
Indications of flucloxacillin?
- Otitis Externa, etc
102
General mechanism of penicillins?
- Contain B-lactam ring responsible for antimicrobial activity
- Inhibit enzymes responsible for cross-linking peptidoglycans in bacterial cell walls
- Preventing osmotic gradient being maintained and leads to cell swelling, lysis and death
103
SE of penicillins?
- GI upset
- Allergy (1-10%)
o Skin rash 7-10 days after 1st exposure or 1-2 days after repeat
o Anaphylaxis
- CNS toxicity
- Antibiotic-Associated colitis
o Tazocin, clindamycin, cephalosporins, fluoroquinolones, co-amoxiclav, ampicillin and amoxillin
- Cholestatic Jaundice
o Co-amoxiclav
104
Interactions of penicillins?
- Reduce renal excretion of methotrexate
| - Broad-spectrum antibiotics enhance anticoagulant effect of warfarin by killing normal vitamin K flora
105
Warnings in penicillin use?
o Dose reduction in renal impairment
| o Avoid amoxicillin in sore throat as can give rash if EBV
106
Names of cephalosporins?
Ceftriaxone
| Cefotaxime
107
Indications of cephalosporins?
```
Ceftriaxone
- 1st line hospital meningitis
- Sepsis
- UTI < 3 months IV with amoxicillin
- UTI > 3months oral
- Upper UTI >3 months
Cefotaxime
- Add on meningitis
- Severe CAP
```
108
Prescription of cephalosporins?
- Usually given 6-12 hourly given orally, IV or IM
109
Names of macrolides?
Clarithromycin
Erythromycin
Azithromycin
110
Indications of macrolides?
Clarithromycin
- Secondary care child CAP alternative
- Tonsillitis, Otitis media and externa if penicillin allergic
Erythromycin
- Primary care CAP alternative to amoxicillin
Azithromycin
- Primary care CAP alternative to amoxicillin
111
Mechanism of macrolides?
- Inhibit bacterial protein synthesis
- Bind to 50s subunit of ribosome and block translocation
- Bacteriostatic which assists immune system in killing and removing bacteria from body
- Synthetic macrolides (clarithromycin and azithromycin) have increased activity against Gram-negative
112
Prescription of macrolides?
- Can be given orally as tablets, suspensions with or without food
- IV must be diluted
113
Indications of trimethoprim?
1st line in UTI for >3 months
114
Mechanism of trimethoprim?
nhibit bacterial folate synthesis, slowing bacterial growth (bacteriostatic)
- Effective against Gram-positive and Gram-negative bacteria
- Widespread bacterial resistance
- Excreted unchanged into urine so used for UTIs
115
SE of trimethoprim?
- GI upset (nausea, vomiting and sore mouth)
- Skin rash (3-7%)
- Haematological disorders – megaloblastic anaemia, leukopenia and thrombocytopenia
- Hyperkalaemia
- Competitively inhibits creatinine secretion by the renal tubules which commonly leads to a small reversible rise in serum creatinine concentration during trimethoprim treatment
116
Contraindications of trimethoprim?
- 1st trimester of pregnancy
117
Cautions of trimethoprim?
o Folate deficiency
| o Dose reduction in renal impairment
118
Prescription of trimethoprim?
- Oral use only usually 12 hourly for 3 days
| - Communicate as with other antibiotics
119
Indications of nitrofurantoin?
Lower UTI in > 3 months
120
Mechanism of nitrofurantoin?
- Metabolised (reduced) in bacterial cells by nitrofuran reductase
- Active metabolite damages bacterial DNA and causes cell death (bactericidal)
- Active against relevant bacteria, reaches therapeutic concentrations in urine through renal excretion and most bactericidal in acidic environments such as urine
- Bacteria with reduced nitrofuran reductase activity are resistant to nitrofurantoin
121
SE of nitrofurantoin?
- GI upset (nausea and diarrhoea)
- Turn urine dark yellow or brown
- Chronic treatment
o Chronic pulmonary reactions
o Hepatitis
o Peripheral neuropathy
- Neonates cause haemolytic anaemia
122
Interactions of nitrofurantoin?
- None
123
Contraindications of nitrofurantoin?
o Pregnant women towards term
o Babies <3 months
o Renal impairment
124
Cautions of nitrofurantoin?
o Long-term use associated with adverse effects
125
Prescription of nitrofurantoin?
- Oral use only usually 3-days
- It should be taken with food or milk to minimise gastrointestinal effects
- Explain as with previous antibiotics
126
Fluids resuscitation dose for children?
0.9% saline – 20mls/kg
127
Oral rehydration fluids in children?
o 50mls/kg over 4 hours orally
128
How to work out fluid deficit in children?
Mild (5%)
o Dry mucous membranes, skin turgor, decreased urine output
Moderate (10%)
o Decreased skin turgor, oliguric, high pulse, >CRT, lethargy
Severe (15%)
o Shock, anuric, hypotension
Calculation
• % dehydration x weight(kg) x 10
• Give as 0.45% saline over 48h
• Add K+ (20mmol/500ml) once child passed urine
129
How to work out maintenance fluids for children?
o Maintenance Fluids (0.9% saline with 5% dextrose with 10mmol KCL)
1st 10kg 100mls/kg/day
2nd 10kg 50mls/kg/day
3rd & subsequent kg 20mls/kg/day
