CPS general Flashcards
what are cardiac contraindications to air travel
uncontrolled HTN, uncontrolled SVT, eisenmenger syndrome
who are recommended for potential hypoxemia evaluation prior to air travel?
hypoxemic hypercarbic known CLD or RLD on home O2 history of difficulty on air travel recent exacerbation CLD other chronic conditions exacerbated by hypoxemia
who is at higher risk of thrombosis during air travel?
major surgery within 6 weeks
thrombophilia
previous VTE
malignancy
consider consult specialist for ASA/LMWH
what advice for AOM and air travel?
if possible, delay 2 weeks before air travel
topical nasal decongestant can be used before takeoff/landing
what do you do for air travel for medical devices?
Gas expansion can occur - ie NG, urinary cath can introduce air into hollow viscus. ALL should be capped during take off and landing
orthopedic casts - can expand during flight. bivalve to prevent pain and circulation problems
Proper elevation and analgesia
features associated with persistence of asthma into school age
up to 60% become asymptomatic by age 6
wheezing episodes
personal or FmhX atopy
age of onset
trajectory over time
Diagnostic criteria for asthma in preschool aged
- document airflow obstrucion
(preferred health care > historical) - documented airflow obstruction reversible
(SABA +/- corticosteroids OR 3mo med ICS OR SABA parent) - No alternative diagnosis
name 5 signs/symptoms that lead you to think other ddx to asthma
- stridor- infection (croup)/laryngomalacia/vascular ring
- 1st episode of wheeze < 1 yo - bronchiolitis
- acute onset during eat/play/recurrent same location - FB/aspiration
- persistent nasal discharge - allergic/infectious
- chronic wet cough, FTT, steatorrhea - CF
Name components PRAM score & interpret
O2 sat (0) >/=95% (2) < 92%
wheeze: absent, expiratory only, inspiratory, audible without steth (3)
Suprasternal: absent/present (0/2)
scalene: absent/present (0/2)
AE: normal, base, apex&base, minimal (3)
severe 8 - 12
mod 4 - 7
mild 0 - 3
reversibility = change in 3
name 3 options for Med dose ICS in child 1 - 5yo
beclomethasone (qvar) 200mc daily dose
ciclesonide (alvesco) 200mcg daily dose
fluticasone (flovent) 200-250mcg daily dose
reasons for referral for asthma specialist (5)
diagnosis uncertain or comorbidity repeat >/= 2 exacerbations needing PO, hospitalization OR freq symptoms (>/=8d/month) despite mod ICS life threatening event or to ICU need for allergy testing other: social, education
definition of noctural enuresis
secondary?
regular bed wetting (>2/week) beyond 5 years old
- when incontintience occurs at least 6mo of continence
what is epidemiology of primary nocturnal enuresis?
more common boys
10% 5 years old
5% 10 years old
1-2% 15 years old
what are general behavioural rx advice for primary enuresis? (4)
goal getting up at night to pee assure access to toilet avoid caffeine/excess H20 prior to bedtime pee QHS clean wet bed in non punitive manner preserve child's self esteeem
what are 3 interventions for nocturnal enuresis?
what are s/e>
- alarms
- disturbs whole family
- cure rate only 50% - desmopressin (ADH)
- headache, water intox, abdo pain - imipramine hydrochloride (TCA)
- irritabilty, anxiety, headaches, overdose arrhythmias, sz
how does bed wetting alarms work?
alarms when child starts to void cure rate < 50% most effective child >7yo and continue until 14 days DRY THEN 7 nights in a row
Normal temps CPS def
AND recommended type for age
Oral 35.5 - 37.5
Ear 35.8 - 38
Axillary 36.5 - 37.5
Rectal 36.6 - 38
Birth - 5 yo: rectal»_space; axillary
> 5: oral»axillary/tympanic
Functional constipation
Rome III criteria
developmental age 4
at least once/week x 2mo
Two or more:
- 2 or fewer BM in toilet/week
- 1 or more fecal incontience/week
- hx retention
- hx painful or hard BM
- large fecal mass rectum
- large diameter stools that obstruct
Functional constipation management
- education - BF infants can have stools qfeed or up to q7-10d
- fecal disimpactation
-meds - trial min 6 months
ie PEG 1g/kg/day - behavioural - sit toilet, diet , CHO (ie prune juice), fiber
medications constipation
list 5 options
lactulose, mineral oil (osmotic) pEG 3350 (Cathartic) phosphate enemas - not recommend< 2yo Bisacodyl senna - idiosyncratic heptitis milk magnesium docusate (softner) duclolax (proknetic)
why are XR ADHD recommended as first line
improve adherence reduce stigma reduce problems with storing/admin drugs @ school pharmacokinetics less likely to be diverted
ADHD cardiac screening
9
SOB with exercise poor exercise tolerance Fainting/seizure with exercise/startle palpations with exercise FmHx unexplained death, SIDS Long Qt syndrome WPW cardiomyopathy PHTN heart transplant implanted defibrilator HTN organic murmur
def SIDS
sudden death of child < 1yo unexplained after case investigation, complete autopsy, exam death scene, review clinical history < 1 in 1000 risk peak 2 - 4 months 90% before age 6mo
what are risk factors for SIDS
3 categories x3
maternal
- < 20yo
- mat smoking
- lower SES
- aborginal
fetal
- prematurity
- male
- LBW
- sibling sids
environmental
- prone sleep
- bed sharing
- over heating
- bed accessorys
what are preventions for SIDS (5)
prenatal care - avoid smoking supine sleep firm sleep surface room sharing - 1st 6mo avoid overheating no bed accessories
healthy active living guidelines for screen time
< 2 yo - NO Screen
2-4yo - 1hr
older children < 2 hrs
Physical activity recommendations
preschool 180min/day
older (~5+) 60min/day
vigorous exercise 3x/week
Physical activity considerations for Chronic diseases (4)
1. asthma - NO scuba if sx/abnPFT ventolin prior to exercise 2. JIA -PA as tolerated -neck xray if neck arthritis 3. hemophilia -factor proph as indicated -written strategies. protective equipment 4. CF -avoid scuba Nacl drinks to prevent hypoN dehydration if enlarged spleen - avoid contact
top 3 errors of using car seats
not well to vehicle > 1” move
straps too loose - > 1finger
chest clip not at armpit level
car seat recommendations
rear facing - until 1 year and 10kg
fwd facing - at least 18kg (40lbs)
booster - at least 36kg and 145cm
then regular seat belt
DM1 in school
schools - train min 2 staff to recognize and rx hypoglycemia
- not found liable if reasonable steps
- provide safe for meds/dispose
- supervised eating
- accommodate if hypoglycemic during exam
- DM ER kit at desk
Physician
- written info for care
- BID/TID care if limited support
Housing needs - types
inadequate housing - need of major repairs
unsuitable housing - crowded. fails meet national occupational standard
unaffordable - 30% or more household income
Screen housing need:
H -harm - housing in need major repair?
O - occupancy - how many people, # rooms
M - moves in lifetime
E - enough income - food security, utilities etc.
Hockey injuries
body checking
body checking - individual defensive tactic to legally separate puck carrier and puck
CPS recommend DELAY until age 13- 14 years old
prevention
4 stage skill development
fair play
concussion risk factors for longer recovery
hx previous injuries headaches difficulty sleeping LD ADHD mental health
def of concussion
complex pathophysiological process affecting brain, induced by biomechanical forces. results in rapid onset impairment that resolves spontaneously
acute concussion management
stop game immediately. remove and med exam ASAP
SCAT3 (sport concussion assessment tool) - brief neuropsych ax)
No imaging unless red flags
REST - no evidence for tylenol/advil
return to learn
return to play
Return to learn
1) cognitive rest - limit tasks & screen time. No school
2) increased - slowly increase at home 15-20min increments
3) modified school attned - 1/2 days, homework 15 - 20min blocks
4) inc attendance - gradually to fully days. tests limited 1/day
5) return to school fully
if worsen at any stage, decrease activity until improve
return to play
1) no activity - remain until sx free 7-10 days
2) light aerobic - walk/swim
3) sport-specific - drills
4) non contact training
5) full contact practice
6) return to play
min 24hrs each step. if symx, go back where asymptomatic for 24-48hrs
repetitive concussion injury
if cumulative, consider retiring from sport
concussion occurs with les force
results in more severe x
more likely due to pt’s playing style, position or sport
concomitant LD, cognitive disabilities
Boxing recommendation
Boxing - encourages and rewards deliberate blows to head. risk of neck, face, head injuries.
Concussion 33% > laceration > #
Chronic traumatic encephalopathy
-caused by cummulative effects of repeated blows. up to 20% professional boxers
-head guards not protective against concussions
OPPOSE boxing as sports for children
playground injuries
UE # most common
head injuries
backyard - 1-4 yo most often
fatality rare - but almost usually due to strangulation
playground prevention
anticipatory guidance
report playground injuries to authorities
municipal planning
new playground guidelines to reduce max height fall, risk of falling etc
parents to provide active supervision
remove helmet prior to play equipment
foods to avoid in < 4 year old due to choking
hard candies gummy candies, chewable vitamins peanuts sunflower seeds fish with bones snacks on toothpicks/skewers
FB aspiration/ingestion 4th leading cause injury hospitalizations - when peak?
in age group < 4years
peak 9-11mo
choking - what common things and how to tell parents to test
food - commonly round and cylindrical (hot dog, grapes)
balloon - most common non food
if can fit through empty toilet paper roll - chocking hazard
athlete back pain
main structural ddx
more likely due to structural injury
- r/o red flags for infection/malignancy, etc
spondylolysis (extension pain)
posterior element overuse (extension)
vertebral body apophyseal avulsion # (flexion pain)
disc herniation (flexion pain
oral health recommendations
1st check up within 1 yo or first 6mo of first tooth eruption
fluoride supplementatio
early childhood caries
prsence of one or more decayed, missing, or filled tooth surfaces in preschool children
vertical transmission streptococcus mutans Associations -chronic disease (ie asthma) - LES, aboriginal, new immigrants -LBW, prematurity, iron def
positional phagiocephaly
Prevention & treatment
cranial asymmetry due to forces that deform shape in supine position (parallelogram)
max at 4 mo, decreases over 2 years
Prevention
prone position 10-15min x TID
Treatment
mild/mod - repositional thearpy and PT. Preferred if < 4mo
severe -
helmet (help rate, but not reverse)
23/hr/day, expensive, risk contact dermatitis, sores
max age to consider = 8 mo
trampoline
warn dangers - most injuries 5 -14 yrs old. # most common. high rate admissions
Advise NOT to buy or allow to use home trampolines
recommendations fever and exercise
IF sx confined to above beck (ie URTI) play as tolerated
if systemic symptoms - refrain 7-14days due to risk of dehydration, progression of illness
EBV infection and return to exercise
spont splenic rupture 0.1-0.5% highest in first 3 weeks
-NO exercise min 3 weeks
If no symptoms, lab markers normal, and no spleen enlargement
RESUME light activity 50%
@ 4 weeks, can resume contact sports
ankle sprain
Ottawa rules
ankle xray pain in malleolar zone AND one: - bone tender @ lateral malleolus or -bone tender @ medial malleolus or - inability to weight bear immediately AND in ER
foot xray pain in midfoot zone and one: -bone tender at 5th metatarsal or -navicular bone or -inability to weight bear immediate AND in ER
ankle sprain rx
P - protect (bracing) R - rest I - ice - 15min TID x 36hrs, NSAIDS C - compression E - elevation
Return to play
- when ROM, strength, proprioception nromal and pain resolved.
usually 1- 6 weeks.
most common ankle injury sprain
by inversio of plantar flexed foot
ATFL - anterior talofibular ligament
if increased severity, calcaneoufibular ligament and posterior-talofibular ligament an be injuried
bronchiolitis higher risk group
prematurity < 35 weeks
age < 3 months
CHD
immunodeficiency
bronchiolitis EBM
- equivocal
- not recommended
equivocal
- HTS
- epi nebs
- nasal suction
- combined epi and dex
not recommended
- ventolin
- steroids
- antivirals
- antibiotics
- cool mist therapies
bronchiolitis admission
severe resp distress o2 > 90% cyanosis/apnea dehydation family social situation high risk for severe disease
bronchiolitis discharge
90% sats
wob improved
PO intake
education and f/u
dental fluorsis
mainly in child < 7 year old, due to excessive fluoride in water, tootpaste, food/drinks
toxic effect 1 - only with dental exam
toxic effect 2 - florid mottling and pitting of teeth. snow capped cups
supplemental fluoride when?
only if > 6mo
AND less than 0.3ppm natural sources
child not brush teeth at least BID
dentist recommends
vision screening
tests
red eye reflex cornea light reflex fundoscopy cover/uncover Snellen vision testing >4yo -letters or HOTV (4 letters or E)
vision screening guidelines
newborn - 3mo - exam, red eye reflex. Refer if high risk (ieT21), FmHx
6 - 12 mo: occular alignment
- fix, follow target. Corneal reflex and cover/uncover
3 - 5 yr: visual acuity age appropriate
6 - 18 year: routine and PRN
footwear
prewalking - not required
shoes - 1.25cm thumb space at top when stand up
flat foot - rarely needs special rx
Time out discipline
age 2 - primary years most effective Duration = min x age . max 5mins introduce by 24mo Place - no distractions, no toys Give warning When time out - ignore when over - don-t rediscuss, move on
toilet training readiness
usually 6 months to attainment
BM and urine control usually 2 - 4 years old
Readiness: ability to walk to toilet stable when sitting on toilet able to remain dry or several hrs receptive/expressive language to communicate desire to please parent desire for independence
toilet refusal
1 - 3 month break suggested
if repeated attempts unsuccessful, refer to GP or developmental peds
advice to parents for toilet learning
decide on vocab to use
ensure toilet position, access
encourage child to tell parent when need void
praise upon success
avoid punishment/neg reinforcement
expect accidents
consistent approach - all caregivers involved
after repeat success, use panties/training pants
swimming lessions
lessons < 4 years old - NOT effective drowning prevention strategy
s/e water intoxication, hypernatremia, seizures, hypothermia, external OM
personal flotation devices - all small children and those who cant swim
parental supervision + encourage first aid/CPR training
residental pools - fence all 4 sides.
literacy promotion recommendations
address @ birth and throughout ASK about literacy - book sharing, access etc library card applications singing, story telling, clinic waiting areas with literacy
direct effects of low literacy on health
incorrect use medications
failure to comply with medical directions
errors in infant formula administration
safety risk in community
(other indirect) unhealthy lifestyles higher rates poverty higher occupational injuries higher stress limit access/understand health services
autism intervention
earlier is better
15 - 40hrs/week
Individualized learning plan
multidisciplinary team
Asthma Risk factors ICU admission and death
previous life threatening events
admisisions to PICU
intubation
deterioration while on systemic steroids
what are symptoms/signs of mild asthma exacerbation
severe asthma exacerbation
impeding resp failure
mild: normal speech, LOC, activity mod wheeze, mild WOB >94% room air peak (personal) > 80%
Severe: agitated, significant WOB speak words wheeze without steth best spiro < 60%
impending resp failure drowsy, unable to eat unable to speak chest silent sat < 90%
asthma exacerbation treatment
mod
keep sats >= 94%
ventolin q20min 1 - 3 doses
orsl asteroids
consider ipratropium x3dose 1hr
asthma severe exacerbation treatment
sats >/=94% ventolin, ipratropium x3 oral steroids (possible IV) NPO consider cont ventolin neb consider IV mgso4
asthma impending resp failure treatment
continuous ventolin and ipratropium x 3 doses NPO, IV access IV methylpred blood work consider IV mgSO4 consider SC PICU consider RSI/ETT
asthma exacerbation admission criteria
O2
persistent increased WOB
B2 agonst more often Q4H after 4-8hr conventional rx
deteriorates while on PO steroids
discharge asthma
complete 3-5day steroids venotlin 0.3puff/kg max 10puff Q4H until resolve return to care if > Q4H written asthma plan review technqiue f/u primary care
GCS scale
E4
- spontaneous > to speech > to pain > none
M6
commands > localize > withdrawal > decorticate > decelebrate > none
V5
- oriented > confused > inappropriate words > sounds > none
Pediatric risk factors for head trauma
larger head to body ratio
(large occiput)
thinner cranial bone
less myelinated tissue
dangerous mechanism of injury for head
MVA
fall >/= 3 feet
down 5 stairs
fall bicycle without helmet
classification Head trauma
severe < 8
mild 14 - 15
mod 9 - 13
CATCH rule
CT head indication
Children with MINOR head injury + one of following: High risk 1. GCS < 15 after 2hrs 2. suspect open or depressed skull # 3. worsening headaches 4. irritability on exam Medium risk 1. basal skull # 2. large boggy hematoma 3. dangerous mechanism
other CT head absolute and relative indications
focal neurological deficit
GCS < 14 (mod/severe head trauma)
suspect open/depressed skull fracture
relative
- persistent irritability < 2 ear old
- seizures
- known coagulation disorder
- clinical deteriation over 4-6hr
minor head trauma management
if asymptomatic –> d/c to reliable parents
written instructions
if headache, vomit, LOC after period of observation then ADMIT
- if persistent > 18-24hrs, likely CT head
if < 2 years, esp < 12 months –> CAUTION
consider skull xray < 2 years old
risk factors post-traumatic seizures
majority within 24hrs
impact seizures - shortly after event. if N CT head/exam, low risk and can be d/c
younger age severe head trauma < 8 cerebral edema SDH open or depressed skull #
anaphylaxis diagnostic criteria
- skin + one system
- resp - wheeze, stridor
- BP or end organ - likely allergen+ 2 systems
- skin
- cardio
- resp
- GI - known allergy + hypotension (> 30% dec SBP or age specific)
common anaphylaxis triggers
Food> hymenopetra (bee/wasp) > medications
food: peanuts, fish, milk, eggs, shellfish
anaphylaxis treatment
IM 1:1000 epinephrine 0.01mg/kg q 5 - 15mins (max 0.5mg)
ABC, large bore IVs
Oxygen, monitors
H - histamine blocker (ranitidine, benadryl) I - IV fluids V - ventolin E - epinephrine S - steroids IV methylpred 1mg/kg
if still persistent hypotension,
IV epinephrine infusion 0.1mcg/kg/min
IV glucagon (on BB) - 20mcg/kg over 5 mins, then infusion 10mcg/min
biphasic reaction 1hr to 72hrs after
- observe in ER 4- 6hrs. tell RTC
- if repeated dose, severe symptoms, admit
- high risk: peanut, asthma, use BB - admit
status epilepticus
options pre-hospital management
lorazepam buccal/PR 0.1mg/kg (max 4mg)
midaz IN/buccal
diazepam DR 0.5mg/kg (max 20)
status epilepticus
second line treatment
IV fosphenytoin (20mg/kg) IV phenytoin (20mg/kg) IV phenobarb (20mg/kg)
if still seizing after 5mins med, use other class
Status epilepticus. if no IV/IO, what 2nd line treatments?
Fosphenytoin IM (20mg/kg) phenytoin IO (20mg/kg) -- paraldehyde PR (400mg/kg) if still seizing after 5 mins use other class
status epilepticus 3rd line
IV midazolam 0.15mg/kg bolus then 2mcg/kg/min
increase 2mcg/kg/min q5 mins
bolus 0.15mg/kg with each increase in infusion rate
max 24mcg/kg/min
if still seizing - thiopental/pentobarbital bolus and continuous
if no seizure - taper after 24-48hrs
common etiologies of status epilpticus
acute CNS infection
metabolic derangement (Ca, glucose, HypNa, anoxic injury)
antiepileptic drug noncompliance/withdrawal
non AED overdose
prlonged febrile convulsions (30%)
cerebral migrational disorders (schizencephaly)
cerebral dysgnesis
Perinatal HIE
progressive neurocognitie disorders
status epilepticus definition
refractory Status epilepticus definition
CSE = continuous GTC activity with LOC for > 30mins or 2 or more discrete seizure without return to baseline
convulsive status eplipticus unresponsive to 2 different antieplieptics ( ie benzo, pheno)
SIADH risk
CNS pulmonary disorders surgical interventions medications (ie morphine) stress, nausea, pain
acute hyponatremia sx
decrease Na < 48hrs
acute cerebral edema, headache, lethargy seizure, brain herniation,
more likely if Na < 130
children higher risk due to higher brain/intracranial ratio
MRSOPA
M mask R reposition S suction O oral airway P pressure A alternative airway
ETT size for PALS
uncuffed 4 + (age/4)
cuffed 3.5 + (age/4)
post resuscitation targets O2, temp
O2 94-99%
temp consider 32-34 degrees
pediatric office recommended equipment
airway
- bag mask
- o2 masks, O2 tank, tubing,
CVS
- cardiac arrest backboard
- BP cuffs
- 16 gauge IO
- IVfluids, tubing, N/S
Meds IM epinephrine (1:1000) neb epinephrine (croup) neb ventolin (+compressor for nebs) (diazepam, glucose determination)
other neck collar dressing, splints, bandage ER container box latex-free gloves
BRUE definition
infant < 1 year old with observe reports sudden brief, now resolved episode with one of following:
- cyanosis/pallor
- absent, decreased, irregular breathing
- change in tone
- altered LOC
BRUE LOW RISK - criteria
> 60 days old GA >/= 32 and cGA > 45 weeks only 1 BRUE (not clusters) Duration < 1 min no CPR by trained health care normal physical exam
BRUE low risk management
educate caregiver about BRUE
offer CPR training
MAY obtain pertussis/ ECG
brief monitor with o2 pulse
NOT extensive blood work, Bcx, LP
Not need U/A, neuroimaging
