Day 2 PAEDS Flashcards
Symptoms and signs of asthma
(4)
Symptoms
cough: often worse at night
dyspnoea
expiratory wheeze on auscultation
reduced peak expiratory flow rate (PEFR)
Risk factors for developing asthma
- personal or family history of atopy
- mantenatal factors: maternal smoking, viral infection during pregnancy (especially RSV)
- low birth weight
- not being breastfed
- maternal smoking around child
- exposure to high concentrations of allergens (e.g. house dust mite)
- air pollution
- ‘hygiene hypothesis’
What is the “hygiene hypothesis”
Reduced exposure to infectious agents in childhood prevents normal development of the immune system resulting in a Th2 predominant response
Asthma brings sensitivity to which medication?
aspirin
What type of sensitivity reaction is asthma?
Type 1
Focusing on atopy, patients with asthma also suffer from other IgE-mediated atopic conditions such as:
- atopic dermatitis (eczema)
- allergic rhinitis (hay fever)
How is asthma investigated?
- Spirometry
- Fractional exhaled nitric oxide (FeNO)
- chest x-ray
What are the typical spirometry results seen in asthma + COPD conditions?
Typical results in asthma
FEV1 - significantly reduced
FVC - normal
FEV1% (FEV1/FVC) < 70%
How does Fractional exhaled nitric oxide (FeNO) testing work?
Fractional exhaled nitric oxide (FeNO)
- nitric oxide is produced by 3 types of nitric oxide synthases (NOS).
- one of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils
- levels of NO therefore typically correlate with levels of inflammation.
Which drugs are used to treat asthma?
- Short-acting beta-agonists (SABA)
- Inhaled corticosteroids (ICS)
- Long-acting beta-agonists (LABA)
- Leukotriene receptor antagonists
Epidemiology of bronchiolitis (3)
- most common cause of a serious lower respiratory tract infection in < 1yr olds (90% are 1-9 months, with a peak incidence of 3-6 months).
- Maternal IgG provides protection to newborns against RSV
- higher incidence in winter
Features of bronchiolitis
(6)
Features
- coryzal symptoms (including mild fever) precede:
- dry cough
- increasing breathlessness
- wheezing, fine inspiratory crackles (not always present)
- feeding difficulties associated with increasing dyspnoea
- interfering with feeding, often a reason for hospital admission is low weight
NICE recommend immediate referral if they have any of the following:
(6)
NICE recommend immediate referral if they have any of the following:
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
- severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air.
In a GP setting NICE recommend that clinicians ‘consider’ referring to hospital if any of the following apply:
- a respiratory rate of over 60 breaths/minute
- difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume ‘taking account of risk factors and using clinical judgement’)
- clinical dehydration.
What is Croup
What is the main characterisation?
Which pathogen is the main cause?
(3)
Croup is a form of upper respiratory tract infection seen in infants and toddlers.
It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions.
Parainfluenza viruses account for the majority of cases.
Epidemiology of Croup
(2)
peak incidence at 6 months - 3 years
more common in autumn
What are the features of Croup?
(4)
- stridor
- barking cough (worse at night)
- fever
- coryzal symptoms
What are the characteristics of “mild” croup?
(4)
- Occasional barking cough
- No audible stridor at rest
- No or mild suprasternal and/or intercostal recession
- The child is happy and is prepared to eat, drink, and play
What are the characteristics of “moderate” croup?
(5)
- Frequent barking cough
- Easily audible stridor at rest
- Suprasternal and sternal wall retraction at rest
- No or little distress or agitation
- The child can be placated and is interested in its surroundings
What are the characteristics of “severe” croup?
(5)
- Frequent barking cough
- Prominent inspiratory (and occasionally, expiratory) stridor at rest
- Marked sternal wall retractions
- Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
- Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
CKS suggest admitting any child with moderate or severe croup.
Other features which should prompt admission include:
(3)
- < 6 months of age
- known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
- uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
Investigations for croup
(3)
- the vast majority of children are diagnosed clinically
however, if a chest x-ray is done:
- a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
- in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Management of croup
(4)
- CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
Emergency treatment:
- high-flow oxygen
- nebulised adrenaline
What is Acute epiglottitis?
(4)
- Acute epiglottitis is rare but serious infection caused by Haemophilus influenzae type B.
- Prompt recognition and treatment is essential as airway obstruction may develop.
- Epiglottitis was generally considered a disease of childhood but in the UK it is now more common in adults due to the immunisation programme.
- The incidence of epiglottitis has decreased since the introduction of the Hib vaccine.
Features of acute epiglottitis
(5)
- rapid onset
- high temperature, generally unwell
- stridor
- drooling of saliva
- ‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
Diagnosis of acute epiglottitis
(3)
- Diagnosis is made by direct visualisation by senior/airway trained staff, see below
However, x-rays may be done, particularly if there is concern about a foreign body:
- a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
Management of acute epiglottitis
(5)
- immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
- endotracheal intubation may be necessary to protect the airway
- if suspected do NOT examine the throat due to the risk of acute airway obstruction
- oxygen
- intravenous antibiotics
Pathophysiology of pneumonia in children
S .pneumoniae is the most likely causative agent of a bacterial pneumonia in children
Treatment of pneumonia in children
(2)
Amoxicillin is first-line for all children with pneumonia
Macrolides may be added if there is no response to first line therapy
Investigations for pneumonia in children
(3)
chest x-ray
in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring is recommend for admitted patients to help determine response to treatment
Signs of pneumonia in children
(3)
signs of systemic inflammatory response: fever, tachycardia
reduced oxygen saturations
ausculatation: reduced breath sounds, bronchial breathing
What is Cushing’s Triad?
(3)
Indications of raised ICP
- Widening pulse pressure
- bradycardia
- irregular breathing
What are the signs of raised ICP?
(5)
headache
vomiting
reduced levels of consciousness
papilloedema
Cushing’s triad
Which conditions are associated with an RAPD?
(2)
- Multiple sclerosis,
- Giant Cell Arteritis
- Glaucoma: While glaucoma normally is a bilateral disease, if one optic nerve has particularly severe damage, an RAPD can be seen however it can cause bilateral APD*
- Other optic nerve inflammations Sarcoidosis, systemic lupus erythematosus, Sjögren’s syndrome*
Investigations for raised ICP
(3)
- neuroimaging (CT/MRI) is key to investigate the underlying cause
invasive ICP monitoring
- catheter placed into the lateral ventricles of the brain to monitor the pressure
- may also be used to take collect CSF samples and also to drain small amounts of CSF to reduce the pressure
- a cut-off of > 20 mmHg is often used to determine if further treatment is needed to reduce the ICP
What blood work should be ordered for a vomiting child?
(3)
Blood gases
acidosis can be caused by diarrhoea
alkalosis can be caused by excessive vomiting
High BUN:Cr ratio indicates dehydration
Management of raised ICP
(4)
raise head to 30 degrees
IV mannitol
Controlled hyperventilation
- aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
- leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain
removal of CSF, different techniques include:
- drain from intraventricular monitor (see above)
- repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
- ventriculoperitoneal shunt (for hydrocephalus)
Dehydration vs Shock
Similarities
- Tachypnea + Tachycardia
Differences
Dehydration
- Appears to be unwell or deteriorating
- Decreased urine output
- Skin colour unchanged
- Warm extremities
- Altered responsiveness (for example, irritable, lethargic)
- Sunken eyes
- Dry mucous membranes
- Normal peripheral pulses
- Normal capillary refill time
- Reduced skin turgor
- Normal blood pressure
Shock
- Decreased level of consciousness
- Cold extremities
- Pale or mottled skin
- Weak peripheral pulses
- Prolonged capillary refill time
- Hypotension
What is a wide pulse pressure?
Usually, the resting pulse pressure in healthy adults, sitting position, is about 30–40 mmHg.
It can become as wide as 100mmHg during exercise.
Features suggestive of hypernatraemic dehydration:
(5)
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
Bloody diarrhoea is seen in which form of infection?
gastroenteritis
Why might recent antibiotic use cause diarrhoea?
It encourages the growth of C.diff while expressing the growth of normal gut flora
What is the most common cause of AKI in children?
Haemolytic Uraemic Syndrome
What is the triad of HUS?
Haemolytic uraemic syndrome
- AKI
- microangiopathic anaemia
- thrombocytopenia
What is “typical HUS”
What are three causes?
secondary (termed ‘typical HUS’)
- classically Shiga toxin-producing Escherichia coli (This is the most common cause in children, accounting for over 90% of cases)
- pneumococcal infection
- HIV
rare: systemic lupus erythematosus, drugs, cancer
What is the cause of primary HUS?
complement dysregulation
What is shock (6)
Shock occurs when there is insufficient tissue perfusion.
- Septic
- Haemorrhagic
- Neurogenic
- Cardiogenic
- Anaphylactic
How is HUS managed?
(3)
there is no role for antibiotics, despite the preceding diarrhoeal illness in many patients
- the indications for plasma exchange in HUS are complicated. As a general rule plasma exchange is reserved for severe cases of HUS not associated with diarrhoea
- eculizumab (a C5 inhibitor monoclonal antibody) has evidence of greater efficiency than plasma exchange alone in the treatment of adult atypical HUS
(3)
Caput succedaneum is a diffuse subcutaneous fluid collection with poorly defined margins (often crossing suture lines) caused by pressure on the presenting part of the head during delivery.
It does not usually cause complications and resolves over the first few days
(3)
Cephalhaematoma is a subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth.
The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput succedaneum).
Cephalhaematoma is more common with instrumental delivery and may cause jaundice, therefore, bilirubin should be monitored.
(2)
A sunken fontanelle may suggest dehydration.
A tense bulging fontanelle may suggest raised intracranial pressure (e.g. hydrocephalus).
(2)
Milia are tiny white cysts containing keratin and sebaceous material. They are very common on the face and most resolve within the first few weeks of life.
A 5-week-old baby is suffering from projectile vomiting after feeds. The vomit is profuse but not bile-stained and occurs within minutes of a feed. On examination, an olive-sized pyloric mass can be palpated.
What is the most likely electrolyte abnormality seen in this infant?
Hypochloremic hypokalaemic metabolic alkalosis
A 34-year-old woman who is 38 weeks pregnant overdoses on lithium. Once she is stabilised, the baby is safely delivered. During routine neonatal checks, a pan-systolic murmur is heard. Cardiac echocardiogram reveals a low insertion of the tricuspid valve with a large right atrium, a small right ventricle and associated tricuspid incompetence.
What is the most likely diagnosis?
Ebstein’s anomaly results in low insertion of the tricuspid valve resulting in a large right atrium and small right ventricle causing tricuspid incompetence.
What is Ebstein’s anomaly?
Ebstein’s anomaly results in low insertion of the tricuspid valve resulting in a large right atrium and small right ventricle causing tricuspid incompetence.
