Essential Conditions (1) Flashcards
1
Q
Causes of neonatal jaundice <24 hours?
A
Haemolytic disorders (Rh/ABO incompatibility, G6PD deficiency, pyruvate kinase deficiency)
Congenital infection - sepsis (GBS, rubella)
2
Q
Causes of neonatal jaundice 24h - 2 weeks?
A
Congential infection physiological jaundice breast milk jaundice, dehydration infection (UTI) haemolytic disorder bruising polycythaemia Crigler-Najjar syndrome (rare – absence or deficiency or glucuronyl transferase).
3
Q
Causes of unconjugated jaundice >2 weeks?
A
Physiological/breastmilk jaundcie Infection (UTI) Congenital hypothyoridism Haemolytic anaemia High GI obstruction (pyloric stenosis)
4
Q
Causes of conjugated jaundice >2 weeks?
A
Pale stools/dark urine, hepatomegaly and poor weight gain
Bile duct obstruction (biliary atresia)
Neonatal hepatitis
5
Q
Test for whether bilirubin is conjugated or not?
A
Bilirubin fraction
6
Q
What is coombes test?
A
Direct antiglobulin test, tests agglutination of RBCs. Positive test in the presence of hyperbilirubinemia suggests a haemolytic jaundice.
Direct Coombes test – used to test for autoimmune haemolytic anaemia
Indirect Coombes test – prenatal testing of women, and testing blood prior to blood transfusion.
7
Q
Management of neonatal jaundice?
A
Plot on treatment threshold chart - according to gestation
Phototherapy
Exchange transfusion
IV immunoglobulin if haemolytic disease or ABO incompatibility
8
Q
What are live vaccines?
A
BCG MMR Oral polio Yellow fever Oral typhoid Intranasal flu Rotavirus
9
Q
Does the MMR contain egg?
A
No
10
Q
Contraindications to vaccination?
A
Anaphylaxis/egg anaphylaxis
Immunosuppression - primary, pregnancy, immunosuppressive therapy (steroids, chemo) –> NO LIVE VACCINES
11
Q
Consequences of measles mumps and rubella?
A
Measles - SSPE, death
Mumps - infertility
Rubella - pregnancy consequences
12
Q
Risk factors for meningitis?
A
Impaired immunity - young age, splenic defects, defects of complement
Low SE status - crowding, poverty, close contact with affected individuals
13
Q
Causes of viral meningitis?
A
Parvovirus (ok), HSV (bad)
14
Q
Presentation of meningitis in neonates?
A
Fever no focus Irritability Seizures Poor feeding Respiratory distress Coma
15
Q
Bacterial causes of meningitis in neonates - 3 months?
A
GBS
E.coli and other coliforms
Listeria monocytogenes
16
Q
Bacterial causes of meningitis in 1 month - 6 years?
A
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
17
Q
Bacterial causes of meningitis in >4 years?
A
Neisseria meningitidis
Streptococcus pneumoniae
18
Q
What is Brudzinski’s sign?
A
Flexion of neck with the child supine causes flexion of knees and hips
19
Q
Kernig’s sign?
A
Child lying supine with hips and knees flexed, back pain on extension of knee
20
Q
What is in a septic screen?
A
Cultures Urine CXR LP Bloods - FBC, CRP, glucose, U+E
MC+S - bloods, stool, throat and urine
21
Q
Contraindications of LP?
A
Focal neurological signs (seizures)
Raised ICP (low HR, high BP, papilloedema)
Shock/CV instability
RISK OF CONING
22
Q
What do you do with LP sample?
A
M,C + S and PCR (amplifies sample)
23
Q
Bacterial meningitis on LP?
A
Turbid
Neutrophils (polymorphs) raised
Protein raised
Glucose low
24
Q
Viral meningitis on LP?
A
Clear
Lymphocytes raised
Protein normal/raised
Glucose normal/low
25
TB meningitis on LP?
Turbid/clear/viscous
Lymphocytes raised
Protein very raised
Glucose very low
26
Managmenent of meningitis?
IMMEDIATE administration of abx and supportive therapy
ABCDE approach - may need boluses for shock
< 3 months = IV cefotaxime + amoxicillin (listeria cover)
>3 months = IV ceftriaxone
Supportive therapy = corticosteroids (not < 3 months), analgesics, antipyretics
27
Prophylaxis in meningitis?
Rifampicin for household contacts
28
Complications of meningitis (immediate)?
Septic shock
Seizures
DIC
Cerebral oedema
29
Complications of meningitis (late)?
Hearing loss
Cerebral palsy (< 2 years)
Epilepsy
30
What is purpura? What does it indicate?
Purplish discoloration of skin produced by small bleeding vessels near the surface.
Indicates a problem with platelet system
31
What are petechiae?
Purpura spots that are very small (<1 cm in diameter)
32
What are ecchymoses?
Larger and deeper purpura
33
Differentials for purpuric rash?
```
Meningococcal septicaemia
HSP
Immune thrombocytopenia
DIC
Lukaemia
```
34
What is HSP?
IgA medicated vasculitis - non-thrombocytopenic purpura.
Lesions confined to buttocks, extensor surfaces of legs (and arms), along with abdominal pain and haematuria.
Child is usually systemically well.
May have haematuria and need to check urine sample with HSP as potential effects on kidney.
35
What is ITP?
Auto-antibody (IgG) formation to platelets - IIb/IIIa glycoprotein.
Children aged 2-10 years
Presents 1-3 weeks after viral infection
Usually self-limiting within 6-8 weeks
WBC should be normal
36
What is DIC?
Coagulation pathway activation --> fibrin deposition in the microvasculature and consumption of coagulation factors and platelets --> thrombocytopenic purpura.
Causes = severe sepsis and extensive damage from trauma or burns.
Presentation = bruising, purpura and haemorrhage.
Investigations = Thrombocytopenia, ↑PTT, prolonged APTT, ↓fibrinogen (correlates most closely with severity).
FFP + platelet transfusion
37
Features of leukaemia?
Clinical features = Malaise, recurrent infections, bruising, petechiae, hepatosplenomegaly, lymphadenopathy.
Bloods = Thrombocytopenia, ↑WCC, ↓Hb
38
Pathophysiology of sepsis?
Shock = Host response includes release of inflammatory cytokines and activation of endothelial cells --> septic shock.
Hypovolaemia = Occurs due to release of vasoactive mediators by host inflammatory and endothelial cells.
Endothelial dysfunction leads to capillary leak --> loss of intravascular proteins and fluid.
Leads to sepsis syndrome and DIC --> distributive and cardiogenic shock.
39
Normal Hb levels at different ages?
Neonate = <140 g/L
1-12 months = <100 g/L
1-13 years = <110 g/L
40
Causes of anaemia in infants?
```
Impaired red cell production
Increased red cell destruction (haemolysis)
Blood loss (uncommon)
```
41
Causes of anaemia if reticulocytes low?
Red cell aplasia
Parvovirus B19
Diamond-Blackfan anaemia
42
Causes of anaemia if reticulocytes high or normal?
High bilirubin --> haemolysis = sickle cell, thalassaemia, hereditary spherocytosis
Normal bilirubin = iron deficiency
43
Causes of iron deficiency?
Inadequate intake – common in infants because additional iron required for increase in blood volume that accompanies growth and to build up child’s iron stores.
Malabsorption
Blood loss
44
Sources of iron?
Breast milk (low iron content but 50% of iron absorbed).
Instant formula (supplemented with adequate amounts of iron.
Cow’s milk (higher iron content than breast but only 10% absorbed) – shouldn’t give to infants.
Solids at weaning (e.g. cereals are supplemented but only 1% absorbed).
45
What increases iron absorption?
Vitamin C
46
Investigations in IDA?
FBC -↓Hb, ↓MCV and MCH (mean cell Hb = average mass of Hb per RBC), ↓MCHC
Blood film - Microcytic, hypochromic anaemia
Serum ferritin - Low (poor iron stores)
47
Management of IDA?
Dietary advice and supplementation with oral iron for several months.
Sytron or Niferex = good oral iron preparations as they do not stain teeth.
Should be continued until Hb is normal and then for a minimum of a further 3 months to replenish iron stores
48
Features of life threatening asthma attack?
PEFR < 33%
Sats < 92%
```
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia
```
49
Max nebs of salbutamol and ipratropium?
```
Salbutamol = hourly
IB = 4 hourly
```
50
Dose of ipratoprium in acute asthma?
250 mcg
51
What is the course of bronchiolitis?
3 day prodrome with ‘cold’ and harsh cough
3 day ill with fever, high-pitched wheeze and breathlessness
3 day recovering
52
Risk factors for bronchiolitis?
Chronic lung diseases (e.g. CF)
Immunosuppressed (e.g. HIV)
Premature or ex-premature infants
Congential cardiac conditions
53
Cause of bronchiolitis? Who does it present in?
RSV
Under 1 year
54
Examination findings in bronchiolitis?
Sharp dry cough
Resp distress
Low grade fever
Tachycardia
FINE END INSPIRATORY CRACKLES
HIGH PITCHED WHEEZE
55
Management of bronchiolitis?
Supportive
Oxygen - Via nasal cannula (2l max – hydrated to not dry out mucosa) Aim for >92%
Monitor for apnoea
Fluids - May need to be given via NGT or IV
Assisted ventilation - CPAP or Full ventilation in a small % of infants admitted.
56
Prevention of bronchiolitis?
Palvizumab = monocloncal antibody to RSV. Given to:
o Premature babies
o Chronic lung disease
o Congential heart disease
o Cystic fibrosis
Monthly injection for 5 months starting in October. Appears to make illness less severe.
57
What causes croup?
Viral croup = 95%
Parainfluenza
RSV/adenovirus/influenza
Bacterial tracheitis = Pseudomembranous croup
Similar to viral croup but child has high fever, appears toxic and has rapidly progressive airways obstruction.
Staph Aureus --> IV Abx
58
Features of epiglottitis?
- Prodrome: coryza
- Barking cough (seal cough)
- Harsh stridor
- Hoarseness of voice
59
Difference between croup and epiglottitis?
Croup = common
Drooling saliva indicates epiglottitis
60
Classifcation of croup severity?
Stridor, subcostal recession, air entry, O2 sats, conscious level
Mild
Moderate
Severe
61
Management of croup?
Mild = reassure + home with advice
Moderate = oral steroids (dex or pred) or nebulised (budesonide)
Severe = oxygen, steroids, nebulised adrenaline (NEED ANAESTHETIST)
62
Cause of epiglottitis?
Hib
63
What do you not do in epiglottitis?
Lie the child flat or examine the throat!
64
Management of epiglottits?
Stabilise child and prevent anything that may precipitate total obstruction of throat.
Emergency otolaryngologist and anaesthetist
Emergency intubation & Admit to ICU
Blood cultures
Steroids
IV Abx
o 2nd/3rd gen cephalosporin – Cefuroxime/Ceftriaxome/Cefotaxime
o 7 days
Rifampicin prophylaxis given to close contacts
65
Causes of viral pneumonia?
Viruses = 14-35% - RSV, adenovirus, rhinovirus, parainfluenza
66
Causes of bacterial pneumonias?
Newborn = group B strep from mother’s genital tract.
Infants and young children = RSV most common but bacterial include Strep. Pneumoniae, Chlamydia. Staph Aureus is infrequent but serious.
School age = Strep. Pneumoniae, Mycoplasma Pneumoniae, Chlamydia Pneumoniae.
All ages – should consider mycoplasma tuberculosis.
67
Management of mild chest infections?
At home
Oral abx
Fluid/temp control/safety net
68
Management of pneumonia?
Admit to ward
Oxygen to maintain sats >92
IV abx/IV fluids
Close obs for deterioration
69
Antibiotics in pneumonia?
- <5 years - Strep Pneumoniae most likely cause Amoxicillin
- >5 years – Mycoplasma Pneumoniae more common Macrolide
- If Staph Aureus suspected or severe pneumonia Co-amoxiclav, cefotaxime or cefuroxime
70
Common cause of tonsillitis?
Group A B-haemolytic strep
EBV
71
Centor criteria?
- Absence of cough
- History of fever
- White tonsillar exudate
- Cervical lymphadenopathy
- Age under 15 add 1 point
0 or 1 – No antibiotic or throat culture necessary (risk of strep. infection <10%)
2 or 3 - Should receive a throat culture and treat with an antibiotic if culture is positive (risk of strep. infection 32% if 3 criteria, 15% if 2)
4 or 5 - Consider rapid strep testing and or culture. (Risk of strep. infection 56%).
72
Management of tonsillitis?
Most cases viral --> no abx, supportive management.
If group A B-haemolytic strep suspected, should give Abx after throat swab for bacterial culture.
Penicillin or Erythromycin
10 day course required.
Avoid amoxicillin because may cause maculopapular rash in cases of EBV infection.
73
Indications for tonsillectomy?
Recurrent severe tonsillitis (as opposed to recurrent URTIs)
Peritonsillar abscess (quinsy)
Obstructive sleep apnoea (adenoids usually removed too).
Adenoids increase in size until 8 years then regress – can narrow the airways in this time.
74
Causes of otitis media?
Viral
- RSV and Rhinovrius
Bacterial
- Pneumococcus
- Haemophilus Influenzae and Maroxella Catarrhalis
75
Management of otitis media?
Most cases resolve spontaneously – abx marginally shorted the duration of pain but have not been shown to reduce risk of hearing loss.
- Co-amoxiclav – covers H.influenzae and Maroxella) – only tell them only to use if child remains unwell for 2-3 days.
- Amoxicillin is widely used.
- Neither decongestants nor antihistamines beneficial.
76
Clinical features of glue ear?
Common between ages of 2-7 years.
Most common cause of conductive hearing loss in children. Can interfere with normal speech development. May result in learning difficulties in school.
Tympanic membrane
Dull and retracted
Visible fluid level
Effusions can be serous (thin), mucoid (thick) or purulent.
77
Management of glue ear?
Usually resolves on its own – no benefit to long term used of abx, steroids or decongestants.
In children with conductive hearing loss grommets (ventilation tubes).
Also may benefit from adenoidectomy – adenoids may harbour organisms that can contribute to infection of Eustachian tube.
78
Difference between viral wheeze and atopic asthma?
No interval symptoms - typically in children under 5
Absence of strong history of eczema/hay fever/asthma
79
Risk factors for viral induced wheeze?
- Maternal smoking
- Prematurity
- Asthma/allergy NOT a risk factor.
80
What is persistent/recurrent wheezing?
preschool and school-aged children – frequent wheeze triggered by many stimuli.
Presence of IgE to common inhalant allergens; dust, pets, pollens; associated with persistence of wheezing beyond preschool years.
81
Most common mutation in CF?
dF508 on chromosome 7
82
What is screened for in CF in the guthrie test?
Immunoreactive trypsinogen and CFTR mutations
83
Problems in CF?
Respiratory
- Recurrent chest infections
(Staph Aureus, Haemophilus Influenzae, Pseudomonas)
- Bronchiectasis (caused by recurrent chest infections --> persistent cough, productive of purulent sputum).
Pancreas (ducts become blocked)
- Pancreatic enzyme insufficiency
- Diabetes mellitus (due to scarring)
- Malabsorption
Liver disease
Male infertility (absence of vas, or blocked ducts)
Sweat gland dysfunction (excessive concentrations of sodium and chloride in sweat).
Meconium ileus in 10-20% (Thick viscoid meconium --> blockage --> Intestinal obstruction, billious vomiting, abdominal distension and failure to pass meconium in first few days of life --> surgery)
84
Sweat test in CF?
Concentration of chloride markedly elevated
```
normal = 10-40 mmol/L
CF = 60-125mmol/L
```
Pilocarpine iontophoresis used to stimulate sweat.
85
CXR in CF?
- Hyperinflation
- Bronchial dilatation (bronchiectasis)
- Increased AP diameter
- Cyst and linear shadows
86
Lung function tests in CF?
- Obstructive pattern
| - Decreased FEV1 and increased lung volumes – decreases as disease progresses
87
Management of CF?
MDT - doctors, physio, dietician etc
RESP
physio
abx (fluclox daily and resuce, daily nebs for pseudomonas)
lung function tests, transplant, flu vaccine, portacath, nebulised DNAse/saline
Nutrition - enzymes, high calorie diet, salt supplementation, fat soluble vitamin supplements
