General Approaches Flashcards
History, examination, investigations, recognising the sick child, prescribing, safeguarding
Paeds history taking
Relationship of adult
Speak to child when appropriate rather than just to adult, adolescent may want to speak alone
Find out what parent/child fear is-often from internet
Be clear with terms e.g. wheeze
SR: general health (active, normal self), growth, feeding/drinking, change in behaviour, normal SR
PMH: depends on age but maternal obstetric problems, birthweight + gestation, perinatal problems e.g. SCBU, immunisations, + normal PMH
DH: past + present inc OTC, known allergies
FH: as they share a home + genes
SH: parent occupation, housing, economic status, smoking at home, relationships, are they happy at home/school, impact of illness on child + family, SW involvement
Developmental: parental concerns, milestones, bladder + bowel control, sleeping, school/nursery issues
Paeds examinations
In younger children permission is from parents, explain to them what will do, distal/less upsetting parts first
Often opportunistic
Resp, CVS, GI, CNS, PNS
Important markers in resp exam?
Sputum rarely produced in children until older
Tachypnoea most sensitive marker
Chest recession most specific marker
Important things CVS exam?
Murmurs: likely significant if conducted all over chest or loud or have thrill or diastolic
Hepatomegaly is a sign of HF in infants
Always palpate femorals in neonates to exclude coarctation of the aorta
Signs of HF in neonates: faltering growth, sweating, tachypnoea, tachycardia, gallop rhythm, cardiomegaly, hepatomegaly
Hepatomegaly in children?
Causes-infection, haematological, liver (e.g. polycystic disease), malignancy (leukaemia, lymphoma, neuroblastoma, Wilms’ tumour), metabolic (glycogen/lipid storage disease), heart failure; or apparent (when chest hyper-expands due to bronchiolitis/asthma)
Splenomegaly in children?
Infection, haematological, malignancy (leukaemia/lymphoma), Still’s disease
Abdominal masses?
Wilms’ tumour - doesn’t cross the midline
Neuroblastoma - irregular firm mass, child usually unwell
Faecal masses - mobile, non-tender, indentable, often in LIF
Intussusception - acutely unwell, most in RUQ
How do you even do neuro exam in children?
Screening: watch play, language/social interactions; in infants may be indicated by posture/limb movements/head control/tone.
Most children don’t have issues so don’t need formal exam
CN: basically same as adult as much as they can do
Peripheral nerves: inspection, can prob do tone in toddlers, power mostly in children who can follow instructions, coordination depends on age, sensation with light touch as screening test, gait/movement if can walk, reflexes (do last, explain, demonstrate on parent/toy - brisk may be anxiety or pyramidal issue, absent may be NMJ/SC issue)
How to examine MSK?
Paediatric GALS rapid screen test: do they have pain/stiffness in joints or muscles or back, difficulty dressing/stairs, observe gait (inc tip toe, heel toe).
Arms- hold out, make fist, pinch index finger + thumb, touch tips of all fingers with thumb, squeeze MCP for tenderness, put hands palm to palm + back to back, reach up to sky, put hands behind neck
Legs - knee effusion, active movement knee, passive movement hip
TMJ
Neck + spine - touch shoulder with ear, bend forward to toes
What are the normal observations in children of varying ages?
<1y: RR 30-40, HR 110-160
1-2y: RR 25-35, HR 100-150
2-5y: RR 20-30, HR 95-140
5-12y: RR 15-20, HR 80-120
> 12y: RR 12-16, HR 60-100
What are the two types of growth charts used?
Age 2w to 4y: UK-WHO growth chart (standard-based)
Age 4-20y: 1990 UK growth chart (reference-based)
How should we measure growth?
Perpendicular measure thing for length + height (not tape measure!)
Head circumference: tape measure. Take the maximum occipital-frontal head circumference (if you can wiggle it up and down then you have the maximum). Take off and put on again 3 times
How often should a baby be weighed?
Routinely in 1st week to check not getting more than a 10% loss (which is normal)
Once a month in the first 6 months
Once every 2 months in 6-12 months
Thereafter every 3m (done routinely at the 12-13m vaccines)
Unless they have sx then don’t do it more often as regression to the mean means there are fluctuations (cause anxiety but normal)
Calculating age for growth chart
Use DOB for accuracy - e.g. if mother says they are 5 months that could mean almost 6 months or just turned 5 months
Preterm <37w: record the actual chronological age from birth, and draw an arrow line back for the number of weeks they are pre-term. E.g. for a 5w old who was 6w early, you’d plot the weight at 5w then arrow back for 6w
How to plot + interpret growth charts
SINGLE DOT
Arrow back for premature
Centile - distance between two of the centile lines. Lines are the blue lines not the grid
If they go across the lines you count the bandwidth (gaps) not the lines
Lines below the 0.4th centile-take bandwidth above to determine where it is
If point is within 1/4 of a space of a line above + below then they are on the centile, e.g. the 91st. If not they should be described as between the two e.g. between the 75th and the 91st. If in doubt go for the line-needs to be clearly in the middle to say it’s between
What is affected first by a new insult?
Weight is usually first thing to drop, then height, then HC last (most protected) so be vigilant
Concerning features on growth charts?
Someone staying below the 0.4th centile-even if following a trend must exclude pathology as is only normal in <0.4% of healthy babies
> 10% weight lost (only occurs in <5% of healthy babies)
> 10% weight lost still at 2w (only in <2% of healthy babies)
More than 2 centiles are crossed over time
How should you approach the CXR in children?
Use rib ends to assess rotation as clavicle ends hard to see
Good inspiration is when the 8-9th posterior rib is visible or 6th anterior rib (posterior only in young children)
Unilateral hyperinflation (Ball-valve effect)
Systematic approach as for adult - deets, ABCDE. Remember hidden spaces like behind the heart/sternum + below diaphragm
How might important abnormalities appear on a CXR?
Neonatal RDS: diffuse ground glass lungs, usually b/l + symmetrical, may have air bronchograms, severe-whiteout. Hyperinflation excludes it if they aren’t ventilated. Surfactant + oxygen to treat
Hyperinflation: flattened hemidiaphragm, >6 ant/>9 posterior ribs above diaphragm, hyper lucent. E.g. asthma, CF, bronchiectasis, bronchiolitis
Consolidation: air in alveoli replaced with pus/transudate/blood/cells. Homogenous opacity, Silhouette sign (loss of lung/soft tissue interface), air bronchogram, no volume loss. May be lobar, diffuse or multi-focal
Collapse: not same as atelectasis is ‘incomplete expansion’. Lobes may collapse when bronchus supplying it is obstructed e.g. aspirated FB, mucus plugging, or compression by an external mass. See displacement of a fissure towards collapsing lobe, air space opacification if lots of volume loss, elevation of ipsilateral hemidiaphragm, mediastinum shifts to affected side
Effusion: transudate or exudate. Lateral decubitus most sensitive. Blunting of costophrenic/cardiophrenic angle, fluid in horizontal/oblique fissure, may see a meniscus, if large may get mediastinal shift away
Possible AXR abnormalities?
Perforation:
- Erect CXR sees even small amount of gas in peritoneal cavity as a crescent under diaphragm
- AXR: pneumoperitoneum (Rigler sign-double wall sign, air on both sides of intestine; can get false double wall sign from two loops of bowel touching)
Obstruction:
- SBO: dilated loops of SB proximal to obstruction (mostly central, valvular conniventes), may have string of beads sign, SB should be <3cm and caecum <9cm
- 3-6-9 rule
- LBO: LB should be <6cm, colonic distention proximal to obstruction + collapse distally, SB may be dilated (if ileocaecal valve is incompetent), may have intramural gas (pneumostasis coli)
Acid-base abnormalities?
Look at patient for context e.g. normal PaO2 when on high flow oxygen (abnormal), normal PaCO2 in asthmatic attack (abnormal-tiring), v low o2 if pt looks very normal and has normal sats (venous sample)
Look at O2: hypoxia kills first. If on O2 therapy then PaO2 should be around 10kPa less than % inspired conc. Hypoxaemic <10, RF when <8, T1RF if just O2 and T2 RF if CO2 also high
Look at pH: is it normal, acidosis or alkalosis?
Abnormality respiratory if abnormal CO2 or metabolic if abnormal HCO3
Resp acidosis: high CO2, normal HCO3 (or raised if less acute due to compensation)
Resp alkalosis: low CO2, normal HCO3 (or low if compensation)
Metabolic acidosis: low HCO3, normal CO2 (or low if resp compensation)
Metabolic alkalosis: high HCO3, normal CO2 (or high if resp compensation)
Anion gap for metabolic acidosis:
- Increased means more acid: DKA, lactic acidosis, aspirin OD
- Decreased means less acid excreted or more HCO3 lost: diarrhoea/ileostomy/Addison’s (retain H+)
Base excess for metabolic issues:
- High (>+2) means metabolic alkalosis or compensated resp acidosis (means high HCO3 in blood)
- Low (
Pyloric stenosis biochemistry?
Hypochloraemic, hypokalaemic alkalosis (due to persistent vomiting)
Dehydration biochemistry
Monitor U+Es and glucose
Metabolic acidosis possible from diarrhoea/ileostomy losses from loss of HCO3
Metabolic alkalosis possible from GI losses of H+ diarrhoea/vomiting
Hypernatraemic dehydration: more water lost than electrolytes, usually due to high insensible losses in fever. ECG becomes hypertonic - fluid shifts to ICF - don’t get signs like reduced skin turgor until later - more dangerous. Replace slowly to avoid cerebral oedema
DKA biochemistry
High glucose Low pH <7.3 Low bicarb <15 Ketones >3 (or ++ on dipstick) Raised anion gap
Abnormal haematological test results
Anaemia - the different types
Coagulation problems
Thrombocytopenia
Sepsis
Microbiology investigations
CSF:
- Bacterial meningitis: turbid, polymorphs, high protein, low glucose
- Viral meningitis: clear, lymphocytes, normal/slightly high protein, normal/slightly low glucose
- Encephalitis: clear, normal/lymphocytes, normal/slightly high protein, normal/slighlty low glucose
Virology - nasopharyngeal aspirate. E.g. for pertussis
Urine - dipstick + laboratory results
A-E assessment
A+B: look listen + feel, signs of resp distress/increased WOB
Circ: feel + assess HR, volume, CRT, BP (correct cuff size)
D: AVPU, pGCS (differences to adults like for vocal responses)
E: rashes, wounds
Paediatric basic life support
Danger
Responsiveness - sternal rub, 2222
Airway - head tilt, chin lift; in infants neutral position of head (avoid overextension), in children head in sniffing position. Jaw thrust if not working
B-check for 10s max with chest movement + breath sounds + feel for air movement
C-check for 10s max. Infant brachial/femoral, child carotid/femoral. If not definitely >60bpm then start CPR
5 rescue breaths first as resp arrest much more likely
Compressions: 15 compressions to 2 breaths, rate of 100-120 per minute. Infants with two thumbs with hands around sternum, small child heel of one hand, older child as per adult. depress sternum by at least 1/3 chest depth
Paediatric EWS
As for adults to recognise deteriorating child
Various types in diff hospitals
Observations vary by age
How are drug doses decided in children?
Weight
Age
Body surface area: uses weight + the Boyd equation (see in BNFc). In metres squared, sometimes used
Also factors in body composition, nutritional status + organ maturation.
Try to avoid IM in children as painful
Common prescribing errors in children + how to avoid
Not using weight + BSA
Ages: <28d most sensitive/premature as reduced drug clearance + differing organ sensitivities
Age: legally required to include age on prescription if <12y, but obv should do this anyway.
Weight: overweight may be given too high a dose, may need to use ideal body weight
If dose <5ml will be given an oral syringe. Adv not to add to infants feed as e.g. milk can alter it/they may not get the full dose
Sugar free for long-term, older children may prefer solid (e.g. capsules-ask). Some flexibility if poss avoid waking them in the night as sleep is important
ADRs: possibly more likely/less identified. Report suspected to Yellow Card Scheme, also the paediatric Orange card scheme
Useful things are the ward pharmacist, BNFc, local guidelines
What can be used for poisoning?
ToxBase
Instruct patients on use of inhaler devices with spacers
Spacers useful to improve delivery of drug to lungs + reduce amount deposited in mouth/throat
For MDI + spacer: remove cap, shake, put spacer on, breathe out gently, make seal, press and inhale (prob 5 times)/with mask place it over the face
For other types
E.g. dry powder inhaler: breathe out, prime, make seal, breathe in deeply + slowly, hold breath 5-10s
Explain PEFR
do this
Instruct patients on use of adrenaline auto-injector devices
Check expiry date
Have available at all times, try to get spare for school
Don’t be afraid to use start having signs of anaphylaxis (sob, swelling of face/tongue/lips, sueden fatigue/dizzinesS), as harm from using inappropriately not high risk! Don’t hesitate
Works by helping to stimulate heart + help breathing
Can use through clothes, remove cap, press firmly into outer thigh (middle third of anterolateral thigh), hold for 10s, massage area gently, call 999, lie flat with legs raised to support BP whilst help arrives. keep child calm
Common antibiotics
Penicillin: BenPen for meningitis in community (must be injected), Pen V (can be oral but unpredictable absorption so for resp tract infections/tonsillitis).
Ampicillin: need empty stomach, not really good unless proved sensitivity. Amoxicillin: mostly for CAP/middle ear infections/UTI. Both of these common to get maculopapular rash, not a true pen allergy, esp likely in glandular fever + leukaemia
Flucloxacillin: otitis externa, severe cellulitis/impetigo, osteomyelitis. Oral or injected. Don’t use in hepatic dysfunction. SI mostly GI disorders
Trimethoprim: UTI + resp infection. CI in blood dyscrasias. S/e diarrhoea, electrolyte imbalance, fungal overgrowth, headache, skin reaction, vomiting
Erythromycin: for penicillin hypersensitivity usually. Is a macrolide. Common SE are all the GI, hearing impairment, skin reaction
Cefuroxime, cefotaxmine, ceftriaxone: cephalosporins, attach to PBP to interrupt cell wall synthesis causing lysis. Used orally + IV, for G+ and G- infections that are susceptible + for Lyme disease. Cross-sensitivity with beta-lactams so do not give if h/o immediate hypersensitivity to penicillin/other beta lactase. Cefotaxime for H influenza, gonococcal, meningitis. Ceftriaxone complicated infections, meningitis, etc etc
Common resp drugs
Salbutamol: beta2 agonist. Can have IV for acute asthma, inhaled via nebs for acute asthma (2.5mg up to 4y, 2.5-5mg 5-11y, 5mg 12-17y, repeat every 20m if needed), or using aerosol (e.g. in moderate attack 2-10 puffs every 10-20m). s/e arrhythmia/dizzy/headache/hypokalaemia in high dose/nausea/palps/tremor
Ipratropium bromide: muscarinic antagonist. CI is atropine hypersensitivity. S/e minimal
Beclomethasone-steroid
Fluticasone -steroid
Salmeterol-LABA. for maintenance.
Montelukast-leukotriene receptor antagonist. for maintenance. s/e as for salbutamol plus muscle cramps
Cetirizine: non sedating antihistamine
Adrenaline
Prednisolone: steroid
Common gastro drugs
Diarolyte: replaces lost electrolytes and promotes rehydration; oral rehydration solution
Gaviscon: for mild GORD. Alginate so like makes a foam or something
Domperidone: anti-emetic. Risk of cardiac s/e so lowest dose poss + don’t use in long QT
Ranitidine: H2RA
Omeprazole: PPI
Lactulose: constipation, osmotic laxative
Movicol: contain macrogol, osmotic laxative
Senocot (senna): stimulant laxative
Picosulfate: stimulant laxative
Common neuro drugs
Sodium valproate-never in girls
Carbamazepine
Diazepam
Lorazepam
Common analgesics
Paracetamol
Ibuprofen
Codeine
Morphine
Other important drugs in children
Furosemide
Insulin
Thyroxine
Anaphylaxis adrenaline dose in children
1:1000 concentration
1 month-5y: 150 micrograms
6-11y: 300 micrograms
12-17y: 500 micrograms, unless small/pre-pubertal in which case use 300 micrograms
Types of child abuse
Physical inc FII + FGM
Emotional e.g. developmentally-inappropriate expectations, conveying that they are worthless, seeing mistreatment of another person
Sexual abuse + exploitation
Neglect: persistent failure to meet a child’s basic physical/psychological needs that is likely to result in serious impairment of their health/development. Things like not providing basic food/clothing/shelter, abandonment, not protecting from danger, inadequate supervision, not accessing medical care
FII
Observing violence from intimate family members
FGM-proceudres involving injury to female genitalia for non-medical reasons. also a human rights violation
Safeguarding red flags
Possible presentations: physical injury, psychological, observing a concerning interaction, child telling someone, abuse observed
Possible flags: multiple A+E, repeated DNAs, delay reporting injury, excessive aggression when asking history, inconsistent stories, bruising in a non-mobile child, bruises away from bony prominences or on head (less likely to be from falling over etc), lacking medical/dental care or immunisations, ravenous hunger/dirty/poorly clothed, adult with alcohol/drug issues, child apathetic/delayed development/antisocial behaviour/delinquency
How would you raise concerns about a child safeguarding issue?
See if needs protection from immediate harm-e.g. admission to hospital for investigations + MDT assessment. Consider safety of other children at home
Local safeguarding children board to coordinate services
Local serious case reviews: look into lack of info-sharing, shaken babies, lack of appropriate actions et
Who’s responsibility is safeguarding?
Everyone has a statutory duty to safeguard children- Children Act 2004
What medical conditions should be excluded when child abuse has been suspected?
Bruising-clotting disorder, Mongolian blue spots on back/thighs
# - osteogenesis imperfecta type I (AD, blue sclerae, osteoporosis, Wormian bones in skull)
Scalds + cigarette burns - bullies impetigo, scalded skin syndrome
Give some causes of a drowsy child
Acute: sepsis, hypoglycaemia, meningitis/encephlitis, low grade infections like TB, malignancy, tooth infection, glandular fever, head injury
Chronic: puberty, insufficient sleep, malnutrition, psychological, hepatitis, anaemia, chronic airway disease, gross obesity, low/high thyroid, Cushing, Addison
Give some causes of childhood fever
Infection: serious bacterial, other like URTI/EBV, fever without obvious source (e.g. osteomyelitis, abscesses, pericarditis), travel-related e.g. malaria
Drug fever
Malignancy: ALL, AML, lymphoma with B symptoms
Autoimmune: RA, IBD, hyperthyroidism
How long should children stay off school/nursery after contracting an infection?
Conjunctivitis, roseola (HHV6), erythema infectiosum (parvovirus), infectious mononucleosis, head lice, thread worms –> no exclusion
Scarlet fever –> 24h after Abx begin
Whooping cough –> 48h after Abx/21d from sx onset if no abx
Measles, rubella –> 4d from rash onset
Chickenpox –> when all lesions crusted over (usually ~5d)
Mumps –> 5d from onset of swollen glands
D+V –> until settled for 48h
Impetigo –> until lesions crusted over
Scabies –> until treated
Influenza –> until recovered
Shaken baby syndrome
Retinal haemorrhages, subdural haematoma + encephalopathy
due to intentional shaking of a child 0-5y
Outline the UK childhood immunisation programme
8 weeks: 6 in 1, pneumococcal, rotavirus, MenB
12 weeks: 6 in 1, rotavirus
16 weeks: 6 in 1, Pneumococcal, MenB
1 year: Pneumococcal, MenB, Hib/MenC, MMR
3y 4m: MMR, 4 in 1
12-13y girls: HPV
14y: 3 in 1, MenACWY (also given to new university students aged 19-25)
What is contained in the combined vaccines?
6 in 1: diphtheria, tetanus, whooping cough, polio, haemophilus influenza B, hepatitis B
4 in 1 preschool booster: diphtheria, tetanus, whooping cough, polio
3 in 1 teenage booster: tetanus, diphtheria, polio
