KC Peds Flashcards
*Infantile colic question stem.
Definition of colic (3 things).
Crying >3 hours per day
>3 days per week
Longer than 3 weeks
*What are 3 clinical features of colic than can help you differentiate from normal crying?
Paroxysmal
Occurs in the evening
Unprovoked
Maximally at 6 weeks
*What is the proposed pathophysiology of colic? (3 possibilities)
Alterations in fecal microflora
Intolerance to cow’s milk protein or lactose
Gastrointestinal immaturity or inflammation
Increased serotonin secretion
Poor feeding technique
Maternal smoking or nicotine replacement therapy
(Think 4 options for baby and 2 for mom)
*What age does colic resolve?
3-6 months
*What are four things a caregiver can do at home to soothe an infant with colic?
Breastfed babies: moms switch to low allergen diet, try probiotics
Bottle: change to hydrolyzed formula
Sucrose solution (whaaaaa?)
Vented bottle
*Ddx (6) toxic appearing neonate
THE MISFITS
T: Trauma, tumor, thermal
H: Heart disease, hypovolemia, hypoxia
E: Endocrine (CAH, DM, thyroid)
M: Metabolic disturbances (electrolyte imbalance), DiGeorge (hypercalcemia)
I: Inborn errors of metabolism - ammonia, urea cycle defect
S: Seizures or CNS abnormalities
F: Formula dilution or over-concentration leading to hypo/hypernatremia
I: Intestinal catastrophe (intussusception, volvulus, NEC)
T: Toxins (including home remedies such as baking soda for burping)
S: Sepsis
At what age does a child 1) roll over 2) sit 3) stands 4) walks
1) 4 mo 2) 6 mo 3) 9 mo 4) 1 year
At what age does a child 1) follow sounds 2) recognizes parents 3) babbles 4) says ‘mama’ or ‘dada’ 5) uses >2 words
1) 1 mo 2) 2 mo 3) 6 mo 4) 9 mo 5) 1 year
What are the three components to the pediatric assessment triangle? What are 4 specific subcategories of each?
Appearance, work of breathing, circulation to the skin
List 4 features on history concerning for child abuse
Box 160.3
History lacking in details, inconsistent story, inconsistent with child’s developmental status, inconsistent between mechanisms and injury
List 5 features on physical exam concerning for child abuse
Box 160.4
bruises in precruising infants, patterned marks, bruises to the ears/trunk/inner thigh/or groin, posterior oropharynx lacerations, posterior rib fractures, bucket handle fractures, fractures in a non ambulatory child, fractures in different stages of healing
What is the max RR and HR in a 5 year old?
See photo
What is the best way to align the pediatric airway
<6 mo: shoulder roll
small child <5 years: no modification needed
>5 years: consider elevating the head
What is the narrowest part of the pediatric airway
Subglottic region
List 10 anatomic difference in the pediatric airway
Large occiput and head: need shoulder roll
Large tongue: needs jaw thrust and oral airway, easily obstructed
Obligate nose breathers
Superior larynx and anterior cords
Large, floppy epiglottis
Large adenoids and tonsils
Small cricoid cartilage
Subglottic space is narrowest airway
Floppy and dynamic trachea prone to obstruction
Smaller trachea length
Larger stomach with higher lungs
Higher metabolic rate, more prone to desaturation: needs preoxygenation
What size endotracheal tube should be used in a child
Age/4 +4 (-0.5 if cuffed)
What distance should an endotracheal tube be advanced
3* uncuffed tube size
Describe the process for transtracheal jet ventilation
Used in children <6 in whom the cricothyroid membrane is not yet well developed. This is used as a bridge to a surgical airway.
1. Attach a 10cc syringe to a short angiocath
2. Palpate the cricothyroid membrane and prep the skin
3. Insert the angiocath down through the cricothyroid membrane 30-45 degrees caudally while aspirating back
4. Slide the plastic IV cannula into the trachea until the hub reaches the skin
5. Remove the needle and syringe
6. Connect the angiocath to a 3ml syringe with the plunger out and a 7.5ETT connector
7. Ventilate and bag through the needle
List the pediatric doses for RSI for etomidate, ketamine, propofol, rocuronium, and succinylcholine
Etomidate 0.3 mg/kg
Ketamine 1-2 mg/kg
Propofol 3 mg/kg
Rocuronium 1-1.2 mg/kg
Succinylcholine 2 mg/kg if under 11 then 1.5
Midaz - 0.3mg/kg
Suggamdex 16mg/kg
Lidocaine 1.5 per rosens box 1 per ACLS
Atropine 0.02mg to dose of 0.5
List 5 techniques to decrease the pain of local anesthetics
Box 162.1
Use a topical agent prior to injection
Use the smallest possible needle
use a warmed solution
Inject slowly
Inject into the subcutaneous space, not the dermis
Minimize the number of punctures
Inject through open wounds, not through intact skin
Buffer the anesthetic with bicarb
List 3 categories of topical anesthetics
EMLA (lidocaine, prilocaine)
LET (lidocaine, epinephrine, tetracaine)
Vapo-coolant
What is the maximum dose of lidocaine, lidocaine with epi, and bupivacaine
Lidocaine: 4-4.5/kg
Lidocaine with epi: 7 mg/kg
Bupivacaine: 3mg/kg
How long should patients be fasting in the ED prior to sedation
ACEP: “procedural sedation not be delayed in adults or children receiving care in the emergency department based upon fasting time”
List the pediatric dose for morphine, hydromorphone, and fentanyl
Morphine 0.1mg/kg IV
Hydromorphone 0.015 mg/kg IV
Fentanyl 2 mcg/kg IV
*Define ALTE/BRUE
The term BRUE is defi ned as an event occurring in an infant younger
than 1 year when the observer reports a sudden, brief, and now resolved
episode of ≥1 of the following: (TRACtor)
(1) Tone - marked change in tone (hyper- or hypotonia)
(2) Respirations - absent, decreased, or irregular breathing;
(3) Altered level of responsiveness
(4) Cyanosis or pallor;
*List 2 evidence based criteria for admission of ALTE/BRUE
If patient is not low risk. Low risk criteria include:
Prematurity: gestational age ≥32 weeks and postconceptional age ≥45 weeks
• First BRUE (no previous BRUE ever and not occurring in clusters)
• Duration of event <1 minute
• No CPR required by trained medical provider
• No concerning historical features
• No concerning physical examination findings
*List 8 risk factors for SIDS
Age <1 year (maximum at 2-4mo)
Smoking
Not sharing a room
Co-sleeping
Bundling
Soft objects in crib
Belly sleeping
Soft sleep surface
Crib bumpers
Parental alcohol/drug use and bed sharing
Low SES
*Ddx ALTE/BRUE (7)
Anemia
Infection
Dehydration
Hypoglycemia
Metabolic disorder
Brain mass
Brain hemorrhage
Seizure
Non-accidental trauma
Arrythmia
Congenital heart defect
Good babies rarely seize or NAP (T)
What is the compression ratio in infants, children, and adults
15:2, 15:2, 30:2 (if no advanced airway; if advanced airway continuous compressions with breath every 3-6 seconds)
What shock should be used for defibrillation
first shock 2J/kg, second shock 4J/kg, up to a max 10J/kg or adult dose
What is the dose for epinephrine, amiodarone, and lidocaine in pediatric ACLS
Epi 0.01 mg/kg (1:10,000)
Amiodarone 5mg/kg
Lidocaine 1 mg/kg
List the 5 Hs and Ts of ACLS
Hypovolemia, hypoxia, hydrogen ion (acidosis), hypoglycemia, hypo/hyperkalemia, hypothermia
Tension pneumo, tamponade, toxins, thrombosis (pulmonary), thrombosis (coronary)
List 5 ways to improve CPR quality
Push hard (>1/3 anterior chest) and fast (100-120 mins) and allow for complete chest recoil
Minimize interruptions in chest compressions
Avoid excessive ventilation
Rotate compressors every 2 mins or sooner if fatigued
Ventilate at 15:2 if no advanced airway
What dose of electricity is used in cardioversion
1-2J/kg
In the context of pediatric bradycardia, when should CPR be started
HR <60
What is the pediatric dose of atropine
0.02 mg/kg to a max of 0.5,g
What is SIDS
Unexpected death of an infant <1 year for which no pathologic cause can be determined
List 5 differentials for BRUE
Gerd, URTI with apnea, coughing, choking, periodic breathing, oral dysphagia, breath holding, seizures, infections, congenital heart disease, non accidental injuries, hypoglycemia, tox
Calculate:
Pediatric ETT size
ETT depth of insertion
Chest tube size
OG size
NG size
Age/4 + 4 (uncuffed) or Age/4 + 3.5 (cuffed)
3 x ETT size
4 x ETT size
2 x ETT size
3 x ETT size
List 3 qualities of skull fractures that make them more significant
Depression, over a vascular channel (middle meningeal artery), diastatic fracture (through a suture) as a cyst may develop at this site
Describe 3 types of scalp hematomas seen in peds
Caput succedaneum: hematoma in the connective tissue layer, freely mobile, crosses suture lines
Subgaleal hematoma: within the loose areolar tissue above the periosteum
Cephalohematoma: collection of blood under the periosteum, does not cross suture lines
List signs of increased ICP in infants and children
ALL: altered LOC, persistent emesis, papilledema, posturing
Infants: full fontanel, split sutures, irritability, sun setting eyes (bilateral downward gaze within an inability to elevate superiorly)
Children: headache, stiff neck, photophobia
Describe how to clear a pediatric C spine
Canadian C spine rule can be used in children >8
As per Trauma association of Canada C spines can be cleared clinically using NEXUS + pain free ROM assessment
Plain radiographs are the initial imaging of choice
If getting a CT head consider doing C spine up to C3 to minimize damage to the thyroid”
How do you distinguish between true and pseudo subluxation at C2/C3
Spinolaminar line of C1-3, If the line crosses C2’s anterior cortical margin by less than 2 mm, (and no cervical soft tissue swelling and no fracture is seen) the image demonstrates pseudosubluxation
List the doses of resuscitation fluids
Crystalloid 20 ml/kg, pRBC 10 ml/kg, platelet 10 ml/kg, FFP 10 ml/kg
List 3 sites for a pediatric IO
Proximal tibia, proximal humerus, distal femur
List injuries associated with lap belt and bike injury with handlebars.
Lap belt (hollow viscus, diaphragmatic hernia, Chance fractures)
Bike injury with handlebars: duodenal hematoma, pancreatic (delayed 24h)
Indications for laparotomy in pediatric trauma.
HD Unstable despite resus + appropriate ED procedures (eg decompression of HTX/PTX)
HD Unstable despite resus + positive FAST
Radiographic evidence of Pneumoperitoneum/ Bladder rupture / Grade V renovascular injury
GSW to the abdomen
Evisceration of abdominal contents
Peritonitis
*3 inclusion criteria for PECARN CT head rule
Children < 18 years
Head trauma
Within 24h
*4 exclusion criteria for PECARN CT head rule
Trivial injury
Penetrating trauma
Brain tumours
Pre-existing neuro disorders
Neuroimaging at outside hospital before transfer
Outline low risk and high risk features for PECARN rule for <2 years and >2 years of age. What is reccomended for each stage?
Acting normally
No LOC (or less than 5s)
Frontal hematoma
No vomiting
No headache
Minor mechanism
*What is an impact seizure
A brief seizure that occurs immediately after an insult (with rapid return to normal level of consciousness) is commonly called an impact seizure.
*Does an impact seizure change management?
CPS: Patients with impact seizures or an isolated post-traumatic seizure shortly after the event, but whose neurological examination and imaging are normal, are at low risk of further complications and may be discharged.
*3 Reasons why pediatric patients are more at risk for intra-abdominal injuries
Children have proportionally larger solid organs, less subcutaneous fat, and less protective abdominal musculature than adults. Therefore they have relatively more solid-organ injury.
Children have relatively larger kidneys with fetal lobulations that predispose them to renal injury.
Children also have a fairly flexible cartilaginous rib cage that allows for significant excursion of the lower chest wall, permitting compression of the internal organs.
*List the high risk criteria for CATCH (4)
W – Worsening Headache
I – Irritability
G – GCS <15 2 hours after the injury
S – Suspected open/depressed skull #
medium risk:
S – Skull #
D – Dangerous mechanism (MVC, fall >3ft or 5 stairs, bike accident without helmet)
H – Hematoma (boggy)
*Mechanism of chance fracture in pediatrics?
Lap belt
*2 injuries associated with chance fractures?
Diaphragmatic hernia
Small bowel injury
*Name 5 differences between the pediatric and adult cspine
Higher anatomic fulcrum (c2-c3)
More lax ligaments of the cervical column. This leads to an increased risk of SCIWORA.
Flatter facet joints with a more horizontal orientation.
Relatively larger head size, resulting in greater flexion and extension injuries.
Incomplete ossification/fusion
Relatively large occiput in children younger than 2 years old leads to flexion of cervical spine if they are laid flat on standard backboard without support under their scapula and pelvis.
Smaller neck muscle mass with ligamentous injuries more common than fractures.
Describe how to calculate APGARS
see photo
List the equipment to assemble in a neonatal resuscitation
Radiant warmer, blankets, towels, plastic wrap (use if baby <32 weeks)
- Suction, bulb syringes(10-12Fr)
- Oxygen (heated)
- Cardiac and O2 monitors (paediatric sized)
- BMV with pressure gage
- Masks, laryngoscopes (Miller 0 and 1), ET tubes (2.5-3.5), CO2 detector, LMA (size 1)
- Meconium aspirators
- IV infusion equipment, including umbilical catheters
Describe the appropriate endotracheal tube size to use in a neonate
see photo
Roughly age in weeks/10
What is the targeted preduct SpO2 after birth at 1 min, 3 min, and 10 mins
60-65%, 70-75%, 85-95%
(goes up by 5% every 5 mins up to 5 mins)
What side does the preductal sat go on
R arm
List 5 corrective maneuvers to improve ventilation in a neonate
MR. SOPA: Mask adjust, reposition airway, suction, open mouth, pressure increase, alternatives (LMA/ETT)
When delivering a baby, when can the infant go directly to the mother
Term, good tone, breathing or crying
When is suctioning recommended?
Routine suctioning of meconium is not recommended
Suction if: meconium + poor tone, poor respiratory effort, bradycardia <100bpm after 1 min PPV
Avoid routine suctioning as this can cause vagal stimulation and bradycardia
Suction the mouth before the nose (prevents aspiration)
When should babies be put directly in a plastic bag
<32 weeks
What are initial respiratory settings for PPV - for NRP
RA (21% O2), PIP 20-25, PEEP 5
If preterm start at 21-30%; up to 100% if compressions started
When should compressions be started as per NRP
HR <60 after 15 seconds of PPV that moves the chest, and after a secure airway
What is the limit of fetal viability
22 weeks or 400g
Describe the process for obtaining umbilical vein access
- Flush a 3.5-5F umbilical catheter with NS and attach to a stopcock
- Clean the cord base (~1-2cm above the skin line). There will be 2 arteries and 1 vein
- Advance the catheter until there is flashback (at the level of the liver. Measure from diploid to umbilical and add 1-2cm or measure total body length/6+1-2cm
- Then pull back until you are 4cm deep (you do not want to deliver any epinephrine to the liver). Tip can be confirmed with X ray
- Place a constricting loop of umbilical tape at the cord base (do not compromise skin)
*26 day old with rhinorrhea and fever; otherwise well. Temperature 38.3ºC. What 5 laboratory tests are indicated?
Blood culture
Urine culture/analysis
LP
CBC/CRP
NPS
*What treatment would you give (febrile neonate)? Be specific with dose, frequency, and duration
- Ampicillin (300 mg/kg/24 hours, divided every 6 hours)
- Gentamicin (4-5 mg/kg/24 hours q24h)
*If all testing comes back negative, now what?
Admission pending cultures
*Risk of SBI in child less than 1 month old
about 10%
*5 organisms that cause SBI in neonates? (3 most common?)
- Group B strep
- E. Coli
- Listeria
- Gonorrhea
- Chlamydia
LEGS - listeria, E coli, GBS, sexual (G/C)
*5 maternal historical factors increasing suspicion for SBI?
- Lack of antenatal care
- Positive GBS swab during T3
- Maternal antepartum fever
- Prolonged rupture of membranes (PROM)
- Instrumentation during delivery
Three things that have to do with mum and then 2 ways you actually give it to the baby
*5 causes of head and torso petechiae in febrile neonate
- Meningococcal septicemia
- Straining / coughing / vomiting
- Non-accidental trauma (shaking, choking, etc)
- ITP
- Trauma from birth
- RhD alloimmunization
- RMSF
- pneumococcal bacteremia
- Streptococcus pyogenes infection
- Leukemia
- DIC
*Antibiotic treatment for febrile 22 day old
- Ampicillin (300 mg/kg/24 hours, divided every 6 hours)
- Gentamicin (4-5 mg/kg/24 hours q24h)
*What are 5 criteria of simple febrile seizure
< 15 min in duration
Single seizure in 24 hrs
Nonfocal, generalized tonic-clonic seizure
Occurs in neurologically and developmentally normal child
Between 6 months and 6 years of age
*What are 3 criteria of complex febrile seizure.
- More than one seizure in 24-hour period
- Seizures lasting longer than 15 minutes
- Seizures have focal component
*What percentage of patients will have recurrence of febrile seizure
30%
*2 other drugs and route (not dose) to give for seizure in peds
- Diazepam PR/IV
- Midazolam IM/IN/buccal/IV
- Lorazepam IV
*3 other meds aside from benzos that you can give IV for seizure (you can assume airway is managed)
- Fosphenytoin
- Levetiracetam (e.g. Keppra)
- Phenobarbital
- Propofol
*Most common cause of serious bacterial infection in infants
UTI
*Organisms that cause SBI in 1-3month olds
o - Haemophilus influenzae
o - Streptococcus pneumonia
o - Neisseria meningitidis
o - Escherichia coli
Add in the meningitis bugs HENS
*What are 6 features in 29-90 day old infants that make them low risk
o Previously healthy infant
o Nontoxic clinically
o No focal source of infection
o Normal WBC (between 5000 and 15,000 WBCs/mm3)
o Fewer than 1500 bands/mm3
o Normal urinalysis
o Normal CSF, if obtained
*Disposition for low risk infant with fever
Home with reassessment in 24h
*What are 5 risk factors for UTI in children
febrile girls <24 months old
uncircumcised boys <12 months old
circumcised boys <6 months old)
vesicoureteral reflux
hypospadias
*What treatment regimen would you use for suspected HSV encephalitis in neonate?
- Ampicillin (300 mg/kg/24 hours, divided every 6 hours)
- Gentamicin (4-5 mg/kg/24 hours q24h)
- Cefotaxime (200mg/kg/day divided q6h)
- Acyclovir (60 mg/kg/24 hours divided every 8 hours)
*Five maternal/obstetrical risk factors for vertical HSV transmission?
- Active genital lesions at or near time of delivery
- Prodromal symptoms at or near time of delivery
- Primary maternal HSV infection
- Premature delivery
- Invasive fetal monitoring
*List 6 clinical findings that make you suspect HSV in a neonate?
- Maternal history of HSV
- Cutaneous vesicles on physical examination
- CNS disease: seizure, lethargy, irritability, tremors, poor feeding
- Ill-appearing or sepsis syndrome (i.e. disseminated disease)
- Transaminitis
- Coagulopathy (i.e. thrombocytopenia)
- CSF pleocytosis (i.e. high lymphocytes)
*What are 5 non infectious causes of fever in peds
Bundling, environmental, leukemia, lymphoma, neuroblastoma, juvenile rheumatoid arthritis, thyroid storm, tox
What is the least sensitive modality for measuring a fever (i.e. which method should have the lowest threshold)
Axillary -> oral -> tympanic -> rectal
14 day infant comes in with a fever. What workup is appropriate
Full septic w/u: blood cultures, urinalysis, LP, CXR - even in the presence of an identified source
14 day infant comes in with a fever. What is the drug therapy of choice?
Ampicillin 50mg/kg with cefotaxime 50mg/kg or gentamicin +/-acyclovir 20mg/kg if HSV.
2 mo infant comes in with a fever. What organisms commonly cause SBI
Haemophilus, Ecoli, Strep pneumo, Neisseria meningitidis
Think Gen H
Briefly describe the Rochester criteria
Sn 81. Derived for 0-2mo population. If well infant, >37 weeks gestation, previously healthy, no evidence of AOM/SSTI/bone/joint infection, normal labs (WBC <15000, Urine, stool) can be d/c with reliable parents for f/u in 24 hours
This is the one most commonly used in Eds as Boston and Philadelphia require LPs and step by step requires procalcitonin
4mo infant comes in with a fever. What investigations are necessary?
None; investigate source only as directed, most fevers represents a self limited virus
According to the step by step algorithm, which children should get a full septic workup
looks unwell, ≤ 21do, leukocyturia, elevated ANC >10,000/CRP >20/procalcitonin
List 5 clinical clues that suggest the presence of HSV infections in infants
maternal hx of genital HSV lesions, vesicles, mucous membrane ulcers, seizures, hypothermias, leukopenia, thrombocytopenia, elevated liver enzymes
Briefly describe the Philadelphia criteria
Sns 98% Sp 42%. Infants 29-60 days old; all well looking. All got BW + urine + CSF. If low risk home w/o antibiotics
Briefly describe the Boston criteria
Sn and Sp not available. Infants 28-89 days old; all well looking. All got BW + urine + CSF. If low risk home with antibiotics
*What is the most common pathogen that causes croup? What are 4 others?
- Parainfluenza virus
- RSV
- Influenza A
- Influenza B
- Rhinovirus
- Adenovirus
- Measles
- Enterovirus
*What are 4 emergency department management priorities for a child with croup?
- Glucocorticoids (dexamethasone 0.15- 0.6 mg/kg)
- Aerosolized epinephrine (indicated if stridor at rest)
- Limit anxiety
- Fever reduction
- Encourage oral intake
- Monitor for improvement/decompensation
*3 year old, febrile, drooling, stridor, no cough. Dx and causative organism.
Epiglottitis, H flu (even still)
*3 year old, febrile, drooling, stridor, no cough. Appears toxic and doesn’t improve with inhaled/oral Tx. Dx and causative organism.
Bacterial tracheitis, Staph aureus/polymicrobial
*This child does not have croup. List 4 other potential causes of stridor
Supraglottic diseases
- Acquired: RPA, PTA, Ludwig’s angina, epiglottitis, foreign body, anaphylaxis, upper airway trauma, upper airway burn
- Congenital: macroglossia (Down syndrome), micrognathia (Pierre Robin, Treacher-Collins), choanal atresia, thyroglossal cyst
Glottic diseases
- Acquired: laryngeal papilloma
- Congenital: laryngomalacia, laryngeal web, vocal cord paralysis
Subglottic diseases
- Acquired: airway foreign body, croup, bacterial tracheitis
- Congenital: subglottic stenosis, subglottic hemangioma, tracheomalacia, tracheal stenosis, vascular ring
*3 year old with stiff neck. Non toxic. Injected pharynx. Most likely Dx?
Retropharyngeal abscess
*2 imaging tests for RPA
o Soft tissue neck X-ray, lateral and AP
o Soft tissue neck CT scan
*2 causes of RPA
o An abscess may result from direct trauma (e.g. toothbrush),
o contiguous spread of infection, or
o hematogenous seeding
*Four bacteria most likely in RPA
o Group A streptococcus
o Staphylococcus aureus (including MRSA)
o Haemophilus influenzae
o Fusobacteria
*For each of the following clinical scenarios, name the most likely diagnosis and causative organism.
a. Child with barky cough and stridor, improved on way to ED
b. Child with dysphagia and stridor, not responding to epinephrine
c. Child with bilateral cervical adenitis and exudate on tonsils
d. Child with torticollis, fever, and URTI sx.
e. Tripod position and drooling.
a. Croup
b. Bacterial tracheitis
c. Strep pharyngitis
d. RPA
e. Epiglottitis/FB
*What are immediate management steps in someone with epiglottis
DO NOT DISTURB THIS CHILD - airway risk; requires immediate ENT consultation
- Provide oxygen and epi neb if tolerated, contact experts for consideration of intubation or tracheotomy
- try to AVOID intubation in the ED, instrumentation may cause laryngospasm
- Ceftriaxone +/- vancomycin +/- steroids
- Adults tend to be more stable as their airways are larger
Intubation
- Maintain the patient upright in a position of comfort
- Awake intubation with light sedation (1mg midazolam)
- Consider glycopyrrolate 0.2mg intravenously
- Flexible laryngoscopy is preferred as it provides the most minimally invasive view of the airway
- Backup adjuncts for surgical airway
What age range is associated with retropharyngeal abscess
Children <6
What is the normal prevertebral soft tissue space in children
C2 <6mm
C6 <14 mm (22 in adults)
What are the recommended antibiotics in retropharyngeal abscess
Clinda + ceftriaxone
What is the most common x ray finding in epiglottitis? The most specific?
Most common: normal (70%)
Most specific: epiglottic width >8mm or aryepiglottic folds >7mm
What is the most common cause of stridor in infants
Laryngomalacia
What is the narrowest part of the pediatric airway
Subglottic region
What are indications for admission in croup
Name two conditions associated with primary tracheomalacia
Down syndrome, DiGeorge syndrome
How can you differentiate between tracheomalacia and tracheal stenosis
Tracheal stenosis should worsen with age as the tracheal diameter is fixed
Tracheomalacia should improve with age as the cartilage strengthens
List 3 secondary causes of tracheomalacia
Vascular ring, cyst, lymphoma, lymphadenopathy
What is the clinical presentation of bacterial tracheitis
Croup-like symptoms that worsen; fever, stridor, cough, toxic appearance
Needs bronchoscopy for diagnosis and therapy (tracheal debridement)
What organisms cause croup
Parainfluenza virus accounts for 50% to 75% of cases; respiratory syncytial virus, influenza A and B viruses, and rhinovirus cause the remainder
*4 things on PRAM score
- Oxygen saturation
- Suprasternal retractions
- Scalene contractions
- Air entry
- Wheezing
*PRAM of 7 represents what degree of asthma exacerbation?
Moderate
*2 MOST important treatments and route (Tx moderate asthma exacerbation)
- Salbutamol (via MDI or nebulizer)
- Dexamethasone (PO)
*10 causes of wheeze in children
- Asthma
- Viral bronchiolitis
- Bacterial tracheitis
- Acute laryngotracheobronchitis
- Epiglottitis
- Acute bronchitis
- Pneumonia (e.g. viral, bacterial, TB)
- Foreign body aspiration
- Heart failure
- Aspiration/reflux
- Anaphylaxis
*3 initial management steps with drug doses and details for moderate asthma
- Ventolin 8 puffs via MDI
- Ipratropium 8 puffs via MDI
- Dexamethasone 0.3 mg/kg PO (rest given as second dose at home)
*3 things on an outpatient prescription for child with recurrent asthma attacks
Salbutamol 2 puffs q4h PRN
Fluticasone 100ug ihn BID x3 months
Dexamethasone 0.3 mg/kg PO
What should the PCO2 be in an asthmatic
Decreased; normal PCO2 is an ominous finding; indicates respiratory fatigue. PCO2 should be decreased with hyperventilation
What are three physiologic reasons children are more at risk for severe asthma exacerbations?
Compliant chest walls -> less able to increased tidal volume. Increased RR may quickly lead to fatigue. Higher oxygen consumption needs and faster desaturations
What is the dosing for ventolin in pediatrics
What is the dose of magnesium in asthma exacerbations
50mg/kg max 2 g
Describe the components of the PRAM score
see photo
What PRAM scores correspond to a mild, moderate, and severe exacerbation
Mild 0-3, moderate 4-7, severe 8+
What is the dose of IV ventolin
<10kg 25mg salbutamol in 50ml syringe
>10kg 50mg salbutamol in 50ml syringe
Continuous infusion 1-10 mcg/kg/min
List 4 populations at risk of severe bronchiolitis
Premature infants, <3 mo age, comorbid disease ex. Congenital cardiac, immunocompromised
Describe the management of bronchiolitis
Hydration, supplemental O2 as necessary
- Equivocal: mild suctioning, 3% saline, epi nebs + dex, epi nebs
- Not recommended: Ventolin, antibiotics, steroids, antivirals, normal saline nebs
*Recognize pneumonia on lateral peds CXR. Most likely organism?
Strep pneumonia
*What is the name of the antibiotic, the dose, the route, and for how long would you treat peds pneumonia?
Amox 90mg/kg divided TIDD for 10 days
*PNA on peds CXR, if patient has SCD, what should you consider?
Acute chest syndrome
*What is the treatment of acute chest syndrome (peds)?
Oxygen for sat >95
Antibiotics
Fluids PRN
Analgesia
Transfusion if anemic +/- exchange transfusion
?consult heme
What is the most common cause of CHD in infants
Acyanotic: VSD. Cyanotic: ToF
What cardiac abnormalities will have increased pulmonary blood flow on CXR
Increase in blood flow suggest s L to R shunt
Acyanotic: ASD, VSD, Eisenmenger’s syndrome, PDA, endocardial cushion defects
Cyanotic: transposition of great arteries, total anomalous pulmonary venous return, hypoplastic left heart syndrome, truncus arteriosus
What cardiac abnormalities will have decreased pulmonary blood flow on CXR
Acyanotic: pulmonic stenosis, aortic stenosis, coarction of the aorta
Cyanotic: ToF, severe pulmonic stenosis, Ebstein’s anomaly, tricuspid atresia, pulmonary atresia, hypoplastic right heart
*Kawasaki criteria
Fever for 5 days plus:
● 4 of:
○ CREAM
■ Conjunctivitis
■ Rash
■ Extremity changes (edema/palmar rash)
■ Adenopathy (cervical)
■ Mucous membrane changes
*The least common finding of Kawasaki disease criteria
Cervical Adenopathy
*Typical age group for incomplete Kawasaki
<6months
*2 treatments for Kawasaki
IVIG and ASA
*Percentage of patients with Kawasaki that get coronary aneurysm
1) treated; 2%
2) untreated 20%
*3 bedside tests you can do to determine CHD and which CHD lesion
- Hyperoxia challenge: Differentiating pulmonary disorders from cardiac disorders
- Pulse delay or absence: Decreased femoral pulses may suggest coarctation of the aorta
- Blood pressure differential: Difference between preductal (i.e. right arm) blood pressure and lower extremity blood pressure > 10 mmHg, think of an obstructive process
*3 causes of ductal cyanotic lesions
• Any infant < 1 month of age with cyanosis or shock should be considered to have a ductal-dependent critical congenital heart disease until proven otherwise.
• As the ductal arteriosus closes, cardiac defects with obstructive lesions of the pulmonary or systemic circulations will be unmasked:
- Tetralogy of Fallot (CXR: Boot-shaped heart)
- Tricuspid atresia
- Pulmonary atresia
- Total anomalous pulmonary venous return (snowman)
- Transposition of the great vessels (CXR: Egg on a string)
*2 causes of ductal shock (cyanotic and shocky in first weeks of life)
- Severe coarctation of aorta
- Severe aortic stenosis
*3 side effects of prostaglandins
- Apnea
- Hypotension
- Bradycardia
- Flushing
- Fever
*1 week old presents with cyanosis: 6 cyanotic heart lesions
Transposition of the great arteries
Total anomalous pulmonary venous return
Tricuspid atresia
Ebstein’s anomaly of the tricuspid valve
Truncus arteriosus
Pulmonary atresia
Hypoplastic right heart syndrome
Hypoplastic left heart syndrome
Tetralogy of Fallot
*Why do patients present with cyanosis in a delayed fashion?
Gradual closure of the ductus arteriosus connection between the pulmonary artery and aortic arch (fully closed at 3 weeks)
*What is the one treatment to give to a newborn presenting with cyanotic heart lesion?
Prostaglandin IV 0.1 mcg/kg/min
*Differential of enlarged mediastinum on CXR in 1 year old with chronic cough
- TB
- Teratoma
- Thymoma
- Lymphoma
- Congenital heart disease
- Thyroid goiter
*How to perform the hypoxia test
ABG is performed after several minutes on high-flow oxygen (100% oxygen), with a PaO2 of more than 250 mmHg excluding hypoxia due to congenital heart disease
PaO2 less than 100 mmHg in a child without obvious pulmonary disease is consistent with a right-to-left shunt
*3 abnormal lab values in Kawasaki
Elevated CRP/ESR
Albumin ≤3 g/dL
Anemia for age
Platelet count of ≥450,000/mm 3
White blood cell (WBC) count ≥15,000 mm 3
Elevation of alanine aminotransferase
Sterile pyuria of ≥10 WBCs per high-power field
PAWAPA
*What are the abnormalities in TOF?
(1) right ventricular outflow tract obstruction
(2) large, unrestrictive, misaligned VSD
(3) over-riding aorta that receives blood flow from both ventricles
(4) right ventricular hypertrophy secondary to the high pressure load placed on the right ventricle by the right ventricular outflow tract obstruction
*3 general principles in management of a Tet spell?
- Increase the SVR
- Abolish the hyperpnea
- Correct metabolic acidosis
*4 drugs would you use in management of a Tet spell?
Oxygen
Fentanyl or Midazolam
Ketamine
Sodium Bicarb
then propranolol or phenylephrine
*What are two non medication interventions you would employ to treat this patient as she is moved into an examining room?
Knees to chest, calm infant in mothers arms
*Explain the pathophysiology of a tet spell
Any event that suddenly lowers the SVR, such as crying or defecation, and hypovolemia or tachycardia will produce a large right-to-left shunt across the VSD.
This drops the O2, increases the CO2 and drops pH.
This causes an increase in RR which drops intrathoracic pressure, increasing venous return and further shunts deoxygenated blood across the VSD.
*Name the 2 congenital long QT and the ion channel affected
Romano-Ward (Na+/K+)
Jervell–Lange-Nielsen (K+)
*4 ECG characteristics that help distinguish SVT from sinus tachycardia
SVT
Presence of retrograde P-waves
Constant R=R
>220 in age < 1yr ; >180 for older children
Paroxysmal attenuation
Sinus Tach
Physiologic variability
Beat to beat variability
Presence of P-waves.
<220 for infants; <180 for children
*What would be the next most appropriate management step in the ED for a stable 3w baby with SVT? Then, the intervention does not work and on reassessment the child looks unwell, grey and has a BP of 55/35. What is your next step?
Vagal (ice to face)
Then cardiovert 0.5 to 1 J/kg
*What pharmacologic intervention can be used for SVT? What are 2 essential aspects of the administration of this medication?
Adenosine (0.1mg/kg), large bore proximal IV with rapid flush.
*3 investigations for coarctation of the aorta
4 limb BP, CXR, echo
*EKG showing long QT. What 2 antibiotics can cause this?
Macrolides: Erythromycin, clarithromycin
Fluoroquinolones: Levofloxacin, moxifloxacin
Describe newborn circulation
Umbilical vein -> ductus venosus (shunts liver where deoxygenated fetal blood is returning) ->
R atrium -> foramen ovale -> left atrium -> aorta OR
R atrium -> right ventricle -> pulmonary arteries -> ductus arteriosus -> aorta
Lungs have higher pressure in utero so blood is shunted across the heart
Describe changes to circulation at birth
L sided pressure > R side and pulmonary blood flow is restored
- Increased global oxygenation causes a physiologic closure of the umbilical arteries, umbilical veins, ductus venous, doctor arteriosus
- Closing foramenoval (complete at 3mo of age)
- Ductus arteriosus closes (15 hrs - 2/3 weeks of life) with a decrease in prostaglandins
Explain the utility of a 4 limb BP
Blood pressures should normally be higher in the lower extremities
SBP > 15-20 mmHg higher in R arm than legs indicative of coarctation or R-to-L shunt across PDA
Explain the utility and pre and post ductal sats
Pre ductal (R hand) vs. post ductal (either foot)
Pre > post = R-to-L shunt. When post ductal saturations are lower there is a mixing of blood through a shunt
Post > pre = TGA with additional anomaly (rare)
abN: > 3% difference b/t UE/LE, < 94% LE, < 90% UE/LE
Explain the hyperoxia test
After several minutes of 100% O2 a PaO2 >250 demonstrates a “pass,” 100-250 represent mixing, and <100 represent a “fail” due to a right to left shunt
Respiratory issues should improve with oxygen and crying
List 5 signs that this cyanotic infant has a congenital cardiac abnormality
A “comfortably” blue baby with no respiratory distress
Cyanosis that gets worsen with crying or feeding
Murmur
PaO2 does not rise with hyperoxia test
Chest radiograph shoes boot shaped, egg on a string, or snowman shaped heart
Upper limb BP > lower limb BP
Preductal sat > post ductal sat
When do infants with duct dependent lesions present in distress
2-3 weeks
Describe the pathophysiology of a tet spell
R sided outflow tract obstruction or lower systemic vascular resistance (ex. crying) leading to R to L shunting through a VSD -> Hypoxia + hyperventilation + acidosis -> increased intrathoracic pressure increases blood flow to the heart, worsening the shunt
List 5 management steps for a tet spell. What does propranolol do?
Goal is to increase pulmonary blood flow by increasing after load and causing L->R shunting
Flex children’s knees to chest, calm the child, administer oxygen
IV and sodium bicarb to reverse the acidosis
Consider intranasal fentanyl or midazolamor ketamine for relaxation
Consider phenylephrine to increase SVR
Consider propranolol 0.1-0.25 mg/kg IV to reduce infundibular spasm
List 5 acyanotic congenital cardiac defects
Increased pulmonary blood flow: L-> R shunt: ASD, VSD, PDA, AVSD, AV malformation
Normal pulmonary blood flow: obstruction (this decreases the blood flow to the lung): Coarctation of the aorta, aortic stenosis, pulmonary stenosis, mitral stenosis
List 5 duct dependent lesions
Acyanotic: duct is needed to get the blood to the body because of an obstruction in the left side of the heart of aortic arch ex. AS/AAA, coarct, hypoplastic left heart
Cyanotic: duct is needed because there is a structural abnormality on the right side that wont allow them to oxygenate blood ex. TOF, TGA, TA, PS/PA, hypoplastic right heart
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: tetralogy of fallot
Cyanotic
VSD + RV outflow obstruction (pulmonic stenosis) + overriding aorta + RVH
Pulmonary stenosis with loud S2
R axis deviation and RVH
Boot shaped heart
Cyanotic with tet spells
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: transposition of the great vessels
Cyanotic
Separate systemic and pulmonary circulation that worsens as the ductus arteriosus closes: Aorta arises from RV and pulmonary trunk through LV, needs PFO, ASD, VSD, DA for mixing
Murmur only if VSD
ECG shows R axis deviation and RVH
CXR shows egg shaped heart (narrow mediastinum)
Cyanotic with CHF if VSD
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: total anomalous venous return
Cyanotic
All pulmonary veins drain into R sided circulation, no pulmonary venous return to L atrium. Leads to RA/RV dilation
Murmur fixed S2 (ASD)
ECG shows R axis deviation and RVH
CXR shows snowman sign
Cyanotic with CHF
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: truncus arteriosus
Cyanotic
Single great vessel for the aorta, pulmonary, and coronary arteries
Single loud S2 with VSD
ECG shows biventricular hypertrophy
CXR shows cardiomegaly, increased pulmonary vascular markings
Cyanotic
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: tricuspid atresia
Cyanotic
No tricuspid valve, decreasing pulmonary blood flow, R atrium needs an ASD or VSD to empty
Murmur is a single S2
ECG shows R and L ventricular hypertrophy
CXR shows decreased pulmonary vascular markings
Cyanotic
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: hypoplastic left heart
Cyanotic
LV hypoplastic may include atretic or stenotic mitral valve. In utero the Rventricle provides the systemic circulation through the PDA. Essential no aorta; dependent on the duct for systemic circulation
Murmur is an ASD
ECG shows R atrial enlargement
CXR shows cardiomegaly, CHF
Cyanotic
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: coarction of the aorta
Acyanotic
Narrowing of the aorta at the level of the ductus.
Murmur is similar to AS: crescendo-decrescendo
ECG shows RBBB, RVH
CXR rib notching on chest xray, cardiomegaly, and pulmonary edema
Associated with bicuspid aortic valves and Turners. BP difference between the upper and lower extremities, brachiofemoral delay. CHF
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: VSD
ACyanotic
Membranes do not close.
Murmur is holosystolic
ECG shows LAH, LVH
CXR may be normal or may show increased vascular markings
Does not present as a newborn due to high R sided pressures
What is Eisenmenger’s syndrome
A worsening, uncorrected L to R shunt increased pulmonary hypertension and eventually leads to a R to L shunt (cyanotic)
Describe the physiology, murmur, ecg, chest x ray, and clinical presentation of: ASD
ACyanotic
Membranes do not close.
Murmur is pulmonic systolic murmur with a split S2
ECG shows RAD, RVH, RBBB
CXR may be normal or may show cardiomegaly with increased vascular markings
Often asymptomatic, may lead to severe CHF if severe
List 5 post of complications of repaired congenital heart defects
Thrombosis, decreased shunt flow, increased shunt flow, CHF, dysrhythmias, myocardial ischemia, endocarditis, pericarditis
Describe 2 innocent murmurs
Pulmonic flow murmur: systolic due to think walls of the pulmonary arteries at birth, should disappear within 3-6 months of age. Tend to be low pitched, soft, systolic
Stills murmur: age 2-6, vibratory musical murmur that is different from the harsh murmur of the VSD. Should increase in the supine position, with fever, excitement, exercise, or anemia
Describe 2 worrisome murmurs
Diastolic, systolic murmurs that are: louder than 3/6, continuous, or associated with a thrill; murmurs that are associated with abnormal heart sounds ex. Clicks, presence of cyanosis or respiratory distress, bounding or weak pulses, abnormal ECG, abnormal cardiac silhouette
List 7 causes of sudden cardiac death in children
Potential causes
- Hypertrophic cardiomyopathy
- Congenital coronary artery anomalies ex. anomalous left coronary artery, congenital coronary artery hypoplasia
- Prolonged QT
- Preexcitation syndromes ex. WPW
- Aortic rupture secondary to Marfan’s syndrome
- Dilated cardiomyopathy
- Myocarditis
- CAD secondary to Kawasaki
- Aortic stenosis
- Mitral valve prolapse
- Blunt trauma
Explain the pathophysiology of hypertrophic cardiomyopathy
Obstructive cardiomyopathy involves a thickened muscular intraventricular septum that bulges into the left ventricle and impedes forward flow, causing SOB, syncope
What is the ECG criteria for hyperopic cardiomyopathy
LVH via voltage criteria: 11, 25, 35, 45
- R wave in aVL >11, R wave in I and S wave in III >25, R wave in V5, V6, S wave in V1 >35, Largest R wave in precordial limbs >45
L sided changes
- L atrial enlargement
- L axis deviation
- ST depression and T wave inversions in L sided leads
Prominent Q waves in lateral and inferior leads
What medications are used to manage hypertopic cardiomyopathy
Beta blockers
What is ALCAPA syndrome
ALCAPA Anomalous left coronary artery from the pulmonary artery. Left coronary artier from the PA (deoxygenated blood)
What is the diagnostic criteria for Kawasaki
Vasculitis with risk of coronary aneurysm, can lead to acquired heart disease
- Fever >5 days (high fever, may not respond to antipyretics) + MyHEART
- Mucosal involvement (fissured lips, strawberry tongue, injected pharynx
- Hand and extremity edema of hands and feet (or peeling)
- Eyes - Bilateral non exudative conjunctivitis
- Adenopathy >1.5cm
- Rash (polymorphous)
- Rash is NOT pruritic and NOT vesicular
- Typically begins on the trunk and spreads to the face and extremities
- Temperature
List 3 lab findings that may occur in Kawasaki
high CRP, anemia, elevated ALT, high platelets >450, high WBC >15, pyuria >10 WBC/hpf, low albumin <3.0
PAWAPA
What is the treatment of Kawasaki
IVIG 2g/kg as a single infusion and ASA (80-100mg/kg/day divided in 4 doses), ideally within 10days
What is the diagnostic criteria for rheumatic fever
JONES criteria + hx of prior group A strep infection
- Major: JONES criteria: joint arthralgias, O carditis (murmur, CHF, pericarditis), nodules, erythema marginatum, Sydenham chorea
- Joint pain is typically migratory in the large joint, with pain out of proportion to the swelling
- Erythema marginatum: non-pruritic, ring-shaped, painless
- Minor: arthralgia, fever, elevated CRP, long PR
FAPER is rheumatic fever, fever, arthalgia, PR long + CRP or ESr
*5 causes of neonatal jaundice (unconjugated) other than physiologic/breast milk
Increased hemolysis of RBCs:
- ABO incompatibility
- Physiologic breakdown of birth trauma hematoma (cephalohematoma)
- Intracranial/intraventricular hemorrhage
- Spherocytosis, elliptocytosis
- Sickle cell anemia
- Thalassemia
- G6PD deficiency
- Pyruvate kinase deficiency
Decreased conjugation:
- Gilbert syndrome
Crigler-Najjar
Infectious:
- TORCHS infection
- Urinary tract infection
- Sepsis
Obstructive (increased enterohepatic circulation):
- Meconium ileus
- Hirschsprung’s disease
- Duodenal atresia
- Pyloric stenosis
Metabolic or genetic:
- Congenital hypothyroidism
*5 causes of direct (conjugated) hyperbilirubinemia
Infectious:
* TORCHS infection
* Urinary tract infection
* Gram-negative sepsis
* Listeriosis
* Tuberculosis
* Hepatitis B
* Varicella
* Coxsackievirus infection
* Echovirus infection
* HIV infection
Obstructive (increased enterohepatic circulation):
* Biliary atresia
* Choledochal cyst
* Bile duct strictures
* Inspissated bile syndrome
* Neonatal hepatitis
* Alagille syndrome
* Byler’s disease
* Congenital hepatic fibrosis
Metabolic or genetic:
* Galactosemia
* Tyrosinemia
* Glycogen storage disease type IV
* Niemann-Pick disease
* Wolman’s disease
* Gaucher’s disease
* Cholesterol ester storage disease
* α1-Antitrypsin deficiency
* Cystic fibrosis
* Dubin-Johnson syndrome
* Neonatal hypopituitarism
* Zellweger’s syndrome
* Donohue syndrome (leprechaunism)
* Rotor syndrome
*What is kernicterus?
Kernicterus refers to the chronic, long-term neurologic sequelae of BIND (bilirubin-induced neurologic dysfunction) from toxic levels of bilirubin and is characterized by yellow staining of basal ganglia.
*What are 3 risk factors for kernicterus ?
Severely elevated bili levels
Failure of phototherapy
BIND
Or Risk factors for the development of severe hyperbilirubinemia:
Prematurity (<37 wks GA)
Isoimmune-mediated hemolysis
ABO incompatibility)
Sepsis
Cephalohematomas,
Dehydration,
Genetically inherited abnormalities
hereditary spherocytosis
glucose-6-phosphate dehydrogenase (G6PD) deficiency.
*Kid swallows coin, it is in his esophagus, 3 places where it can get stuck
- Upper esophageal sphincter (cricopharyngeus muscle)*
- Aortic arch
- Left mainstem bronchus
- Lower esophageal sphincter (diaphragmatic hiatus)
*3 mechanical ways to get FB out of the esophagus
- If in upper esophagus, Kelly clamps or Mcgill forceps under direct visualization
- Pass Foley catheter beyond foreign body, inflate balloon
- Esophageal dilator to push foreign body into stomach
- Endoscopy
*FOUR mechanisms of injury for button battery in esophagus
- Pressure necrosis
- Leakage of alkaline electrolyte
- Generation of electrical current
- May leak mercury ? toxicity
*5 indications for further workup of neonatal jaundice
- Jaundice within first 24 hours of life
- Elevated direct (conjugated) bilirubin level
- Rapidly rising total serum bilirubin unexplained by history of physical examination
- Total serum bilirubin approaching exchange level or not responding to phototherapy
- Jaundice persisting beyond 3 weeks of age
- Sick-appearing infant
*10 day old with: Total bilirubin 170 Conjugated bilirubin 50
c. What is the most likely diagnosis?
d. What is the next step in management?
Breast milk jaundice. Keep feeding.
*Single most important lab test in 4week old jaundiced
Total bili
*3 causes of obstructive jaundice
Obstructive (increased enterohepatic circulation):
- Meconium ileus
- Hirschsprung’s disease
- Duodenal atresia
- Pyloric stenosis
Direct:
* Biliary atresia
* Choledochal cyst
* Bile duct strictures
* Inspissated bile syndrome
* Neonatal hepatitis
* Alagille syndrome
* Byler’s disease
* Congenital hepatic fibrosis”
*Single best imaging test for obstructive causes
US
*3 hematologic causes of jaundice in newborn
ABO incompatibility
Physiologic breakdown of birth trauma hematoma (cephalhematoma)
Intracranial/intraventricular hemorrhage
Spherocytosis, elliptocytosis
Sickle cell anemia
Thalassemia
Glucose-6-phosphate dehydrogenase deficiency
Pyruvate kinase deficiency
*2 most common causes of jaundice in newborn
Physiologic jaundice
Breastfeeding jaundice
*Abnormal time frames for jaundice
(a) Anything in the first 24 hrs of life
(b) Beyond the first 3 weeks of life
*XR findings of intussusception
- Dilated loops of small bowel
- Paucity of gas in colon
- Target sign
- Meniscus sign (i.e. air compressed like meniscus from invaginating bowel)
- Free air
- Soft tissue density
- Obscured liver edge
Note: Ultrasound is the diagnostic imaging modality of choice, features of intussusception:
*4 other causes of bowel obstruction in children
- Severe constipation
- Adhesions from prior surgery
- Volvulus
- Hirschsprung’s
- Meckel’s diverticulum
- Incarcerated hernia
- Cancer/mass
- FB
- Hernia
*Causes of LGIB in infancy
Necrotizing enterocolitis
Intussusception
Gastroenteritis
Milk allergy
Vascular malformation
Meckel’s
*5 potential causes of intussusception in older child
HSP vasculitis
Meckel’s diverticulum
Lymphoma, polyps
Postsurgical scars
Celiac disease
Cystic fibrosis
*Contraindications of air enema
Peritonitis or sign perforation
*3 week old with bilious vomiting and double bubble sign on AXR Dx and 3 other causes of obstruction in 3mo old
Duodenal atresia
Malrotation with midgut volvulus
Meckel’s diverticulum
Intussusception
Bowel obstruction
Incarcerated hernia
*4 indications for removal of gastric FB
Obstruction
Perforation
>2 cm wide
>5 cm long
Containing toxins
Inability to pass – not passed stomach x 3-4 weeks, same intestinal location x 1 week or absolutely no change in position in 24hrs
Sharp or pointed (toothbrush, bone, pick)
High powered multiple magnets
*4 lab tests for jaundice in well appearing newborn
Bilirubin total and indirect
CBC with smear
Coombs
*Conjugated hyperbilirubinemia, list 2 tests you would order next in its evaluation
Abdo U/S
Blood cultures
*Table for causes of LGIB by age (6 months, 2 years, 10 years)
INFANCY
Necrotizing enterocolitis
Intussusception
Gastroenteritis
Milk allergy
Vascular malformation
CHILDHOOD
Gastroenteritis
Intussusception
Meckel’s diverticulum
Inflammatory bowel disease
Vascular malformation
Henoch-Schönlein purpura
Hemolytic-uremic syndrome
Colitis
ADOLESCENCE
Gastroenteritis
Intussusception
Meckel’s diverticulum
Inflammatory bowel disease
Vascular malformation
Henoch-Schönlein purpura
Hemolytic-uremic syndrome
Polyps
Colitis
List 4 side effects of phototherapy
Risks: bronze-baby syndrome, temperature instability, diarrhea, eye protection for the retina, interference with maternal bonding
- No risk of UV radiation or dehydration
Infants has rising bilirubin despite phototherapy. List 3 next steps
Exchange transfusion (separate nomogram), triple phototherapy, IVIG
What is Gilbert syndrome
Gilbert syndrome: autosomal recessive disorder of UDP glucuronosyl transferase, 5% affected. Normal conjugated, higher unconjugated hyperbilirubinemia. Crigler Najjer syndrome is a more severe type of Gilbert
List indications for Emergency Removal of Gastrointestinal Foreign Bodies
[Box 171.3]
Signs of respiratory distress
Evidence of esophageal obstruction (inability to swallow secretions)
Button battery in esophagus
Sharp or long >5cm object in the esophagus or stomach
High powered magnets
Signs of intestinal inflammation, obstruction, or perforation
Esophageal foreign bodies impacted for >24 hours or an unknown amount of time
What x ray finding is associated with NEC
Pneumatosis
What is the clinical presentation of pyloric stenosis
Projectile non bilious vomiting in infants immediately after feeding; seen in 3-5 weeks of ago
What is the diagnostic criteria for pyloric stenosis on US
Thickness >3mm and length >14mm
PIE-lyric stenosis 3.14 is 3mm thick and 14mm long
What lab abnormality is associated with pyloric stenosis
hypochloremia hypokalemic metabolic alkalosis
Lose acid so metabolic acidosis and low chloride. Loss K because its turns on RASS and H/K pump at kidney
List 4 supportive management strategies for an infant with GERD
avoid cigarettes smoke, anti reflux positioning, smaller and more frequent feeds, thickened bottle feeds, hypoallergenic trial.
What is the diagnostic modality of choice for malrotation with volvulus
upper GI contrast series
List 3 pediatric conditions associated with bowel obstruction? (3 different locations in GI tract)
duodenal w Down Syndrome, jejunal-ilea w Cystic Fibrosis, Colonic w Hirschsprung disease
What x ray finding is associated with intestinal atresia
double bubble sign (duodenal atresia)
List 5 potential lead points for intussusception
lymphoma, Peyer’s patches enlarged post viral infection, meckel’s, appendix, post surgical scars, celiac disease
What clinical triad is associated with intussusception
pain, palpable abdominal mass, blood in stool
What is the treatment for intussusception
air contrast enema
List 5 differentials for abdominal pain in each of the following age groups: 1) infancy 2) childhood 3) adolescence
see photo
Besides primary functional, list 5 other etiologies for constipation
Neurogenic: Hirschsprung disease, CP, spinal cord injury, infantile botulism
Endocrine: CF, electrolyte abnormalities (hypercalcemia), hypothyroid, SM
Other: celiac, cows milk allergy
What is the definition of colic
Crying >3x/day >3 days/week >3 weeks
What clinical tetrad is associated with HSP
Palpable purpura (generally in lower extremities), arthritis/arthralgias (lower extremities, bilateral), abdominal pain, renal disease (hematuria)
RAAPP
Renal disease (hematuria)
Abdo pain
Athralgia
Palpable Purpura
List 5 complications of HSP
GI: intussusception -> which leads to GI bleeding PLUS pancreatitis
Renal: nephritis -> Which leads to hypertension
List causes of pancreatitis more commonly seen in pediatric patients
Trauma: ex. Bicycle crash, handlebar injuries
Infection: EBV, CMV
Systemic: autoimmune (Sjogren, IBD, primary biliary cholangitis), cystic fibrosis, sickle cell
Drugs: metronidazole, valproate
List 10 causes of biliary tract disease in children
Hemolytic disease: sickle cell, spherocytosis (pigment stones from hemolytic anemia are more common than cholesterol stones)
Cystic fibrosis
Drugs: TPN, ceftriaxone in the newborn
Infectious causes: sepsis, RMSF, salmonella, recent URTI, Kawasaki, strep pharyngitis
List 5 GI and 5 non GI causes of vomiting in children
GI: obstruction, gasto, peritonitis, hepatitis, appendicitis, pyloric stenosis, midgut volvulus, intussusception, inborn errors of metabolism
Non GI
CNS: space occupying lesion
Tox: ingestion, drug effect
Endocrine: Addisonian, diabetic ketoacidosis, CAH
Renal: UTI, pyelonephritis, renal failure
Cardiac: CHF
Infection: pneumonia, OM, sinusitis, sepsis
List 5 GI and 5 non GI causes of diarrhea in children
GI: Malabsorption (ex. Milk intolerance), IBD, IBS, short gut, infectious gasto, intussusception, appenditis, HUS, colitis
Non GI
Drug: ingestion, overdose
Endocrine: thyrotoxicosis, addisonian crisis, diabetic enteropathy, CAH
Renal: UTI, pyelo
Infection: pneumonia, AOM, sinusitis, sepsis
Which organisms responsible for infectious gastro should get routine treatment with Abx
Campylobacter, Cdiff, Giardia, Entamoeba
Samonella, campylobacter, cryptosporidium are maybes
List 5 causes of gastroenteritis in pediatrics
Similar to adults
- Viral 70-80%: rotavirus (vaccine available), norovirus, adenovirus
- Bacterial 10-20%: salmonella, shigella, campylobacter, yersinia, Ecoli, clostridium, staphylococcus, vibrio
- Protozoa <10%: cryptosporidium, giardia
List 6 indications for medical evaluation of diarrhea in children
Young age <6 mo or <8kg, history of premature birth, fever, visible blood in the stool, high output, persistent vomiting, signs of dehydration, change in mental status, failure of oral rehydration
List 5 signs and symptoms of dehydration
Dry mucous membranes, delayed cap refill, tears, educed skin turgor, depressed fontanel, lethargic mental status, sunken eyeballs, hypotension, tachycardia, reduced urine output
What volume of oral rehydration solution is recommended in pediatrics
Remember there are two types of dehydration that get oral rehydration solution - MILD and MODERATE
Mild 30-50ml/kg
Moderate 60-80 ml/kg
25% in the first 4 hours, replace ongoing losses 10 per BM and 2 per kg for vomit?
List 6 differentials for volume depletion
Renal: diuretics, renal tubular acidosis, renal failure, urinary obstruction, diabetes insipidus, diabetes mellitus, hypothyroidism, adrenal insufficiency, renal trauma, salt wasting nephritis
Extrarenal: third spacing (pancreatitis, sepsis), skin losses (burns), CHF, liver failure, hemorrhage
What is the calculation for pediatric maintenance fluid
4 mls/kg for first 10, 2 mls/kg for second 10, 1 ml/kg each additional kg
What volume of IV fluids should be given for severe dehydration
20 ml/kg
List 5 bacteria (causing GI illness) that produce toxins
Vibrio cholerae, salmonella, shigella, e coli, c diff
*What are 3 physiologic reasons children are more susceptible to the complications of an acute diarrheal illness?
Larger ECF compartment so more susceptible to dehydration by GI losses
Higher metabolic rate with high turnover of fluids
Limited metabolic substrate reserves (glucose, fat…)
Limited access to water
Kidney are less capable of retaining water
*What are 3 bugs that routinely require Abx treatment?
Salmonella TYPHI
Campylobacter jejuni
C. diff
Could also include the protozoa:
Entamoeba histolytica
Giardia intestinalis
*What are 5 components of the Gorelick scale?
General appearance
Cap refill
Tears
Mucous membranes
Eyes
Breathing
Quality of pulses
Skin elasticity
Heart rate
Urine output
*Rehydration of moderate dehydration: Type of fluid, route of fluid administration, volume of fluid, and over how long
Oral rehydration: Pedialyte, or whatever the kind the kid will drink
80 mL/kg for moderate (6% to 9%) volume depletion
Replace 25% of above per hour x4h and then reassess
Replace losses 10ml/kg stool and 2ml/kg emesis as well
Give zofran if puking.
*Stem: 4yoM bloody diarrhea 10d ago, now very dehydrated and HSM on exam. Most likely Dx and etiologic agent:
HUS and e. coli o157:H7
*3yo with 24h vomit and diarrhea. Normal vitals. How to rehydrate?
Oral rehydration
*3 complications of HSP
- Acute renal failure
- Nephritic syndrome
- Nephrotic syndrome
- Hypertension
- Scrotal edema
- Intussusception
- Gastrointestinal bleeding
*Most common indicated treatment in HSP
NSAIDs
Steroids can be used for severe pain
*3 lab findings in HUS
Elevated leukocyte count
Elevated CRP
Schistocytes
Teardrop cells
Helmet cells
Microspherocytes
Burr cells
Thrombocytopenia
Anemia
Elevated creatinine
*5 complications of HUS
Metabolic acidosis
Hyperkalemia
Thrombocytopenia
Hypertension
Seizures
Acute renal insufficiency
Stroke
Pancreatic insufficiency
Toxic megacolon
Ischemic colitis
Intussusception
Perforation
*9 y/o boy with 4hrs of testicular pain (previous shorter episodes – self resolved). On exam he has a tender and swollen right sided hemiscrotum.
a) 2 emergent diagnoses that require immediate intervention
b) 3 alternative dx which do not require immediate intervention
c) 2 tests that you would perform in the emergency department
d) If this was a 67 y/o man instead, which 2 other dx would you consider
a) testicular torsion, incarcerated hernia
b) epididymitis, hydrocele, appendix testes torsion
c) US and urinalysis/culture
d) STI, lymphoma
*3 management steps and 3 lab tests for PSGN
Management: consult nephro, diuretics, monitor BP
Tests: ASO titre, urinalysis, urea and lytes, complement
*Treatment for balanoposthitis and 2 complications
sitz baths, topical antifungals, hydrocortisone, keflex
complications include cellulitis and constrictive phimosis
*4 causes of painless scrotal swelling
Hydrocele, varicocele, reducible hernia, germ cell tumour
CHF/cirrhosis, epididymal cyst, idiopathic scrotal edema
*4 causes of painful scrotal swelling
Torsion
Hernia
Appendix testes torsion
Epididymitis
Orchitis
Trauma
*1 investigation for scrotal swelling
US
*Immediate management for possible torted teste
Call urology
*7 etiologies for dysuria in children
Chemical irritation (bubble bath)
Abuse
Appendicitis
UTI
FB
Candida
Balanoposthitis
Balanitis
Paraphimosis
Pinworms
Straddle injury
Self-stimulation
*List top 2 pathogens causing UTI
e. coli and klebsiella
What is a Bell Clapper deformity
Tunica attaches higher on the spermatic cord and testicular fixation does not occur
What is testicular appendix torsion
Torsion of the testicular appendix (remnant of the paramesonephric duct). May be seen as a blue dot (only in 25% of cases). If there is no testicular torsion appendix torsion is treated conservatively; NSAIDs, ice etc
List 3 physical findings of testicular torsion
Swollen, high riding testes, abnormal lie, lack of cremastic reflex
List 3 reasons for normal ultrasound with torsion
early in disease course, intermittent torsion, partial obstruction (venous obstruction without arterial obstruction)
Describe 1 physical maneuver that can be used in a patient with torsion
manual de-torsion; like ‘opening a book’ twisting the testes from midline to lateral. Successful if immediate relief, can try twisting past 360 degrees.
List 5 infectious and 2 non infectious causes of epididymitis
Viral: coxsackie, varicella, mumps
Bacterial: STIs (chlamydia, gonorrhea), Ecoli, Klebsiella, Pseudomonas, Staph, Strep
Rare infectious causes: tuberculosis, syphilis, fungal
Non infectious: Drug related: amiodarone, Immune: Bechet’s
Which types of hydrocele needs referral for surgical repair
Communicating
What is a varicocele
Dilated veins of the pampiniform plexus due to incomplete drainage. “Bag of worms” texture
List 3 types of testicular tumors. Which type is the most common in young men?
Teratomas, embryonal carcinomas, yolk sac tumors, choriocarcinomas, Leydig cell tumors, Sertoli cell tumors, lymphoma. Germ cells are the most common
What is the difference between phimosis and paraphimosis
Phimosis: stenosis of the foreskin, preventing retraction over the glans
Paraphimosis: foreskin is retracted and becomes trapped in that position; unable to retract the skin distally
see photo
List 5 strategies for reducing a paraphimosis
Sugar soaked gauze or LET gel
Compression of the glans with a wrap to reduce edema
Ice
Pain control
Manual reduction: pressure on the glans with traction on the foreskin
Dorsal slit
Where should anesthesia be injected for a dorsal slit procedure
10 o’clock and 2 o’clock for dorsal anesthesia
6 o’clock if anesthesia is needed for the whole penis
Describe the procedure for a dorsal slit
Dorsal penile nerve block: inject lidocaine (without epi) at 10 and 2 o’clock positions. Should feel a pop as the needle passes through the fascia. Aspirate before injection.
Dorsal slit: clamp the foreskin between two hemostats for 2 mins. Cut with a scalpel. Edges need to be sutured. Needs to be referred to urology for circumcision
List 2 main types of priapism and for each describe
1) blood flow
2) etiology
3) clinical presentation
4) blood sample
Ischemic: low flow due to venous outflow obstruction. Causes: leukemia, sickle cell. Clinical presentation: rigid, painful. Blood sample: Hypoxic Pa O2 <30, hypercapnic PaCO2 >60, acidotic <7.25
Nonischemic: high flow to due increased arterial flow. Causes: trauma, fistulas. Clinical presentation: not rigid or painful. Blood sample: similar to normal arterial blood; PaO2 >90, PaCO2 <40, pH 7.40
What is stuttering priapism
Intermittent ischemic priapism, often due to sickle cell
List 3 management strategies for priapism
Conservative management: ice, physical activity, warm bath
PO pseudoephridine
Aspiration 20-30cc at a time
Irrigation with NS or dilute phenylephrine (100-500 mcg of phenylephrine/ml)
List 2 management strategies for priapism unique to sickle cell
Administer oxygen to keep sats >95%
Exchange transfusion to reduce HbS <30%
What is balanoposthitis? Balanitis?
Balanoposthitis is cellulitis of the glans, foreskin
Balanitis is cellulitis of the glans only
List 5 causes of balanoposthitis/balanitis
Poor hygiene, contact dermatitis, local trauma
STIs
Bacterial infection: staph, Ecoli, strep (esp. if still in diapers)
Candida, tinea
List 3 causes of circumcision
Bleeding, urethral meatal stenosis, phimosis
List 5 causes of renal masses in children
Cystic lesions, severe hydronephrosis
Solid masses: Wilm’s tumor, neuroblastoma, renal cell carcinoma, mesoblastic nephromas, cystic nephromas
List 5 risk factors for the development of pediatric UTI
female gender, uncircumcised male, age (females <2 years, males <6mo), white race, fever >2days, fever >39 degrees, hx of UTI, sexual activity, anatomic abnormalities, poor hygiene, voluntary urinary retention, abnormal bladder emptying due to constipation
List 5 organisms that commonly cause UTI in pediatric patients
KEEPS - Klebsiella, Ecoli (most common), Enterobacter, Proteus, Staphylococcus
List 3 causes of culture -ve dysuria
viral urethritis/cystitis, urethritis (contact irritation, self stimulation, poor hygiene, foreign body, trauma, sexual or physical abuse), STIs, renal disease (glomerulonephritis, kidney stones)
What is the laboratory definition of UTI
UTI if >50,000 cfu/ml on urinalysis
List the antibiotic that you would use to treat a UTI in a 1) <1 mo old 2) <2 year old 3) >2 year old
<1mo: IV Abx x7 days (Cefotaxime, Ampicillin)then oral Abx (amoxicillin, Septra, Cephalexin)
>1mo <2yr: Admit if toxic, treat with CTX then oral Abx
>2 yr: oral Abx for 7 days
- Cefixime 8mg/kg/day, Amoxicillin 50mg/kg/day (divided in 3 doses), Cephalexin 500mg/kg/day (divided in 4 doses)
List 2 antibiotics that should NOT be used to treat UTIs in children
Macrobid, Fluoroquinolones
An 18 months F is dx with a UTI and sent home with Abx. What follow up is needed?
Child <2 yrs of age: Should be investigated after the first UTI with a renal/bladder ultrasound to identify any significant abnormalities. May need follow up with a voiding cystourethrogram if there are signs of a vesicoureteral reflux (hydronephrosis, scarring)or obstructive uropathy
List 10 causes of hematuria in children
[Box 173.2]
Extrarenal: trauma, meatal stenosis, exercise, menstrual cycle, rectal bleeding, foreign bodies, cystitis, epididymitis
Intrarenal: pyelonephritis, kidney stones, glomerulonephritis, acute interstitial nephritis, acute tubular necrosis, glomerular disease, renal vein or artery thrombosis, polycystic kidney disease
Systemic: HSP, lupus, HUS, sickle cell, bacterial endocarditis, bleeding disorders, medications (amitriptyline, ibuprofen, dyes)
What is the laboratory definition of hematuria
Microscopic >5RBCs/huff
Macroscopic gross hematuria visible to the naked eye
What is post strep glomerulonephritis? What are typical lab findings?
PSGN is a sequelae of streptococcal pharyngitis believed to result from the deposition of circulating immune complexes in the kidney, occurs ~2 weeks after primary infection
Dx with hematuria (often with RBC casts) and hx of strep infection (+ASOS titre)
Managed with restriction of fluid and salt intake, thiazide diuretics
List 5 causes of proteinuria. What are false positives and false negatives?
Pathologic: nephrotic syndrome, lupus, glomerulonephritis, post transplantation, heavy metal poisoning, UTI
False positive: urine with blood, vaginal secretions, semens,
False negative: dilute urine
What is a significant amount of protein on a urine dip
3+ protein
What is the treatment for primary nephrotic syndrome
Corticosteroids; prednisone 2mg/kg/day divided TID
List the indications for hospitalization in nephrotic syndrome
fever (relatively immunocompromised), hypertension, marked impairment in renal function
List 10 causes of AKI
Prerenal: decreased volume (burns, third spacing, sepsis), cardiac shock, decreased renal artery blood flow
Intrarenal
- Glomerular: PSGN, pyelonephritis
- Systemic: HUS, HSP, lupus, sepsis
- Toxins: heavy metal poisoning, myoglobin, antibiotics, anticonvulsants, dyes
Post renal: kidney stones, tumors, infection renal vein thrombosis
List the diseases associated with each of the following:
- Red casts
- White casts
- Granular casts
- Hyaline casts (devoid of contents)
- Fatty casts
- Eosinophils casts
Red casts = glomerular nephritis or vasculitis
White casts = renal parenchymal inflammation, AIN
Granular casts = debris, cellular remnants, ATN
Hyaline casts (devoid of contents)= prerenal azotemia or obstruction ex. dehydration, exercise
Fatty casts: nephrotic syndrome
Eosinophils casts = allergic interstitial nephritis
List 10 causes of hypertension in pediatrics
see photo
What 1 test is most important in HSP
Urine for hematuria and proteinuria; if normal no need for further renal function test
What is the most common cause of HUS
Shiga producing Ecoli STEC
What clinical symptoms are associated with HUS
Renal failure, microangiopathic hemolytic anemia, thrombocytopenia
Describe the step by step algorithm
See photo
List 5 contraindications to LP
Overlying infection/cellulitis
Coagulopathy
Signs of high ICP
Focal neurologic deficits
HD instability
Plt <50
List 10 causes of altered mental status in peds
see photo
List empiric antibiotics for meningitis in each of the following age groups:
0-28 days, 28 days to 3 mo, >3 mo
0-28: amp + gentamicin or cefotaxime
28-3mo: ampicillin or vanco + cefotaxime or ceftriaxone
>3mo: cefotaxime or ceftriaxone + vancomycin
What are the two main types of seizures
Partial: consciousness maintained
Generalized: consciousness is lost
*5 criteria of simple febrile seizure
- Seizure in presence of fever
- No CNS infection/other identifiable cause
- Generalized seizure
- Lasts less than 15 minutes
- No recurrence during 24-hour period
- Occurs in neurologically and developmentally normal child between 6 months and 6 years of age
*3 criteria of complex febrile seizure
- More than one seizure in 24-hour period
- Seizures lasting longer than 15 minutes
- Seizures have focal component
*What percentage of patients will have recurrence of febrile seizure
30%
*3 other meds aside from benzos that you can give IV for seizure (you can assume airway is managed)
- Fosphenytoin
- Levetiracetam (e.g. Keppra)
- Phenobarbital
- Propofol
- Valproic acid
*Child has recurrence of seizure in ED without IV or IO access. 2 drug options (give dose, route)
- Lorazepam 0.1 mg IO
- Midazolam 0.1-0.2 mg/kg IM
- Midazolam 0.2 mg/kg buccal
- Midazolam 0.2 mg/kg IN
- Diazepam 0.5 mg/kg PR
*Contraindications to LP
signs of elevated ICP, focal neurologic deficits on examination, and underlying coagulopathy
*3 most common pathogens in neonatal meningitis
- Group B streptococcus
- Escherichia coli
- Listeria
*5 symptoms of shunt obstruction
Headache
Vomiting
Diplopia
Blurred vision
Confusion
Irritability
Lethargy
*5 signs of shunt obstruction
CN6 lateral gaze palsy
Papilledema
Sunset eyes
Ataxic Gait
Differentially size pupils
Altered Mental Status
Cranial suture diastasis
*2 causes of communicating and 2 causes non-communicating hydrocephalus
1) IVH, meningitis, NPH, choroidal plexus tumour
2) Obstructive tumour, SAH with obstructive clot
*Ddx for gait ataxia in childhood
Acute cerebellar ataxia (MCC)
Acute postinfectious demyelinating encephalomyelitis
Brainstem encephalitis
Drug ingestion
Guillain-Barré syndrome
Metabolic disorders
Aminoacidopathies
Mitochondrial disorders
Organic acidopathies
Urea cycle disorders
Migraine headaches
Multiple sclerosis
Neoplasm
Opsoclonus-myoclonus syndrome
Recurrent and chronic genetic ataxias
Seizures
Stroke
Vertebral artery dissection
*2 week old baby had fever for 4 hours and brief unilateral seizure activity. Bulging fontanelle. Ddx:
Meningitis
Encephalitis
Abscess
Non-accidental trauma
Spontaneous ICH
Complex febrile seizure
3 medications for 2 week old baby had fever for 4 hours and brief unilateral seizure activity. Bulging fontanelle
Ampicillin, gentamycin, acyclovir
List 5 causes of seizure, and 5 causes of seizure unique to pediatrics
Fever: meningitis, encephalitis, brain abscess
Trauma: cerebral contusion, intracranial hemorrhage, impact seizure
Tox: drug intoxication or withdrawal
Metabolic: hypoglycemia, hyponatremia
Vascular: AV malformations, CVST, stroke
VP shunt malfunction
Unique to peds: inborn errors of metabolism, neurocutaneous disorders (neurofibromatosis, tuberous sclerosis, Sturge-Weber syndrome), cerebral palsy, simple febrile seizures, non accidental injury
Which traumatic seizures are less worrisome
Impact seizures that occur within 1 hour of head trauma
Early post traumatic seizures in the first week may be associated with cerebral edema or intracranial hemorrhage
What symptoms are associated with baby botulism
Constipation, poor feeding, weak cry, hypotonia
What is the treatment for baby botulism
Botulism immunoglobulin 50mg/kg
What is the definition of status epilepticus
Seizure lasting longer than 5 minor recurrent seizure >5 min without a return to baseline
What is the definition of epilepsy
More than 1 unprovoked seizure
List 4 types of generalized seizures
Absence, tonic/clonic, myoclonic, atonic, infantile spasms
What percentage of children experience a febrile seizure
5%
What is the risk of recurrence with febrile seizure
33%
What is the risk of epilepsy following febrile seizure
1-2% vs. 0.5-1% in the baseline population
What workup is required for simple febrile seizures
List 5 reasons to consider an LP in febrile seizure?
No specific workup is required; only the workup you would have done in the source
Red flags to consider doing an LP for meningitis: post ictal symptoms lasting >1 hr, any physical signs of meningitis(neck stiffness, petechial rash, photophobia), irritability or lethargy, already on antibiotics, incomplete immunizations, complex febrile seizures
list indications for neuroimaging in the context of a febrile seizure
suspicion of non-accidental injury, signs of increased ICP, persistent abnormal neurologic status, underlying CNS disorders (ex. VP shunt)
List 5 differentials for seizure disorder in children (sounds like seizure but not a seizure)
breath holding, syncope, GERD (Sandifer’s syndrome), chorea (acute rheumatic fever), myoclonic jerks, rigors, night terrors, tic d/o, migraines, drug exposure/tox
Describe the treatment algorithm for status epilepticus
0-5 mins: benzos (0.1mg/kg lorazepam, 0.2 mg/kg midazolam, 0.5 mg/kg diazepam PR)
5-10 mins: benzo again
15 mins: 2nd line agent (20 mg/kg phenytoin, 20 mg/kg phenobarbital, 20PE/kg fosphenytoin, 20mg/kg Keppra, 20 mg/kg Valproic acid)
After 3rd seizure medication prepare for intubation
List the pediatric dosing of hypertonic saline, dextrose, and calcium gluconate
3% NaCL 3ml/kg
10% dextrose 2-5 ml/kg
10% calcium gluconate 100mg/kg (1 ml/kg)
What neurologic disease is associated with 1) café au lait spots 2) ash leaf spots
Neurofibromatosis, tuberosclerosis
List indications for CT head in a headache
[Box 174.3]: abnormal neurological exam findings, signs and symptoms of elevated ICP, meningeal signs + altered mental status or focal neurologic findings, significant head trauma, severe nocturnal headaches that awaken the patient from sleep, severe “worst headache of my life” presence of a VP shunt, chronic progressive headache
Consider if: headache or vomiting on awakening, unvarying location of headache esp. occipital, persistent headache with no family history of migraines, neurocutaneous syndrome, age <3
What is acute cerebellar ataxia
Disease caused by an autoimmune response post infection that leads to cerebellar demyelination. Causes 40% of pediatric ataxia. Sx are maximal at onset. Mental status is normal
List 10 risk factors for stroke in the pediatric patient
Cardiac: congenital cardiac disease, R to L shunts, endocarditis, arrhythmias, cardiac tumors, cardiac surgery
Heme: sickle cell disease, HUS, TTP, polycythemia, DIC, leukemia, cancer
Vasculitis: lupus, moyamoya, Takayasu
Infection, metabolic, vascular, trauma, substances
What is benign paroxysmal vertigo of childhood
Repeated vertiginous episodes with occasional vomiting
Remits spontaneously within months to years
Most frequent cause is migraine headache, with vertigo as an aura
BPPV is rare in children, earliest report at 11 years old
What constellation of symptoms are associated with the Miller Fischer variant of GBS
Ataxia, loss of DTR, ophthalmoplegia of vertical gaze
Ben saying “AOA”
*Describe the treatment of pediatric supracondylar fractures as per the Gartland classification system
I Nondisplaced fracture - splint or case x3w
II Displaced fracture with intact posterior cortex - cast vs. pinning. Many NV status re-checks in firs 24-48h
III Displaced fracture with no cortical contact - pinning. Many NV status re-checks in firs 24-48h
*What are 4 complications of supracondylar fractures? What is deformity called?
• Malunion
• Ischemic contracture (Volkmann contracture), due to damage/occlusion of the brachial artery
• Damage to ulnar, median or radial nerve (most common: anterior interosseous nerve, a branch of median nerve)
• Compartment syndrome
• Cubitus varus deformity (“gunstock” deformity)
*Most common complication of supracondylar #
anterior interosseous nerve (AIN) neurapraxia (brachial artery is second)
*How can you test for AIN neuropraxia?
Motor: Distal phalanx flexion (thumb and first finger) Make the OK sign
Purely motor - no sensory
*8 year old child with fall on elbow from trampoline; normal neurovascular status. Obvious swelling at elbow. Brought in by dad.
What are three interventions you can do at this point?
Analgesia
Immobilization
Xray
*Recognize Monteggia and explain findings
Injury defined as proximal 1/3 ulnar fracture with associated radial head dislocation
*What are the ossification centres in the paediatric elbow? Write them in order.
Capitellum
Radial head
Internal epicondyle
Trochlea
Olecranon
External epicondyle
The approximate ages at which these sites ossify are 1, 3, 5, 7, 9, and 11 years, respectively
*2 lines on pediatric elbow XR (eg. supracondylar fracture)
Anterior humeral line
Radiocapitellar line
*What are 4 XR findings of supracondylar fracture?
Anterior fat pad
Posterior fat pad
Capitella not in line with anterior humeral or radiocapitellar lines
Baumann’s angle greater or less than 75-80deg
Cortex disruption
*5 categories of diagnosis and specific causes for child with a limp
- Infection: septic arthritis, OM
- Trauma: Fracture, overuse
- Neoplastic: Leukemia, Ewing’s
- inflammatory: JRA, TS, Rheumatic fever
- Hematologic: SCD, Hemophilia
- Misc: LCP, SCFE
*4 investigations for child with limp
WBC
ESR
Synovial fluid for gram stain, culture and cell count
xray
*Causes of osteomyelitis in children
S. aureus (MCC)
GBS
Kingella
H flu
S. pyogenes
N. gonorrhea
*List ossification centres and when they ossify
C - Capitellum (1)
R - Radial head (3)
I - Internal (medial) epicondyle (5)
T - Trochlea (7)
O - Olecranon (9)
E - External (lateral) epicondyle (11)
*4 XR findings of SCFE
- Widening of physis
- Posterior step-off at physeal plate
- Klein’s line does not come in contact with epiphysis (known as “Trethowan sign”)
- Crescent-shaped, increased density in proximal portion of femoral neck due to superimposition of posteriorly displaced epiphysis on femoral neck (known as “blanch of Steel” sign)
*5 Risk factors for SCFE
- Gender, boys > girls
- endocrinopathies,
• hypothyroid,
• ,
• hypogonadism,
• exogenous growth hormone. - renal osteodystrophy, and
- radiation therapy
- Obesity
*Complications of SCFE
- Further slippage
- Avascular necrosis
- Chondrolysis (i.e. acute cartilage necrosis)
Longer term:
- Non-union
- Premature closure of epiphyseal plate
- Degenerative changes
Outline the technique for reduction of pulled elbows
Flexion-supination or hyper-pronation of the elbow (the other hand holding the elbow to feel for a click)
*What would cause these strategies to fail (reduction of pulled elbow)?
- Annular ligament rupture
- improper technique
- edema
- hematoma
- spasm
- fracture
*2 XR findings in septic arthritis
- Normal X-ray
- Periarticular soft tissue swelling
- Widening of joint space
- Obliteration or displacement of gluteal lines
- Asymmetric fullness of iliopsoas and obturator soft tissue planes
- Subchondral bone erosions*
- Narrowing of joint space*
*Late findings
*2 XR findings in transient synovitis
- Normal X-ray
- Medial joint space widening
- Accentuated peri-capsular shadow
- Waldenstrom’s sign/ Lateral displacement of femoral epiphysis, with surface flattening secondary to effusion
*4 tests that would help distinguish between septic arthritis and transient synovitis
Kocher criteria
- Fever >38.5
- Inability to bear weight
- ESR > 40
- WBC > 12
*What specific treatment would be most appropriate (be specific) if suspected septic arthritis
ROSENS: Nafcillin, 50 mg/kg, and ceftriaxone, 50 mg/kg
*Define torus (buckle) fracture
Buckling of bone without cortical disruption, tends to occur from compression failure at the metaphyseal-diaphyseal junction
*Define greenstick fracture
Cortical disruption on one side of a long-bone, with the periosteum on the fracture’s compression side remaining intact
*Define plastic deformation
Bone is bowed, with no obvious cortical disruption
*Illustrate the salter-harris classification
see photo
*What is the most common organism causing septic arthritis?
Staph aureus
*Bony cause of limping in a toddler
1) Toddler’s fracture
2) Osteochondroma
3) Septic joint
4) Osteomyelitis
5) Non accidental injury
6) DDH
*Systemic cause of limping in a child
1) JRA
2) Rheumatic fever
3) HSP
4) Sickle Crisis
5) Congenital Limb length discrepancy
6) appendicitis/ torsion
*Causes of limping in an adolescent
1) SCFE
2) Osgood Schlatter’s disease
3) Femoro patellar syndrome
4) Gonococcal arthritis
5) Ankylosing Spondylitis
*4 life or limb-threatening causes of limping
1) Nec Fasc
2) Osteomyelitis
3) Popliteal aneurysm (all)
4) septic joint
5) compartment syndrome
List 4 conditions that can mimic child abuse
Osteogenesis imperfecta, osteopenia of prematurity, scurvy, copper deficiency, Menkes disease, diffuse osteopenia
List 4 differences between pediatric and adult bone
Active growth plates with risk of growth arrest in fracture
Weaker, more porous bone that is more likely to fracture
Thicker more active periosteum that promotes healing
Remodeling allows for greater angulation and displacement
Which Salter Harris fractures are intraarticular
III and above
list 4 types of fractures unique to pediatrics
SALTER Harris
Greenstick
Bowing/plastic deformation
Buckle/Torus
Bucket handle fracture
What is the most common joint for septic arthritis in a pediatric patient
Knee
List 4 risk factors for septic arthritis
Preceding viral infection, trauma, immunodeficiency, hemoglobinopathy, diabetes, RA, previous surgery, intra articular injections or operations
List 3 organisms that can cause septic arthritis
Staph aureus, Group B strep, Neisseria gonorrhea, Streptococcus pneumonia, Kingella kingae, hemophilia influenza
List 4 types of pediatric bone tumors
Osteoblastoma (bone forming), oestoma (non spreading, non cancerous) osteochondroma (cartilage forming), cystic tumors, giant cell tumor
What type of vascular injury can occur with supracondylar fractures
Brachial artery injury; Volkmann ischemia
What is Baumann’s angle
Line through the midshaft of the humerus and the growth plate of the capitellum. Should be ~75%; but best to compare to the other side
List 2 reduction techniques for a nursemaid’s elbow
Hyperpronation or supination/flexion
Describe the anatomic abnormality in a nursemaid’s elbow
Radial head subluxes out of the annular ligament
What is a Tillaux fracture
Salter Harris III fracture that extends through the distal tibial physis and exits intra articularly; the anterior ATFL pulls the lateral epiphysis from the medial malleolus
What is a Triplanar fracture
Salter Harris IV fracture that occurs in the sagittal, coronal, and transverse planes; similar mechanism to a Tillaux
List 3 types of apophysitis and their anatomical location
Osgood Schlatter - tibial tubercle
Little league elbow - medial epicondyle
Sever’s disease - calcaneus
What is SCFE
Displacement of the capital femoralepiphysis from the femoral neck through thephysical plate
What is Legg-Calve Perthes
Avascular necrosis of the femoral head with a subchondral stress fracture
What age does Legg-Calve Perthes typically present
Between the ages of 4 and 10 years
Describe the progression of x ray findings for Legg-Clave Perthes
Initial phase - smaller femoral head, widening of medial joint space, subchondral lucency, subchondral collapse, irregular physeal plate, blurry and radiolucent metaphysis
Fragmentation - epiphysis begins to fragment and there are areas of radiolucency as the new bone forms; speckled calcification
Reossification - normal bone density returns, radiodensities replace radiolucency
Healed - residual deformities, early arthritis
List 3 clinical findings of developmental dysplasia of the hip
leg length differences (Galeazzi’s sign), asymmetric skin fold, decreased range of motion, positive Barlow and Ortolani
Describe the Barlow and Ortolani tests
Barlow - provocative maneuver to sublux a hip: Stabilize the pelvis, place thumb on the inner aspect of the thigh near the lesser trochanter, abduct the hip while exerting downward pressure on the thigh
Ortolani - reduction maneuver: Stabilize the hip, slightly abduct the infant’s hip, pull up in the GT to gently reduce the hip
List 3 difference in drug metabolism between adult and pediatric patients
Skin: increased surface area and hydration; net increased absorption of topical medications
Distribution: higher total body water and volume of distributions affects drug concentrations
GI: Higher gastric pH affects the bioavailability of acid labile drugs
Drug metabolism is different in infants and neonates as their metabolizing enzymes are not yet mature. Children 1-6 may actually have higher metabolism and may require relatively higher doses
Absorption via non oral route (ex. IM) is unpredictable
List 3 drugs that should be avoided in the pediatric patient
ASA: Reye’s syndrome
Doxycycline: tooth discolouration
Cough and cold products
Ceftriaxone, septa: increased bilirubin can lead to kernicterus
*10 historical features concerning for abuse
- Injury pattern inconsistent with the injury mechanism
- Mechanism inconsistent with developmental stage
- Inconsistent history provided by different care providers (stories don’t match up)
- Inconsistent history provided by same care provider at different times
- Prior history of abuse
- Injury sustained as a result of punishment to the child
- History of similar or multiple injuries in the past
- History of drug abuse
- Unwanted pregnancy / child
- History of domestic violence in the household
*10 fractures or fracture patterns concerning for abuse
- Any fracture < 1 yr
- Fractures of different ages
- Multiple #
- Skull # (complex more suspicious than linear)
- posterior Rib #
- CMLs (classic metaphyseal lesion /bucket handle)
- Vertebral #
- Midshaft diaphyseal humeral/femur # (in non-weight bearing children)
- Scapular #
- Periosteal bone formation
*Nurse brings in her child with multiple skin abscesses, grew e.coli last presentation. 2 tests:
Skeletal survey
re-culture
*Nurse brings in her child with multiple skin abscesses, grew e.coli last presentation. Dx and treatment
Munchausen by proxy
Medical management then social services for child, psych for mother
List 5 soft tissue injuries concerning for child abuse
Injuries/bruising to theoral mucosa, lip lacerations, tongue lacerations, frenulum tears, ear helix, neck
Patterned marks ex. bites
Burns ex. immersion burns, cigarettes, hair curler
What are reporting obligations for suspected child abuse
Mandatory reporting to CAS (not police) up until age of 16 by you (the one who received the information)
List 5 pediatric ‘one pill can kill’ ingestions
ABC GET MOM
- Antimalarials
- Beta blockers
- Clonidine, calcium channel blockers
- Glyburide (or another sulfonylurea)
- Ethelene glycol (antifreeze)
- Tricyclic antidepressants (amitriptyline)
- Methanol (nail polish remover)
- Opioids (hydromorphone)
- Methyl salicylates (oil of wintergreen)
What are causative organisms in cystic fibrosis
Staphylococcus aureus and Pseudomonas aeruginosa.
But, Burkholderia cepacia, a significant pathogen in CF patients, has been associated with an accelerated decline in clinical status and increased mortality. In general, antimicrobial coverage is similar to that for Pseudomonas.
Inconsolable crying in an infant
Intussception/ infection
Trauma/ torsion
Cardiac
Reflux
Eye (corneal abrasion)
Strangulation (hair tourniquet)
PECARN rule for abdominal CT in peds trauma
How does voice change in GCS if patient is under 2 years old?
5 - coos
4 - irritable/ cry
3 - cries with pain
2 - moans
1 - nothing
