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
PECARN rule for abdominal CT in peds trauma
