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Speciality Medicine > Lecture 8: Peds > Flashcards

Lecture 8: Peds Flashcards

1
Q

The normal child:
* Communicate with who? (2)
* Observe what?
* Have a general idea for what?

A
  • Communicate with the child
  • Communicate with the parents
  • Observe the child and the child-parent interactions
  • Have a general idea of milestones and development for each age group
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2
Q

When is there implied consent with treating minors?

A

Treating minors: implied consent in an emergency (life or limb threatening)

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3
Q
A
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4
Q

Special Needs:
* Children with special needs have what?
* Have a high index of what?
* Nothing will be what?

A
  • Children with special needs have more difficulty with routine pediatric illnesses
  • Have a high index of suspicion
  • Nothing will be “simple”
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5
Q

Special needs:
* They will usually get what?
* Listen to who?
* Consult when?

A
  • They will usually get admitted
  • Listen to the mother; she knows more about the patient’s medical conditions than you ever will
  • Consult early; err on the side of the patient
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6
Q

Fever:
* Most what?
* What is it? (2)

A

Likely most common complaint in the ER

What is it?
* It is a SYMPTOM
* It is NOT an ILLNESS

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7
Q

Fever:
* APP states a fever to be what?
* Oral temperatures are what?
* Who must get a rectal temp?
* What temps are notoriously unreliable?

A
  • AAP states a fever is a RECTAL temperature 100.4°F (38°C) or higher
  • Can be life-threatening illness
  • Oral temperatures are lower, rectal temp is a must <2yo
  • Axillary and TM temperatures are notoriously unreliable
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8
Q

AAP does not recommend Meds for what temps? When do you give meds? What meds do you give?

A

AAP does not recommend Meds ≤ 102°F (38.9°C) – advise hydration and monitoring. Meds are typically given to reduce discomfort
* ≥ 102°F – Give acetaminophen 15 mg/kg per dose or ibuprofen 10 mg/kg per dose.

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9
Q

What are the sources of fever?

A
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10
Q

Fever Phobia:
* What is it?
* How often do parents recheck temp?
* How many parents believe fever causes brain damage or dealth?

A
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11
Q

Fever Phobia:
* No evidence to support what?

A

NO evidence to support that any degree of fever due to elevation of hypothalamic set point in a previously healthy normal child can cause brain damage!

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12
Q

What are 5 reasons why fevers are a good thing?

A
  • Retards growth of and reproduction of many pathogens
  • Increases production of antibacterial substances by neutrophils
  • Increases interferon release and activity
  • Increases leukocyte proliferation and activity
  • Increases antibiotic production
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13
Q

Fever protocol (under 29 days)
* What are you looking for in the CSF studies?

A
  • Culture
  • Cell count
  • Glucose
  • Protein
  • HSV PCR
  • Enterovirus PCR – June to November
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14
Q

Fever protocol (under 29 days)
* What is the time goal for antibiotics?
* What are the three antibiotics?

A

Goal is 1 hour
* Ampicillin 50 mg/kg
* Cefotaxime 50 mg/kg
* Vancomycin 15 mg/kg for septic shock or SSTI

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15
Q

Fever Protocol <29 days
* All patients will be what?
* What do you need to check?
* What do you need to give
* Very quick what?

A
  • ALL PATIENTS WILL BE ADMITTED
  • ABC’s, dextrose/accucheck
  • 20 mL/kg NS bolus, re-evaluate, repeat
  • Very quick full septic work up and antibiotics within an hour of arrival
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16
Q

When do need to give antivirals when fever protocol under 29 days old?

A

Acyclovir 20 mg/kg per dose
* Ill appearing
* Mucocutaneous vesicles
* Maternal history of HSV
* Seizure
* Elevated LFT’s
* Meningitis

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17
Q

A 25 day old baby comes in for fever of 101F but test positive for flu, do you discharge the baby or admit the baby to the hospital?

A

ADMIT!!!! (under 29 days, all fevers are admitted)

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18
Q

Fever: 0-3 months
* What is more likely?

A

recognition of occult infection or bacteremia in well-appearing infants is difficult, which makes bacteremia more likely

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19
Q

1-3 month fever protocol:
* What is blood work needs to be done?
* What urine needs to be done?
* What viral studies need to be done?

A

No spinal tap
Less likely viral (unlike under 29 days old)-> more likely bacterial

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20
Q

What are good markers for appenditis?

A

CBC and CRP

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21
Q

Fever: 3-24month
* Low risk of what?
* What can often be found?
* Higher incidence of what?

A
  • 3-24 months – low (0.5-1%) risk of bacteremia
  • Often a source can be found
  • Higher incidence occult bacteremia with higher fevers (typically due to strep. pneumoniae)
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22
Q

Fever: 3-24 months
* What is the typical work up?
* What do you give if high suspicion of bacteremia?
* _ _
* Encourage what?

A
  • Typical work up – CBC, blood cultures, urine cultures with UA, CRP/ESR/PCT, stool cultures
  • Rocephin (Ceftriaxone) – Q24hrs, only if bacteremia of high suspicion (i.e. not a clear case of something else)-> leukocytosis
  • Follow up (can only do if non-toxic and can tolerate PO)
  • Encourage PO fluids
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23
Q

Fever:
* Easier to evaluate who?
* Lower incidence of what?
* higher incidence of what?
* What can be seen in this group?

A
  • Easier to evaluate in children over 3
  • Lower incidence of bacteremia
  • Higher incidence of strep pharyngitis
  • Mycoplasma pneumonia seen in this group
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24
Q

Fever
* What do you give to children over 3?

A

Acetaminophen: 10-15 mg/kg per dose Q 4 hours

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25
Q
A
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26
Q

Meningitis
* Bacterial meningitis is a complication of what?
* What is highest incidence group?
* What do you need to get done to dx?
* What about antibiotics?
* Consider what before antibiotic dose?

A
  • Bacterial meningitis is a complication of bacteremia
  • Highest incidence: birth – 2 years old
  • LP
  • Empiric age-related antibiotic choices (ampilicin
  • Consider dexamethasone before first antibiotic dose in children older than 1 month (before to decrease cytokine reaction)
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27
Q

how do prophylax contacts to meningitis?

A

Prophylax contacts - Rifampin

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28
Q

Crying, irritability, lethargy in neonates: What do you need to look for?

A

take it seriously; look for infection, trauma, heart failure, metabolic abnormalities or intra-abdominal emergencies (incarcerated hernia, volvulus)

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29
Q

Projectile vomiting – after the second and third week of life
* What do you need to think of? Check what first?

A

gastric waves if give them some water, feel olive – pyloric stenosis – ABCs, hydration, surgery
* Olive size (1-2cm) mass in RUQ will be concerning for pyloric stenosis)-> Next step is US

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30
Q

Neonatal problems:
* What is importent to ID for babies under 30 days old?
* Why x-ray?
* What are things you need to worry about?
* Generally seen where?

A
  • Necrotizing enterocolitis (NEC) – feeding intolerance, abdominal distention, bloody stools (late sign), apnea, shock. (under 30 days or over 30 days with TPN drip)
  • X-ray – air in the bowel wall and hepatic portal air; free air with perforation
  • ABC’s, hydration, broad-spectrum antibiotics, surgery consult
  • Generally seen in the NICU rather than the ED
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31
Q

Dehydration SXS
* Mild 3-5% body weight loss:
* Moderate 6-9% body weight loss:
* Severe more than 10% weight loss:

A
  • Mild 3-5% body weight loss: thirsty, alert, restless but fairly normal exam
  • Moderate 6-9% weight loss (if diarrhea and vomiting every hour for a few days).->Restless, lethargic, irritable; rapid, weak pulse; sunken anterior fontanel and eyes; absent or reduced tears; dry mucous membranes; reduced urine output (dark), capillary refill about 2 seconds
  • Severe more than 10% weight loss: Anuric or oliguric; drowsy, limp; cold; cyanotic extremities; comatose; rapid, feeble pulse; sunken fontanel and eyes; absent tears; very dry mucous membranes; capillary refill greater than 3 seconds; this patient is in shock – Get ABC and bolus NS and reassess
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32
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A
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33
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34
Q
A

a. 1. positive pregnancy test, lower quad pain and tenderness, amenorrhea, adnexal tenderness
2. cervical motion tenderness, possible fever
3. US: free fluid in the pelvis

b. 1. viral illness
2. X-ray: infiltrates, possible consolidation

c. 1. urinary prefequency, dysuria, noctoria
suprapubic tenderness

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35
Q

Breathing:
* What is an emergency? What are the sxs?
* What is common issue with 3 week olds?
* RSV can cause what?
* Pertussis causes what?

A
  • Rapid breathing (especially grunting) is an emergency; nasal flaring, retractions
  • 3 weeks – Chlamydia pneumonia – 50% have conjunctivitis- See ”staccato” (inspiration between each cough) cough
  • RSV can cause pneumonia, suspect <2yo
  • Pertussis-paroxysms of cough with cyanosis; post-tussive vomiting+ facial brusing
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36
Q

Bronchiolitis
* RSV peaks when in FL?
* How do you dx?
* What are the sxs?

A
  • RSV: In Florida, peaks November through January
  • Clinical diagnosis; can sent Nasopharyngeal swab for RSV
  • Common cold-like symptoms usually appear 4–6 days following infection
  • Wheezing
    * Apnea is more common in neonates and preterm infants
    * Only symptoms of RSV may include decreased activity and appetite, irritability
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37
Q

Bronchiolitis
* How do you txt?
* What was used in the past?

A
  • Can try nebulizers with beta agonists or racemic epinephrine; if they work, continue them; steroids and antibiotics typically not indicated
  • Hypertonic saline has been used in the past, not recommended based on guidelines
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38
Q

Pediatric Heart Disease
* Known as what?
* When there is a fever, remember what?
* who do you contact for transplant?
* What are some sxs?
* What do you need to focus on?
* What do you check?

A
  • Known congenital heart disease: a new illness may cause decompensation; speak to the pediatric cardiologist
  • Fever: remember endocarditis dt to defects
  • s/p transplant: speak to the transplant team
  • Unknown disease: poor feeding (exertional dyspnea), tachypnea (TOF=blue while eating)
  • ABC’s – early referral or transfer
  • Triple check any drug doses
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39
Q

Otitis media:
* What are the sxs?
* What is a must if avaiable?

A
  • Otitis media: fever, crying, pulling at ear
  • Pneumatic otoscopy is a must, if available
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40
Q

Otitis Media
* What is the txt?
* What should you consider if recurrent infections?
* What can persistent effusion cause?
* What are some considerations?

A
  • Amoxicillin standard dose 40-45 mg/kg/day; high dose: 80-90 mg/kg/ TID if there is drug resistance in community
  • Recurrent infections: treatment failure->Consider cephalosporins
  • Persistent effusion: speech development
  • Considerations: prolonged antibiotic therapy; myringotomy and tympanostomy tubes (2-3 infections within a year)
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41
Q

Otitis Externa:
* What is affected?
* What are the causes? (3)
* What are the sxs? (5)

A
  • Auricle, external canal
  • Infection, inflammatory, trauma, all 3
  • Pain, itching, redness, tenderness, discharge
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42
Q

Otitis Externa
* What is the txt?
* What do you not prescribe?
* No what?

A
  • Ear wick – cortisporin otic solution (neomycin and polymyxin b sulfates and hydrocortisone)or Ciprodex (cipro +dexamethosone)
  • Do not prescribe oral meds for this
  • No swimming!
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43
Q

Pharyngitis
* What is the common organism?
* What are the sxs?
* What type of rash?

A
  • Streptococcal – GABHS
  • Erythema and exudate of tonsils, uvula and pharynx; petechiae of soft palate; enlarged anterior cervical nodes
  • Scarlatiniform rash (sand paper)
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44
Q

Pharyngitis
* What do you use to culture or not culture? (2)
* Why do you txt?

A

To culture or not to culture?
* Consider CENTOR criteria (look up on MdCalc)
* Do if immunosuppressed or many kids at home

TX hastens recovery, prevents suppurative complications and prevents rheumatic heart disease (but NOT Post streptococcal Glomerulonephritis – but not all get it though)

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45
Q

Pneumonia
* Organisms tend to be what?
* What can be life threatening?
* Considee the risks of what?
* What do you need to do for the exam?
* Err on the side of who?

A
  • Organisms tend to be age-related
  • Both bacterial and viral pneumonia can be life-threatening
  • Consider the risks of the child (healthy, normal versus low birth weight or co-morbidities)
  • Careful exam (count RR more than 1 minute, note any signs of distress while child is on mothers lap)
  • Err on the side of the patient

  • repeat infections=CF
  • under 37 weeks=underdeveloped lungs
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46
Q

Asthma:
* What do you first?
* What do the vital signs include?
* What does FEV1 correlate with?

A
  • Physical exam and nebulizer first then take the history
  • Vital signs include pulse ox and supplemental oxygen should be given early
  • FEV1 correlates with airway obstruction; pre- and post-treatment PEFRs should be obtained
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47
Q

Asthma:
* What should you note
* ABG’s reserved to determine what?
* What is not indicated but typically done in ER?

A
  • Note breathlessness, respiratory rate, use of accessory muscles, retractions, wheezing (or absence of it), pulse, pulsus paradoxus; ask parent how this attack compares with previous ones
  • ABG’s reserved to determine pCO2
  • CXR generally not indicated, but is typically done in ER
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48
Q

Asthma:
* What is the txt?
* What should you add?
* What do you if severe?
* What do you give early?

A
  • Beta-receptor agonists by nebulizer or MDI, usually the former
  • Add atrovent to the nebulizer
  • SQ epinephrine 0.01 mg/kg 1:1000 SQ up to 0.3 mL (or terbutaline more beta-2-specific) same dose up to 0.25 mL
  • Corticosteroids: early; 1-2 mg/kg prednisone or prednisilone po

* IV fluids too

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49
Q

Asthma:
* What can you give fast to relax smooth muscle
* What can you consider?

A
  • MgSO4 25-50 mg/kg IV over 20 minutes ; may repeat; (maximum dose for children is 2 grams)
  • Consider heliox for the asthmatic who has not improved but in whom intubation is not imminent

heliox: decrease atomic weight of O2 and makes the O2 go in smallr air spaces

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50
Q

Seizures
* Who needs a complete evaluation? (3)
* What do you need to do? (2)
* What exams do you need to do? (3)
* Labs? (8)
* What should you consider? (4)

A
  • First-time seizure, neonatal seizure or status epilepticus: Complete evaluation
  • ABC’s, bedside glucose
  • Hx, PE (trauma), neuro exam
  • Labs: CBC, lytes including calcium and magnesium, BUN, creatinine, UA, tox screen, CT brain, CXR
  • Consider: skeletal survey; additional lab tests for liver, infection
  • Consider: LP for meningitis
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51
Q

Febrile Seizures
* Associated with what?
* What are the sxs?
* Most common in who?
* What does not rise the rise?

A
  • Associated with fever, without evidence of IC infection or defined cause, usually between 6 months and 5 years of age
  • Generalized, last less than 15 minutes, normal neuro exam and no prolonged post-ictal period; work up based on the child’s age and condition; LP if suspicion for meningitis (causes seizures)
  • Most common neurologic disorder of infants and young children
  • Maximum height of fever NOT rate of rise is main determinant of risk

Occurs in 2-4% of children

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52
Q

Simple Febrile Seizure
* _ seizure?
* last how long?
* Does not recur when?
* What is the temp?
* What the age range?
* Only slightly higher risk of what?

A
  • Generalized seizure
  • Lasts < 15 minutes
  • Does not recur during a 24-hour period
  • Temperature >38°
  • Older than 3 mos and < 6 yrs
  • Only slightly higher risk of future epilepsy
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53
Q

Simple Febrile Seizure: What I tell parents
* They do not do what?
* Recurrence rate?
* First seizure with what? Subsequent with what?
* Very minimal risk for what?
* Outgrow them when?
* Family?

A
  • They do not harm your child
  • 30% recurrence
  • First seizure with high fever, subsequent with lower fever
  • Very minimal risk for seizures later in life
  • Outgrow them by 5 years
  • Can run in families
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54
Q

Simple Febrile Seizure: What I tell parents
* What will not prevent a febrile seizure?

A

GIVING APAP OR IBUPROFEN WILL NOT PREVENT A FEBRILE SEIZURE

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55
Q
A
56
Q

Complex Febrile Seizure
* _ seizure
* How long?
* Mulitple within?
* Increase risk of what?

A
  • Focal seizure
  • Prolonged, > 15 minutes
  • Multiple within 24 hours
  • Increase the likelihood of future afebrile seizures

Multiple sall seziure under 15 minties

57
Q

Status Epilepticus
* What do you check (2)
* What is the seizure management?

A
58
Q

Status Epilepticus
* Consider hx of what? What can you add to txt?

A

Consider recent hx of TB prophylaxis (INH)
* Pyridoxine with INH intake, if the other drugs won’t work

59
Q

Upper Respiratory Emergencies
* What is a sign of upper airway obstruction?
* Under 6 months?
* Over 6 months?

A
  • Stridor – upper airway obstruction
  • Less than 6 months of age: congenital such as laryngotracheomalacia
  • Older than 6 months: croup, epiglottitis, retropharyngeal abscess, foreign body aspiration
60
Q

Pain management:
* _ scales
* What can you give?
* Opioids can cause what? What to reverse it?
* _ sedation
* What can be given IM? Beware of what?

A

Narcan has shorter half life than opiods itself – do narcan drip; Although the necessity of drip has been questioned.

61
Q

MSK disorders:
* Septic arthritis occurs in who?
* What are the sxs?
* Prompt what? (7)
* What is benign, and self limiting
* _ support

A
  • Septic arthritis occurs in all groups but especially in children less than 3
  • Fever, apparent pain or limp
  • Prompt antibiotics, Xray, CBC, CMP, PCT, ESR, CRP
  • Transient synovitis – benign, self-limiting
  • Symptomatic support
62
Q

Acute Flaccid Myelitis
* Presents as what? Highest incidence when?

A

Presents as acute flaccid limb weakness
* Highest incidence in summer or early fall, especially following URI type symptoms days/weeks prior

63
Q

Acute Flaccid Myelitis
* How do you dx and tx it?

A

MRI of entire spine and brain with and without contrast is necessary to diagnose new spinal cord lesions spanning over one or more vertebral segments
* Excludes preexisting malignancy or vascular disease
* CSF to follow to screen for PMN or lymphocytosis

No treatment, therefore management is supportive (steroids)

64
Q

Kawasaki Disease:
* What type of disease?
* Fever?
* What are the sxs? (7)

A
  • Mucocutaneous lymph node disease
  • Fever for at least 5 days
  • Conjunctivitis
  • Dry, fissured lips
  • Strawberry tongue
  • Oropharyngeal edema
  • Erythema of palms and soles, edema of hands and feet, periungual desquamation
  • Polymorphous rash
  • Cervical lymphadenopathy
65
Q

Kawasaki Disease
* Complicated by what? (4)
* What is the txt?(2)

A
  • Complicated by: Coronary artery aneurysms (prone to thrombosis); MI, dysrhythmias, death
  • IV gamma globulin, aspirin
66
Q

UTI
* Neonates may present with what?
* Any child less than 3 months needs to be what?
* All children <3months with UTI’s needs what?

A
  • Neonates may present with jaundice, poor feeding, irritability, lethargy, sepsis
  • Any child less than 3 months needs to be hospitalized
  • All children <3months with UTI’s need imaging (US and VCUG) or radionuclide cystography
67
Q

Vomiting, Diarrhea
* What do you need to do for dehydration?
* R/O what?
* Well child, not dehydrated (or only mildly dehydrated):
* No longer suggest what?
* Careful what?

A
  • Dehydration: ABCs, bedside glucose, IV NS 20 mL/kg, reassess, repeat UP TO 3 BOLUSES (children in shock need 60 mL/kg in first hour)
  • R/O life-threatening diseases
  • Well child, not dehydrated (or only mildly dehydrated): ORS (pedialyte), feed early
  • No longer suggest BRAT; clear liquids can made diarrhea worse; feed early (no more starvation!)
  • Careful discharge instructions and close follow up

If it’s a male – check testes. Also think DKA in child with abd pain,

68
Q

Fluid & Electrolyte Therapy
* What do you give if hemorrhagic?
* What do you give to a child who is NPO?
* Use what? Not what?

A

We have discussed resuscitation fluids (up to 60cc); If hemorrhagic – 10cc/kg of blood.

child who is NPO:
* First 10 kg: 100 mL/kg/day – 1000cc +
* Second 10 kg: 50 mL/kg/day – 500 cc +
* More than 20 kg: 20 mL/kg/day

Use kg not pounds (read test questions and convert: there are 2.2 lbs in a kg)

69
Q

Oral Rehydration Therapy
* Fluid replacement to do what?
* What is equally successful?
* Less _
* Easily _

A
  • Fluid replacement to prevent or treat dehydration
  • ORT and IV hydration are EQUALLY successful (if they can drink then do oral)
  • Less invasive
  • Easily done
70
Q

ORT
* What is the MOA?
* Administered how?
* Prevents child from what?

A
  • When glucose is present in a solution, Na and K absorption are increased and cells are hydrated faster
  • Administered in measured amounts at a given time
  • Prevents child fromgulping all the fluid down at once andvomiting
71
Q

ORT:
* Dosing?
* Start when?
* Use what?
* Get who involved?
* Do not let child do what?
* If vomit then do what?

A
  • Administer 1-2 mL/kg every 3-5 min
  • Start 20 min after the ODT Zofran
  • Use a syringe or medicine cup
  • GET THE PARENTS INVOLVED
  • DO NOT let the child control how much they drink
  • If vomit, wait 20 minutes and start over
72
Q
A
73
Q
A
74
Q

Constipation: normal stooling pattern
* What will pass in 24 hours in FT newborn?
* How many stools in the first week?
* What about the first 3 mos? (breast vs formula)
* By 2 yo?
* After 4yo?

A
75
Q

What is the GI transit time:
1 – 3 mo=
4 – 24 mo =
3 – 13 yo =
Puberty + =

Some normal breastfed newborns may stool w/ what?

A
76
Q

Constipation Management
AAP recommends how much fiber?
What can also help?
What can you use for older kids?

A
77
Q
A

Mouth to anus x-ray

78
Q

Battery ingestion:
* What is a common age group?
* What is the peak age?
* What is most common?

A
79
Q

Battery Ingestion:
* What is badness?

A
80
Q

Button Battery
* Strong potential for what? (3)
* Most are what?
* 80% are what?
* What is too big?
* What is strongly associated with major complications and death?

A
81
Q

KNOWWW

Battery ingestion:
* What is the battery ingestion hotline?
* What is the poison control center hotline

A
82
Q

Battery Ingestion
* Significant what?
* What can occur within 1 hr and 2 hr?
* What can happen as early as 8 hrs?

A
83
Q

Battery Ingestion: Management
* Locatize battery with what?
* What is the 12/12 rule?
* Otherwise call who?

A
  • LOCALIZE battery w/ AP and lateral XR’s nose to anus
  • 12/12 rule: Asymptomatic, > 12 yo, confirmed ingestion of SOLITARY, small (≤ 12 mm diameter), w/o co-ingestion of a magnet may undergo observation for battery passage at home as long as the patient or caregiver is reliable and able to promptly seek medical treatment
  • Otherwise call surgery/GI/Pulmonary depending on location and type and with magnet coingestion
84
Q

What’s new for battery ingestion
* What can you give until child is able to reach hospital?
* What do you give within an hour of removing the battery?
* Do not use honey if what? (3)

A
85
Q

Abdominal Emergencies:
* GI bleeding can have what?
* What can be a ominous sign?
* Masses could herald what?
* What do you need to order and consult?

A
  • GI bleeding can have many ominous causes
  • Jaundice can be an ominous sign
  • Masses could herald a tumor (Wilm’s)
  • ABC’s, bedside glucose, consult early and then get imaging studies once consultants on board
85
Q

Intussusception
* What is a common situation?
* Pain attacked recur when?
* What occurs after a few hours?
* What is a late sign?
* May palpate what?

A
  • 6-18 month old stops playing, screams, obvious discomfort; then starts playing again
  • Painful attacks recur at closer intervals and with increasing duration
  • Vomiting after a few hours
  • Currant jelly stool (late)
  • May palpate a sausage-shaped mass in right abdomen
86
Q

Abdominal Emergencies
* What are causes of life threatening abdominal pain?

A

Appendicitis, congenital anomalies, DKA, ectopic pregnancy, hemolytic uremic syndrome, incarcerated hernia, intussusception, complicated PUD, pneumonia, sepsis, trauma, volvulus, toxins (iron)

87
Q

Intussusception
* What is dx and often curative?
* What do you need to order?

A
  • Air contrast enema is diagnostic and often curative
  • ABC’s, bedside glucose, call consultant early
88
Q

DKA
* What are sxs?
* Often onset after what?
* What is the most common presenting complaint?
* Most dreaded complication in children is what?

A
  • Polyuria, polydipsia, polyphagia with relative volume depletion; weight loss, anorexia, genital Candida in toilet trained child; secondary enuresis
  • Often onset after a mild viral illness
  • Interestingly, abdominal pain seems to be the most common presenting complaint->Delayed gastric emptying vs ileus
  • Most dreaded complication in children is cerebral edema with mortality rates to 90%

DKA presents the same way as previously discussed for adults

89
Q

Actions of Insulin
* > Glucose uptake by what? Storaged as what?
* What does increase lipogenesis cause?
* What happens when glycogenolysis is decreased?

A
90
Q

DKA in children
* What do you give if hemodynamically stable?
* How do you give maintance fuilds (what is the acutal calculation?
* How much insulin do you give?

A

70kg60% = 42 * (1-140/160). 42(1-7/8) = 421/8=420.125=5.25 Liters.

91
Q

DKA in children
* When do you add dextrose?
* When do you give potassium repletion?
* Serum electrolytes when?
* Where should they be admitted?

A
  • Add dextrose to IVF when glucose is 200-250
  • Potassium repletion only with urine production
  • Serum electrolytes Q 2 hours; serum glucose hourly
  • ICU
92
Q

Bicarbonate Theories
* Avoid bicarbonate but consider if what?
* What can occur? Explain?

A
  • Avoid bicarbonate; consider if pH less than 7.0
  • “Paradoxical” Central metabolic acidosis may occur
    * Bicarbonate is broken down to Carbonic Acid and Water to cross the Blood-Brain Barrier
93
Q

Cerebral Edema
* What is it a complication of?
* Most common in who?
* Manifests how?
* What are the sxs?
* What is the txt?

A
  • Worst possible complication associated with treatment of DKA
  • Most common in children under 5
  • Manifests 6-12 hours after onset of fluid replacement therapy (especially in DKA) in 0.1-1% pf cases
  • Half may have symptoms of headache, declining mental status, seizures, papillary edema; first symptom may be respiratory arrest
  • Mannitol and fluid restriction
94
Q

AMS:
* What is the mnemonic for the causes?

A
95
Q

Hypoglycemia
* What do you need to do with AMS?
* Glucose <70 in a pediatric patient is what?

A
96
Q

Hypoglycemia Treatment: For conscious patients, able to swallow and not NPO
* What do you need to give?

A

Provide 15g fast acting carbohydrates. Examples:
* 4 oz. of juice or other sweetened (non-diet) beverage OR
* 8 oz. of skim (fat free) milk
* For less than 1 year of age, may use breast milk or form

97
Q

Hypoglycemia Treatment
* How do you retest the blood glucose?

A

Retest blood glucose level in 15 minutes (15/15 rule)
* If blood glucose not above 70 mg/dL, repeat 15/15 rule.
* If BG is less than 70 mg/dl after TWO treatments, call physician.
* If blood glucose greater than 70 mg/dL, no further treatment is needed.

98
Q

Hypoglycemia Treatment
* For patients who are NPO, have an altered mental status, or unable/unwilling to swallow. What do you give for IV access?

A
99
Q

Hypoglycemia Treatment
* For patients who are NPO, have an altered mental status, or unable/unwilling to swallow. What do you give witout IV access?

A
  • > 33.01kg: 1mg IM; if no response is observed within 15 minutes, may administer a second 1mg dose
  • <33.01kg: 0.03mg/kg IM; If no response is observed within 15 minutes, may administer a second 0.5mg (or 0.02 to 0.03 mg/kg) dose.
100
Q

Thyrotoxicosis
* Most pediatric patients with thyrotoxicosis have what? What is that?
* The most devastating complication of hyperthyroidism is what?
* What is usually present?

A
101
Q

Thyrotoxicosis
* What will the labs show?

A

Laboratory findings will usually demonstrate an elevated free thyroxin (T4) level and a suppressed TSH level

102
Q

Thyroid Storm
* Classic symptoms associated with thyrotoxicosis include (don’t have to have all 5):

A
  • sweating
  • Palpitations/Hypertension
  • diarrhea, weight loss
  • menstrual changes (no menses)
  • Tremor(outstretched hands)
103
Q

Thyroid Storm
* Temp?
* What happens to HR?
* What type of changes?

A
  • Temperature > 37.8 C (100 F)
  • Tachycardia (classically out of proportion to fever (goes up by 20bpm, not 10)
  • CNS changes (early – excitation, late - depression)
104
Q

Thyroid Storm
* What is the treatment (3Ps and 2Ss)

A
105
Q

Myxedema Coma
* What is it?
* What the sxs?

A
106
Q

Myxedema Coma
* What do the labs show?
* What is the txt?

A
  • Low/undetectable T4 and High TSH
  • Tx: Thyroxine and Hydrocortisone and treat underlying cause
107
Q

Adrenal Crisis
* Adrenal insufficiency (Addison’s Disease) occurs when? What are the hormones?

A

Adrenal insufficiency (Addison’s Disease) occurs when there is absent or inadequate production of adrenal hormones (cortex)
* Cortisol – glucocorticoid
* Aldosterone – mineralocorticoid
* Androgens

108
Q

Adrenal Crisis
* Any stressful event may lead to what?
* What is most common?

A

Any stressful event may lead to an acute decompensation characterized by altered mental status, electrolyte abnormalities, gastrointestinal disturbances, and even circulatory collapse
* Autoimmune is most common, although methadone use can precipitate

109
Q

What are the sxs of adrenal crisis?

A
  • Weakness, lethargy, easy fatigability
  • Hypotension
  • Fever is common
  • GI upset including nausea, vomiting, and abdominal pain
  • Altered mental status or seizures
  • Circulatory compromise or even frank collapse
110
Q

Adrenal Crisis
* What do the labs show?
* What is the txt?

A

Lab findings: due to aldosterone/cortisol deficit
* Low sodium
* Slightly increased potassium
* Low blood glucose (profound)
* Increased BUN/Cr=Azotemia

Tx: Supportive via correction of deficits AND hydrocortisone

111
Q

Hyperleukocytosis
* What does the neutrophil count show? What can it cause?
* Leukemic blasts: What are the issues with this? (2)

A

Neutrophil count (CML) > 250,000 may cause vasoocclusive complications

Leukemic blasts
* Blast crisis is a poor prognosis in ALL
* Symptomatic hyperleukocytosis and AML associated with initial high mortality

112
Q

Leukostasis in microvasculature leads to what clinical symptoms? (3)

A
  • Pulmonary: hypoxemia, dyspnea
  • Increased viscosity, thrombi
  • CNS: headaches, vision changes/loss, focal deficits (similar to stroke)
  • Plethora, cyanosis, papilledema
113
Q

How do you txt Hyperleukocytosis?

A

Tx with leukopheresis and chemotherapy

114
Q

Hyperviscosity Syndrome
* What it is?
* What are the sxs?

A
  • Increased viscosity from circulating immunoglobulins (most commonly from IgM Waldenstrom macroglobulinemia) – similar to MM
  • SXS: headache, fatigue, blurred vision, thrombotic complications (i.e. stroke, mesenteric ischemia).
115
Q

Hyperviscosity Syndrome
* What do the labs show?
* What is the txt?

A
  • Labs: Elevated serum viscosity, peripheral smear (Rouleaux formation), A globulin gap (total protein – albumin = 4 or greater) may be present
  • TX: Plasmapheresis and hematology consult
116
Q

Febrile Neutropenia
* Should be considered how?
* What can cause higher mortality?
* What is the goal?
* Risk of death increases with what?

A

Should be considered an emergency
* Early studies have shown high mortality when initiation of appropriate antibiotics is delayed
* Goal: empiric antibiotics within 60mins of arrival
* Risk of death increases with lower ANCs (especially <100)

117
Q

Febrile Neutropenia
* What is the definition?

A

Neutropenia: ANC < 500
* Absolute neutrophil count (ANC)=total WBC X (% neutrophils + % bands)

Plus

Fever: single temp > 38.3°C (101°F) or 38.0°C (100.4°F) sustained greater than 1 hour

118
Q
A
119
Q

Idiopathic Thrombocytopenic Purpura (ITP)
* What it is?
* More common in who?
* What are the sxs?
* What do the labs show?

A
  • Autoimmune disease against platelets
  • More common in children following a viral illness
  • Signs & Symptoms: purpura, petechiae, epistaxis and menorrhagia
  • Labs: low platelets (<100k), otherwise CBC is essentially normal
120
Q

Idiopathic Thrombocytopenic Purpura (ITP): What is the txt for:
* Platelets <30,000 WITH Life-Threatening Bleed
* Platelets <20,000 WITH bruising, petechia, purpura (Grade 1 or 2 bleeding)
* Platelets >10,000 without evidence of any bleeding or platelets >20,000 with Grade 1 or 2 bleeding
* Platelets <10,000

A
121
Q

Thrombotic Thrombocytopenic Purpura (TTP)
* What are the sxs?
* What do the labs show?
* How do you dx it?

A
  • Signs & Symptoms pentad: fever, anemia (microangiopathic hemolytic anemia), jaundice, fluctuating neuro deficits, renal failure
  • Labs: low platelets, low H & H, high retic, Serum LDH and indirect bilirubin are high & haptoglobin is low due to hemolysis
  • Dx: hemolytic anemia, + schistocytes, thrombocytopenia, neuro signs
122
Q

Thrombotic Thrombocytopenic Purpura (TTP)
* Txt?
* Presents similar to what?

A
  • Tx: plasmapheresis (plasma exchange transfusion), DO NOT TRANSFUSE PLATELETS – they will clump due to antibody agglutinations
  • Presents similar to HUS, but more neuro symptoms and less renal failure type picture
123
Q

Von willebrand disease:
* What is it?
* What do the labs show?

A
  • autosomal dominant condition involves deficiencies of vWF & Factor VIII. Since vWF functions in adherence of platelets & maintains plasma levels of VIII, this disease results in abnormalities of clotting & platelet function.
  • Labs: prolonged bleeding time (occasionally PTT and Factor VIII levels are abnormal), Normal CBC, Normal PT/INR
124
Q

von Willebrand Disease
* What is definitive dx?
* What are the sxs?
* What is the txt?

A
  • Definitive DX: vWF immunologic assay (low vWF activity)
  • Bleeding Episodes-> Signs & Symptoms: epistaxis, easy bruising, menorrhagia, or dental bleeding
  • Tx: Desmopressin (for most patients), Cryoprecipitate (has factor 8), OCPs may help increase vWF and limit menstrual bleeding in females
125
Q

Hemophilias
* how do you dx? What are the different types?
* Treat what?

A
126
Q
  • 8 yr old with hemophilia A is hit on head by fastball
  • H/A, vomited, sleepy
  • What is your next step?
A

What is your next step?
* Give factor 8.

If don’t know which hemophilia.
* FFP/Cryoprecipitate (contains factor VIII and vWF) may be used in hemophilia A (however, not the first choice).

When in doubt, FFP has all of the factors

127
Q

Disseminated Intravascular Coagulation (DIC)
* What is it?
* What are the sxs?
* What are conditions associated with DIC?

A
  • Excessive activation of coagulation with consumption of clotting factors
  • Microangiopathic hemolytic anemia, hemorrhage & thrombosis
  • Conditions associated with DIC: Infection (most common), carcinomas and acute leukemia, trauma, acute hepatic failure, pregnancy complications (RPC), Venom from bites, ARDS, transfusion reactions.
128
Q

Disseminated Intravascular Coagulation (DIC)
* how do you dx it?
* How do you tx it?

A

Diagnosis
* INCREASED: FDP’s, D-dimer, PT & aPTT
* DECREASED: platelets, fibrinogen (factor 1) – consumes them

Treatment
* Treat underlying etiology (infection) and replace all factors, platelets and fibrinogen (cryoprecipitate)

129
Q

Sickle Cell Crisis
* What is the MCC?
* What is the second most common?
* May present as what?
* What will be elevated?
* Typically have what?

A
  • Painful vasooclusive crisis is MCC
  • Acute Chest Syndrome is Second most common
  • May present as Acute Abdominal pain or Chest Pain
  • Reticulocyte counts will be elevated
  • Typically will have anemia
130
Q

What is the txt of sickly cell crisis?

A

Tx – O2, Hydromorphone, IVF, transfusion in Hgb <7

131
Q

Tumor Lysis Syndrome
* Prophylaxis with what?
* Usually occurs 1-3 days after what?
* Patients may develop what?

A
  • Prophylaxis with Allopurinol, fluids & diuresis have reduced the incidence.
  • Usually occurs 1-3 days after radiochemotherapy of hematologic malignancies
  • Patients may develop renal failure
132
Q

Tumor Lysis Syndrome
* Characterized by what?

A

Characterized by the triad of:
* hyperkalemia
* hyperphosphatemia (w/ secondary hypocalcemia)
* hyperuricemia

133
Q

Tumor Lysis Syndrome
* What are the sxs?
* How do you dx it?
* What does the EKG show?

A
  • SXS – fatigue, lethargy, nausea, vomiting, & cloudy urine
  • Diagnosis: electrolyte panel including BUN, Cr., Uric Acid, Phosphate, and Calcium.
  • EKG – may show signs of Hyperkalemia
134
Q

Tumor Lysis Syndrome
* How do you treat hyperkalemia?
* How do you treat hypcalcemia?
* How do you treat hyperuricemia?
* When do you need emergency dialysis?

A
135
Q

SVC syndrome:
* What does the CXR show?
* What will 25% have?
* What is supportive care?
* What do you if airway compromised?

A
  • CXR documents widening superior mediastinum
  • 25% have R pleural effusion
  • O2, bed rest, elevation of the head and upper body
  • Airway compromise – orotracheal intubation
136
Q

SVC Syndrome
* XRT for what?
* Chemotherapy+ XRT for what?
* What needs to happen with Clotted central catheters ?

A
  • XRT for non-small cell lung cancer
  • Chemotherapy+ XRT for small cell lung cancer & lymphoma
  • Clotted central catheters withdrawn & anticoagulation Rx started

Speciality Medicine (12 decks)

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