Lecture 8: Peds Flashcards
The normal child:
* Communicate with who? (2)
* Observe what?
* Have a general idea for what?
- 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
When is there implied consent with treating minors?
Treating minors: implied consent in an emergency (life or limb threatening)
Special Needs:
* Children with special needs have what?
* Have a high index of what?
* Nothing will be what?
- Children with special needs have more difficulty with routine pediatric illnesses
- Have a high index of suspicion
- Nothing will be “simple”
Special needs:
* They will usually get what?
* Listen to who?
* Consult when?
- 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
Fever:
* Most what?
* What is it? (2)
Likely most common complaint in the ER
What is it?
* It is a SYMPTOM
* It is NOT an ILLNESS
Fever:
* APP states a fever to be what?
* Oral temperatures are what?
* Who must get a rectal temp?
* What temps are notoriously unreliable?
- 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
AAP does not recommend Meds for what temps? When do you give meds? What meds do you give?
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.
What are the sources of fever?
Fever Phobia:
* What is it?
* How often do parents recheck temp?
* How many parents believe fever causes brain damage or dealth?
Fever Phobia:
* No evidence to support what?
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!
What are 5 reasons why fevers are a good thing?
- 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
Fever protocol (under 29 days)
* What are you looking for in the CSF studies?
- Culture
- Cell count
- Glucose
- Protein
- HSV PCR
- Enterovirus PCR – June to November
Fever protocol (under 29 days)
* What is the time goal for antibiotics?
* What are the three antibiotics?
Goal is 1 hour
* Ampicillin 50 mg/kg
* Cefotaxime 50 mg/kg
* Vancomycin 15 mg/kg for septic shock or SSTI
Fever Protocol <29 days
* All patients will be what?
* What do you need to check?
* What do you need to give
* Very quick what?
- 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
When do need to give antivirals when fever protocol under 29 days old?
Acyclovir 20 mg/kg per dose
* Ill appearing
* Mucocutaneous vesicles
* Maternal history of HSV
* Seizure
* Elevated LFT’s
* Meningitis
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?
ADMIT!!!! (under 29 days, all fevers are admitted)
Fever: 0-3 months
* What is more likely?
recognition of occult infection or bacteremia in well-appearing infants is difficult, which makes bacteremia more likely
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?
No spinal tap
Less likely viral (unlike under 29 days old)-> more likely bacterial
What are good markers for appenditis?
CBC and CRP
Fever: 3-24month
* Low risk of what?
* What can often be found?
* Higher incidence of what?
- 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)
Fever: 3-24 months
* What is the typical work up?
* What do you give if high suspicion of bacteremia?
* _ _
* Encourage what?
- 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
Fever:
* Easier to evaluate who?
* Lower incidence of what?
* higher incidence of what?
* What can be seen in this group?
- Easier to evaluate in children over 3
- Lower incidence of bacteremia
- Higher incidence of strep pharyngitis
- Mycoplasma pneumonia seen in this group
Fever
* What do you give to children over 3?
Acetaminophen: 10-15 mg/kg per dose Q 4 hours
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?
- 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)
how do prophylax contacts to meningitis?
Prophylax contacts - Rifampin
Crying, irritability, lethargy in neonates: What do you need to look for?
take it seriously; look for infection, trauma, heart failure, metabolic abnormalities or intra-abdominal emergencies (incarcerated hernia, volvulus)
Projectile vomiting – after the second and third week of life
* What do you need to think of? Check what first?
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
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?
- 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
Dehydration SXS
* Mild 3-5% body weight loss:
* Moderate 6-9% body weight loss:
* Severe more than 10% weight loss:
- 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
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
Breathing:
* What is an emergency? What are the sxs?
* What is common issue with 3 week olds?
* RSV can cause what?
* Pertussis causes what?
- 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
Bronchiolitis
* RSV peaks when in FL?
* How do you dx?
* What are the sxs?
- 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
Bronchiolitis
* How do you txt?
* What was used in the past?
- 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
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?
- 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
Otitis media:
* What are the sxs?
* What is a must if avaiable?
- Otitis media: fever, crying, pulling at ear
- Pneumatic otoscopy is a must, if available
Otitis Media
* What is the txt?
* What should you consider if recurrent infections?
* What can persistent effusion cause?
* What are some considerations?
- 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)
Otitis Externa:
* What is affected?
* What are the causes? (3)
* What are the sxs? (5)
- Auricle, external canal
- Infection, inflammatory, trauma, all 3
- Pain, itching, redness, tenderness, discharge
Otitis Externa
* What is the txt?
* What do you not prescribe?
* No what?
- 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!
Pharyngitis
* What is the common organism?
* What are the sxs?
* What type of rash?
- Streptococcal – GABHS
- Erythema and exudate of tonsils, uvula and pharynx; petechiae of soft palate; enlarged anterior cervical nodes
- Scarlatiniform rash (sand paper)
Pharyngitis
* What do you use to culture or not culture? (2)
* Why do you txt?
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)
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?
- 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
Asthma:
* What do you first?
* What do the vital signs include?
* What does FEV1 correlate with?
- 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
Asthma:
* What should you note
* ABG’s reserved to determine what?
* What is not indicated but typically done in ER?
- 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
Asthma:
* What is the txt?
* What should you add?
* What do you if severe?
* What do you give early?
- 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
Asthma:
* What can you give fast to relax smooth muscle
* What can you consider?
- 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
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)
- 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
Febrile Seizures
* Associated with what?
* What are the sxs?
* Most common in who?
* What does not rise the rise?
- 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
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?
- 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
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?
- 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
Simple Febrile Seizure: What I tell parents
* What will not prevent a febrile seizure?
GIVING APAP OR IBUPROFEN WILL NOT PREVENT A FEBRILE SEIZURE
Complex Febrile Seizure
* _ seizure
* How long?
* Mulitple within?
* Increase risk of what?
- Focal seizure
- Prolonged, > 15 minutes
- Multiple within 24 hours
- Increase the likelihood of future afebrile seizures
Multiple sall seziure under 15 minties
Status Epilepticus
* What do you check (2)
* What is the seizure management?
Status Epilepticus
* Consider hx of what? What can you add to txt?
Consider recent hx of TB prophylaxis (INH)
* Pyridoxine with INH intake, if the other drugs won’t work
Upper Respiratory Emergencies
* What is a sign of upper airway obstruction?
* Under 6 months?
* Over 6 months?
- 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
Pain management:
* _ scales
* What can you give?
* Opioids can cause what? What to reverse it?
* _ sedation
* What can be given IM? Beware of what?
Narcan has shorter half life than opiods itself – do narcan drip; Although the necessity of drip has been questioned.
MSK disorders:
* Septic arthritis occurs in who?
* What are the sxs?
* Prompt what? (7)
* What is benign, and self limiting
* _ support
- 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
Acute Flaccid Myelitis
* Presents as what? Highest incidence when?
Presents as acute flaccid limb weakness
* Highest incidence in summer or early fall, especially following URI type symptoms days/weeks prior
Acute Flaccid Myelitis
* How do you dx and tx it?
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)
Kawasaki Disease:
* What type of disease?
* Fever?
* What are the sxs? (7)
- 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
Kawasaki Disease
* Complicated by what? (4)
* What is the txt?(2)
- Complicated by: Coronary artery aneurysms (prone to thrombosis); MI, dysrhythmias, death
- IV gamma globulin, aspirin
UTI
* Neonates may present with what?
* Any child less than 3 months needs to be what?
* All children <3months with UTI’s needs what?
- 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
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?
- 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,
Fluid & Electrolyte Therapy
* What do you give if hemorrhagic?
* What do you give to a child who is NPO?
* Use what? Not what?
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)
Oral Rehydration Therapy
* Fluid replacement to do what?
* What is equally successful?
* Less _
* Easily _
- 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
ORT
* What is the MOA?
* Administered how?
* Prevents child from what?
- 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
ORT:
* Dosing?
* Start when?
* Use what?
* Get who involved?
* Do not let child do what?
* If vomit then do what?
- 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
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?
What is the GI transit time:
1 – 3 mo=
4 – 24 mo =
3 – 13 yo =
Puberty + =
Some normal breastfed newborns may stool w/ what?
Constipation Management
AAP recommends how much fiber?
What can also help?
What can you use for older kids?
Mouth to anus x-ray
Battery ingestion:
* What is a common age group?
* What is the peak age?
* What is most common?
Battery Ingestion:
* What is badness?
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?
KNOWWW
Battery ingestion:
* What is the battery ingestion hotline?
* What is the poison control center hotline
Battery Ingestion
* Significant what?
* What can occur within 1 hr and 2 hr?
* What can happen as early as 8 hrs?
Battery Ingestion: Management
* Locatize battery with what?
* What is the 12/12 rule?
* Otherwise call who?
- 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
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)
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?
- 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
Intussusception
* What is a common situation?
* Pain attacked recur when?
* What occurs after a few hours?
* What is a late sign?
* May palpate what?
- 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
Abdominal Emergencies
* What are causes of life threatening abdominal pain?
Appendicitis, congenital anomalies, DKA, ectopic pregnancy, hemolytic uremic syndrome, incarcerated hernia, intussusception, complicated PUD, pneumonia, sepsis, trauma, volvulus, toxins (iron)
Intussusception
* What is dx and often curative?
* What do you need to order?
- Air contrast enema is diagnostic and often curative
- ABC’s, bedside glucose, call consultant early
DKA
* What are sxs?
* Often onset after what?
* What is the most common presenting complaint?
* Most dreaded complication in children is what?
- 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
Actions of Insulin
* > Glucose uptake by what? Storaged as what?
* What does increase lipogenesis cause?
* What happens when glycogenolysis is decreased?
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?
70kg60% = 42 * (1-140/160). 42(1-7/8) = 421/8=420.125=5.25 Liters.
DKA in children
* When do you add dextrose?
* When do you give potassium repletion?
* Serum electrolytes when?
* Where should they be admitted?
- Add dextrose to IVF when glucose is 200-250
- Potassium repletion only with urine production
- Serum electrolytes Q 2 hours; serum glucose hourly
- ICU
Bicarbonate Theories
* Avoid bicarbonate but consider if what?
* What can occur? Explain?
- 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
Cerebral Edema
* What is it a complication of?
* Most common in who?
* Manifests how?
* What are the sxs?
* What is the txt?
- 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
AMS:
* What is the mnemonic for the causes?
Hypoglycemia
* What do you need to do with AMS?
* Glucose <70 in a pediatric patient is what?
Hypoglycemia Treatment: For conscious patients, able to swallow and not NPO
* What do you need to give?
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
Hypoglycemia Treatment
* How do you retest the blood glucose?
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.
Hypoglycemia Treatment
* For patients who are NPO, have an altered mental status, or unable/unwilling to swallow. What do you give for IV access?
Hypoglycemia Treatment
* For patients who are NPO, have an altered mental status, or unable/unwilling to swallow. What do you give witout IV access?
- > 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.
Thyrotoxicosis
* Most pediatric patients with thyrotoxicosis have what? What is that?
* The most devastating complication of hyperthyroidism is what?
* What is usually present?
Thyrotoxicosis
* What will the labs show?
Laboratory findings will usually demonstrate an elevated free thyroxin (T4) level and a suppressed TSH level
Thyroid Storm
* Classic symptoms associated with thyrotoxicosis include (don’t have to have all 5):
- sweating
- Palpitations/Hypertension
- diarrhea, weight loss
- menstrual changes (no menses)
- Tremor(outstretched hands)
Thyroid Storm
* Temp?
* What happens to HR?
* What type of changes?
- 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)
Thyroid Storm
* What is the treatment (3Ps and 2Ss)
Myxedema Coma
* What is it?
* What the sxs?
Myxedema Coma
* What do the labs show?
* What is the txt?
- Low/undetectable T4 and High TSH
- Tx: Thyroxine and Hydrocortisone and treat underlying cause
Adrenal Crisis
* Adrenal insufficiency (Addison’s Disease) occurs when? What are the hormones?
Adrenal insufficiency (Addison’s Disease) occurs when there is absent or inadequate production of adrenal hormones (cortex)
* Cortisol – glucocorticoid
* Aldosterone – mineralocorticoid
* Androgens
Adrenal Crisis
* Any stressful event may lead to what?
* What is most common?
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
What are the sxs of adrenal crisis?
- 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
Adrenal Crisis
* What do the labs show?
* What is the txt?
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
Hyperleukocytosis
* What does the neutrophil count show? What can it cause?
* Leukemic blasts: What are the issues with this? (2)
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
Leukostasis in microvasculature leads to what clinical symptoms? (3)
- Pulmonary: hypoxemia, dyspnea
- Increased viscosity, thrombi
- CNS: headaches, vision changes/loss, focal deficits (similar to stroke)
- Plethora, cyanosis, papilledema
How do you txt Hyperleukocytosis?
Tx with leukopheresis and chemotherapy
Hyperviscosity Syndrome
* What it is?
* What are the sxs?
- 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).
Hyperviscosity Syndrome
* What do the labs show?
* What is the txt?
- 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
Febrile Neutropenia
* Should be considered how?
* What can cause higher mortality?
* What is the goal?
* Risk of death increases with what?
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)
Febrile Neutropenia
* What is the definition?
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
Idiopathic Thrombocytopenic Purpura (ITP)
* What it is?
* More common in who?
* What are the sxs?
* What do the labs show?
- 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
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
Thrombotic Thrombocytopenic Purpura (TTP)
* What are the sxs?
* What do the labs show?
* How do you dx it?
- 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
Thrombotic Thrombocytopenic Purpura (TTP)
* Txt?
* Presents similar to what?
- 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
Von willebrand disease:
* What is it?
* What do the labs show?
- 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
von Willebrand Disease
* What is definitive dx?
* What are the sxs?
* What is the txt?
- 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
Hemophilias
* how do you dx? What are the different types?
* Treat what?
- 8 yr old with hemophilia A is hit on head by fastball
- H/A, vomited, sleepy
- What is your next step?
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
Disseminated Intravascular Coagulation (DIC)
* What is it?
* What are the sxs?
* What are conditions associated with DIC?
- 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.
Disseminated Intravascular Coagulation (DIC)
* how do you dx it?
* How do you tx it?
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)
Sickle Cell Crisis
* What is the MCC?
* What is the second most common?
* May present as what?
* What will be elevated?
* Typically have what?
- 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
What is the txt of sickly cell crisis?
Tx – O2, Hydromorphone, IVF, transfusion in Hgb <7
Tumor Lysis Syndrome
* Prophylaxis with what?
* Usually occurs 1-3 days after what?
* Patients may develop what?
- Prophylaxis with Allopurinol, fluids & diuresis have reduced the incidence.
- Usually occurs 1-3 days after radiochemotherapy of hematologic malignancies
- Patients may develop renal failure
Tumor Lysis Syndrome
* Characterized by what?
Characterized by the triad of:
* hyperkalemia
* hyperphosphatemia (w/ secondary hypocalcemia)
* hyperuricemia
Tumor Lysis Syndrome
* What are the sxs?
* How do you dx it?
* What does the EKG show?
- SXS – fatigue, lethargy, nausea, vomiting, & cloudy urine
- Diagnosis: electrolyte panel including BUN, Cr., Uric Acid, Phosphate, and Calcium.
- EKG – may show signs of Hyperkalemia
Tumor Lysis Syndrome
* How do you treat hyperkalemia?
* How do you treat hypcalcemia?
* How do you treat hyperuricemia?
* When do you need emergency dialysis?
SVC syndrome:
* What does the CXR show?
* What will 25% have?
* What is supportive care?
* What do you if airway compromised?
- CXR documents widening superior mediastinum
- 25% have R pleural effusion
- O2, bed rest, elevation of the head and upper body
- Airway compromise – orotracheal intubation
SVC Syndrome
* XRT for what?
* Chemotherapy+ XRT for what?
* What needs to happen with Clotted central catheters ?
- XRT for non-small cell lung cancer
- Chemotherapy+ XRT for small cell lung cancer & lymphoma
- Clotted central catheters withdrawn & anticoagulation Rx started
