Paediatric Flashcards
Blue Zone in Paediatrics
Increased vigilance zone
- increase frequency of observation- clinically determined
Manage anxiety, pain and review oxygenation in consultation with nurse in charge
Consider if the observation, trends in observation or clinical assessment reflect deteroiation
Yellow zone in paediatrics
- only systolic BP
=clinical review - call the home team or designated responder within 30 mins
Red Zone
3 yellow zone = red zone Mandatory call zone Urgent response by rapid response team Designated responder The right expertise - know about graded response Rapid response - notes, handover, obs etc
Altered calling criteria for kids
In conjunction with paediatrician
Match the criteria for patient with chronic disease
Trajectory of illness (in line with response to treatment)
Eg. day 3 of bronchiolitis = worst so change for the day
Make the trigger more sensitive
ALL altered calling criteria reviewed within 36 hours
Na water balance in preterm babies
Salt water balance is modulated by ADH via osmoreceptors and baroreceptors.
There is tendency to lose sodium in urine over first weeks as the increased GFR excesses ability to reabsorb Na
High level of transepidermal loss <28/40
Respiratory related water loss can be countered with warm humidified gases
Weight loss post birth
Normal is up to 10% of weight loss Failure to lose weight = fluid retention/overload >10% weight loss = assess feeding Weight all babies at day 3 Check UEC if weight loss >12%
Hyponatraemia in newborns
Causes: water overload (first weeks), maternal fluid overload, iatrogenic, sick infant (birth asphyxia, sepsis), excessive renal loss, GI loss via diarrhoea, trainable
Symptoms: irritalibity, apnea’s, seizure
Treatment: depends on underlying cause
Do not correct rapidly due to risk of neurological damage
Hypernatremia in newborn
Risk of seizures if Na >150 mmol/L Causes: water depletion, excess administration Two major risk groups: 1. extreme preterm infants 2. breast fed infants with poor intake
Treatment- increased fluid intake
Hypokalemia in newborns
Causes: excessive losses via diarrhoea, vomiting, NG aspirate, stoma, renal diuretics or inadequate intake
Correct with supplementation: risk of arrthymia
Hyperkalemia in newborn
Causes: failure to excrete K+ ie. renal failure
Treatment: myocardial stabilisation, Ca gluconate
Causes of IUGR
Fetal, placental or maternal
Fetal
- fetal genetic abnormalities, fetal infection, fetal structure anomaly, Down syndrome
Maternal
- multiple gestation, maternal genetic factors., obstetric condition associated with diminished flow (pre-eclapmsia), teratogens (warfarin, metotrexate), assisted pregnancy, higher altitude, maternal age, Down syndrome
Placental
- CPM, ischemic placental disease
Classifications of IUGR
Symmetrical
- 20-30%
- all organs decrease proportionally
- due to global impairment of cellular hyperplasia early in gestation
- thought to result from a pathological process manifesting early in gestation
Asymmetrical
- 70-80%
- relatively greater decrease in abdo size (liver vol and subcutaneous fat)
- asymmetrical fetal growth is capacity of fetus to adapt
Screening for IUGR
Fundal height - upper edge of pubic symphysis to top of fundus
- serial
If fetus <10th percentile then monitor for growth and physiology
Sonographic estimation for fetal weight <3rd, 5th and 10th percentile
Investigations for IUGR
Complete history and examination
Ultrasound biometry - biparietal dia, head circumference, abdo circumference and femur length
Fetal survey - omphalocele, gastroschisis, diaphragmatic hernia, skeletal dysphasia and congenital heart defects - because 10% of fetal growth restriction = congenital anomalies
Fetal echocardiogram- only if seems abnormal
Fetal genetic studies-
Infection workup
Plotting fetal weight 2-4 week interval to look at velocity
What are some respiratory diseases of neonates
Transient at hypnoses of newborn Pneumothorax Congenital pneumonia Meconium aspiration syndrome Respiratory distress syndrome (hyline membrane disease) Apnoea of newborn
What is transient tachypnoea of newborn
Pulmonary odema caused by excess lung fluid/delayed resorption
4 hours within birth
Tachypnea >60RR, cyanosis, increased WOB “mucous” breath sounds clear
CXR- streaking with fluid in fissure, increased lung vol (flat diaphragm)
Resolves in 24 hr - supplemental oxygen, consider CPAP and ABX
RF- elective LSCS, gestational diabetes
Pneumothorax
Spontaneous in 2% of births
Alveoli = hyperinflated and rupture, air then tracks into the visceral
Decreased air entry + trachea deviated
CXR- collapsed lung, lack of peripheral lung marking, ipsilateral translucency
None if asymptomatic, O2 as required, chest drain if severe
RF- lung disease, positive pressure breath (resuscitation),
Generally good prognosis
Congenital pneumonia
Caused by aspiration of infected amniotic fluid - GBS, E.coli, listeria, chlamydia other gram negatives
Within the first 24 hours
Investigation: septic screen (before starting abx), CXR
Treatment: chest physio, ABX (benzyl, ampicillin and gentamicin)
RF: prolonged rupture of membrane, chorioamniotits, foetal hypoxia
Pelvic organ prolapse
Anterior: cystocele - urethrocele Posterior: rectocele - enterocele Uterine prolapse Vaginal vault prolapse Uterine providential- all walls of vagina and cervix
Dx using POP-Q (The 9 measurement)
Stage 0= nil
Stage 1= >1cm above hymen
Stage II= <1cm distal to hymen
Stage III= 1-2 cm distal to hymenal plane
Stage IV = complete evertion to uterine procidentia
De Lancy vaginal support
Level 1:
- Cardinal (Mackenrodt’s)
- Pubocervical = anterior
- Uterosacral = posterior
Level 2
- Pelvic fascia and paracolpops
- Arcus trendiness fasciae pelvis (ATFP)
- Vesicovaginal fascia and rectovaginal septum - denoviller’s fascia
Level 3
- Peritoneal body (post)
- Perineal transverse muscle
- Bulbocarvenous muscle
- Anterior pubouretheral ligament
Colposcopy
- indications
- anatomy
- abnormalities
Colposcopy - is a procedure using colposcope for illuminating magnified view of the cervix, vagina and anus
Used to identify precancerous and cancerous cells
Indications
- FU to abnormal cervical screen
- FU to abnormal finding on gross exam
- Evaluation of visually abnormal cervix, vagina and vulva
- Evaluation post Rx of cervical neoplasia
No absolute contraindications
Anatomy ectocervix = squamous cell
SCJ = junction between squamous and glandular cells
Squamous = smooth pink-grey Ectocervix, glandular pink red Endocervix
Transformation = original SCJ and remaining squamous
Jaundice in the first 24 hours of birth
Jaundice in the first 24 hrs is always pathological
Causes of jaundice in the first 24 hrs rhesus haemolytic disease ABO haemolytic disease hereditary spherocytosis glucose-6-phosphodehydrogenase
Jaundice in the neonate from the c. 2-14 days is common (up to 40%) and usually physiological. It is more commonly seen in breast fed babies
Jaundice after 14 days of birth
If there are still signs of jaundice after 14 days a prolonged jaundice screen is performed, including:
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs
Causes of prolonged jaundice biliary atresia hypothyroidism galactosaemia urinary tract infection breast milk jaundice congenital infections e.g. CMV, toxoplasmosis
Infantile spasms
Infantile spasms, or West syndrome, is a type of childhood epilepsy which typically presents in the first 4 to 8 months of life and is more common in male infants. They are often associated with a serious underlying condition and carry a poor prognosis
Features
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap
Investigation
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
Management
poor prognosis
vigabatrin is now considered first-line therapy
ACTH is also used
Fragile X syndrome
Fragile X syndrome is a trinucleotide repeat disorder.
Features in males learning difficulties large low set ears, long thin face, high arched palate macroorchidism hypotonia autism is more common mitral valve prolapse
Features in females (who have one fragile chromosome and one normal X chromosome) range from normal to mild
Diagnosis
can be made antenatally by chorionic villus sampling or amniocentesis
analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis
A 2 day old baby who was born by a ventouse delivery is noted to have a swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis?
Cephalohematoma
Cephalohematoma
Between periosteum and skull - remember SCALP.
Most commonly in parietal region and is associated with instrumental deliveries.
Swelling appears 2-3 days following delivery and does not cross suture lines
Gradually resolves
Jaundice may develop as complication
Caput succadeneum
Caput succadeneum is commonly seen in newborns immediately after birth. It occurs due to generalised superficial scalp oedema, which crosses suture lines. It is associated with prolonged labour and will rapidly resolve over a couple of days.
Subaponeurotic haematoma
Subaponeurotic haematoma is a rare condition where bleeding occurs that is not bound by the periosteum. It can be life threatening and presents as a fluctuant scalp swelling, which is not limited by suture lines.
Craniosynostosis
Craniosynostosis is uncommon and is where there is premature closure of cranial sutures, causing deformity of the skull. It can be evident at birth and may be associated with genetic syndromes. The shape of the skull will depend upon which sutures are involved. Other clinical features include early closure of the anterior fontanelle and raised ridge along the fused suture.
A baby born at 35 weeks gestations via normal vaginal delivery is found to be irritable 48 hours after birth and suffers a convulsion. There is no obvious head trauma or swellings. Which one of the following cranial injuries is most likely to have occurred?
Intravascular Hemorrhage
A boy is noted to have a webbed neck and pectus excavatum
Noonan Syndrome
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
