paediatrics Flashcards
AKI in children
3.9 cases per 1000 admissions. significantly higher mortality than those that don’t get aki (15% vs 0.6%)
causes: shock, sepsis, intubation, extracorporeal support, congen cardiac abnormalities.
majority therefore pre-renal causes.
test for serum creatinine if in a high risk group or scenario. (inc diarrhoea)
urine output < 0.3 mL/kg/hour for 24 hours or anuria for 12 hours.
serum creatinine increase to > 3-fold above baseline.
Ix: bloods, urinalysis, urine microscopy, ultrasound.
Rx: monitor, maintain, minimise
stop any ACEi, ARB, NSAIDS, COX.
signs of hypovolaemia- 10ml/kg fluid challenge IV
euvolaemia- 10ml/kg over 1 hour
hypervolaemia- 3-5mg frusi, dialysis if no response.—- if still vbad venesection 5ml/kg.
then treat as per fluid charts.
ADHD
neuro-developmental disorder characterised by inattention, hyperactivity, and impulsivity.
can be primarily inattentive or impulsivity.
symptoms manifest in two or more settings, for example in home and school.- inability to do work, form relations, careless mistakes, not listening etc, loosing things.
RF: strong family history
male, epilepsy.
Dx: need to have symptoms present before age 12. made by clinical history. in uk by specialist.
suggested to use a rating scale but not on its own exclusively.
Rx: pre school children (up to 6)- parent education-
2’- methylphenidate
school age (6+): Psychoeducation + behavioural therapy.
2’- stimulant (methylphenidate, amfetamine)
3’- atomoxetine
discuss anaemia in children
iron deficiency most common cause.
normal anaemia investigations- i.e MVC.
big- folate/ b12
small- iron deficiency (ferritin lower than 20?) or thalassaemia major trait.
normal- consider reticulocyte count- inc– loss.
no inc- consider the nasties.
diagnosis of autism spectrum disorder
A. persistent defects in reciprocal communication and interaction accross multiple contexts.
B. restrictive and repetative interests and patterns of behaviour, at least 2 of stereotyped motor movements speech, inflexibleness of routines, fixated interests, hyper/po reactivity to stimuli
C. must be present in early developmental period
D. causes clinically significant impairment in social, occupational, or other areas of functioning,
E. not better explained by intelectual disability, or global dev delay. may be concurrent but needs to be lower than expected level.
risk factors, ix, rx, autism
male, family history, gestational valproate exposure, genetic inheritance.
Ix: it is a clinical diagnosis based on prev flashcards findings.
questionnaires and tools can help.
Rx: behavioural interventions for family and patient, involve school/ social support
consider speech and language therapy
‘total communication approach’- i.e using as many methods as able to communicate with the patient rather than forcing them to use one.
biliary atresia
a progressive necroinflammatory process involving some or all of the biliary tree.
either congenital absence of formation, or formation and autoimmune destruction, presents in newborn babies/ first few weeks of life.
obstruction then goes onto destroy the liver.
assoc with rotavirus infection maternally.
1 in 10000 babies (very roughly)
S+S: pale stools, hepatomegaly, jaundice lasting longer than 14 days in a newborn. dark urine and faliure to thrive often present.
Ix: serum total or conjugated bilirubin—- over 17 is diagnostic
LFT with high GGT. PT/INR for liver function.
Rx: ideally around 60 days post birth.
if liver functioning - hepatoportoenterostomy
if not functioning - liver transplant
without surgery the condition is fatal. portal htn leads to live failure.
bronchiolitis
an acute viral infection affecting the lower respiratory tract.
causing epithelial destruction, oedema, mucous + inflammatory debris. most common cause of resp admission in under 1s.
respiratory syncytial virus most common cause.
mostly self limiting + symptomatic support.
illness for 10-14/7. cough can persist longer + wheeze.
S+S: cough, wheeze, tacypnoea
RF: <3/12. winter, prematurity, tobacco exposure. + anything congen/immunodef
Ix: pulse ox, ELISA, CXR, PCR.
Rx: supportive – escalate up to ICU
ribavirin - in those with severe disease.
some role for prophylaxis in infants –palivizumab
paediatric candidiasis- specifically management in the paed, associations, treatments.
commonly oral candidiasis
admit if systemic illness, widespread infection (retrosternal pain, pain on swallow)
exclude risk factors (DM in child, hematinic deficiencies + poor hygiene)
Rx: topical antifungal- miconazole oral gel (4/12 and over)
2’- nystatin
hygiene advise, if using corticosted inhaler rinse mouth after.
refer to paediatrician if 2/52 treatment does not work. or sus of immunodef.
discuss paediatric cardiac arrest- the reversible causes. treatment for vt/svt. the most common cause.
respiratory failure is most common cause.- start o2 if 3% below target sats, avoid over oxygenation (unless carbon monoxide)
attempt 2x cannula access. - then IO
fluid bolus 10ml/kg upto 40-60ml/kg in the first hour.
SVT or VT- if decompensated- cardioversion 1J/kh up to 4j/kg.
if not decomp- adenosine
if non shockable- iv adrenaline 0.1mg/kg in 1:10000 solution. - 1st dose ASAP.
further adrenaline 3-5 mins intervals.
consider and correct the 4H and 4T.
Hypoxia
Hypovolaemia
Hyper/hypokalaemia, metabolic
Hypothermia/hyperthermia
Thromboembolism (coronary or pulmonary)
Tension pneumothorax
Tamponade (cardiac)
Toxic/therapeutic disturbance.
chickenpox
acute infectious viral disease
varicellar zoster
vesicular rash, fever, malaise.
transmission by droplet or personal contact. incubation 1-3 weeks.
Ix: clinical diagnosis
Rx: generally no treatment for children under 14.
if over 14 and within 24 hours of onset consider acyclovir
if immunocompromised - admit if complications (encephalitis etc) - supportive care as needed
if the itch is mad -Chlorphenamine if over 1 year old.
discuss congenital heart disease classifications
left to right shunts- typically acyanotic.
e.g septal defects (atrial, ventral or atrioventral), patient ductus arteriosus, anomalous pulmonary venous connection. ——– cyanosis only occurs if large and not repaired, or dev pulm vasc disease.
right to left shunts– deox blood reaching aorta +/- inc or dec pulm blood flow.
e.g tet of fallot, transposition of great arteries, ebsteins anomaly
obstructive valvular and non valvular
left vent outflow obstruction
coarctation of aorta
pulm valve stenosis
aortic valve sten.
discuss Ventral septal defect
most common CHD 20% of all cases.
classified as
A- outlet - may be large
B- perimembranous- often solitary and close on own.
C- inlet
D- muscular- most common, vast maj close within 2 years.
if small may be asymptomatic
if larger- presents 6-8 weeks after birth tacycardia, pnoea, pallor, poor feeding, poor weight gain.- related to pulm oedema.
– if large most will develop pulm vasc obstructive disease. after 2 years.
holosystolic murmur, left vent hypertrophy on ecg. big heart on cxr
Rx: if small leave
if big - diuretics, closure surgically or catheterlly.
atrial septal defect
4-5% of all CHD
found in 40% of downs syndrome pts.
? may present with left axis deviation on ECG.
cardiomegaly, increaced pulm markings on CXR. some pulm oedema but can be mild.
Rx: if complete- repair between 3-6 months of age.
lifelong follow up- 15% get aggressive mitral regurg.
patent ductus arteriosus
ductus usually closes within the first 24 hours of birth
persistent patency occurs in 1-2000– around 10% of all CHD
RF: low birth weight, born at altitude.
S+S: continuous murmur
increased pulmonary blood flow, a wide pulse pressure, and ‘bounding’ pulses.
gradual increase in cyanosis as the disease progresses. initially may be limited to lower body.
Ix: crx, ecg, echo will allow for visualisation.
Rx: NSAIDS initially to try and get to close.- 10mg/kg loading. 5mg/kg for 2 doses.
surgical ligation 2nd line.
if older or adult- coiled.
discuss tetralogy of Fallot
most common cyanotic CHD, representing 4% to 8% of all defects
can occur on own, or as part of di george syndrome.
4 abnormalities: outflow ventral septal defect
overriding aorta
right ventricular outflow tract obstruction
right ventricular hypertrophy.
S+S: progressive cyanosis (right to left shunt) and dyspnoea as a young chilld.
may squat to shunt
2’ erythrocytosis.
loud ejection systolic murmur with radiation to both axilla (RVOT obstruction)
‘tet spells’ where there is a rapid onset of sob can occur. - need treatment- reduced RV outlet flow. - may die
Ix: cxr- boot shaped heart (25%), pulse ox, echo.
Rx: hypercyanotic spells- consider beta blocker (2nd line after knees to chest/ manoeuvres to help)
new-born and very poorly- give a prostaglandin E1- keep Ductus arteriosus open (alprostadil)
if that doesn’t work- surgery/ shunt/ coil
surgery is definitive, no formal recs due to complexity + variation.
transposition of the great arteries
common- 4% of all CHD
incompatible with life unless something else also wrong (e.g PDS, VSD, ASD)
presents in first few hours of life as medical emergency. ductus closes over the 1st 3-14 days.
S+S: prominent right ejection impulse, a single loud heart sound.
no murmur unless VSD (which would be ejection systolic).
Rx: Prostaglandin E1- maintain DA
septostomy in emergency
arterial switching operation in first weeks of life is needed.
adults with RV dysfunction post op are heart transplant candidates.
congenital hip dislocation
developmental dysplasia of the hip- spectrum of conditions which dislocation is the most significant.
the femoral head has a significantly abnormal relationship with the acetabulum
premature arthritis and disability
Barlow (dislocation) and Ortolani (relocation) are tests to use- loose diagnostic use by 6 months.
usually picked up at screening at 2 weeks.
RF: +ve fam hist, female, breech presentation at/ near term.
Ix: tests at physical exams
USS if less than 6/12
x-ray if older than 6/12
Rx:
for hips that reduce and then dislocate again.
<6months = pavlic harness
2’- closed reduction with spika casting
3’ open reduction with spica casting
6-18 mos- closed reduction with spika casting.
18+- open reduction with spika casting.
open reduction with spika- any age.
constipation in children
infrequent passage of stools leading to 1 or more of:
painful defecation;
overflow faecal incontinence;
rectal faecal impaction;
active defecation avoidance behaviour.
Rf: low fibre, poor nutrient, genetic, stress, physical disability, obesity.
Ix: history taking, maj of cases are functional.- clinical diagnosis
consider abdo x-ray
Rx: no impaction
dietary + behaviour modification
add polyethene glycol (PEG) as OSMOTIC laxative.
With impaction- go straight to osmotic laxative.
consider softener if withholding behaviour.
dehydration in paediatrics
D+V are the most common causes (viral)
dehydration causes 15-30% of all deaths under 5.
S+S: Dry oral mucosa, decreased skin turgor, prolonged capillary refill, tachycardia, and irritability,
if severe dehydration- altered mental status, lethargy- will be significantly ill.
(severe is more than 10% body water loss, mild is above 5%)
Ix: serum sodium- will establish if tonic, hypertonic, hypotonic.
K- if diarhoea- likely to be low
work out dehydration % by- (well weight- current weight)/ well weight
Rx: ORT solutions with a total osmolarity of 200 to 310 mOsm/L- if mild-moderate.
bolus- 10mg/kg delivered in less than 10 mins, NaCl.
maintenance- based on weight
100 ml/kg/day for first 10kgs
50ml/kg/day for 2nd 10 kgs
20 ml/kg/day after 20kgs.
developmental delay
failure to attain developmental milestones as compared to peers.
gross and fine motor, speech and language, cognitive and performance, social, psychological, sexual, and activities of daily living
can be in one- isolated
2/ more- multiple
most- global.
mild- up to 33% lower than normal
moderate -up to 66% lower than normal
severe- over 66%.
Ix: as most cases are idiopathic labs aren’t that useful.
need a full assessment and history of how and when milestones where achieved.
Rx: solve any specific sensory impairments (e.g glasses)
overdose
if presenting within 1-2 hours of ingestion activated charcoal can be used. only with ET tube due to risk of aspiration
50-100G as a single dose.
OR can give 50G an hour for 4 hours for some specifics.
paracetamol- establish time, if not known use staggered overdose protocol. special scale for less than 40kg children.
within 1 hour- charcoal.
measure at 4 hour- plot of treatment graph- NAC IV.
if staggered- start NAC
opioid- ABCD- 100% o2 via facemask.
naloxone
observe- up to 24 hours if methadone OD. less for normal preparations.
most of the rest of them is charcoal and hope.
functional abdominal pain
mis interpretation of signals from bowel e.g bloating, stretching.
1/4 of adolescent abdominal pain is functional.
pain is located around umbilicus.
unusual patterns of pain.
may experience early saity etc.
RF: anxiety, dep, stress, traumatic experiences.
Ix: clear detailed history- report of symptoms without physical signs on examination.
Rx: education, support,
GORD in children
can get normal physiological reflux in infants after a meal- posset
- will begin before 8 weeks and 90% ease before 1 year of life.
A diagnosis of GORD should be suspected if there is visible regurgitation and one or more of the following:
Distressed behaviour such as excessive crying, crying when feeding, back arching.
Hoarseness and/or chronic cough.
A single episode of pneumonia.
Unexplained feeding difficulties such as refusing to feed, gagging, choking.
Faltering growth.
Heartburn, retrosternal pain, or epigastric pain
Ix: feeding assessment. thorough history (i.e onset after 6/12- something else), hydration, timing of vomiting etc.
Rx:- refer same day if bloodstaining vomit, bilious vomit, multiple projectile voms.
refer to paediatrician if faltering growth of aversion of food due to vom.
If baby is thriving- leave as is , its calm.
if not thriving- feeding assessment + advice e.g reduce size, thicken feed.
2’- alginate (gaviscon) trial for 2/52- continue if effective.
3’- PPI
always have cows milk allergy at back of mind.
what does hepatomegaly signify within the heart
right ventricular faliure
