Paediatrics Flashcards
When is congenital heart disease detected?
Picked up during antenatal ultrasound screening at 20 weeks –> fetal echo
In which congenital heart diseases do you get L –> R shunt?
VSD, PDA, ASD
Patient breathless, asymptomatic
More common than R –> L shunt
In which congenital heart diseases do you get R –> L shunt?
Tetralogy of fallot
Transposition of great arteries
Patient cyanotic
Less common than L –> R
Causes of congenital heart disease?
Maternal rubella, SLE and diabetes Warfarin Fetal alcohol syndrome Down's syndrome - leads to AVSD, VSD Other syndrome's e.g. Edward's, Patau's, Turner's
Fetal circulatory changes around birth
In utero:
- Low pressure in LA as little blood returns from the lung
- High pressure in RA as receives all systemic and placental venous return
- Foramen ovale (between atria) and ductus arteriosus (between PA and aorta to bypass lungs) are open, blood flows R → L
At birth:
- First breath increases pulmonary blood flow and LA pressure
- No placenta decreases RA pressure
- LA pressure> RA pressure so foramen ovale closes
First hours/days of life:
-Ductus arteriosus closes
Treatment of shunts (what keeps open/closes defect)?
Prostaglandins keep shunts open, important when baby cyanotic (i.e. in R –> L shunts in TOF and TGA) - keeps open until surgery
Prostaglandin inhibitors i.e. NSAIDS e.g. IV indomethacin/ibuprofen close defect in L –> R shunts
DDx of breathless child?
Croup, asthma, bronchiolitis, pneumonia, URTI, acute epiglottitis, foreign body inhalation
Most likely diagnosis of breathless child with barking cough and mild intercostal recessions?
Croup (laryngotracheobronchitis)
Cause of croup?
Parainfluenza virus
What age group does croup affect?
6 months to 6 year olds
Symptoms of croup?
Barking cough, stridor, fever, coryzal symptoms
Management of croup?
Single dose dexamethasone (or prednisolone) - 0.15mg/kg
Management of croup in patient with low sats?
High flow O2 and nebulised adrenaline
Cause of bronchiolitis?
Respiratory syncytial virus (RSV)
Management of bronchiolitis?
Self-limiting so supportive only: O2, fluids
Prophylaxis for RSV in high-risk children?
Palivizumab
Prophylaxis for RSV in high-risk children?
Palivizumab
Cause of septic arthritis?
Staph. aureus
Investigations for septic arthritis?
Joint aspiration (+ culture), blood cultures, infection more likely to be systemic in children
Management of septic arthritis?
IV antibiotics (probably flucloxacillin)
DDx for limp in child
Septic arthritis; transient synovitis (would be viral, less systemically unwell, no pain at rest but pain & reduced int. rot.n, normal WCC, CRP, ESR); osteomyelitis (similar presentation to SA, MRI, XR);
DDH –infant, barlow and otolani manouvres test in neonatal screening, asymetric skin folds, breech delivery assoc, important complication – necrosis of femoral head;
Perthes disease – avascular necrosis of femoral epiphysis of femoral head, boys 5-10, insidious limp or hip/knee pain, shown on XR;
Slipped upper feomral epiphysis – 10 – 15 yrs esp. obese boys, can follow minor trauma or be insidious, reduced abduction and internal rotation’
NAI - esp. in fractures before walking age, repeated admissions to A&E;
JIA – presistent joint swelling for over 6 weeks, mostly females, exclude infection, malignancy etc
Most likely diagnosis in 3 wk old baby with non-bilious projectile vomiting after feeding? No PMH, on exam: poor weight gain, dehydrated, mass felt in RUQ.
Hypertrophic pyloric stenosis
Physiology of hypertrophic pyloric stenosis?
Hypertrophy of pylorus –> impaired gastric emptying –> stomach contents forced to leave stomach as vomit.
Metabolic abnormality in pyloric stenosis?
Hypochloraemic hypokalaemic metbolic alkalosis.
Radiological features of pyloric stenosis?
USS - non-passage of gastric contents into prox duodenum.
XR - delayed gastric emptying, peristaltic waves, string sign/double-track sign, beak sign
Management of pyloric stenosis?
Stop oral feeds, IV fluids – 0.9% sodium chloride, 5% dextrose, 20mmol KCl (apart from for resus), admit to paeds:
- Atropine (oral or IV) – 85% success rate and requires long hospital stay
- Pyloromyotomy (Ramstedt’s procedure)
Intussusception symptoms?
Sudden onset paroxysms of colicky abdo pain +/- crying
Child may appear well between paroxysms initially
Early vomiting - rapidly becomes bilious
Neuro sx e.g. lethargy, hypotonia or sudden alterations of consciousness
Dehydration, pallor, shock
Drawing up of legs to chest
Irritability, sweating
Pathophysiology of intussusception
Intestine folds into the next part of it causing obstruction
Where in bowel is most common site of intussusception?
Terminal ileum/ileo-coecal valve
What signs of intussusception would you find on exam?
Sausage shapen mass in abdomen, red currant jelly stool
Complications of intussusception?
Bowel perforation, necrosis, peritonitis.
Management of intussusception?
Enema - water soluble contrast or air contrast, resection of affected bowel
Management of intussusception?
Enema - water soluble contrast or air contrast, resection of affected bowel
What causes jaundice <24h of birth?
PATHOLOGICAL. Caused by haemolysis, congenital infection etc.
Causes of jaundice >24h of birth?
Physiological, dehydration, breast milk
Causes of jaundice after 2 weeks of age?
Biliary atresia (pale stools, dark urine), UTI, congenital hypothyroidism
Main complication of jaundice?
Kernicterus - encephalopathy from unconjugated bilirubin in the brain
Ix for jaundice?
Transcutaneous bilirubinmeter, diagnose with serum bilirubin
Management of jaundice in babies?
Plot bilirubin on gestation specific chart according to age since birth, phototherapy of exchange transfusion.
What is necrotising enterocolitis (NEC)?
Bacterial invasion of ischaemic bowel wall, typically seen in premature infants.
Symptoms of NEC?
Vomiting, poor feeding, distended abdomen, blood in stool
May progress to shock, perforation
Treatment of NEC?
IV antibiotics, TPN, ITU
Pattern of measles rash?
Maculopapular rash - becoming patchy and confluent.
Starts behind ears, spreads to face and then trunk.
How long is child with measles infective for?
4 days before rash appears to 4 days post appearance of rash.
Othr sx of measles besides rash?
Presence of Koplik’s spots (white spots on buccal mucosa), non-productive cough, conjunctivitis, fever, running nose
How can diagnosis of measles be confirmed?
Saliva swab or serum for measles-specific IgM or RNA
Management of measles?
Self-limiting disease. Treat sx, stay at home to stop spread
Complications of measles?
Encephalitis, giant cell pneumonia, subacute sclerosing panencephalitis (5-10 years later), febrile convulsions, keratoconjunctivitis, corneal ulceration
Criteria for diagnosing Kawasaki’s?
Fever of >39 for 5 days plus 4/5 of:
- Cervical lymphadenopathy >1.5cm
- Non-vesicular rash
- Bilat. dry conjunctivitis
- Erythema, odema/desquamation of extremities
- Inflammation of lips, mouth, tongue (strawberry tongue)
Management of Kawasaki’s disease?
IV immunoglobulins (10-20% don’t respond), aspirin (reduces thrombosis risk), other: corticosteroids, anti-TNF, immunosuppressive therapies
Complications of Kawasaki’s disease?
Coronary artery aneurysms, cardiac valve disease (mitral regurg.), MI, sudden cardiac death etc.
