Paediatrics 9 Flashcards
1
Q
Diffuse brain injury
A
- Concussion- often mild, usually normal CT
- Diffuse axonal injury- due to shearing forces. Associated with high velocity and deceleration. In the CT you may see widespread punctate haemorrhages
2
Q
What exacerbates secondary brain injury
A
- Hypoxia
- Hypercarbia and iatrogenic hypocapnia
- Hypotension and hypertension
3
Q
Respiratory arrest
A
- The cessation of breathing
- Causes: obstructive airway, COPD, asthma, stroke, head injury, drug overdose
- Clinical presentation: gasping or irregular breathing, cyanosis, unconsciousness and absence of breath sounds
- Investigations: ABG, obs
- Management: Endotracheal intubation or tracheostomy, ventilation
- Once stabilised transfer the patient to HDU or ICU for ongoing monitoring
4
Q
Features of respiratory arrest
A
- Agonal breathing: gasping, laboured breaths that occur infrequently and irregularly
- Absent breathing
- Cynaosis, decreased consciousness
- Silent chest on auscultation
- Dysphonia, nasal flaring
5
Q
Rubella
A
- Viral illness transmitted via respiratory droplets
- Prevention: MMR vaccine
- Symptoms: fever, coryza, arthralgia, post-auricular lymphadenopathy. A rash that begins on the face and moves to the trunk
- Investigations: diagnosed with serological testing like rubella specific IgM
- Supportive treatment with antipyretics and analgesia. Need to be isolated to prevent spread particularly against pregnant people
6
Q
Rubella pregnancy
A
- Can cause congenital rubella syndrome in pregnant women (especially in first 20 weeks)
- Fetal abnormalities: Cataracts, Deafness, Patent ductus arteriosus, Brain damage
7
Q
Self harm paediatrics
A
- Causing harm to oneself physically
- Associated with BPD, depression, anxiety disorder, PTSD and eating disorders
- Types: cutting skin, burning oneself, hitting oneself, overdosing on medication
- Aim is to prevent immediate risk and for long term prevention of recurrence
- Management: CBT and antidepressants
- If significant risk can be hospitalised
8
Q
Small for gestational age: complications
A
- Iatrogenic prematurity
- Antenatal or intrapartum asphyxia
- Operative delivery
- Perinatal death including stillbirth
- Neonatal hypoglycaemia and hypocalcaemia
- Necrotising enterocolitis
9
Q
SGA delivery
A
- <37 with absent/reverse end diastolic flow measured on a umbilical artery doppler= recommend Caesarean section
- <37 weeks with abnormal end diastolic flow measured on a umbilical artery doppler= offer induction of labour
- At 37 weeks with normal umbilical artery doppler= offer induction of labour
10
Q
SGA and severe SGA categories
A
SGA = estimated foetal weight (EFW) OR Abdominal Circumference (AC) is less than the 10th centile on a customised growth chart
Severe SGA =EFW OR AC less than the 3rd centile on a customised growth chart
11
Q
SGA diagnosis
A
Serial ultrasound scans are used for diagnosis of SGA performed from 26-28 weeks gestation. US measurement of size and assessment of wellbeing with umbilical artery doppler is performed every 3-4 weeks until delivery
12
Q
SGA screening
A
Any woman with one major risk factor will be referred for serial growth scans, which are essential to monitor and diagnose SGA. If a woman has three or more minor risk factors, she should be referred for uterine artery Doppler at 20-24 weeks gestation. Women with abnormal uterine artery Doppler should also be referred for serial growth scans.
13
Q
SGA risk factors
A
- Major: previous stillbirth, previous SGA fetus, cocaine use, >40, maternal disease, threatened miscarriage, low PAPP-A, pre-eclampsia, cigarette somking
- Minor: nulliparity, IVF, maternal BMI <20 or >25, previous pre-eclampsia
14
Q
Causes of SGA
A
- Constitutionally small
- Non-placental mediated growth restriction: chromosomal or structural abnormalities, fetal infection, inborn errors of metabolism
- Placental mediated growth restriction: pre-eclampsia, autoimmune disease, thrombophilia, renal disease and essential hypertension
15
Q
Management of SGA
A
- Conservative: smoking cessation, drug counselling
- Medical: if SGA fetus between 24 and 35+6 weeks gestation get a single course of antenatal corticosteroids
16
Q
Soft tissue injury
A
- Can be caused by sports, recreational activities or accidental falls. Tend to heal in a few weeks
- Types: Sprains, strains (pulled hamstring), bruises and cuts
- Symptoms: pain, swelling, bruising, limited range of movement, weakness, tenderness
- Management RICE method, analgesia, possibly physical therapy
- RICE: Rest, Ice, Compression, Elevation
- Prevention: proper warm up and stretch, prevent overuse, use protective gear
17
Q
Causes and complications of Subarachnoid haemorrhage
A
Causes of SAH:
- head injuries (traumatic SAH)
- Spontaneous SAH: intracranial aneurysm (berry aneurysm), arteriovenous malformation, pituitary apoplexy, mycotic (infective) aneurysm
Complications of SAH; Re-bleeding, hydrocephalus, vasospasm, hyponatraemia (due to SIADH), seizures
18
Q
SAH clinical features and examination
A
- Clinical features: thunderclap headache, N+V, photophobia, neck stiffness, altered consciousness, focal neurological signs (cranial nerve palsies and speech distubrance)
- Fundoscopy: subhyaloid haemorrhage
- Examination: positive kernig or Brudzinski’s sign, papiloedema
19
Q
SAH investigations
A
- Non-contrast CT: if done within 6 hours and no evidence of blood then dont do an LP
- Do an LP: if CT is done >6 hours after symptom onset and is normal. LP should be done >12hr after symptoms. Will see xanthochromia
- CT intracranial angiogram: once spontaneous SAH is confirmed to identify causative agent
20
Q
SAH management
A
- Refer to neurosurgery: treated with a coil
- Oral nimodipine: to prevent vasospasm
- Supportive: bed rest, analgesia, VTE prophylaxis, stop antithrombotics
21
Q
Subdural haemorrhage
A
- bleeding between the dura and arachnoid matter: often due to significant head trauma causing rupture of bridging veins. Can occur spontaneously. Can be either acute or chronic
- Presentation: altered consciousness, headache, vomiting, focal neurological deficits
- Chronic changes: cognitive changes, gait disturbance or hemiparesis
- Diagnosis: CT shows a crescent shaped hyperdense blood collection (banana)
- Management: surgical intervention (decompressive craniotomy) with medical management
22
Q
Testicular torsion: basics
A
- twist of the spermatic cord resulting in testicular ischaemia and necrosis.
- most common in males aged between 10 and 30 (peak incidence 13-15 years)
23
Q
Testicular torsion features
A
- pain is usually severe and of sudden onset
- the pain may be referred to the lower abdomen
- nausea and vomiting may be present
- on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
- cremasteric reflex is lost
- elevation of the testis does not ease the pain (Prehn’s sign)
- Lie of the testis may be horizontal (bell-clapper position)
- In neonatal torsion the patient may be asymptomatic and present as a firm, hard and enlarged testis in a blue scrotum
24
Q
Testicular torsion management
A
- treatment is with urgent surgical exploration with fixation of the testicles with orchidoplexy
- if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
- Manual detorsion can be performed if the patient presents early
- Post operatively the patient is provided with scrotal support and advised bed rest for 24 hours and refrain from heavy lifting or exercise for the first few weeks
25
Testicular torsion investigations and complications
- Doppler ultrasound scan: shows lack of blood flow to the testis
- Surgical exploration confirms the diagnosis
Complications: atrophy or necrosis of the testis, infection, subfertility
26
Tonsilitis
Inflammation of palatine tonsils (often due to infection)
- Causes: Viruses (rhinovirus, coronavirus, RSV, EBV); bacteria (mainly group A beta-haemolytic streptococci (strep pyogenes) = ‘strep throat’)
- Symptoms: Throat pain; odynophagia; referred ear pain; hoarse voice (esp. if associated laryngitis); headache; small children may have abdominal pain
- Signs: Red, swollen tonsils +/- exudate; fever; cervical lymphadenopathy
- Investigations: Usually not needed; sepsis 6 if septic; consider throat swab (esp. for streptococci)
- Refer: Difficulty breathing; dehydration; systemic illness/possible sepsis; peritonsillar/retropharyngeal abscess
27
Centor criteria
- Exudate on tonsils (1 point)
- Tender anterior cervical lymph nodes (1 point)
- Absence of cough (1 point)
- Fever >38 degrees (1 point)
28
FeverPAIN
- Fever during previous 24 hours
- P – Purulence (pus on tonsils)
- A – Attended within 3 days of the onset of symptoms
- I – Inflamed tonsils (severely inflamed)
- N – No cough or coryza
- Chance of having bacterial tonsilitis
- Prescribe antibiotics if >4
29
Tonsilitis management
- Safety net: if pain hasn’t settled >3 days or fever >38.3
- Conservative: Explanation and reassurance, ‘delayed prescription’
- Medical: Analgesia/antipyretics (paracetamol/ibuprofen); topical analgesia (benzydamine spray); consider antibiotics if Centor score >3 (10 days penicillin V/clarithromycin)
30
Tonsilitis antibiotics
A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression would warrent a course of antibiotics:
- 1st line: Penicillin V for 5-10 days
- Alternative in penicillin allergy: Clarithromycin/Erythromycin
31
Tonsilitis surgery
- Tonsillectomy if recurrent episodes (3 yearly for 3 years; 5 for 2 years or 7 in 1 year)
- Also indicated for obstructive sleep apnoea from enlarged tonsils/adenoids
- Admit for drainage if peritonsillar abscess forms
32
Tonsilitis complications
- Chronic tonsillitis
- Peritonsillar abscess, also known as quinsy
- Otitis media if the infection spreads to the inner ear
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
33
Toxic shock syndrome
- Life threatening condition: caused by S.aureus and S.pyogenes
- Causes: Tampons, skin infections (abscess, boils, cellulitis), burns, URTI
- Symptoms: Fever, Hypotension, rash (sunburn like rash that leads to desquamation), Sepsis symptoms
34
Treatment of toxic shock
- Hospitalisation and ICU
- Broad spectrum antibiotics
- IV fluids and vasopressors
- Surgical intervention for source control
- Supportive care
35
Viral upper respiratory tract infection
- Causes: Rhinovirus, Influenza virus, Coronavirus and Adenovirus
- Clinical diagnosis
- Symptoms: nasal congestion, sore throat, cough, tiredness, earache, hoarseness and fever
- Signs: erythema at the back of the throat, nasal discharge, tender cervical lymphadenopathy
- Supportive management: admission for frail or elderly. Lasts for 7-10 days. Advise paracetamol, fluids and rest
- Complications: Sinusitis, Otitis media, secondary bacterial infection i.e. pneumonia, exacerbations of asthma or COPD
36
UTI: causative organisms and predisposing factor
Causative organisms: E.coli (80%), Proteus, Pseudomonas
Predisposing factors
- Incomplete bladder emptying: infrequent voiding, hurried micturition, obstruction by full rectum due to constipation, neuropathic bladder
- Vesicoureteric reflux: a development anomaly found in 35% of children with a UTI
- Poor hygiene
37
UTI and gender
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is higher in girls.
38
UTI presentation at different ages
- infants: poor feeding, vomiting, irritability, lethargy, offensive urine
- younger children: abdominal pain, fever, dysuria
- older children: dysuria, frequency, haematuria. Less likely to get fever as you age
- features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
39
NICE guidelines for checking urine samples in a child
- if there are any symptoms or signs suggestive or a UTI
- with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
- with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
40
Urine collection methods
- clean catch is preferable
- if not possible then urine collection pads should be used
- cotton wool balls, gauze and sanitary towels are not suitable
- invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
41
UTI management
- infants <3 months old should be referred immediately to a paediatrician
- children >3 months with an upper UTI should be considered for admission to hospital. If not admitted give oral antibiotics i.e. cephalosporin or co-amoxiclav for 7-10 days
- children >3 months old with a lower UTI should be treated with oral antibiotics for 3 days, usually trimethoprim or nitrofurantion. Parents should bring the children back if they remain unwell after 24-48 hours
- antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
- Lower UTI’s are usually treated with nitrofurantoin, upper UTI’s are usually treated with cephalosporin
- If recurrent UTI’s refer to secondary care
42
Investigations following a UTI
- Renal ultrasound- only if they have an atypical UTI
- Micturating cystourethragram- to assess for abnormal bladder function
- DMSA scan- 4 to 6 months after acute infection to detect renal parenchymal defects
43
What investigations are recommended for children under 6 months after a first atypical urine infection or recurrent UTI?
Renal ultrasound, DMSA and MCUG.
Gold standard for renal cortical scarring: DMSA
44
When is a UTI classed as atypical
- Poor urine flow
- Abdominal or bladder mass
- Raised creatinine
- Septicaemia
- Failed to respond to treatment with suitable antibiotics within 48 hours
- Infection with non E.coli organisms
45
UTI diagnosis
- Positive leukocytes and nitrites on urine dip
- Positive urine culture with appropriately collected urine (clean catch; non-contaminated collection pad/catheter sample/suprapubic aspirate)
46
Urticaria
- Hives’: common dermatological condition caused by transient pruritic wheals in the dermis
- Rah: pale pink raised skin, pruritic
- Either acute (<6 weeks) or chronic (>6 weeks)
- Due to mast cell degranulation to an allergen
- Clinical diagnosis but can use skin prick test or serum tryptase levels
- Management: avoid triggers and antihistamine. First line: non sedating antihistamine (loratadine) then sedating (chlorpenamine). Prednisolone if severe or resistant
47
Viral exanthema
- A widespread maculopapular rash caused by viral infections
- Systemic symptoms: fever, malaise and lymphadenopathy
- Causes: measles, rubella, varicella zoster, erythema infectiosum (fifth disease) and roseola (6th disease)
- Investigations: serology and PCR
- Management: antipyretics and analgesia
48
Bacterial causes of gastroenteritis
- Staphylococcus aureus: usually found in cooked meats and cream products.
- Bacillus cereus: mainly found in reheated rice.
- Clostridium perfringens: usually found in reheated meat dishes or cooked meats.
- Campylobacter
- coli including E.coli 0157 (which can cause haemolytic uraemic syndrome)
- Salmonella, Shigella
49
Viral causes of gastroenteritis
- Rotavirus (most common cause of infantile gastroenteritis): part of the vaccination programme
- Norovirus- most common cause of viral gastroenteritis of all ages
50
Viral gastroenteritis
- Clinical diagnosis: self-limiting episode of diarrhoea, nausea and vomiting lasting <14 days.
- Before starting IV fluids do an FBC and U&E
- Normally dont need stool sample unless presence of blood, long lasting diarrhoea recent travel or suspicion that its non-viral
- Can get transient Lactose intolerance
