paediatrics Flashcards
Name the 3 fetal shunts
ductus venosus
ductus arteriosus
foramen ovale
what circulatory changes happen at birth
- reduced ciruclating prostaglandins at birth causes closure of the ductus arteriosus
- babies 1st breath causes pulmonary flow resistance to fall meaning pressure in the R atrium decreases, and pressure in the L atrium increases because more blood returns from the lungs, meaning L ventricular pressure also increases causing the forman ovale to close.
Name 3 causes of a left to right shunt
ventricular septal defect
atrial septal defect
patent ductus arteriosus
what are the 2 types of atrial septal defect and describe them
- secundum ASD = a hole in the centre of the septum, often involves the foramen ovale
- partial ASD = a hole in the very bottom of the atrial septum often involving the AV valve and displaces the AV node.
name the symptoms of an atrial septal defect in children
- asymptomatic
- recurrent chest infections
- difficulty feeding
wheeze - failure to thrive?
what type of murmur is heard with a secundum atrial septal defect and where is it heard
a crescendo-descendo ejection systolic murmur with a split second heart sound heard at the upper left sternal edge
what type of murmur is heard with a partial ASD and where is it heard
apical pansystolic murmur with a split second heart sound
What investigations would you order to diagnose an atrial septal defect
- ECG
- CXR
- echo with doppler ultrasound
what chest xray findings would you see in a infant with an ASD
cardiomegaly (may be R ventricle hypertrophy)
enlarged pulmonary arteries
increased pulmonary vascular markings
^ because the blood is shunted from left to right so more blood is in the R ventricle and pulmonary flow is increased
what would you find on an ECG of a baby with a secundum ASD
partial RBBB
R axis deviation
what would you find on an ECG of a baby with a partial ASD
superior QRS axis
how do you manage small ASD’s
watch and wait
how do you manage larger ASD’s
secundum = cardiac catheterisation to insert occlusion device via the femoral vein
partial ASD = surgery to close the hole
At what age is surgical correction of ASD’s undertaken
at 3-5 years of age to prevent R heart failure later on in life.
which syndromes are associated with ventricular septal defects
turners syndrome
downs syndrome
which vessel is used for cardiac catheterisation
femoral vein
define a small ventricular septal defect
a hole less than 3mm in size
- usually asymptomatic and will close spontaneously
define a large ventricular septal defect
a defect that is the same size of/bigger than the aortic valve.
- requires treatment
name symptoms of a large ventricular septal defect
- can present with heart failure and SOB in the 1st week of life
- recurrent chest infections
- poor feeding, poor weight gain
- dyspnoea
- tachypnoea
- tachycardia
- enlarged liver
name the signs of a large ventricular septal defect
- tachycardia
- tachypnoea
- hepatomegaly
- soft pansystolic murmur
- sometimes no murmur
- loud pulmonary 2nd sound
what type of murmur is heard in a large ventricular septal defect and where
soft pansystolic murmur at the left lower sternal edge
- no murmur indicates a larger hole
what investigations would you order to diagnose a ventricular septal defect
CXR
Echo
ECG
what would you find on chest xray of patient with a large VSD
cardiomegaly
increased pulmonary vascular markings
enlarged pulmonary arteries
pulmonary oedema
name a complication of large untreated VSD
R heart failure
how would you manage a small VSD
watch and wait if no pulmonary hypertension or heart failure evident
how would you manage a large VSD
- prophylactic antibiotics to reduce risk of bacterial/infective endocarditis
- whilst waiting for surgery manage heart failure with diuretics, additional calories for growth and Catopril (ACE inhibitor). Digoxin can also be used to reduce sympathetic tone and improves growth outcomes.
- surgery at 3-6 months of age to close the hole
at what age is surgery for large ventricular septal defects carried out
at 3-6 months of age
where is the ductus arteriosus located
connects the pulmonary artery to the descending aorta
name a risk factor for patent ductus arteriosus
maternal rubella infection
name symptoms of patent ductus arteriosus
SOB, poor feeding, poor weight gain, recurrent chest infection
name signs of a patent ductus arteriosus
- crescendo descendo murmur below the left clavicle
- increased pulse pressure presenting as a collapsing or sounding pulse
name 6 common causes of vomiting in infants
- GORD
- infection (non specific) e.g UTI, resp infection, gastritis, meningitis
- intestinal obstruction - volvulus, malrotation, intersusseption, pyloric stenosis, hirschprungs disease, duodenal atresia, strangulated hernia
- inborn error of metabolism
- food allergy or intolerance
- cows milk protein
- eosinophilic oesophagitis
name 6 common causes of vomiting in pre-school aged children
Gastritis
Infection - UTI, resp, gastritis, meningitis
coeliac disease
intestinal obstruction - volvulus, intersusseption, malrotation, constipation
renal failure
testicular torsion
raised ICP
name 6 causes of vomiting in older children/adolescents
gastroenteritis coeliac disease peptic ulcer intestinal obstruction bulemia testicular torsion raised ICP migraine diabetic DKA pregnancy appendicitis infection - sepsis/meningitis
define GORD
involuntary reflux of gastric contents into the oesophagus
Management of GORD in children
thicken feeds
PPI - omeprazole
H2 receptor antagonst - ritanidine
surgery if severe/persists
why is GORD common in the 1st year of life
because infants spend a lot of time horizontal, have a fluid only diet and have involuntary relaxation of the lower oesophageal spinchter possibly due to underdevelopment/low tone
symptoms of GORD
regurgitation of food vomiting cough in older children poor feeding faltering growth if severe
risk factors for GORD in children
prematurity
bronchopulmonary dysplasia
cystic fibrosis
which surgical procedure can be used to treat GORD if severe
Nissen fundoplication
how would you investigate GORD
24 hour oesophageal pH monitoring
mainly a clinical diagnosis
endoscopy with biopsy can be used to confirm if there are complications associated with GORD
name complications that can arise from GORD
oesophagitis = haematemesis, poor feeding, iron deficiency anaemia
pulmonary aspiration of contents = recurrent infection, wheeze, cough
failure the thrive/poor growth
dystonic neck posturing
what is eosinophilic oesophagitis?
inflammation of the oesophagus caused by infiltration and activation of eosiniphils in the oesophageal mucosa and submucosa
more common in children with other atopic diagnoses e.g asthma, eczema
symptoms of eosiniphilic oesophagitis
vomiting
bolus dysphagia (getting stuck in chest)
pain on swallowing
treatment of eosinophilic oesophagitis
oral corticosteroids e.g viscous budenoside
what is pyloric stenosis
hypertrophy of the pyloric muscle (usually fundus) causing projectile vomiting in infants
symptoms of pyloric stenosis
- projectile vomiting that gradually increases in frequency
- presents at 2-8 weeks of life
- poor feeding, cant keep food down
- poor weight gain
- hungry after vomiting so crys
signs/examination findings shown in pyloric stenosis
gastric peristalsis seen in upper right quadrant
olive shaped mass palpable
if abdomen is distended gas should be removed via NG tube to allow for examination
investigations in pyloric stenosis?
ultrasound scan of abdomen
U+E, blood gas will show hypochloraemic metabolic alkalosis with low potassium and low sodium due to vomiting.
management of pyloric stenosis?
correction of alkalosis pyloromyotomy surgery (either by a periumbillical incision or laparoscopy)
Which virus is responsible for the majority of gastroenteritis in childrem
rota virus
name causative organisms of gastroenteritis in children
rotavirus adenovirus campylobacter jejuni e.coli shigella salmonella
most common causative bacteria of gastroenteritis in children
campylobacter jejuni
what signs indicate an salmonalla/shigella gastro infection
blood and mucus in the stools, diarrhoea/vomiting
symptoms of gastroenteritis
rapid onset loose watery stools and vomiting, abdo pain, contact with someone with D+V or travel abroad or eating out at restaurant
how would you investigate suspected gastroenteritis
- FBC. U+E, LFT
imflammatory markers
stool and blood culture
check plasma electolytes, creatinine and glucose if there is prolonged diarrhoea or if fluids are required (dehydration)
what should you always check for in children with prolonged diarrhoea
dehydration =
physical exam
stool and blood culture
check plasma electrolytes, creatinine and glucose
if shocked check blood gases
differential diagnosis for diarrhoea and vomiting in children
cow milk protein allergy coeliacs lactose intolerance intestinal obstruction e.g volvulus intersusseption malrotation pyloric stenosis acute appendicitis DKA sepsis meningitis migraines in older kids
define clinical dehydration
a loss of bodyweight between 5-10%
define shock (hypovolaemic?)
a loss of bodyweight over 10%
what are the signs of hypovolaemic shock
pale motted skin prolonged capillary refill loss of skin turgor sunken eyes sunken fontanelle cold extremities dry mucous membranes reduced urine output hypotension tachypnoea reduced consciousness
what puts infants at risk of dehydration
- passing 6+ watery stools over 24 hours
- malnutrution
- preterm
- low birthweight
- unable to tolerate feeds/fluids
- not offered fluids
- vomiting
management of gastroenteritis
correct dehydration with oral rehydration solution/fluids if needed
antibiotics not helpful unless sepsis
give indications for antibiotics in children with gastroenteritis
only indicated if sepsis/ immunocompromised/ extra intestinal spread of infection.
what is post gastroenteritis syndrome
where the child has watery diarrhoea when you re-introduce feeds after infection depsite no infection being present (just has to re adjust and treat with oral rehydration solution)
name 5 causes of gastritis
h.pylori infection autoimmune gastritis crohns NSAID use increased stomach acid secretion
even though P.U.D is rare in children, when should you consider peptic ulcers in children
when they show symptoms and they have a 1st degree relative with P.U.D
name symptoms of gastritis
nausea
vomiting (usually no blood unless severe)
abdominal (epigastric) pain
dyspepsia
name possible complications of gastritis
bleeding - iron deficiency anaemia
sepsis
treatment of h.pylori
triple therapy -
amoxicillin
omeprazole (PPI)
and Clarythromycin or metronidazole
how do you diagnose gastritis caused by h.pylori infection
C breath test
serum serology for h.pylori
stool antigen test
when should children with suspected gastritis be referred for further investigation
when they don’t respond to treatment - refer for upper GI endoscopy
what is functional dyspepsia
sort of like IBS, affects the stomach causing vomiting, cramps etc usually after food, delayed gastric emptying,
no real cause.
usually diagnosed after suspected gastritis doesnt improve with treatment and upper GI endoscopy is normal
how do you treat functional dyspepsia
hypoallergenic diet
symptoms of ibs in children
non specific: abdo pain watery/loose stools bloating constipation feeling of incomplete defecation
what is a common cause of appendicitis in children
faecoliths
describe abdo pain in apendicitis
begins peri umbilical and general then localises in the right illiac fossa (mcburneys point).
Pain aggravated by moving, walking and coughing
severe sharp pain
what is abdominal guarding a sign of
peritonitis
symptoms of acute appendicitis
severe abdo pain R illiac fossa vomiting anorexia fever diarrhoea
what would you find on abdominal examination of child with acute appendicitis
guarding rebound tenderness severe pain R illiac fossa mass child may prefer to sit/lie still with knees to chest
how would you manage a child with suspected acute appendicitis
review and observations every couple of hours initially (bc can rapidly progress in children)
IV fluids and antibiotics to try and clear infection
USS to confirm appendix with increased blood flow/inflamed
appendicectomy
name 2 complications of acute appendicitis in children
peritonitis
abscess formation
what is intersusseption
Invagination of one section of bowel into the other. when proximal bowel telescopes into distal bowel
where does intersusseption most commonly occur
at the illeocaecal valve (junction between small and large bowel)
what age does intersusseption commonly present
between 2 months - 3 years of age
what is the most common cause of intestinal obstruction in neonates
intersusseption
what causes intersusseption
unknown. associated with viral infection causing enlargement of peyers patches. Usually requires a lesion that obstructs normal peristalsis causing the lesion and that section of bowel to move forwards into the next section with peristaltic waves.
common lesions include polyps, meckels diverticulum, areas of intramural haemorrhage (e.g henoch-schonlein purpura)
what bowel lesions are associated with causing intersusseption
viral infection causing enlargement of peyers patched
polyps
meckels diverticulum
henoch schonlein purpura
symptoms of intersusseption
- abdo pain (severe colicky that gradually gets worse)
- child goes pale and draws legs up to their chest
- child falls asleep between episodes
- vomiting
- constipation (from obstruction)
- refuses feeds
- lethargy
- abdominal distension (trapped gas)
- may present with hypovolaemic shock due to pooling of fluid in the bowel
what is found on examination of a child with intersusseption
red currant jelly stools
sausage shaped mass in abdomen
distension
what investigations would you do to diagnose intersusseption
abdo X ray - shows distended small bowel, no gas in distal colon
USS confims diagnosis = doughnut sign!
A doughnut sign is found on abdominal ultrasound scan, what is the diagnosis
intersusseption
redcurrant jelly stool is associated with which disease
intersusseption
treatment of intersusseption
- fluid resus is shocked
- if no complications radiologist performs rectal air insufflation
- if complications surgery to correct the bowel
complications associated with intersusseption
bowel perforation
peritonitis
bowel necrosis
hypovolaemic shock from pooling of fluid in the bowel
what is a meckels diverticulum
embryological remenant of the vitello-intestinal duct that contains pancreatic tissue and ectopic gastric mucosa
where is meckels diverticulum found
an outpouching in the small intestine
what can meckels diverticulum cause
usually asymptomatic but can cause GI bleeding or obstruction i.e volvulus, malrotation, intersusseption
can also cause diverticulitis
how is meckels diverticulum diagnosed
technetrium scan shows increased isotope uptake
or laparoscopy
treatment of meckels diverticulum
surgical resection only required if symptomatic
what is malrotation
intestinal obstruction caused by incomplete rotation of the intestine during fetal development. often leads to volvulus which is a life threatening acute emergency.
name complications of a volvulus
volvulus ischaemic bowel bowel necrosis peritonitis shock (hypovolaemic)
symptoms of malrotation with volvulus
BILE STAINED DARK GREEN VOMITING
abdo pain
abdo distension
abdo wall oedema
what investigations would you order in a child with suspected malrotation
urgent upper GI contrast study
bloods
how would you manage malrotation
if obstruction = fluid resus and antibiotics
surgery - ladds procedure is used if the bowel is healthy
if bowel unhealthy then laparotomy used to untwist the volvulus
if ischaemic bowel then may need resection of the bowel.
How would you test renal function in children
- plasma creatinine concentration
- eGFR
- plasma urea concentration
- creatinine clearance
name causes of high plasma urea that isn’t renal failure in children
gastrointestinal bleeding
catabolic states
high protein diet
what tests would you do in suspected sepsis in a child
blood culture FBC CRP urine dipstick MC+S lumbar puncture - rapid antigen screening consider CXR
symptoms of kawisaki disease
high fever lasting > 5 days conjunctivitis rash (red palms and feet) adenopathy (cervical lymph nodes) strawberry tongue hands and feet changes (eg palmar erythema, arthralgia)
