Paediatrics Flashcards
Sepsis definition
life threatening organ dysfunction caused by a dysregulated host in response to an infection
Toxic shock syndrome
septic shock caused by superantigens produced by toxin-producing staph aureus or strep pyogenes
High risk factors for sepsis
<2months premature unimmunised immune def/supp asplenic indwelling lines malignancy (neutropenic) recent surgery
Sepsis abx <2months
Amp 50mg/kg
Gent 7.5mg/kg >1month or 4mg/kg <1month
+ cefotaxmine 50mg/kg meningitis
Sepsis Abx >2months
cefotaxime 50mg/kg max 2gr
cipro 10mg/kg max 500mg if pen anaphylax
Septic shock:
Add gent 7.5mg/kg and vanc 15mg/kg max 750mg
Septic shock PICU criteria
fluid non-responder 40ml/kg inotropes reduced LoC hypotension coagulopathy/DIC lactate>4 toxic shock
Blood culture volumes
neonatal aerobic 1ml+
standard bottles 4ml+
Targets for fluid resus
U/O 1ml/kg/hr
improved mental state
nomal HR
CRT <2 normal perfusion
TSS abx
cefotaxime 50mg/kg
lincomycin 15mg/kg (max 1.2gram)
Adrenaline doses
push dose 1mcg/kg infusion 0.05-0.1mcg/kg/min Can go higher but more side effects === add 1ml of 1:10,000 to 9ml n.saline = 10mcg/ml
==
Cardiac arrest 10mcg/kg
Calcium gluconate doses
Calcium gluconate 10% in 10ml
0.5ml/kg = 0.11mmol/kg
IV hydrocortisone dose
1mg/kg if known adrenal insufficiency or intotrope resistant
Septic shock DDx
Anaphylaxis cardiogenic shock inc congential cardiac, duct dependent lesions obstructive shock neurogenic shock hypovolaemic shock congential metabolic disorder
warm shock
vasoplegic wide pulse pressure flash CRT tachycardia bounding pulse
cold shock
vasoconstricted narrow PP tachycardic slow CRT tend to be younger
Sepsis Ix
Blood culture VBG - lactate base deficit Co2 glucose FBC - plt (DIC) WCC (hi or lo) ECU - Cr AKI Coags (DIC) LFTs - hi bili ALT if liver failure from MODs LP - ?meningitis and no features of raised ICP
LP in septic shock
Do not delay abx do not perform if child has Reduced LoC Focal neuro signs Raised ICP sx Haemodynamic instability resp compromise
send for WCC and PCR
Sepsis signs
fever hypothermia AMS (lethargy or agitated) abnormal HR, RR, CRT petechia / purpura / widespread erythema
Resus end points
CRT<2 Normal BP for age Normal HR warm U/O 1ml/kg/hr normal mentation o2 sats >92%
NETS referral - Airway
airway obstruction - mod+ distress
Croup + 2 adrenaline + ongoing distress
symptomatic FB
post tonsil haemorrhage
NETs referral GI
button battery FB - vomiting, secretions, drooling, unable to eat acute GIB insussception+shock surgical abdo
NETS referral Resp
Despite max tx hypoxia apnoeic events resp support required severe distress congenital heart/lung dx mediastinal mass
NETS referral Neuro
Raised ICP signs VPshunt dysfunction ICH with hi ICP meningitis with shock/seizures/raised ICP Status epilepticus TM or GBS (potential to deteriorate)
NETS referral cardiac
congenital disease + resp distress poor perfusion arrhythmia Altered LoC
NETS referral endocrine
DKA +
<5 yr
pH <7.15 after 2 hours
severe headache / altered LoC
NETs referral systemic
septic shock / TSS
anaphylaxis with ongoing sxs despite tx
pain OOP to clinical exam findings
Non-pharma pain Mx
Immobilise RICE Dressings distract toy/bubbles/phone Swaddle Skin to skin Feeding / dummy Breathing techniques
Sucrose dose
PO 0.1-0.5ml 2mins pre-procedure
max 5ml/day <3month
max 10ml/day >3month
Paracetamol dose
PO 15mg/kg/day IBW
4-6hourly (IV Q6H)
Max 90mg/kg/day >1month
Ibuprofen dose
PO 10mg/kg/day 6-8hourly
max 30mg/kg/day
2.4gram max
Fentanyl dose
IN 0.75-1.5mcg/kg
Max 75mcg Q10min
Divide between nostrils
IV 0.5-1mcg/kg Q5-10min
Oxycodone dose
PO >12months
0.1-0.2mg/kg Q4hr
max 5-10mg dose
Morphine dose
IV up to 0/05-0.2mg/kg
max 5-10mg 2-4hourly
Moderate dehydration (5-9%) signs
tachy lethargy tachypnoea sunken eyes dry MM decreased skin turgor CRT >2
Severe dehydration -(>=10%) Shock
Reduced LoC Tachy Tachypnoea / kussmaul hypotensive pale/mottled cold weak pulse decreased skin turgor CRT >2++ Deeply sunken eyes
IVF bolus
0.9% NaCl
10-20ml/kg
max 40ml/kg then likely need inotropes
IVfluid maintenance calc
0.9%Nacl+5% glucose
4-2-1 rule ml/hr
4ml/kg 1st 10kg =4xweight 2ml/kg next 10kg =40ml + 2x(weight-10) 1ml/kg up to 60kg =60ml + (weight-20)
- 2/3 rate for unwell kids
- Replace 5% over 24hours then remainder over next 24hours
Seizure Tx
Midazolam x2
IN/IM 0.3mg/kg
IV/IO 0.15mg/kg
Levetiracetam
IV 40mg/kg over 5m (max 2.5gram)
Phenobarbitone <1yr
20mg/kgover 20min (<1gr)
Intubate - propofol 2-3mg/kg Roc 1.2mg/kg
Hyperkalaemia Tx
(5 drugs)
- Calcium gluconate 10%
0. 11mmol/kg - 10% dextrose 5ml/kg/hr
- Actrapid 0.1u/kg/hr
- Furosemide 1mg/kg
- Sodium bicarbonate 8.4% 1mmol(1ml)/kg
Hypertonic saline dose
3% NaCl 3ml/kg over 10mins large vein
Intubation medication
ketamine 1-2mg/kg
200mg/2ml dilute to 20ml (10mg/ml)
Rocuronium 1.2mg/kg
50mg/5ml vial (10mg/ml)
60sec onset
Fentanyl 1mcg/kg pain
2-5mcg/kg induction
100mcg/2ml, dilute to 10ml (10mcg/ml)
Propofol 2-3mg/kg
Mag sulfate dose
0.2mmol/kg over 20mins if pulse present
10mmol/5ml
APLS Intervention (4)
15:2 compression/vent
Adrenaline 10mcg/kg
Defib 4j/kg
Amiodarone 5mg/kg after 3rd shock if shockable
Weight estimate
(age+4)x2
ETT tube sizing
Age/4 + 3.5 for cuffed
Glucose dose
10% dextrose 2ml/kg
BP normal estimate
Agex2 +65mmHg
ETT tube depth estimate
> 1yr Age/2+13
<1yr weight/2 +8
Vital normal ranges Simplified 0-6month 6-12month 1-4years
0-6month
HR 80-180
RR <40
BP 60-90
6-12month
HR 70-150
RR <35
BP 90-100
1-4
HR 70-120
RR 20-30
BP 100
> 4 like adults
Unsettled baby red flags (3)
sudden onset irritability/cry
Parental PND
NAI risks as sign of abusive head trauma
Unsettled baby DDx (8)
NAInjury incarcerated inguinal hernia / torsion sepsis / infection hair tourniqet corneal abrasion?? Raised ICP Non-IGe cows milk allergy
Acute abdo pain
Non-abdominal causes (9)
DKA HSP Pneumonia Hip pathology UTI/pyelo testicular torsion sepsis sickle cell VOcrisis toxins/OD
Acute abdo pain Ix
urine - culture UTI ketone /glucose DKA protein/casts AKI/HSP pregnancy
VBG - pH, base deficit, electrolytes, lactate
EUC - Cr AKI
BSL - DKA, sepsis hypo
LFT, lipase
USS - appendix/pyelo/ureteric calc/cholecystitis/intersussception/ ovarian torsion
AXR -obstruction
CXR - pneumonia
Neonatal acute abdomen
DDx (5)
hirschsprung enterocolitis Nec enterocolitis incarcerated hernia volvulus intersussception
Infant/child Acute Abdo DDx (9)
pyloric stenosis meckel's diverticulum incarcerated hernia volvulus intersussception abdominal trauma appendicitis ovarian torsion testicular torsion
Adolescent acute abdo DDx (9)
ectopic pregnancy IBD PID pancreatitis cholecystitis appendicitis ovarian torsion testicular torsion abdominal trauma
Trauma team activation
10
Abnormal vitals for age GCS<9 specific injuries including- spinal flail chest major vascular penetrating/crush/severe blunt to head or torso limb amputation burns>20% BSA or inhaled Multiple body regions
I-MIST-AMBO handover
ID - name, age, weight MOI Injuries/info Signs (inc first, worst, recent) Tx to date Allergies Meds B/G Other - fam contact
NAI Concerns (5)
Delay in seeking tx despite signif injury
Inconsistent hx over time or between caregivers
MoI inconsistent with developmental stage
caregiver impairment
Allegation raised by caregiver/child
<12months most common
NAI injury patterns (12)
Bruise
#
Bleed
bruising (<9months) face/ears/buttocks/back bruising in shape of object/ligature Multiple injuries at different stages of healing or bilateral torn frenulum long bone # (exc toddler #) posterior rib # skull (non-parietal) metaphyseal, bucket handle scapular # sternal #
Retinal haemorrhage
ICH
Paeds airway differences (8)
smaller oral cavity larger tongue larger occiput flex forward if flat obligate nasal breather <6months larynx higher +anterior (c2/3) larger epiglottis projects posteriorly cricoid narrowest point susceptible to oedema shorter trachea - ETT dislodgement
Paeds breathing differences (3)
ribs horizontal - limits TV diaphragmatic breathers (need stomach decomp) less type 1 fibres so fatigue quicker higher met rate - increased o2 demand
Circulating blood vols neo infant child adult
90ml/kg neo (NN)
80ml/kg infant (EEnfent)
70ml/kg child
65ml/kg adult
Paeds circulation differences (6)
smaller blood vol overall lower systemic vasc res hypotension/bradycardia late signs U/O 1-2ml/kg/hr fixed SV so need to increase HR to inc CO smaller vessels, hard access
Peads D + E differences
(4 + 2)
ant font open <18months
thinner cranial bones
larger head, higher centre of gravity inc head trauma
fulcrum c1-2 so higher c-spine injuries
larger SA:BM ratio, increased heat loss
Inc glucose requirement as lower glycogen stores
increased BMR
Asthma definition
chronic inflammatory disease of airways characterised by reversible airway obstruction, hyper-responsive airways and bronchospasm
What is breath stacking?
Increased autoPEEP due to increased resistance leads to dynamic hyperinflation due to air trapping
Unable to expire full breath during expiratory time
Asthma DDx (7)
ANAPHYLAXIS Inhaled FB pneumonia bronchiolitis congenital - laryngomalacia CF GORD
Asthma Red Flags (5)
previous ICU poor adherence poor control brittle asthma hx anaphylaxis
Asthma useful exam findings (3 main)
- WoB - accessory muscle, recession, tug
- General appearance
- Mental status
nb wheeze intensity, tachycardia after salbutamol, ability to talk, initial 02 less helpful.
Asymmetrical lung sounds in ?asthma DDx
Mucus plugging
pneumothorax
inhaled FB
pneumonia
INH Salbutamol dose
100mcg/puff via spacer
<6 6puffs
>6 12 puffs
20mins x3
INH Ipratropium dose
21mcg/puff via spacer
<6 4 puffs
>6 8 puffs
20mins x 3 max 1 hour
Asthma steroid doses
PO pred 2mg/kg max 60mg stat then 1mg/kg/day
IV methylpred 1mg/kg Q6hr
IV hydrocort 4mg/kg max 300mg Q6Hr
Asthma MgSO4 dose
MgSO4 50%
vial is 10mmol/5ml
1ml=2mmol=500mg
dilute to 10mmol/50ml
- > 0.2mmol/ml
DOSE 0.2mmol/kg over 20 max 8mmol (40kg)
Asthma 02
If sats persist below 90%
HUMIDIFIED
IV salbutamol dose
15mcg/kg/min over 10mins
1-2mcg/kg/min
NIV benefits (7) in asthma
-Improve ventilation (reverse acidosis + hiC02)
- Prevent atelectasis, alveolar recruit (inc 02)
- Reduced V/Q mistmatch
- Reduce dead space
- Decrease WoB if PEEP matches intrinsicPEEP ->Reduce fatigue
- Pre-oxygenate if prepping for intubation and may avoid need
NIV risks in asthma (9)
- Dynamic hyperinflation if external PEEP > intrinsic PEEP
- Barotrauma
- Air swallowing - abdo distension
- Hypotension if hypovolaem
- May delay intubation
- Aspiration
- Pressure ulcers/necrosis
- claustrophobia/anxiety
- Increased ICP / IOP
When to avoid NIV (5)
Reduced LoC Agitated Vomiting Profuse secretions Signif haemodynamic instability
HFNC rate
2l/kg/min
humidified with small amount of PEEP
Reduce dead space
Intubation/IPPV in asthma -things to do (3), drugs to use (3)
1.Cuffed tube
2.Good sedation - Reduce 02 consumption
anxiety
CO2 production
3.NGTube to decomp
ketamine/roc/IVFluid
Ventilation aims asthma
3 things to prevent
7 changes to vent
Prevent:
1) Dynamic hyperinflation
2) Barotrauma
3) Haemodynamic comp
Low TV Low RR (half rate) Low PEEP (match iPEEP) Plateau pressure <30 Prolong expiratory time I:E >4 Permissive hi-CO2 pH7.25 Change peak pressure alarm to high setting
Intubation/IPPV Hypotension (6)
Tension pneumothorax sedation reducing vascular tone unmasked hypovolaem PPV reduce venous return, reduced preload Dynamic hyperinflation mucus plugging
Ventilation IPPV asthma acute deterioration -
6 steps
Disconnect Manually decompress Bag - chest sounds/chest rise Needle decompress if tension CXR - ETT location IVF bolus 20ml/kg n.s IV vasopressor 0.05-1mcg/kg/min
Asthma admission criteria (3)
ICU admission
Mod+ criteria
Poor response/unable to wean salbutamol
02 requirement
-Respiratory support
IV adrenaline infusion preparation
0.6mg/kg (600mcg/kg) in 50ml glucose 10%
1ml/hr = 0.2mcg/kg/min
dose 0.05-1mcg/kg/min
e.g 10kg child 6mg in 50ml =120mcg/ml -> 0.2mcg/kg/min = 2mcg/min = 120mcg/hr = 1ml/hr
Asthma discharge criteria
3 clinical
3 safety
Mild - well 1 hour post assessment
02>90% and well
adequate oral intake
adequate education
Observed spacer use
action plan
GP/paed f/u planned <48hours
Bronchiolitis definition
Viral LRTI generally affects <2yrs old
Bronchiolitis pathology (4)
oedematous epithelium
obstruction
atelectasis
wheeze
Respiratory distress signs
nasal flare recession grunting apnoeas blue spells wheeze
Infant feeding volumes
150ml/kg/day
divide into 6-8 feeds
3-4hourly
Bronchiolitis b/g red flags (8)
chronological age <10weeks chronic lung disease congenital heart disease indigenous immunodeficient trisomy 21 smoked exposed neurological condition
Bronchiolitis Exam features (6)
resp distress / accessory muscle use behaviour resp rate 02 sats/requirement apnoeas feeding
Bronchiolitis Mx
5
minimal handling
NGT 2/3 maintenance if <50% intake in 24hrs
NP 02 if sats<90%
cease once >90 for 2hr
IN saline drops to assist with feeding or superficial suction
HFNC if failed low flo
2l/kg/min 40% fio2 then titrate down
bronchiolitis intubation (3)
- increased wob/fatigue despite NIV
- recurrent apnoeas
- to transport to tertiary
Adrenaline side effects / complications (6)
tachycardia hypertension n+v hypokalaemia high lactate ischaemia/tissue necrosis if extravasation
Status epilepticus definition
Seizures lasting >5mins or repeated seizures without full recovery to normal consciousness between episodes
Seizure causes -
GET METHI
neonate version too, different MEI
Glucose - hi, low
Electrolytes - Na, Ca, Mg
Trauma - head injury, ICH,
Med changes /adherence Eclampsia Tox inc TCA, antipsych,antichol, withdrawal Hypoxia /hyperthermia Infections inc encephalitis
in neonates -
M - metabolic IEM
E - environmental
I - infantile spasms
Seizure DDx
Paroxysmal non-epileptic Extensor posturing (ICP) Chorea, Tics Dystonic reactions tetany
Status Epilepticus Tx
2xbenzo Midazolam 0.15mg/kg IV 0.15-0.2mg/kg IM 0.3mg/kg IN
Levetiracetam
40mg/kg max 2.5gram over 5mins
Phenytoin
20mg/kg (max1.5gr)
rate 1mg/kg/min
Phenobarbitone
20mg/kg (max1gr)
rate 1mg/kg/min
RSI/IPPV
propofol 2-3mg/kg
ketamine 1-2mg/kg
Roc 1.2mg/kg
Discharge after seizure (6)
Certain of the Dx No further seizure after 4hrs obs Alert and at baseline normal obs caregiver educated and able to return if further seizures f.u organised
THE MISFITS- the crashing neonate
Trauma Heart disease Endocrine Metabolic/ electrolyte iEMetabolism Seizures Formula errors Intestinal catastrophe Tox Sepsis
Paediatric assessment triangle inc
TICLS
Appearance
TICLS -
tone,
interaction, consolable, look(gaze) , speech (cry)
WoB
nasal flare, grunt, recession, head bob, tachypnoea
Circulation
pallor, mottled, blue,, grey
Hyperoxia test
100% fio02 for 10mins. If sats <95% or less 10% change then likely cardiac cyanotic heart disease.
tx PGE1 0.05-0.1mcg/kg/min
Herpes simplex tx
IV acyclovir 20mg/kg 8hourly
congenital adrenal hyperplasia signs
hyperK hypoNa Hypogly Hypotension Shock refractory to fluid and intotropes
ambiguous genitalia
clitoromegaly
hyperpigmented
SVT treatment
adenosine 0.1mg/kg, increase to by 0.1mg/kg up to max of 0.5mg/kg
synchronised DC cardioversion 0.5-1j/kg
peripheral cyanosis DDX (4)
septic shock
cardiogenic shock
hypovolaemic shock
environmental - hypothermia
CVS - causes of crashing neonate
cyanotic heart disease
heart failure from myocarditis, arrythmia, sepsis
persistent pulmonary hypertension
cyanotic heart disease 5Ts tet tot tran tri trunc
R -> L shunt Tetralogy of fallot total anomalous pulmonary venous ret. transposition great arteries tricuspid valve atresia truncus arteriosus
PDA required for systemic circulation - grey baby
4
cyanosis + poor systemic circulation (all affecting left side) TGA hypoplastic left heart coarc of aorta critical aortic valve steno
PDA required for pulmonary circulation
Blue baby - systemic perfusion adequate, but cyanosed (right sided)
tricuspid atresia
ToF
critical pulm valve stenosis
PGE-1 Dose
alprostadil / Prostin
SEs (4)
0.05-0.1mcg/kg/min
Should see improvement within 30-60mins
Reduce dose once able
S.Es apnoeas, fever, flushing, cardiovascular collapse
Tetralogy of Fallot
Cyanotic heart defect 1.VSD 2.Pulmonary stenosis 3.overriding aorta 4,RVH
Blue baby as relies on PDA for pulmonary circulation as blood flow directed through VSD into aorta not PAs
transposition of great arteries
aorta arises from RV, pulmonary arteries arise from LV. Need a PFO for blood to cross between RA and LA
total anomalous pulmonary venous drainage
pulm veins connect to systemic veins so return to RA. Need ASD for blood to flow from RA to LA.
Only cyanotic heart defect that will get worse with PGE-1
dilates pulm vasc and increased l>r shunt through PDA
Tricuspid atresia
No connection between RA and RV (hypoplastic)
Need VSD for blood to get from LV to RV/lungs
Truncus arteriosus
Aorta and PA have single origin. Blood from LV and RV pass across VSD into a single trunk
Pulm circ exposed to systemic pressures and flow
Infantile spasms
most common severe epilepsy of infants
stereotyped clusters of neck/trunk/limb muscle spasms. Brief, bilateral, symmetric
assoc. west syndrome, T21, tuberous sclerosis, HIE
thyrotoxicosis tx (4)
methamizole 0.25mg/kg PO BD
potassium iodide 0.05ml Q8hr after methamizole
pred 1mg/kg PO
propanolol 0.5-1mg/kg PO BD
Inborn errors of metabolism
bloods + tx
VBG - AG glucose ammonia lactate ketones EUC LFT FBC/coags may also be deranged
5ml/kg 10% dextrose IV
Inborn errors of metabolism blood interpretations
HAGMA - organic acids
NAGMA - carb or fat e.g glycogen storage disorder
Ammonia - urea cycle disorders
Hypoglycaemia+ketonuria = fatty acid oxidation disorder
Hypogly w/out ketone = carb metabolism or organic acidaemia
SVT treatment
stable - try vagal manoeuvres inc modified valsalva in older children or diving reflex in infants
Adenosine 100mcg then increase increments up to 500mcg (no more than 1.2mg)
Synchronised DC cardioversion 1j/kg then 2j/kg
SVT 5 D’s of adenosine failure
DELIVERY - too slow DISTANCE - cannula to far from heart DOSE - often 170-200mcg required DRUGS - theophylline interacts DIAGNOSIS - LGL or fascicular VT
SVT S+S paeds
pallor, SoB, poor feeding palpitations chest discomfort
What drugs to avoid in paeds SVT
B-blocker and verapamil
profound AVBlock
negative inotropy
sudden death
Febrile convulsion
Brief isolated generalised tonic clonic seizure that occurred with an acute febrile illness
Increased risk of febrile seizure recurrence
1st convulsion <18months
fam hx febrile convulsions
fam hx epilepsy
complex febrile seizure (3)
Duration >15mins (though really >5 as will treat from status)
>1 in 24hrs
Focal symptoms
Discharge criteria febrile convulsion
simple f.convulsion
Returned to baseline
source of infection can be managed as an OP
caregiver education / able to return etc
GP f.u arranged within 7 days to evaluate illness
Neonatal fever pathogens (6)
GBS ecoli listeria HSV salmonella parechovirus
Neonatal sepsis signs (8)
paed assessment triangle marked lethargy inconsolable cry tachypnoea inc. WoB Poor perfusion Persistent tachycardia mod-severe dehydration seizures Parental concern
Neonatal fever workup (6)
BC FBC CRP Urine MCS LP (if no CI) \+/- CXR
29day-3 month work up
If typical resp then consider urine MCS (5% of RSV also have UTI) If no clear source Urine MCS FBC CRP BC
29day-3month discharge criteria
Normal urine microscopy neut <10 CRP <20 feeding well no features of SBI
Features concerning for SBI (7) Similar to toxic features but extras
Decreased perfusion pallor >CRT tachycardia Reduced U/O
Decreased alertness
Rigors
Joint swelling
CXR criteria in infants
cough, tachypnoea, increased WoB sats <93% temp >39 WCC >20
Which groups required work up inc BC, FBC, CRP, urinalysis for SBI >3months age group
toxic / septic features
immunocompromised
petechial rash (worrisome)
unimmunised
When would you consider urinalysis in >3month old with fever who has no risk factors and immunised?
symptoms of UTI
Fever >48hours and no clear source
Discharge criteria >3months with fever
No further Ix or IV tx required
No features of SBI
Able to hydrate
Safe discharge into community
Paediatric ECG differences (9)
RVH features rightward axis dominant R V1 RSR' V1 juvenile TWI V1-V3 (7days to 7yrs) Inferolateral Qs, narrow
sinus arrhythmia, faster rate QTC <490 Shorter intervals (smaller heart) BER - twave is rightward leaning
Evan’s rule for paeds hypertrophy
LVH - V6 R bisects baseline of V5
RVH - V1 R’ larger than R in RSR’
Supracondylar # classification
Gartland I-IV
I - no displacement,
II - displaced with posterior cortex intact
III - displaced, multiple planes
IV - complete disruption, unstable flex/extension
suprcondylar # MoI
Fall on outstretched hand
98% extension type injury, distal fragment posterior
2% flexion type / direct blow to olecranon
distal fragment anterior
NVI in supracondylar # and how to test (4)
- AIN A-OK sign
- Radial n. STOP sign, paper
- ulnar n. (flexion) scissors, finger abduction
Brachial artery
Supracondylar # humeral xray findings (6)
posterior fat pad anterior sail sign displaced anterior humeral line altered baumanns angle >5% compared to other exclude radial #
Supracondylar # urgent ortho review
signs of NVI brachialis sign risk of compartment syndrome floating elbow Open injury unable to reduce in ED
long term complications supracondylar # (4)
volkmann’s ischaemic contracture (finger flexion, pronated wrist)
cubitus varus deformity
myositis ossificans
nerve injury (AIN / radial / ulnar)
AIN injury test
A-OK sign
unable to flex
thumb IPJ (FDP)
index finger DIPJ (FPL)
Elbow xray interpretations steps (7)
- true lateral hour glass
- fat pads inc sail sign
- Anterior humeral line
- radiocapitellar line
- Baumanns angle
- cortices
- CRITOE
CRITOE
capitellum radial head internal (medial epicondyle) trochlea olecranon external (lateral epicondyle) 1-3-5-7-9-11 easiest, girls before boys
Upper limb nerve test - rock paper scissors
Rock - median n. finger flexion
Paper - radial n. wrist and MCPJ extension
Scissors - ulnar n. finger abduction, small muscles of the hand
Where to test sensation in the hand
ulnar n - ulnar border of little finger
median n - tip of middle finger
radial - snuff box
lateral condyle # MOI and mx
fall on outstretched arm with varus stress
refer all to ortho as potential for poor outcome
medial epicondyle # MOI and MX
avulsion of the attachment of common flexors of the forearm. valgus stress with contraction of forearm flexors
operative if >15mm displaced, elbow dislocation with medial epicondyle incarceration
n.b exclude medial condyle # which is intra-articular
Monteggia fracture dislocation
occurence
classification
most common
MUF - ulnar fracture, radial head dislocation (radioulnar joint)
1% upper limb fractures
Bado classification, most anterior dislocation of radial head and ulna shaft fracture (type 1)
monteggia fracture dislocation complications
radial nerve and posterior interosseus nerve neuropraxia
paper
STOP
thumbs up
n.b wrist extension may have some sparing in PIN
monteggia xray assessment lines
radio capitellar line - should pass through centre of capitellum
posterior border of ulna line- should be straight, bowing suggests plastic deformity
syncope definition
brief LoC associated with loss of postural tone and spontaneous recovery
Syncope classification (ROC)
Reflex (neurocardiogenic)
Orthostatic
Cardiac
Syncope red flags (7)
No prodrome During exercise Whilst supine Palpitations Chest pain Cardiac hx fam hx sudden death
Syncope DDx (3s)
Seizure
Stroke
Sugar (hypoglycaemia)
Syncope Ix (6)
LSBP ECG BSL if soon after FBC - anaemia HCG - ectopic Lactate - seizure
cardiac syncope
tachy
brady
structural
WPW Brugada Long QT Short QT CPVT
complete HB - myocarditis, endocarditis, RF
HOCM
ARVC
Critical AS
HOCM
info
No.1 cause sudden cardiac death in children 1/500
LVOT obstruction
arrhythmogenic chaotic architecture
aberrant coronary arteries
HOCM ECG
LVH precordial hi voltage
non-specific ST and T wave changes
dagger like qs inferolateral
Apical HOCM precordial deep TWI
ARVD ECG
Epsilon wave TWI V1-3 QRS widening V1-3 PVCs VT with LBBB morphology as RVOT tachy
WPW info
pre-excitation syndrome
accessory pathway - bundle of kent
valsalva or AVBlockers make pre-excitation more pronounced
AVRT or AF
WPW ECG
short PR 120ms
broad QRS with slurred delta wave
-ve delta in aVL = pseudoinfarct pattern
dominant R in V1-3
type a TWI V1-3 sim to RVH pattern
Brugada info
Auto D sodium channelopathy
ecg findings unmasked with fever / ischaemia / drugs
hypok
treat ICD or quinine in neonate
Brugada diagnosis criteria (6)
VF/VT Inducible VT Syncope fam hx SCD Noctural agonal resps fam members with coved type ECG
brugada ECG
1) coved type = coved STE in >1 of V1-V3 follwed by TWI
2) saddleback >2mm STE in V1-V3
3) either patter with <2mm STE
Measles rash
Morbiliform erythematous Macpap start at hairline and spread inferiorly 2-3 days after onset sxs
Measles sxs (7)
High fever Cough Coryza Conjunctivitis (non-exu) Morbilliform rash Koplik spots \+/- forcheimer spots
Scarlet fever (GAS) sxs (7)
High fever Exudative pharyngitis Cervical lymphadenopathy Strawberry tongue (after white coating peels off) abdo pain headache Erythematous rash with circumoral pallor
Scarlet Fever Rash (7)
1-2 days post sx onset scarletiniform - generalised erythema with tiny papules sandpaper texture circumoral pallor pastia's lines desquamation fingers/toes
Suppurative complications of GAS
OM -> mastoiditis sinusitis peritonsillar abscess retropharyngeal abscess meningitis bacteraemia
Non-suppurative complications of GAS
ARFever -> RHD PSGN TSS Scarlet fever Guttate psoriasis PANDAS
Rubella rash
Rose pink Macpap spreads inferiorly (less widespread than measles) skin may flake after congatious 7days pre- 7 days post rash
Erythema infectiosum
‘Slapped cheek’
cause & rash
Parvovirus B19 5th disease Erythematous cheeks lacy recticular rash on extremities -ve aplastic crisis
Roseola Infantum cause
HHV6 + 7 Rose pink mac pap Trunk -> neck -> limbs surrounding white halos Appears AFTER fever
Roseola sxs
High fever - risk febrile convulsion URTI lymphaednopathy eyelid oedema nagayama spots on soft palate
Pityriasis rosea rash
HHV6 / 7
herald patch on trunk prior to rest of rash spreading.
Scaly patches / plaques
Christmas tree pattern follows langer lines
Kawasaki criteria
mucocutaenous lymph node syndrome
high fever >=5 days +
4/5 of
1) Bilateral non-ex conjunctival injection with peri-limbic sparing
2) oropharyngeal mucus membrane changes inc strawberry tongue, cracked red lips, pharyngeal erythema
3)cervical lymphadenopathy 1 node >1.5cm
4. Extremity swelling (periungal desquamation 2 weeks later)
5. generalised polymorphorous rash
Kawasaki disease tx
IVIG 2g/kg over 10hours
Can rpt if fever persists
(CAA reduced from 20% to <5%)
aspirin 3-5mg/kg PO 6-8 weeks
Stevens-Johnson Syndrome & TENS causes
Type 4 hypersensitivity reaction to drugs or infection or idiopathic (50%)
sulfa containing abx, pencillins, anticonvulsants eg sodium valproate
NSAID, allopurinol
CMV, EBV, coxsackie, mycyplasma, HIV.
50% recent URTI
SJS rash
<10% BSA skin detachment targetoid (like EM) diffuse erythema macular purpuric nikolsky +Ve start on trunk, extend out
TEN risk and mortality
HIV (100 fold) TBI, SLE, any immunocomp
>30% BSA skin detachment
staph scolded skin syndrome -
dermatitis exfoliative neonatorum
scarlatiniform erythema, +ve nikolsky sign bulla
No MM involvement
erythema multiforme causes and rash
causes similar to SJS/TEN though separate entity
HSV, mycoplasma, sulfa drugs, abx, anticonvulsants
Target lesions spread centripedally
Minor- pruritic, no MM
Major - non-pruritic, MM involvement, palms soles extensors
Lyme disease - tick borne borrelia burgdorferi rash
erythema migrans - large annular /target or bullseye.
dark border, central clearing
Bronchiolitis assessment criteria Bronchiolitis Originates With Feeling Awful
Behaviour O2 sats WoB Feeding Apnoeas
