paeds Flashcards
causes of dehydration main categories
reduced intake
increased loss
causes of dehyrdration
REDUCED INTAKE
- dysphagia /neurodisability (cleft palate, developmental delay, cerebral palsy)
- vomitting (gastroenteritis, GORD, URTI, chemo)
- behavioural/ psych (food refusal, anorexia)
- child neglect
INCREASED LOSS
- gut (gastroenteritis, IBD, stoma)
- kidneys (renal tubular disease, nephrogenic diabetes insipidus, renal dysplasia)
- lungs (cystic fibrosis, cardio/resp diseases)
- skin (burns, cystic fibrosis, sepsis/fever)
signs of dehydration - mild (5% water loss), moderate, severe (10%)
thirst
dry lips
restless, irritable
sunken eyes
reduced skin turgor
decreased urine output
anuria
cold, mottled peripheries, hypotension
reduced conciousness
dehydration complications
constipation
developmental delays
UTI
failure to thrive, malnutrition
managment principles of rehydration for different levels of dehydration
Not dehydrated (eg elective surgery) = maintenance Dehydrated = maintenance + correct deficit Shocked = maintenance + correct deficit + bolus (C as part of ABCDE - part of their resuscitation)
maintaince of hydration formula
first 10kg = 100ml/kg (10x100)
second 10kg = 50ml/kg
all other kg = 20ml/kg
this = daily total. so divide by 24 for hourly amount
how to calculate estimated weight
Estimated weight (kg) = (age +4 ) x2
defecit correction for hydration formula
Deficit % x 10 x weight (kg)
Over 24h or 48h
fluid bolus for dehydration amount
20mls/kg of 0.9%
Sometimes 10ml/kg more
Sometimes less than 20 – give 10ml/kg of 0.9%
- Trauma
- DKA
what is monitored in dehydration
BP HR O2 sat RR Capillary refill Temperature Appearance and behaviour - Lips dry - Sunken eyes - Skin turgor - Restless - Reduced consciousness U/Es Urine output
ondasteron =
prevents vomitting. try in dehydrated, esp gastroentiris
when are fluids given orally/ IV for dehydration
flexible but generally 5% (mild) - oral; 10% severe - IV
toddlers diarrhea
Foul smelling, watery. May contain mucus or undigested material
No other thriving problems in baby
Exclusion diagnosis (infection, malabsorption)
extra things to ask in paeds history
Feeding /hydration
- How often
- How much
- How long on breast
- Fed overnight
- Wet nappy - how many, how much wetness (heaviness of nappy)
- Bowels opening - diarrhea
Fever
- If checking temperature, how – Under arm best, What reading, Since when
- Any action eg paracetamol
Rashes
- inc Non-blanching -septicaemia
Behaviour
- Are they their usual selves
- How happy - have you seen them smile today
Contacts
- Who lives at home? Are they well?
- Anyone ill at school
- Been abroad?
Ask about birth history
- How many weeks
- Mode of birth (vaginal, elective, emergency, instrumental)
- Any time in neonatal unit after birth
- Feeding
Development
- “Have you got any concerns about development?”
- Ask about milestones - independent walking etc
- Growth
vaccination history
- Are they up to date
- Flu
- Any extra?
- Preterm have additional winter vaccines
extra things to ask in paeds history
Feeding /hydration
- How often
- How much
- How long on breast
- Fed overnight
- Wet nappy - how many, how much wetness (heaviness of nappy)
- Bowels opening - diarrhea
Fever
- If checking temperature, how – Under arm best, What reading, Since when
- Any action eg paracetamol
Rashes
- Non-blanching -septicaemia
Behaviour
- Are they their usual selves
- How happy - have you seen them smile today
Contacts
- Who lives at home? Are they well?
- Anyone ill at school
- Been abroad?
Ask about birth history
- How many weeks
- Mode of birth (vaginal, elective, emergency, instrumental)
- Any time in neonatal unit after birth
- Feeding
Development
- “Have you got any concerns about development?”
- Ask about milestones - independent walking etc
- Growth
vaccination history
- Are they up to date
- Flu
- Any extra?
- Preterm have additional winter vaccines
kawasaki presentation / diagnosis
Fever (Essential)
4 out of 5 of:
- Skin rash - diffuse
- Conjunctivitis - red eyes
- Periphery change - Peeling of fingers / swelling / red / pain
- Cracked lips, Swollen red tongue
- Swollen neck lymph gland - painful, solitary, large
non blanching rash- what are you thinking of
meningitis septicaemia
also could be ITP and HSP
if just face/neck/conjunctival petichiae - may be due to retching/ vomitting –> pressure
ASD triad
Rituals
- Certain order in bedroom, fixed on daytimes
- rigid, resist change
Unusual /delayed language
- May have seen speech and language therapist, language may appear stilted
Social difficulty
- Lack of theory of mind, can’t read others
- Lack of understanding unspoken social rules, idioms, body language
PTSD triad
Intrusive sensations, memories/ flashbacks
Avoidance
- Of places, of talking/ thinking about it
Anxiety
kocher’s criteria
Kocher's criteria Fever >38.5 CRP>20 ESR >40 in first hr Cannot bear weight WBC >12
for septic arthritis (limping child)
also - pain often at rest
any age
most common UTI cause. treat with what
e coli
cefcefotaxime
If unresponsive to this, meropenem (a carbapenem) (broader)
flucoxycylin good for what
staph aureus
perthes disease
3-10y Self limiting Ischaemia → necrosis of femoral head Unilateral Seen on X ray Pain, effusion, limited range of motion
Transient synovitis
3-10y
Usually following resp infection (but the effusion is sterile!)
Usually no pain at rest/passive movements
Slipped upper femoral epiphysis
Onset of puberty
Tall and thin or short and obese
Pain, leg length shortening
seen on X ray
what could cause limping
Toxic synovitis = most common - Benign, self limiting Infection - osteomyelitis, septic arthritis - systemically unwell, prev infection Fracture Tumour - Pain, tender, mass possibly Arthritis Slipped upper femoral epiphysis - Onset of puberty - Tall and thin or short and obese - Pain, leg length shortening Perthes disease - Self limiting - Ischaemia → necrosis of femoral head - Unilateral - Pain, effusion, limited range of motion
could be foot, leg, thigh, hip, knee, spine, testiclar or abdomen
presentation of malignancy (general)
Localised mass
- Lymphadenopathy
- Organomegaly
- Soft tissue or bony mass
- Airway obstruction as a result
Disseminated disease → infiltrates bone marrow → anaemia → infections, bruising
Headaches, increase ICP signs (brain tumour)
Fever, weight loss, fatigue
leukaemia
- commonness
- symptoms
- investigations
Leukaemia is common esp ALL
Fatigue Fever Frequent infections Lymphadenopathy hepato/splenomegaly Anaemia - pale, bruising Bone/ joint pain
Blood film - see blastocyte Serum chemistry CXR Bone marrow aspirate Lumbar puncture
Chemo
Haemopoetic stem cell transplant
CNS tumours presentation and treament
Presentation Headache, often worse lying Vomiting, esp early morn Papilloedema Nystagmus Ataxia Behavioural changes Squint
Treatment Surgical resection Radiotherapy Chemo palliative care
negative long term effects of cancer treatment
Endocrine (brain surgery) Intellectual cardiac/renal toxicity - chemo Fertility Psychological
wilms =?
nephroblastoma
ADHD criteria
3 key symptoms = inattention, hyperactivity, impulsivity
6 symptoms of inattention
- Lack of attention to detail, careless mistakes
- Difficulty sustaining attention
- Does not seem to listen when spoken to directly
- Fails to finish tasks
- Difficulty organizing
- Avoids or dislikes tasks that require sustained mental effort
- Often loses things needed for tasks
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
OR 6 symptoms of hyperactivity or impulsivity
- fidgets/taps hands/legs / squirms in seat
- Leaves seats when expected to stay in seat (school, eating, activity)
- runs/ climbs in inappropriate situations
- Unable to play/ leisure quietly
- “On the go”
- Talks excessively
- Blurts out answer before question finished
- Difficulty waiting their turn
- Interrupts or intrudes
Present before 12y
Present in 2 or more settings
Must affect functioning
No better diagnosis
ADHD treatment
Nonpharmalogical
- Parent management and training = 1st line
- —Plan for day, routine
- —Positive reinforcement
- —Brief, specific instructions
- —Incentives eg star chart
- —Keep social interactions with others short and sweet
- —Regular exercise
- —Regular and healthy diet
- —Support from school
- CBT
Pharmacological
- Not advised for pre-school children
- Stimulant
- —Increase dopamine in brain
- —Ritalin (short acting)
- —Delmosart (long acting)
- —Lisdexamfetamine
- Non stimulant
- —Reduce norepinephrine breakdown
- —SNRI - atomoxetine
- —Guanfacine
- Combined therapy
- Side effects
- —Anxiety
- —Reduced appetite
- —Hypertension
- —Psychosis (rare)
MODY
- what might make you suspcious that t1dm is acc mody
- diagnosis
Lots of family with DM
C peptide robust
No antibodies for insulin
Genetic testing
JIA
- commonnes
- when
- diagnosis
- features
Most common inflammatory condition
Juvenile = Onset before 16th birthday
Idiopathic = no other identified cause- diagnosis of exclusion
Rule out:
- Reactive arthritis (following other infection)
- Malignancies inc blood born ones like leukaemia
- Non accidental injury
- Septic arthritis
Arthritis = joint swelling (or painful restriction of movement) - lasting 6w Features - Persistent joint swelling - Joint stiffness - esp morning - Loss of range of movement - Pain - Warmth - Colour change - Joint deformity - Accelerated bone growth - if one leg longer
oligoarticular JIA
4 or fewer joints involved
Typically lower limb
associated with chronic anterior uveitis
polyarticular JIA
More than four joint involved
More rapid bony destruction
Often small joints eg hand/feet
Psoriatic JIA
May be before / after / same time as joint problems
Family link common
Dactylitis , nail pitting - can diagnose it even if child has not yet developed psoriasis
often associated with chronic anterior uveitis
Enthesitis -related JIA
Akin to ankylosing spondylitis in adults
Plantar fasciitis - sore underside of feet
Lower back joints sacroileus often involved
systemic arthitis JIA
Auto-inflammatory Spiking fever Rash Lymphadenopathy Hepatosplenomegaly Fluid effusions - eg ascites
chronic anterior uveitis
Silent - no signs/ symptoms
Can cause blindness
Often present in JIA, so all children with JIA/suspected JIA are screened several times a year
Especially connected to oligoarticular and psoriatic JIA
what should you screen for when you see dysmorphic features
cardiac conditions
Trisomy 21
- VSD
- AVSD
- Tetralogy of fallot
Turners syndrome
- Coarctation of aorta
- Bicuspid aortic valves
- Aortic stenosis
- Aortic dissection (later in life)
Noonans
22q11p.2 deletion syndrome
complex congenital cardiac conditions
= combination of congenital cardiac conditions
pulmonary vascular resistance pre and post birth
High pulmonary vascular resistance (alveoli closed) so blood bypasses lungs
After birth, baby takes breaths, alveoli open, so pulmonary vascular resistance falls, so blood goes to lungs rather than to L side of body
physiological fetal circulation shunt closing and why
After birth, baby takes breaths, alveoli open, so pulmonary vascular resistance falls, so blood goes to lungs rather than to L side of body
Oxygen presence also reduces prostaglandins so ductus arteriosus tissue contracts and closes (first shunt to close)
Then L side pressure increases so less foramen ovale activity so closes
The umbilicus is cut - so no blood from placenta to umbilical vein and ductus venosus - so this shunts closes too
types of ASD
Ostium secundum - in middle of septum
Ostium primum - at bottom of atrial septum, closer to AV valves, associated with AVSD
Sinus venosus defect - at top of septum - rare and hard to pick up with echo
ASD presentation
Asymptomatic when younger Only if large will immediate lung effects transpire Fixed and widely split S2 sound Systolic murmur in pulmonary region Palpitations
VSD presentation
Pulmonary oedema (Pulmonary artery blood is mixed. High pressure → increased pulmonary blood flow)
Infection of IE around defect
Asymptomatic often until pulmonary vascular resistance falls
Poor feeding
Failure to thrive
Tachypnoea
Gallop rhythm, 3rd heart stand, thrill
Pan systolic murmur, best heart in lower left sternal edge, radiating to axilla and upper sternal edge
Hepatomegaly
Oedema
AVSD
=?
Presentation
Atrial and septal septum defect, involving the crux of the heart and leaflets (so worse than ASD +VSD)
Common in trisomy 21
So important to look for dysmorphism in cardiac examination
Poor feeding Failure to thrive Tachypnoea Gallop rhythm, 3rd heart stand, thrill Can lead to to pulmonary vascular disease rapidly Murmur arises from valvular regurgitation Hepatomegaly Oedema
patent ductus arteriosus presentation
Preterm Pulmonary oedema (High pressure blood into lungs from aorta to pulm artery) Poor feeding Failure to thrive Tachypnoea Easily palpable femoral pulses Gallop rhythm (3rd heart sound), thrill Continuous machinery murmur Hepatomegaly Oedema
types of L–>R shunts
management
ASD
VSD
AVSD
patent ductus arteriosis
Increase calorie intake NG feeds Diuretics ACE i Surgical or catheter device occlusion
coarctation of aorta signs
Weak femoral pulses– Compare to brachial
Pre and post ductal difference in o2 saturations - IF duct is open (Open aids survival - bypasses coarctation )
4 limb BP - upper/lower limb discrepancy
If ductus arteriosus closing/ closed - collapsed and acidotic
Murmur over back if older child
