Paeds Flashcards
Sepsis 6.
3 in 3 out
Out
- blood cultures
- lactate
- urine output
In
- high flow O2
- fluids
- antibiotics
Fluid bolus vol in children?
10mls/kg. Over <10mins
Use normal saline 0.9% NaCl
Maintenance fluid vols in children?
First 10kg- 100mls/kg/day
Second 10kg- 50mls/kg/day
Over 20kg- 20mls/kg/day
Estimating child weight 1-10yo?
Weight (kg)= (Age + 4) x2
2 signs of meningism can be found on examination?
Brudzinski sign- hips and knees flex in response to neck flex ion
Kernig’s sign-resistance to knee extension when the hip is flexed
Most common causative organisms of meningococcal sepsis in children over 3 months?
Neisseria meningitidis- gram -ve diplococci
Haemophilus influenzae (type B)- gram -ve bacilli
Streptococcus pneumoniae- gram +ve cocci
Most common causative organism of meningococcal septicaemia in under 3 month olds?
Group B streptococcus- gram +ve cocci
Escherichia coli- gram negative rod
Listeria monocytogenes- gram +ve rod
Strep pneumoniae- gram +ve cocci
Signs and symptoms of meningococcal disease?
High temp
Vomiting
Headache
Drowsiness
Stiff neck
Photophobia
Non-blanching rash
In babies- bulging fontanelle
Meningitis- Household contact prophylaxis?
Ciprofloxacin single dose within 24 hours of diagnosis
Ensure up to date with vaccinations at later point
2nd line- rifampicin twice a day for 2 days
A gram -ve diplococci confirmed cause in ?meningitis. What organism most likely?
Neisseria meningitidis
Less than 3 months old with meningococcal septicaemia. What antibiotics? Why?
Cefotaxime or ceftriaxone AND amoxicillin or ampicillin
To cover for listeria monocytogenes which can cross the placenta and is resistant to cephalosporins
Other meningitis investigations?
Lumbar puncture. Send for biochem, cultures and PCR
Bacterial finding on LP?
Yellow/ turbid colour
⬆️⬆️⬆️ Neutrophils
〰or⬆️ Lymphocytes
⬆️⬆️⬆️ Protein
⬇️⬇️⬇️ Glucose
Viral findings on LP?
Clear fluid
〰or⬆️ Neutrophils
⬆️⬆️⬆️ Lymphocytes
〰or⬆️ Protein
〰 Glucose
TB findings on LP?
Yellow and viscous
〰or⬆️Neutrophils
⬆️⬆️⬆️ Lymphocytes
⬆️⬆️Protein
⬇️⬇️⬇️ Glucose
Ie combo of bacterial and viral. Looks like bacterial with potentially normal neutrophils
Fungal findings on LP?
Yellow and viscous colour
〰or⬆️Neutrophils
⬆️⬆️⬆️ Lymphocytes
〰or⬆️Protein
〰or⬇️Glucose
Tx is suspected meningitis in community?
IM Benzylpenicillin and transfer to hospital
1st line abx of meningitis in hospital?
IV 3rd gen cephalosporin e.g. cefotaxime or ceftriaxone.
Acyclovir if suspecting HSV
+/- dexamethsone, O2, fluids, ITU if comatose
LP contraindications?
Raised ICP: reduced consciousness, bradycardia & HTN, focal neurology, unequal/dilated pupils
Coagulation abnormalities- inc platelets <100
Local infection
Extensive or spreading purpura
Shock
Ongoing convulsions
Resp insufficiency- LP can cause resp arrest
3 initial investigations to confirm DKA?
BM- raised blood sugars?
ABG- acidotic?
Ketones- raised?
Key presenting features of DKA?
Confusion, vomiting, abdo pain
Thirsty, passing lot of urine
Thin/losing weight. Increased appetite
3 diagnostic features for DKA?
Acidosis- pH<7.3 OR bicarb <15mmolL
Ketonaemia >3mmolL
Hyperglycaemia- >11mmolL (can be normal in known diabetics)
High bloods sugars (>30mmolL) with little or no acidosis or ketones. Diagnosis?
Hyperosmolr hyperglycaemic state- requires different tx to DKA
DKA management?
ABC
Cannula & bloods
Fluid resus. 10ml/kg bolus
Ongoing fluids
Insulin- start 1-2hours after fluids. 0.05-0.1 units/kg/hr
Nursing obs hourly
Change fluids to 5%glucose+0.9% NaCl+20mmolKCl when glucose drops to 14mmolL
Initial mx of DKA?
Iv fluids then insulin
Ongoing fluid therapy? Vol and type?
Hourly rate:
[(Deficit - vol of unshackled bolus) / 48hrs ] /maintenance hourly
0.9% Saline + 20mmol K+ in every 500ml bag
DKA therapy complications?
Cerebral oedema
Hypokalaemia
Hypoglycaemia
Aspiration pneumonia
Death
DKA severity?
pH <7.1 = Severe DKA (10% dehydration)
pH <7.2 = Moderate DKA (5% dehydration)
pH <7.3 = Mild DKA (5% dehydration)
Fluid deficit calc?
Fluid Deficit (ml) = Weight (kg) x Dehydration x 10
Fluid deficient example
In 5% Dehydration and 20kg child without shock
Fluid Deficit = 20 x 5 x 10 = 1000ml
Hourly rate = [(Deficit – Initial unshocked bolus) ÷ 48] + Maintenance
= (1000 – 200) ÷ 48) + Maintenance
= 17 + 62 (using formula for maintenance) = 79ml/hr
Fluid deficiencies example
In 10% Dehydration and 60kg child with shock
Fluid Deficit = 60 x 10 x 10 = 6000ml (Do not subtract bolus!) Hourly rate = (Deficit ÷ 48) + Maintenance
= (6000 ÷ 48) + Maintenance
= 125 + 96 (using formula for maintenance) = 221ml/hr
Cerebral Oedema
Features of cerebral oedema?
Headache
• Agitation or irritability
• Unexpected fall in heart rate
• Increased blood pressure
• Deteriorating level of consciousness • Abnormal breathing patterns
• Oculomotor palsies
• Abnormal posturing
• Pupillary inequality or dilatation
Drugs to manage cerebral oedema?
Hypertonic saline
Mannitol
+restrict maintenance fluids, senior support
3yo girl. 7d high temp. B/l neck lumps on d3. Maculopapular rash on torso and back. Skin peeling on hands and feet. Lips cracked and inflamed tongue. Both eyes red. Diagnosis?
Kawasaki disease
- a vascular disease affecting small and medium vessels. Need to rule out in all children with fever >5days
Important extra investigation if suspecting Kawasaki disease?
Request echo to look for coronary artery echo
Treatment for Kawasaki?
IV immunoglobulins
High dose aspirin
2yo boy. 3d fever, cough, coryzal, b/l red eyes. Widespread maculopapular rash started behind ears and spread. Buccaneers mucosa has red spots with white but in middle. Diagnosis?
Measles
Measles complications?
Pneumonia- 6% cases
Otitis media- 7% cases
Giant cell pneumonitis- in immunocompromised
Neurological
- Acute demyelination encephalitis
- Subacute sclerosis panencephalitis
- Measles inclusion body encephalitis- months after, often fatal
GI- diarrhoea
Vit A deficiency and visual impairment
What gestation is risk of congenital rubella syndrome highest?
Weeks 8-10 (first trimester) of pregnancy- 90% surviving infants have defects
Congenital rubella syndrome triad?
Deafness
Eye abnormalities
Cardiac defects
Slapped cheek syndrome aka?
Parvovirus B19
Erythema infectiosum
Fifth disease
Why to pregnant women need to avoid parvovirus?
Infection in 1st trimester associated with 19% risk of foetal death. Or serious abnormalities
And severe anaemia of last 18weeks
10yo boy. Raised purpuric rash on legs and buttocks. Abdo pain 2days. No D+V. Mild pain in knees. Otherwise well and stable.
Urine dip proteinuria 2+, haematuria 1+
Diagnosis?
Henoch-Schönlein purpura
Raised red/purple bruise looking area mostly lower body.
Abdo pain, n v + bloody d.
Joint inflammation and pain
Proteinuria and haematuria
Management of Henoch-Schönlein purpura?
Usually self limiting, by 6w.
Symptomatic tx. Nephrology referral if severe renal involvement e.g. macroscopic haematuria, hypertensive, proteinuria >3m, haematuria >1y
What advice would you give to newly diagnosed patients with ITP?
ITP- Immune thrombocytopenia
Avoid NSAIDS
Avoid contact sports and high risk things e.g. climbing frames. Closer supervision at school
Avoid IM injections
Recognise head injuries
Mild bleeding in ITP tx? E.g. epistaxis, gum bleeding
Transexamic acid
20-25mg/kg TDS up to 5d
ITP treatment
1st line- prednisolone
2nd line- IV immunoglobulins
Chronic
- ?splenectomy- of >5yo and steroid ineffective
- platelet infusions
- rituximab
Tx for broncholitis?
Supportive
O2
CPAP if resp failure likely
Most common cause of bronchiolotis?
RSV- Respiratory syncytial virus
Prophylaxis for bronchiolitis in high risk children?
Palivizumab
Only in premature/chronic lung disease of newborn
Haemodinamicly affected congenital heart disease
Severe immunodeficiency
Done up to case 6 of PowerPoint James sent me
3yo boy with recent cold, now has barking cough, a fever and noisy breathing. Inspiratory stridor and subcostal recessions. 1st line tx?
It’s Croup
Oral dexamethasone- 150 mcg/kg stat
Croup peak incidence age? Most common presenting features?
6 months to 3 years
Struggling to breath, stidor- seal/dog like barking cough
Hoarse voice
Low grade fever- up to 38.5
Most common cause of croup?
Parainfluenza virus
Causes airway inflammation of supraglottic, glottic, subglottic and trachea
Initial management of croup?
Keep child calm
Oral dexamethasone
If severe- nebulised adrenaline
What organism classically causes epiglottitis?
Haemophilus influenzae B
Now very rare due to HiB immunisation
Epiglottis 1st line management?
Keep child calm! Ie leave alone
IV abx- IV cephlosporin (ceftriaxone or cefuroxime or cefotaxime) for 7-10days
Steroids e.g. dexamethasone
?ITU and intubation
Stridor differentials?
Croup
Epiglottitis
Foreign body
Masses- haemangiomas, goitre, lymphomas
Quinsy- peritonsillar abscess
Laryngomalacia- congenital abnormality of voice box
Subglottic stenosis
Cause of whooping cough?
Bordetella pertussis- a gram negative bacteria
What is quinsy?
Aka peritonsillar abscess
Can cause:
- sore throat
- fever
- referred ear pain
- swollen tender lymph nodes
Specifically:
- trismus- can’t open mouth
- “hot potato voice” due to pharyngeal swelling
- swelling and erythema next to tonsils
Most common cause of quinsy?
Often had recent tonsillitis
Usually caused by:
- Group A Strep (streptococcus pyrogenes)
Can be caused by:
- staphylococcus aureus
- Haemophillus influenzae
Management of quinsy?
Hospital for needle aspiration or surgical drainage
Abx: broad spec e.g. co-amoxiclav
Sometimes: steroids e.g. dexamethasone
Acute asthma. Peak flow % for
- moderate exacerbation
- severe
- life threatening
Moderate- >50% predicted
Severe <50% predicted
Life threatening <33% predicted
Signs of life threatening asthma attack? (6)
Peak flow <33% predicted
O2 sats <92%
Silent chest
Exhaustion and poor respiratory effort
Hypotension
Cyanosis
Altered consciousness/confusion
Staple acute asthma management?
O2 of <92% sats
Bronchodilators
- salbutamol
- Ipratropium bromide
- MgSO4
Steroids- prednisone oral or IV hydrocortisone
(Antibiotics- of bacterial cause e.g. amoxicillin or erythromycin)
Stepwise approach to acute asthma attack?
Salbutamol inhaler- via spacer, 10 puffs every 2hours
Nebulisers- salbutamol and Ipratropium bromide
Oral prednisolone e.g. 1mg/jug/day
IV hydrocortisone
IV MgSO4
IV salbutamol
IV aminophylline
