Paeds Flashcards
Difference in presentation between vasovagal syncope and anaphylaxis with collapse
Vasovagal - pale, bradycardic
Anaphylaxis - flushed, tachycardia
Presentation for simple febrile seizure
6-60 month child, previously well
generalised tonic-clonic, no focal component
<15 mins
No more than once in 24 hours
No prev neuro problems
Admission criteria for febrile seizure
> 15 mins
Recurrence within 24 hours
Focal component
Needing medication to terminate
Treatment for status epilepticus (>5 mins)
Position semi-prone
O2 via face mask
Diazepam
0.25mg/kg PO or IV
0.7mg/kg PR
Max 10mg
Midazolam
0.5mg/kg, buccal
Max 10mg
Types of seizures
Partial:
From focal lesion, often temporal lobe
Simple partial (unimpaired consciousness)
- motor, somatosensory, autonomic, psychic signs
Complex partial (impaired consciousness, amnesia)
- +/- automatism
Complex partial proceeding to generalised
Generalised:
Absence - lapse of consciousness
Myoclonic - sharp jerking
Clonic - rhythmic shaking
Tonic - increased rigidity
Tonic-clonic - rigidity + rhythmic shaking
Atonic - drop attack
Appropriate parent given emergency medication doses for child with prev hx non-febrile seizure
Diazepam 0.3-0.5mg/kg PR
Midazolam 0.2-0.3mg/kg buccal
Repeat only under medical supervision
HR range in children
<1 - 110-160
1-2 - 100-150
2-5 - 95-140
5-12 - 80-120
12+ - 60-100
Sinus tachycardia vs SVT
Sinus tachycardia: <220bpm, normal wave form, child unwell/in pain
SVT: >220, abnormal P wave axis, child looks well
Management of SVT in children
Vagal manoeuvres:
Infants - cold water immersion
Child - ice cold face cloth
5+ - blowing on thumb with straining, handstand, trendelenburg, legs up
Adenosine:
100mcg/kg
200mcg/kg
300mcg/kg
Amiodarone - usually used in post-op setting
Causative organisms for meningitis in neonates and children
Neonates: Group B Strep, Enterococci, E. coli, Listeria
Children: Strep pneumoniae, N meningitidis, H influenza type B
Antibiotics for suspected meningicoccal disease in children
Ceftriaxone 100mg/kg (max 2g) IV/IM
Benzyl penicillin 50mg/kg (max 2g) IV/IM
Risks for asthma in children
Atopy
Passive smoker
Crowded home, damp, mouldy
Family hx asthma
When to consider prednisolone in child with asthma
Moderate to severe asthma
Age >5
Or age 1-5 if
- severe attack
- Hx prev severe attacks
- Likely prolonged hospital stay (>6 hours)
Management of asthma in children
Mild:
6 puffs salbutamol via spacer
Discharge when can space to 2hours
Moderate:
Above plus:
May need full blast
Prednisolone 1mg/kg if >5 or meeting criteria
Discharge when can space to 2 hours and no O2 requirement
Severe:
Above plus:
Salbutamol 2.5-5mg nebs
Ipratropium 4 puffs or 250mcg nebs
Life threatening:
Urgent transfer
Nebs - continuous
High flow O2
IV lines
Hydrocortisone 4mg/kg IV
Symptoms of hypovolaemic shock in children
Early:
Pallor, cool peripheries, drowsiness/disinterest, tachycardia disproportionate to fever/distress, reduced urine output
Cap refill not reliable
Late:
Low BP
Management of shock in children
IV access - aim 24G + or intraosseous
IVF - 20mg/kg bolus
Consider trauma - C spine immobilisation, exsanguination - FFP and blood
Hypotension refractory to volume replacement - dopamine 5mcg/kg/min increase to 10-15
Consider spinal shock
Age group for unintentional poisoning
12-36 months
Medications where 1-2 tabs can be lethal to <10kg toddler
CCBs
Amphetamines
Dextropropoxyphene
Chloroquine
TCAs
Opioids
Sulphonylureas
Theophylline
Non pharmaceuticals which can results in severe toxicity if ingested
Organophosphates
Paraquat
Camphor
Naphthalene
Hydrocarbons, solvents, eucalyptus oil, kerosene
Medications that cause sodium channel blockade
TCA
propanolol
Quinidine, flecainide, first gen antihistamines
Cocaine
Bupivicaine
Dextropropoxyphene
Carbamazepine
Management of poisoning
Airway - intubate if airway corrosion, GCS <8, prolonged seizure
Breathing - O2, ventilations as required
Circ - IV fluid bolus 20mg/kg, inotropes
Avoid B blockers in sympathomimetic OD
NaHCO3 if sodium channel blockade
Disability
Seizures - Midazolam 0.15mg/kg IV, repeat
Phenobarbitone 20mg/kg IV (2nd line)
Do not use phenytoin (prolongs Na channel blockade)
Naloxone if suspect opioid OD - 0.1-0.8mg/kg
If suspect benzo OD - observe. Flumazenil dangerous in mixed OD
Correct hypoglycaemia
- dextrose 10% 5mL/kg bolus + 4mL/kg/hour infusion
Maintain normothermia
Criteria for referral for fever in child
<28 days (adjusted age)
<3 months (adjusted age) discuss with paeds, bloods
>3 months: significant illness, sepsis, unknown source
NICE traffic light fever risk in children
Amber:
Age 3-6 months, temp >39
Fever >5 days
Reported pallor, decreased activity
Increased WOB, sats <95
Tachycardia
Mild dehydration
Signs of bone/joint pain
Red:
Age <3 months, temp >38
Pale, mottled, appears ill
Severe WOB, RR>60
Reduced skin turgor
Signs of meningitis
Seizures
Types of croup
Viral laryngotracheitis
- Parainfluenza, RSV, adenovirus, influenza
- Younger age group
- Coryzal illness
Recurrent/spasmodic croup
- older children
- Without URTI signs
RR normal values for children
WHO criteria for tachypnoea
<1: 30-60
1-2: 24-40
2-5: 22-34
5-12: 18-30
12+: 12-16
WHO:
<2 months: >60
2-12months: >50
1-5 years: >40
Symptoms of epiglottis
Sniffing position
Drooling
Sudden onset fever, dysphagia
Symptoms of mild, moderate, severe croup
Mild
No iWOB, stridor with distress, no hypoxia
Moderate
Stridor at rest, mild WOB, no hypoxia
Severe
Severe WOB, tachycardia, pallor, restlessness, lethargy, cyanosis, reduced breath sounds
Management of croup
Mild-moderate
Dexamethasone 0.16mg/kg, or prednisolone 1mg/kg 2 days
Reduce anxiety
Usually resolves in <48 hrs
Contagious for 4-6 days
Severe
Dexamethasone 0.6mg/kg
O2 high flow
Consider nebulised adrenaline
Refer to hospital
Causes of gastroenteritis
Viral >70% rotavirus, norovirus, enteric adenovirus
Bacteria 10-20%
Salmonella, Campylobacter, E coli, Shigella
Parasites <10% - giardia, cryptosporidium
Causes of bacillary dysentery
Abx management
Entero-invasive E coli - no abx
Enterohaemorrhagic E coli - abx contraindicated, risk of HUS
Salmonella - amoxicillin/cotrimoxazole 7/7
Campylobacter - erythromycin 5-7/7
Shigella - ceftriaxone
Yersinia - 3rd gen cef
C diff
Gastroenteritis notifiable diseases
Campylobacter
Cryptosporidium
Cholera
Giardia
Shigella
Salmonella
Yersinia
Suspected outbreak, person in high risk category
Chemical/bacterial/toxic food poisoning - botulism, toxic shellfish poisoning, verotoxin, shiga toxin E coli
Indication for NG rehydration
Refusing oral fluids
Failed oral rehydration
Intractable vomiting/profuse diarrhoea
Caregiver not coping with giving oral fluids
Indication for IV rehydration in children
Shock
Unsafe (decreased LOC, ileum, surgical abdo)
Hyperosmolality (Na >170, osmol >350)
Failed oral and NG
>4 years old, better tolerating IV than NG
Ondansetron dose in children
8-15kg 2mg
15-30kg 4mg
30kg + 8mg
Presentation and management of haemolytic uraemia syndrome
Enterohaemorrhagic E coli or Shiga toxin producing Shigella (outside NZ)
Severe anaemia, thrombocytopenia, AKI
- Do not use antibiotics, antidiarrhoeals
- Early aggressive rehydration
- Paeds urgent referral
Symptoms to suspect hypernatraemia/hyperosmolality in gastroenteritis
Moderately dehydrated
Symptoms disproprotionate to level of dehydration
- Irritability, lethargy, doughy skin, fever
ORT amounts in child with gastroenteritis
Mild dehydration ~50ml/kg deficit
Shocked ~100mL/kg deficit
5mL/min or 25mL/5 mins
Or 25mL/kg/hour for 4 hours
Extra 10mL/kg for each loose stool
Bronchiolitis age group
6-12 months
12-24 months less common
Timeline of bronchiolitis infection
Cough, wheeze, WOB, nasal discharge, fever
Peaks day 2-3
Resolves by day 7
Cough for 3 weeks
Risk factors for bronchiolitis
Premature <37 weeks
Young <10 weeks
Maori/Pacific
Low SES
Smoking
Crowded, damp housing
<2 months breastfeeding
Comorbidities - Down, congenital heart disease, chronic lung disease, CF, immunodeficiency, chronic neurological disease
Mild, moderate, severe bronchiolitis
Mild
Normal behaviour, normal RR, no accessory muscles, sats >92, no apnoea, normal feeding
Moderate
Some irritability, mild increased RR, tracheal tug/nasal flare, sats 90-92, brief apnoea, some trouble with feeding
Severe
Lethargy, fatigue, severe raised RR, marked chest wall retraction, sats <90, frequent, prolonged apnoea, unable to feed
Indications for chest xray in children
Ambiguous clinical findings
Unresponsive to abx therapy
<3 months age
Severely unwell
Management of CAP in children
Amoxicillin 25mg/kg tds 7 days
or
Erythromycin 10mg/kg QID 7 days (>5 years)
Signs of sexual abuse in child with UTI
Unusual/excessive genital itching
Bruising, swelling, bleeding, redness in genitals
Age inappropriate sexual play/knowledge/interest
Fear of certain people/places
Indication for USS in child with UTI
<12 months with first febrile UTI
Severe illness
Recurrent febrile UTI
Atypical hx
Outpatient USS renal tracts within 6 weeks
Indication for empiric treatment of UTI
Specific urinary symptoms
3 months - 3 years with non-specific symptoms (fever, lethargy, abdo pain)
>3 years, dipstick positive for nitrites
>3 years, dipstick with leuks, urinary symptoms
Do not treat asymptomatic bacteriuria in children/infants
Types of UTI in children
Cystitis - lower UTI without fever
Pyelonephritis/febrile UTI - renal or lower UTI with fever
Atypical UTI - sepsis, bacteraemia, obstructive uropathy, fail to respond to abx in 48 hrs, renal impairment, non-E.coli organism
Recurrent UTI -
2+ episodes febrile UTI
1 febrile UTI + 1 cystitis
3x cystitis
ABx for mild uncomplicated UTI in children
Cotrimoxazole 24mg/kg, BD 3/7
Cefalexin 25mg/kg BD 3/7
Augmentin 30mg/kg tds 3/7
Nitrofurantoin 1.5mg/kg QID 3/7 - nor for pyelo or renal impairment
Moderate - treat for 7 days
Severe - single dose IV gentamicin, then 6/7 oral
Types of lice
Head lice - Pediculus humanus, captitis
Body lice - Pediculus humanus, corporus
Pubic lice - Phthirus pubis
Management of lice
Environmental - hot wash, dryer or dry clean or seal in bag for 2/52, vacuum environment
Medication:
Head lice - dimethicone, 2 treatments, 7/7 apart
Wet combing every 4 days until no lice with 3 consecutive combings
Pubic lice - permethrin, 2 treatments, 7/7 apart
Scabies presentation
Symmetrical lesions, sparing head and neck, burrows in peripheries
Crusted scabies in elderly, young, immunocompromised - can occur on neck + face
Intense itch, may last for weeks after completing treatment
Management of scabies
Launder/air for 72 hours
Vacuum
Clean nails
Medical
- permethrin for pt and all close contacts. 2 treatments 7/7 apart
- PO ivermectin - failure of topical treatment, crusted scabies, outbreak
Repeat in 2/52
Topical steroids/antihistamines for itch
Modified GCS for children
Eyes:
4 - open spontaneously
3 - open to shout/speech
2 - open to pain
1 - not opening
Voice:
5 - appropriate words, smiles, coos
4 - inappropriate words (<5), confused, consolable crying
3 - inappropriate words (>5), inconsolable, cries/screams (<5)
2 - incomprehensible, grunts, agitation
1 - none
Movement:
6 - follow commands, normal movement
5 - localises pain
4 - flexion withdrawal
3 - flexion - abnormal decorticate
2 - extension - decerebrate
1 - no movement
Causes of chest pain in children
Signs of organic disease
Idiopathic - most common
MSK
Resp/asthma
GI/GORD
Psychogenic
Cardiac < 1%
Wakes from sleep, acute origin, fever
Indications for investigation in children with chest pain
Sudden onset, exertional
Fever, cough, SOB
Foreign body, trauma, drooling
Unwell, abnormal vital signs, examination
Tall, thin, pectus excavatum/carinatum
Cardiac risk factors - systemic inflammatory disorder, malignancy, thrombophilia, myopathy
FHx sudden unexplained death, cardiomyopathy, severe familial hyperlipidaemia,
Most common medical and surgical causes for abdominal pain in children
Medical - gastroenteritis (vomiting, then pain)
Surgical - appendicitis (pain then vomiting)
Ddx child with abdo pain
Constipation (LLQ, suprapubic)
Obstruction - intussusception, incarcerated hernia, volvulus (colicky)
Mesenteric lymphadenitis
PID
Abdominal trauma
Don’t forget
Diabetes
HSP
pneumonia
Sickle cell crisis
Mediterranean fever
HUS
Drugs
Porphyria
Presentation of appendicitis in <3
Late presentation, non classical symptoms
Pain, fever, vomiting, diarrhoea
Cough, rhinitis, grunting, pain on right hip movement
Presentation of appendicitis age 3-6
24hr vague abdo pain
fever, vomiting, anorexia
Paediatric Appendicitis Score
+2 each:
- RLQ tenderness to cough/percussion/hop
- Tenderness RIF
+1 each:
Anorexia
Fever
Nausea/vomiting
leukocytosis
Neutrophilia
Migration to RLQ
<4 low risk, 4-6 equivocal, >6 high risk
Alvarado score for paediatric appendicitis
+2 each:
RLQ tenderness
Leukocytosis
+1 each:
Fever
Rebound tenderness
Migration to RLQ
Anorexia
Nausea, vomiting
Neutrophilia
<4 low risk, 4-6 equivocal, >6 high risk
Most common cause of bowel obstruction in <3
Intussusception
Risk factors for intussusception
Male
Intestinal malrotation
Prev intussusception
Sibling with intussusception
cystic fibrosis
Intestinal polyps
Recent viral illness
Symptoms + signs of intussusception
Intermittent crying, pulling knees to chest
Blood in stool - currant jelly
Vomiting, fever, diarrhoea
Abdominal mass, sausage shape, usually in RUQ, enlarges during episodes of pain
Status of inguinal hernia
Reducible - sac completely empties
Irreducible - cannot completely empty sac, due to adhesions, faeces, fibrosis of neck of sac
Obstructed - causing mechanical bowel obstruction, loop of bowel viable
Strangulated - blood supply impaired, imminent gangrene
Cause of inguinal hernia
Patent processus vaginalis
Herniation of bowel, omentum, ovaries, peritoneal fluid (hydrocele)
Risk factors for inguinal hernia
Males
Prematurity
Undescended testes
Family history hernias
Cystic fibrosis
Developmental hip dysplasias
Urethral abnormalities
Indications for referral for inguinal hernias
Irreducible
Strangulated
Obstructed
Suspected ovary - do not attempt reduction
Signs of perforation, peritonism, sepsis
Reducible hernias - outpatient referral
Neonate <1 week
Infant 2-4 weeks
Child 1-3 months
Rome III criteria for functional constipation
Under 4:
2 of following over at least 1 month
Over 4:
2 of following at least weekly over last 2 months, IBS excluded
- <2 BM/week
- > 1 faecal incontinence/week (toilet trained)
- Excessive stool retention
- Painful/hard BM
- Large faecal mass in rectum
- Large diameter stool obstructing toilet
Red flags for organic causes of constipation in children
Onset <1 month
Delayed meconium passage
Failure to thrive
Abdo distension
Intermittent diarrhoea + explosive stools
Empty rectum
Tight anal sphincter
Pilonidal dimple with hair
Midline pigmentation of lower spine
Abnormal neuro exam
Occult blood in stool
Extraintestinal symptoms
Gushing of stools with rectal exam
No hx withholding/soiling
No response to conventional treatment
Treatment of constipation
Increased fruit, vegetable, fluid intake
Regular toileting after meals
- Lactulose
- Molaxole - can be used for disimpaction + maintenance
- Glycerol supps for significant faecal impaction
Treat for duration of constipation, wean slowly
Most common epiphyseal injury in children
Salter Harris II
Most common site for Salter Harris III fracture
Proximal and distal tibial epiphyses
Most common site for Salter Harris IV fracture
Lateral condyle humerus
Complications of elbow fractures
- Vascular - brachial artery, median nerve injury
- Compartment syndrome - anterior compartment swelling, compression of median nerve, radial artery
- Volkmann’s isachaemic contracture - flexor compartment > flexion + pronation
- Malunion
- Myositis ossificans
Child with a limp - ddx
Fracture
Acute abdomen, psoas abscess
Discitis, vertebral OM
Malignancy
Haemarthrosis
Lyme disease
Acute rheumatic fever, gonococcal arthritis
Rheumatological
Meningitis
Septic arthritis
Types of gait
Steppage - abnormal hip and knee flexion. Foot drop.
Trendelenburg - pelvis tilts towards unaffected side. DDH, weak hip abductors
Circumduction - knee hyperextended, abduction of hip. Leg length discrepancy, neurological joint stiffness.
Equinus - tip toed. Club foot, cerebral palsy, tight Achilles, calcaneal fracture, foreign body, leg length discrepancy.
SUFE - mild, moderate, severe slip
Mild <33% or <30 degrees
Moderate 33-50% or 30-50 degrees
Severe >50% or >50 degrees
Complications of SUFE
AVN
Early OA
Necrosis of articular cartilage
Gentle manipulation or traction can cause aseptic necrosis
Non-pharmalogical ways to manage pain
Explanation
Relaxation
Distraction
Splinting
Indication for EMLA
3-5mm tissue depth for 2 hours
Apply 90 mins prior to procedure
To intact skin under occlusive dressing
Venepuncture, cannula, LP, bladder aspiration
Maximum dose EMLA
1 tube = 5g
3-11 months - 2g over 20cm2
1-5 years - 10g over 100cm2
6-11 years - 20g over 200cm2
Complications
Methaemoglobinaemia
Local oedema, vasoconstriction
Symptoms of LA toxicity
Mild:
Perioral tingling, tongue numbness
Tinnitis, dizziness
Flushing
Anxiety/agitation
Severe:
Muscle twitch
Nystagmus
Hypertonia, seizure
Bradycardia, hypotension
Arrhythmia
LOC, coma
Risk factors for NAI
Child - behavioural difficulties, chronic illness, disability, preterm, unwanted child, unplanned pregnancy
Parent - Low self esteem, poverty, poor impulse control, substance/ETOH, young parent, hx abuse, mental illness, poor knowledge of child development/unrealistic expectation, negative perception of normal child behaviour
Environment - isolation, poverty, unemployment, low education, single parent, non-biological male, family-partner violence
Red flags in presentation for NAI
Delayed presentation - no reasonable explanation
No hx injury, uncorroborated, changes, vague
Injury inconsistent with development
Injury inconsistent with history
Repeated trauma
Young child <2 with head injury
Injuries suspicious for NAI
Complex skull #, parental, linear fracture, subdural bleed, hypoxic-ischaemic brain injury, retinal haemorrhage
Bite marks, bruises of different ages, clustered/patterned bruises, bruises in shielded places (axilla, inner arm, thigh)
Burns - sharply demarcated, shielded areas (posterior body, LL buttock, perineum, back of hand), bilateral/symmetrical
Contusion, laceration, ruptured internal organs without major trauma
Rib fractures
Metaphyseal fractures (corner, bucket handle)
Unusual fracture site - lateral clavicle, hand, feet sternum, scapula, spine
Femoral fracture in child not yet walking
<3 years old with humeral shaft fracture
Ligature marks
Oral injuries
Genital/perineal trauma without straddle injury
