Paeds Flashcards
list 6 causes for stridor
- croup
- laryngomalacia
- epiglotitis
- laryngeal FB
- retropharyngeal abscess
- bacterial tracheitis
What are the indications for intbation in croup
exahustion
T2rf
T1RF
decreased consciouness and cant protect airway
imminent airway obstruction
What are the steps for managing laryngospasm
analgesia options and side effects
What are the diagnostic criteria for Kawasaki Disease
Fever for 5 days + 4 of the following
* bilateral non purulent conjunctival infection
* mucous membrane changes eg strawberry tongue or red or cracked lips
* polymorphous rash
* peripheral changes eg plantar and palmar erythema
* cervical lymphadenopathy - usually unilateral and painful
what are the key investigations and why in ?kawasaki?
- ECHO - ?CA aneurysm, effusions, MR regurg. now and in 8 weeks
- cultures - ?bacterial infeciton
- strep serology - ?strep
- measles PCR - ?measles
- FBC - ?thrombocytosis - common in week 2 of disease
- ECG - long PR
Treatment for Kawasaki
- IV Igs 2g/kg over 10 hours
- aspirin 3-5mg/kg for 8 weeks
- steroids
- pandaol, fluid, fibrinolytics
2 year old with abdo pain
findings
Diagnosis
soft tissue mass/shadow RUQ
small bowel distension left side
paucity of gas central
bowel obstruction
what are the common causes of bowel obstruction in children under 5
- intersuscception
- incarcerated inguinal hernia
- malrotation of gut with volvulus
- adhesions post surgery
- annular pancreas
what are the common causitive agents for bronchiolitis?
- RSV
- parainfluenza
- human metapneumovirus
- rhinovirus
what clinical features warrant admission for bronchiolitis
poor feeding
apneoic episodes
markedly tachypnoeic
sats under 90
what factors increase risk of apnoea in bronchiolitis
low birth weight
premature
under 3 months old
immunodeficient
comorbidities
moderate V severe bronchiolitis
Moderate
feeding over 50%
SOB on feeding
moderate WOB
sats under 94
lethargy
mild dehydration
Severe
poor feeding
apneoic episodes
markedly tachypnoeic
sats under 90
severe dehydration
differential diagnosis for bronchiolitis and descriminatory finding
- bacterial pneumonia - one sided creps, signs of sepsis
- cardiac failure - murmur, hepatomegalt
what criteria need to be met for discharging bronchiolitis
- parents happy
- sats over 93/94
- feeding close to normal
- no apnoea
- normal behaviour
- normal WOB
characteristic examination finding of bronchiolitis
widespread coarse crackles to the midzone
initial management of severe bronchiolitis
- Cancel orders for adrenaline and salbutamol
- Senior review to confirm diagnosis
- High flow nasal prongs: 2L/Kg, titrate fiO2 for SpO2 94-98%
- NGT placement v IV for hydration
- Admission under paediatrics
what is the criteria for a BRUE (Brief resolved unexplained event)
- less than 1 year old
- less than a minute but usually 20-30 seconds
- return to normal baseline
- no obvious medical cause
- central cyanosis +/- absent or irregular breathing
What are the features of a low risk BRUE
- no concerning exam featurs
- over 60 days old
- born over 32 weeks and corrected gestaional over 45
- no CPR but trained healthcare professional
- first event
- under 1 minutes long
differentials for BRUE
Resp - inhaled FB
Cardiac - CHD or prolonged QT
neuro - head injury or seizure
abdo - intersuscception
Injury - shaken baby, OD
Metabolic - hypoglycaemia, hypocalcaemia
what are the indications for admission with BRUE?
- Post-conception age <48 weeks
- Ill appearing or concerning findings on examination
- Bronchiolitis or Pertussis with apnoea
- Suspicion of non-accidental trauma
- Past medical history that places them at risk for poor outcomes
- Prolonged central apnoea or more than 1 episode in 24 hours
- Family history of SIDS or multiple BRUEs
- Poor follow-up
- Parental concern/anxiety
sick child rang through - what immediate steps do you make?
- clear resus bay and ensure department handed over
- prepare medical roles
- ensure nursing roles
- involve paeds/anaesthetics/ICU
- get paeds resus trolley
- prepare paeds drugs and doses
- paeds airway and access stuff
what are three non duct dependant causes of neonatal cardiac disease
TOF
VSD
ASD
trucus arteriosis
remember
arrthymias
cardiomyopathy
what endocrine issues can cause neonatal collapse
- congenitial adrenal hyperplasia
- addisons
- electrolyte disturbance
intepret
treatment
right middle lobe pneumonia
abx duration for pneumonia
3-5 days
w
what are the possible reasons for recurrent pneumonia in children?
recurrent re-infection
bronchiectasis
inhaled FB
CF
immunedeficiency
what further investigations would you do for recurrent chest infections?
FBC
Igs
sweat test
CT chest
bronchoscopy
features and most likely diagnosis
Features
* discrete lesions of various sizes
* purpura
* ?brusing
* across foot and distal leg
Most likley diagnosis
HSP
Differentions
ITP
TTP
HUS
meningitis
SJS/TEN
Why is this HSP?
Symptoms?
HSP rash usually on lower legs and buttocks
characteristic brusing appearance
Sx
joint pain
abdo pain
renal failure
rash
post viral
swelling in hands and feet
what investigations would you do and why for ?HSP
urinalysis - ?blood in renal failure
BSL - ?sepsis
FBC - ?sepsis or thromboytopenia
Plt - ?ITP
cultures - ?sepsis
what are the complications of HSP?
- renal failure - nephritis
- GI haemorrhage
- intersussception
- torsion
- orchitis
- recurrent HSP
what are the categories of dehydration severity
what clinical signs should be monitored during rehydration?
weight
urine output
CRT
HR
ongoing losses
signs of overload
what congenital syndromes are associated with neonatal bowel obstruction?
CF
Downs
A 36 hour old neonate presents with a community nurse because of failure to pass
meconium. There has been mucous-like vomiting but the neonate otherwise looks well.
(a) A normal digital rectal examination excludes which diagnosis?
(b) The successful passage of an NG tube excludes which diagnosis?
(c) What is the characteristic X-ray appearance of duodenal atresia?
(a) A normal digital rectal examination excludes which diagnosis?
Imperforate anus
(b) The successful passage of an NG tube excludes which diagnosis?
Oesophageal atresia
(c) What is the characteristic X-ray appearance of duodenal atresia?
Double bubble sign
with neonatal bowel obstruction needing transfer, what should be done to ensure a safe transfer?
- vital signs documentation
- oxygen as required
- temp noting and monitored
- BSL measurement and correcting if needed
- IV access
- IV fluid manaement
- NG on free drainage
- AXR
what are the non congentital causes of neonatal bowel obstruction
gastric volvulus
gastric atresia
duodenal web
intersusccpetion
hirscsprungs
meconium ileus
colonic atresia
anal atresia
anorectal abnormalities
what are the criteria for a simple febrile convulsion?
none of the following
1. focal features at onset or during
2. more than 15 mins
3. recurrence within same febrile illness
4. incomplete recovery within one hour
febrile convulsion
abnormalities and clinical impression
spiral fracture of left humerus
NAI
if you suspect NAI what are the important components of an exam
exam for signs of neglect and abuse
* burns
* multiple bruises inconsistent with age
* other fractures
* bite marks
* development assessment
fracture with suspected NAI
Management
- analgesia
- plaster or reduction
- admit
- notify child services
what features of an injury history are consistent with NAI
- **inconsistent mechanism
- inconsistent history**
- delayed presentation
- multiple presentations
- DV
- FH with other siblings
- substance abuse
- foster care
- single parent family
- FTT
- inappropriate interactions
other than fractures what injuries are associated with NAI
Soft Tissue
○ Any injury in ‘non mobile’ child of this age is a concern
○ Various Bruises
○ Various Ages
○ Circumferential Injuries
○ Usually NOT over bony prominences
● Burns
○ Cigarette burn
○ Immersion pattern on legs
○ Buttocks
○ Genital Areas
○ Hands
● Head Injury
○ Intracranial haemorrhage(s) - various - e.g. EDH
○ Retinal heamorrhage(s)
● Abdominal
○ Perforated viscus, solid organ injury
what examination features of a child would indicate a LP?
- bulging fontanelle
- irritable and unconsolable
- neck stiffness
- petichial non blanching rash
- photophobia
- no other source
what features need to be met for safe discharge of a child with a fever
- follow up within 24 hours
- sensible parents
- proximity to hospital and ability to return
- looks well
- previously healthy
- urine clear
- cxr clear
- LP normal
- bloods unremarkable
FTT
features of exam and relevance
- vital signs - look for shock eg sepsism congenital heart disease
- weight, length, head circumferance - for growth chart to compare with birth
- fontanelle - ?raised ICP
- chest exam - ?pulmonary oedema
- CVS - murmurs/coarctation
- jaundice -?biliary atresia
- bruising - NAI
FTT
investigations and relevance
- BSL – hypoglycaemia in metabolic conditions, sepsis
- ECG – tachyarrhythmias can present as failure to thrive
- VBG – assess degree of hypoperfusion – eg lactate / metabolic acidosis
- Bilirubin / LFTs – esp if jaundiced – exclude congenital liver problem
- FBC – anaemia from congenital haemolytic cause
- Septic screen – urine / CXR / LP where indicated from examination to exclude infection
- Urine for metabolic screen – where suggested by hx or metabolic acidosis
what can neonatal jaundice cause if left untreated?
what are the complications?
**kernicterus **- chronic bilirubin encephalopathy
Complications
* Acute - seizures and coma
* chronic - cerebral palsy, developmental delay, death
what are the benign and pathological causes of neonatal jaundice?
Benign
* breast milk jaundice
* normal physiological jaundice due to immature hepatocytes
Pathological
* Sepsis
* haemolysis (rhesus, ABO)
* liver trouble - hepatitis, biliary atresia
* bowel obstruction
* hypothyroidism
how can serum bilirubin help with assessment of neonatal jaundice?
- higher total level the greater the risk
- conjugated worse as indicates obstructive cause
what are the maternal and neonatal risk factors for significant hyperbilirubinaema?
maternal
* Blood group and ABO incompatibility
* previous neonatal jaudice
* poorly controlled diabetes
* FH - G6PD/heriditary spherocytosis
Neonatal
* poor feeding
* GI - bowel obstruction, biliary atresia
* haem - polycytheamia
* sepsis
neonatal jaundice
what are the indications for bloods on a kit with gastro
- renal disease
- diuretic use
- altered conscious state
- profuse loss
- ileostony
- ?sepsis
- prolonged symptoms
- hypoglycaemia
what clinical signs indicate severe dehydration
- altered conscious state
- CRT over 4 seconds
- sunken eyes
- dry mucous membranes
- reduced urine output
What is an appopriate rehydration regime for moderate dehydraiton
anti emetic if vomiting
ORS
IV v NG
slow 10-20mls/kg/hr
rapid 25mls/kg/hr
HUS
haemolytic anaemia
infection with dehydration
hepatitis/cholecystitis/intersussception
a kid - interpret
Normocytic, normochromic severe anaemia, associated reticulocytosis. Coombs
negative (non immune mediated)
* Suggestive haemolytic anaemia
causes of a generalised seziure in a child
hypoglycaemia
hypoxia
febrile illness
head trauma
toxins
child seizure
what is the treatment of a non febrile seizure in child
- stop seizure - iv midal 0.1ml/kg
- give sugar if hypoglycaemic 2ml/kg 10% dexrose
- IV phenytoin
- prepare for intubation/support airway 20ml/kg
define syncope
abrupt loss of consciousness and postural tone from transient global hypoperfusion followed by spontaenous complete recovery
what is the most common cause of syncope in children
what syncope is unique to preschool
vasovagal
breath holding
what are the red flag features of paediatric syncope
- syncope during exercise
- chest pain prior
- sob prior
- palpitations prior
- FH sudden cardiac death
- known structural heart disease
what paediatric syncope, what conditions do you look to rule out on an ECG
- HOCM
- brugada
- Long QT
- short QT
- WPW
- AVRD
what is the difference between petichae and purpura
petichae - small pinpoint lesions less than 2mm
purpura - larger non blanching spots
differentials for petichae in kids
Thrombocytopenia
Increased destuction - ITP, TTP
* Decreased production*, leukemia, aplastic anaemia, fanconi anaemia
Platelet dysfunction
* congential
* acquired eg NSAIDS
Coagulation deficiencies
* congenital - VWD
* acquired - liver disease, vit k deficiency*
Loss of vascular integrity
* trauma and increases venous pressure eg strangulation, coughing, tournequet
* vasculitis - HSP, SLE
* Toxins - penicillins
* Sepsis - DIC
describe acid base disturbance and likely diagnosis
Hypochloraemic Metabolic alkalosis – HCO3 51
Respiratory compensation – Expected CO2 is 0.7x51 + 20 = 55
HAGMA – anion gap is 138 – 69+51 = 18
pyloric stenosis - confirm via US
- Infective - pneumonia, meningitis
- cardiac - duct dependent lesion, non cyanotic congenital heart disease
- surgical - malrotation, intersussception
- neuro - seizures
- trauma - ICH
- endocrine - CAH
- metabolic - hypoglycaemia
unwell kid
describe and interpret
RUL collapse/consolidation
LUL consolidation
NG in not far enough
pneumonia or bronchiolitis with collapse
laryngoscope size for kids
k
key features and diagnosis
Features
distressed infant
erythema to face torso and limbs
desquamation to various parts
no mucous membrane involvement
Stap scolded skin syndrome
- Asthma - FH, nocturnal cough, atopy
- Infection eg RSV - fever, runny nose, looks unwell
- inhaled FB - sudden, choking, missing toy
- allergic reaction - known allergy, associated rash
- cardiac failure- known cardiac disease, oedema, FTT
- reflux, difficuluty feeding, bad breath, worse post food
what exam featurs suggest inhaled FB
focal monophonic wheeze
focal consolidation
unilateral hyperinflation
what are the drug doses for paeds RSI
- Suxamethonium – 1-2mg/kg
- Ketamine – 1-2 mg /kg
- Fentanyl – 2-3 mcg/kg
what equipment do you want ready for paeds RSI
- Bag/valve mask/neopuff/anaesthetic circuit
- ETT size 3.5 cuffed (Accept 3 and 4)
- Paedcap/capnography
- Laryngoscope size 1 &2 miller and/or mc blade
- Ventilator
- Suction catheter
- Oropharyngeal/nasopharyngeal airways
- Stylet/bougie
- LMA (Size 1)
describe abnormalities
differentials
- Severe hyperkalaemia
- Hypoglycaemia
- Partially compensated metabolic acidosis
- Mild hyponatraemia
Differentials
CAH
dehydration
renal failure
sepsis
heart failure
inborn error of metabolism
what are the tests for CAH?
serum cortisol and 17 hydroxyprogesterone
plasma renin and ACTH
what is the treatment for a baby with CAH?
- 10% dextrose 2-5mls/kg
- IV fluids – 10 mls per kilo normal saline
- FIRST LINE Steroids – stress hydrocortisone 25mg initially then 5-10 mg 6 hourly
Extra
Mineralocoricoid replacement - Fludrocortisone 0.05-0.1 mg
daily
desribe rash and diagnosis
causes
treatment
erythematous, raised plaques, confluent, target sign =** Erythema multiforme**
Causes
Infection - HSV 1 and 2, mycoplasma, VZV, adenovirus
*Drugs *- NSAIDS, penicillins
no specific treatment
sore throat and rash
describe rash
diagnosis
erythematous, widespread, macular
Scarlet fever
dd:
measles
rubella
drug eruption
what is the treatment for scarlet fever
penicillin
what are the complications of scarlet fever
- Renal failure
- Rheumatic heart disease
- Abscess – peritonsillar or retropharyngeal
- Bacteraemia/ Sepsis
- Pneumonia
- Hepatitis
what causes a blistering rash in children
- staph scolded skin syndrome
- SJS/TEN
- bullous impetigo
relevant findings and diagnosis
HAGMA: AG= Na – (HCO3 + Cl)
Appropriate respiratory compensation
CO2 = 1.5*HCO3 + 8
Diabetic ketoacidosis
why do you get the following in DKA
* low Na
* Low Cl
* high K
- low Na - dilutional due to hyperglycaemia
- Low Cl - loss from kidneys to maintain electrucal neutrality due to ketones
- high K - due to acidosis
what investigations may you do in a child with first time DKA
Serum ketone finger prick – in DKA to monitor response to treatment with serial measures
UEC – assess for pre-renal renal failure with DKA
Urine – for UTI in febrile / urinary symptoms,
CXR – assess for pneumonia if respiratory symptoms present
CT head – if signs of cerebral oedema eg reduced LOC
Serum antibodies – in first time DKA
(Accept other thigns that look for cause if explained well – BC, LP)
Treatment for DKA
- Bolus 10ml/kg N/S aiming for improved perfusion
- Replace fluid deficit over 24 -48 hrs (deficit plus maintenance)
- -Initially use N/S then change to N/S plus 5%D when BSL <15
- Add 20-40mmol/L K to each bag once K <5.5
- Insulin 0.1U/kg infusion
- Correct cause eg Abs for sepsis
what are the obstructive and non obstructive causes of neonatal vomiting
Obstructive
* Obstructed hernia
* Necrotising enterocolitis
* Biliary atresia
* midgut volvulus
* pyloric stenosis
Non-obstructive
* Acute gastroenteritis
* Sepsis
* Inborn errors of metabolism
* Non-accidental injury (space occupying lesion e.g. SDH)
causes of paediatric anaemia and findings on film/FBC
- Iron Deficiency – microcytic, hypochromic; target cells, pencil cells
- Acute Leukaemia – blasts on film
- Aplastic Anaemia – low reticulocyte count
- GIT bleed (ie Meckel’s diverticulum) – elevated reticulocytes
- Haemoglobinopathy ie thalassaemia – nucleated RBCs, microcytes
- Congenital Haemolysis ie sickle cell disease sickle cells
- Acquired Haemolysis ie HUS – schistocytes, red cell fragments
- Abnormal red cells – ie spherocytosis - spherocytes
differentials
measles
chicken pox
rubella
slapped cheek (parvo)
viral xantham
CTD
SJS/TEN
staph scalded
what are the measles specific features of history and exam
History
Rash day 3-5 of fever
starts on face
unimmunised/contact history
Exam
Kopliks spots
conjunctival injection
coryza
management of measles
● tell public health
Check rest of family – contact and immunisation status / offer MMR/IG where appropriate
● History - Check for any pregnant staff / high risk contacts
● High risk contacts may need to be admitted and treated in a single room with Measles IG
● Notify staff who had contact with patient- immunisation if required/Staff Health/Infection
control . Ensure we have all the appropriate contact numbers for family and staff
● Educate staff- patient should not have been in W/R, should have had resp isolation
● Advice to family about isolation - four days after rash appears
● Advice to family about how to get help after they leave the ED today
what is the test for measles
IgM/IgG serology
Nasal PCR
what are the complications of measles
- pneumonitis
- meningitis
- encephalitis
- otitis media
- acute sclerosing panencephalitis
- dehydration
what are the risk factors for post natal depression
history of depression
previous post partum depression
history of mental illness
lack of social support
unwanted pregnancy
complicated birth
feeding difficulties
baby has special needs
what are the indicators for admission to hospital with post natal depression
psychosis
thoughts of self harm
thoughts of infant harm
any suicidality
poor social support
what are the risk factors for neonatal resus
how can you estimate gestiational age?
- enquire about LMP
- fundal height umbi at 20 weeks xiphsternum at 36
- Ultrasound measures eg femur length
clinical signs of a duct dependant lesion
Treatment
cyanosis/hypoxia
no femoral pulses
hepatomegaly
murmur
Treatment
prostaglanding infusion NB apnoea
100ng/kg/min
what are the cardinal features of life threatening asthma?
- confusion
- coma
- exhaustion
- hypotension
- poor respiratory effort
- silent chest
- cyanosis
what is the immediate management of severe asthma in a child
- salbutamol 6 puffs inh/neb 20 minutely for one hour then review
- ipatropium bromide 4 puffs 20 minutely
- pred 1mg/kg
- magnesium sulphate 50mg/kg IV bolus
what are the complications of severe asthma post treatment?
- worsening hypoxia of hypercarbia despite treatment
- apnoea
- altered consciounsess
- pneumothorax
- vomiting
- agitation secondary to salbutamol
ventilation settings in asthma
causes of hypotension and tachycardia post intubation
incorrect tube position
equipment failure
tension pneumothorax
gas trapping
affect of agents
dose and side effects of second line asthma treatment
what are the potential complications of intubating a child with asthma
tension pneumothorax
barotrauma
hypotension
cardiac arrest
asthma intubation
Hypoxia/ Pre-oxygenation: HFNC 15lpm throughout, consider BiPAP as pre-ox strategy, avoid apnoea, induce sitting up
High-pressure ventilation: manual ventilation, increased pressure limits to maintain
PPlat <30cmH20
Cardiovascular collapse with raised thoracic pressures: Fluid bolus, start adrenaline
Dynamic Hyperinflation: Slow bag – 4-6/min, disconnect from ventilator
Positive
* mass in hilar, lilely mediastinal
* intubated with ET tube correctly cited
* left lung hypoinflation
Negative
* no mass
* no cardiomegaly
* no pleural effusion
* no bony involvement
Differentials
Lymphoma
TB
thymic cyst
goitre
thymoma
neuroblastoma
