Paeds 5 Flashcards
How is chondromalacia patellae managed?
Physiotherapy for quadriceps strengthening
How is osteochondritis dissecans managed?
Pain relief
Rest and quadriceps exercise
Occasionally need surgery
How is subluxation of the patella treated?
Reduction and immobilisation
Rehab
Outline the treatment of Perthes disease.
o Acute Pain - supporting care with simple analgesia
o < 5 years
• Mobilisation and monitoring (healing potential is good at this age)
• Non-surgical containment using splints
o 5-7 years
• Mobilisation and monitoring
• Surgical containment
o 7-12 years
• Surgical containment
• Salvage procedure (remodel the acetabulum)
o 12+ years
• Salvage procedure
• Replacement arthroplasty
How is septic arthritis treated?
Antibiotics (initially IV for 2 weeks, followed by 4 weeks oral)
Suspected Gram-positive
Vancomycin + joint aspiration
2nd line = clindamycin or cephalosporin + joint aspiration
Suspected Gram-negative
3rd generation cephalosporin (e.g. ceftriaxone) + joint aspiration
2nd line = IV ciprofloxacin + joint aspiration
Affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically)
What are the aspects of managing juvenile idiopathic arthritis?
Multidisciplinary team Physiotherapist and occupational therapist NSAIDs Corticosteroids DMARDs (methotrexate is first-line)
How is vitamin D deficiency/Rickets treated?
Calcium and ergocalciferol OR cholecalciferol
NOTE: pseudovitamin D deficiency is treated with alfacalcidol or calcitriol
How might you investigate a patient presenting with migraines?
Headache diary for 8 weeks to help identify triggers
Outline the steps in the acute management of a migraine.
Step 1: simple analgesia
Step 2: nasal sumatriptan
Step 3: nasal sumatriptan and NSAID/paracetamol
Step 4: consider adding prochlorperazine or metoclopramide
Which medications are used to prevent migrianes?
Topiramate and propranolol
How should you manage a febrile convulsion during the seizure?
Protect them from injury
Do not restrain
When the seizure stops, check the airway and place in the recovery position
If > 5 mins –> rectal diazepam (can be done twice) or buccal midazolam (only one dose)
An ambulance should be called if the seizure continues
What should be tested in all children who have a seizure?
Blood glucose
Which children who have had a febrile convulsion require hospital assessment by a paediatrician?
First febrile convulsion
Diagnostic uncertainty about the cause of the seizure
Focal features of the seizure
Seizure recurs within the same febrile illness (or within 24 hours)
< 18 months old
Parents are anxious
No apparent focus of infection
What is the recurrence rate of febrile convulsions?
1 in 3
What are some cardinal features of childhood rolandic epilepsy?
Unilateral facial sensorimotor symptoms
Oropharyngeal ictal manifestations
Arrest of speech
Hypersalivation
NOTE: this is not usually treated and children will grow out of it (around 14-18 years)
What is the first-line AED for generalised seizures?
Valproate
NOTE: ethosuximide can be used for absence seizures
Name some antiepileptics that can worsen certain forms of epilepsy.
Lamotrigine - worsens myoclonic
Carbamazapine - worsens absence
What is the first-line AED for focal seizures?
Carbamazepine or lamotrigine
What advice should you give to parents with regards to activities that may be dangerous with epilepsy?
Avoid situations where having a seizure could lead to injury or death (e.g. swimming unsupervised)
Driving is allows only after 1 year free of seizures
The school should be made aware of the diagnosis
How is Guillain-Barre syndrome managed?
Supportive
Respiratory support
IVIG
Plasma exchange
Which milestones would you expect the average child to have reached by 7 months?
Gross Motor: sits without support
Fine Motor: transfers objects from hand to hand
Hearing, Speech and Language: turns to voice, polysylabic babble
Social/Emotional: finger feeds, fears strangers
Which milestones would you expect the average child to have reached by 1 year?
Gross Motor: stand independently
Fine Motor: pincer grip (10 months), points
Hearing, Speech and Language: 1-2 words, understands name
Social/Emotional: drinks from cup, waves
Which milestones would you expect the average child to have reached by 15-18 months?
Gross Motor: walks independently
Fine Motor: immature grip of pencil, random scribble
Hearing, Speech and Language: 6-10 words, points to 4 body parts
Social/Emotional: feeds self with spoon, beginning to help with dressing
Which milestones would you expect the average child to have reached by 2.5 years?
Gross Motor: runs and jumps
Fine Motor: draws
Hearing, Speech and Language: 3-4 word sentences, understands 2 commands
Social/Emotional: parallel play
List the median ages for gross motor development milestones.
6-8 weeks: raises head to 45 degrees when prone
6-8 months: sits without support (first with round back, then straight back)
8-9 months: crawling
10 months: cruising
12 months: walks unsteadily
15 months: walks steadily
List the median ages for vision and fine motor milestones.
6 weeks: follows moving object or face by turning head
4 months: reaches out for toys
4-6 months: palmar grasp
7 months: transfers toys from one hand to another
10 months: mature pincer grip
16-18 months: makes marks with a crayon, tower of 3
3 years: draws a circle
List the median ages for hearing, speech and language development.
3-4 months: vocalises alone or when spoken to, coos and laughs
7 months: turns to soft sound out of sight
10 months: sounds used discriminately to parents (mama/dada)
12 months: 2-3 words other than mama or dada
18 months: 6-10 words, shows two parts of the body
20-24 months: use 2 or more words to make simple phrases
2.5-3 years: talks constantly in 3-4 word sentences
List the median ages for social, emotional and behavioural development.
6 weeks: smiles responsively 6-8 months: puts food in mouth 10-12 months: waves bye bye, plays peek-a-boo 12 months: drinks from cup 18 months: uses spoon 18-24 months: symbolic play 2 years: dry by day 2.5-3 years: parallel play, takes turns
How is paracetamol overdose managed?
Measure plasma paracetamol concentration at 4 hours and plot on normogram
Treat with IV N-acetylcysteine if necessary
How is carbon monoxide poisoning treated?
Presents with headache, nausea, confusion and drowsiness
High-flow oxygen
Hyperbaric oxygen therapy may be considered
How is salicylate poisoning treated?
Presentation: vomiting, tinnitus, respiratory alkalosis
Measure plasma salicylate concentration at 2-4 hours
Alkalinisation of urine with sodium bicarbonate increases urinary excretion
Consider haemodialysis
How is TCA overdose treated?
Treat arrhythmias and give sodium bicarbonate
Support ventilation
How is ethylene glycol poisoning treated?
Presentation: intoxication, tachycardia, metabolic acidosis
Fomepizole inhibits the production of toxic metabolites (ethanol can also be used)
How is iron overdose treated?
Presentation: vomiting, diarrhoea, haematemesis, late drowsiness/coma/shock/hypoglycaemia
Serum iron level 4 hours after ingestion is the best measure of severity
IV desferoxamine chelates iron
How is organophosphorus pesticide poisoning treated?
Supportive Atropine (large dose) Pralidoxime (reactivates actylcholinesterase)
NOTE: presentation is mainly cholinergic features
What is a port wine stain?
Capillary malformation in the dermis that is present from birth and persists for life
If in the trigeminal nerve distribution, some children may have Sturge-Weber syndrome and should have an MRI
Describe the appearance and progression of cavernous haemangiomas.
Appears within the first month of life
Grows before shrinking and disappearing (before 5 years)
Describe the inheritance pattern of von Willebrand disease.
Type 1 and 2 = autosomal dominant
Type 3 = autosomal recessive
How should bladder outflow obstruction be investigatd?
MCUG
What are the two different types of polycystic kidney disease and how do they differ?
Autosomal Dominant - mainly in older children/adults, cysts are large
Autosomal Recessive - presents in childhood with bilateral renal masses, respiratory distress due to pulmonary hypoplasia and congenital hepatic fibrosis with pulmonary hypertension
What are the aspects of managing Duchenne muscular dystrophy?
Physiotherapy to prevent contractions Exercise and psychological support Surgery (e.g. tendoachilles lengthening) CPAP for nocturnal hypoxia Glucocorticoids may slow degeneration
What’s the main difference between Duchenne and Becker muscular dystrophy?
Duchenne - no dystrophin - severe symptoms (LE: 20-30 years)
Becker - abnormal dystrophin - milder symptoms
What are some consequences of neural tube defects?
Paralysis and muscle imbalance (needs physiotherapy)
Sensory loss (can lead to accidental damage)
Neuropathic bladder
Bowel denervation
Scoliosis
Hydrocephalus
How is hydrocephalus treated?
Ventriculoperitoneal shunt
Outline the management of idiopathic intracranial hypertension.
Eliminate causal factors Weight-reduction Low-sodium diet and fluid restriction Acetazolamide Analgesia VP shunt
List some clinical features of a child at high-risk of sepsis.
Behaviour: • No response to social cues • Appears ill • Does not wake, or if roused does not stay awake • Weak, high-pitched and continuous cry
Heart Rate:
• Tachycardia (different at different ages)
• < 60 bpm at any age
Respiratory Rate • Tachypnoea (different at different ages) • Grunting • Apnoea • SpO2 < 90% on air
Mottled or ashen appearance Cyanosis of the skin, lips or tongue Non-blanching rash Aged < 3 months with temperature > 38 degrees Temperature < 36 degrees
Which investigations constitute a septic screen?
FBC Blood culture CRP Urinalysis LP CXR
Also do a VBG
NOTE: if < 1 month, all children should have an LP
Outline the role of a VBG in managing a child with moderate to high risk of sepsis.
> 2 mmol/L or evidence of AKI –> treat as high-risk
< 2 mmol/L = repeat assessment at least hourly, ensure review by senior clinician, identify a cause and manage it
Outline the non-pharmacological steps taken in the management of high risk sepsis.
Immediate review by senior clinician VBG (gas, glucose, lactate, FBC, U&E, creatinine, clotting) Broad spectrum antibiotics immediately Monitor continuously Monitor mental state using GCS or AVPU
Outline how the lactate guides treatment in high risk sepsis.
> 4 mmol/L = IV fluid bolus without delay, refer to critical care
2-4 mmol/L = IV fluid bolus without delay
< 2 mmmol/L = consider IV fluids
