Paeds 6 Flashcards
Which antibiotics are used to treat meningococcal sepsis?
Community: IM benzylpenicillin
Hospital: IV ceftriaxone
Outline the ABC approach to anaphylaxis.
Airway - look for and relieve any obstruction, intubate if necessary
Breathing - check whether it is normal
If unresponsive/not breathing normally - start CPR
Circulation: check pulse and blood pressure
Everything Else: check skin and inside of the mouth for urticaria and angio-oedema
Outline the use of adrenaline in anaphylaxis.
IM adrenaline 1:1000 (as per age-related guidelines) into thigh
Assess response after 5 mins
Repeat IM injection at 5 min interval until there has been a response
NOTE: IV adrenaline is only used for advanced life support
Aside from adrenaline, what else should be given to a patient in anaphylaxis?
High flow oxygen
IV fluids (titrate against blood pressure)
Chlorphenamine 10 mg IV
Hydrocortisone 200 mg IV
NOTE: if there is a wheeze, may require bronchodilators
What should be monitored whilst a patient is receiving treatment for anaphylaxis?
Blood pressure
Pulse
Respiratory function
Outline the neonatal resuscitation guidelines.
- Dry the baby
- Within 30 seconds: assess tone, breathing and heart rate
- Within 60 seconds: if gasping or not breathing – give 5 inflation breaths
- Re-assess: if NO increase in heart rate, look for chest movement
- If chest NOT moving: recheck head position, consider 2-person airway control and other airway manoeuvres, repeat inflation breaths
- If NO increase in heart rate: look for chest movement
- When chest is moving: if heart rate is not detectable or slow (< 60/min) start compression with 3 compressions per breath
- Reassess heart rate every 30 seconds: if heart rate is not detectable or slow (< 60/min) consider venous access and drugs (e.g. atropine)
Outline the steps in paediatric basic life support.
- Are they unresponsive?
- Shout for help
- Open airway
- Look, listen and feel for breathing
- Give 5 rescue breaths
- Check for signs of circulation
- 15 chest compression: 2 rescue breaths (15:2)
List some possible presenting features of cerebral palsy.
Unusual fidget movements (e.g. asymmetry, paucity) Abnormalities of tone (e.g. hypotonia) Delayed motor milestones Feeding difficulties Persistent toe walking
Outline the aspects of managing cerebral palsy.
MDT approach
Physiotherapy - encourage movement, build strength
Speech and Swallow - ensure safe swallow, improve language abilities
Occupational therapy
Medications (baclofen for stiffness, melatonin for sleep, laxatives for constipation and anticholinergics for drooling)
List some comorbidities that are commonly associated with cerebral palsy.
Learning disability (1 in 2) Behavioural difficulties (2 in 10) Chronic constipation (3 in 5) Visual impairment (1 in 2) Hearing impairment (1 in 10) Low bone mineral density Epilepsy (1 in 3)
What are the three main types of cerebral palsy?
Spastic (hemiplegic, quadriplegic, diplegic)
Dyskinetic
Ataxic
NOTE: injuries causing brain damage up to 2 years can be classified as cerebral palsy
Outline the aspects of management of autism spectrum disorders.
Psychosocial interventions (increase attention and reduce repetitive/ritualistic behaviours)
Speech and language therapy
Pharmacological (antipsychotics may be considered for difficult behaviour)
Attend to family/carers needs
Assess for learning disability and discuss EHC plan
NOTE: < 10% can function independently as adults
What is the first-line management of ADHD?
ADHD-focused group parent-training programme
Offer individualised training programmes if the needs are too complex
NOTE: consider up to 10-week watch and wait period before this
Outline the step by step medical management of ADHD.
Methylphenidate (6 week trial)
If unsuccessful, consider lisdexamphetamine (or dexamphetamine)
If unsuccessful, consider atomoxetine or guanfacine
What is an important thing to do before starting patients on medication for ADHD?
Establish baseline physical state (especially HEIGHT) and perform an ECG
The medications can cause loss of appetite and stunted growth and the development of tics (they are also cardiotoxic)
NOTE: recommend yearly off medication trials
How should medical treatment of ADHD be monitored?
Consider using symptom rating scales (e.g. Conner’s)
Measure height every 6 months
Measure weight every 3 months
Monitor HR and BP every 6 months
Outline the aspects of managing Down syndrome.
MDT
Screen for abnormalities - AVSD, duodenal atresia
Parental counselling and education
Individualised education plan
Genetic counselling about future pregnancies
List some conditions that are associated with Down syndrome.
Coeliac disease Hypothyroidism Alzheimer's disease Epilepsy Hearing and visual defects
What are the three types of insulin therapy?
Multiple Daily Injection
Basal-Bolus: injections of short-acting insulin before meals + 1 long-acting insulin (generally the 1st option for new diagnoses)
Continuous SC Insulin Infusion: regular and continuous insulin delivered through a pump
1, 2 or 3 injections per day: mix of short-acting and long-acting insulin
How often should capillary glucose be measured in patients with T1DM?
At least 5/day
Fasting/through the day target: 4-7
After meals: 5-9
In which patients might you consider continuous glucose monitoring?
Frequent severe hypoglycaemia
Hypoglycaemia unawareness
Inability to recognise or communicate symptoms of hypoglycaemia (e.g. cognitive impairment)
Which complications of T1DM require on going monitoring?
Thyroid disease - annually from diagnosis
Diabetic retinopathy, nephropathy and hypertension - annually from 12 years
How should mild-to-moderate hypoglycaemia be managed?
Fast-acting glucose by mouth (e.g. lucozade)
Check blood glucose in 15 mins (repeat glucose if necessary)
As symptoms improve, switch to oral complex long-acting carbohydrate
How should severe hypoglycaemia be managed?
In Hospital: IV 10% glucose (max 500 mg/kg of body weight)
Community: IM glucagon (500 µg < 8 yrs or 1 mg > 8 yrs) or glucogel
Once symptoms improve, give oral complex long-acting carbohydrate
Which observations should be recorded in a patient with DKA?
- Level of consciousness
- Vital signs (HR, BP, Temp, RR)
- History of nausea or vomiting
- Clinical evidence of dehydration
- Body weight
Which biochemical parameters should be measured in a patient with DKA?
pH and pCO2 Plasma sodium, potassium, urea and creatinine Plasma bicarbonate Blood glucose Blood ketones
Outline how the fluid deficit in DKA is estimated.
5% fluid deficit = mild-moderate DKA (> 7.1)
10% fluid deficit = severe DKA (< 7.1)
Outline how maintenance fluid requirements are calculated in patients with DKA.
< 10 kg = 2 ml/kg/hour
10-40 = 1 ml/kg/hour
40+ = 40 ml/hour
These are lower than standard maintenance fluid calculations because of the risk of cerebral oedema
Which fluids should be given when rehydrating patients with DKA?
0.9% saline ONLY until plasma glucose < 14 mmol/L
Then change to 0.9% saline + 5% dextrose
Rehydrate over 48 hours
Consider switching to oral fluids once the child is alert, ketosis is resolving and they can tolerate oral fluids
What should all fluids administered to patients with DKA contain?
40 mmol/L potassium chloride (unless renal failure)
Describe how insulin therapy should be given in DKA.
Start IV insulin infusion 1-2 hours after beginning IV fluid therapy
Use soluble insulin at 0.05-0.1 units/kg/hour (disconnect insulin pump if present)
Consider increasing insulin dose if no reduction in blood ketones after 6-8 hours
When can SC insulin be started in a patient with DKA?
Consider if ketosis is resolving, child is alert and can tolerate oral fluids
Start SC insulin at least 30 mins before stopping IV insulin
If using an insulin pump, start the pump at least 60 mins before IV insulin is stopped
How should a child be monitored whilst receiving treatment for DKA?
Measure at least HOURLY
• Capillary blood glucose
• Vital signs (HR, BP, Temp, RR)
• Fluid balance with fluid input and output charts
• Level of consciousness (using modified GCS)
NOTE: if severe DKA or < 2 years, monitor every 30 mins
What else should be monitored in a patient receiving IV therapy for DKA?
Continuous ECG (detect hypokaleemia)
NOTE: if K+ < 3 mmol/L, consider temporarily stopping the insulin and discuss with paediatric critical care
What should be measured 2 hours after starting treatment for DKA and at least every 4 hours afterwards?
Glucose (laboratory)
Blood pH and CO2
Plasma sodium, potassium and urea
Beta-hydroxybutyrate
NOTE: every 4 hours, review clinical status, blood results, ECG trace and fluid balance
List some clinical features of cerebral oedema.
Headache
Agitation or irritability
Unexpected fall in heart rate
Increased blood pressure
How is cerebral oedema resulting from DKA treatment managed?
IV mannitol or hypertonic sodium chloride
How is congenital hypothyroidism treated?
Start thyroxine treatment within 2-3 weeks of age and continue throughout life
With adequate treatment, intelligence and development should be normal
How is acute symptomatic hypocalcaemia managed?
IV calcium gluconate
NOTE: chronic is managed with oral calcium and high dose vitamin D analogues
Outline the aspects of managing congenital adrenal hyperplasia.
Corrective surgery (usually at puberty)
Life-long glucocorticoids
Mineralocorticoids (if salt loss)
Monitor growth, skeletal maturity, plasma androgens and 17a-hydroxyprogesterone levels
Outline the management of an Addisonian crisis.
IV hydrocortisone
IV saline
IV glucose
Fludrocortisone may be needed
How is androgen insensitivity syndrome managed?
Investigation: karyotype
Bilateral orchidectomy (risk of testicular cancer) Oestrogen therapy
For how long should children with measles or rubella be excluded from school?
4 days from the onset of the rash
Which investigations should be requested in a patient with suspected non-accidental injury?
Skeletal survey
CT head scan
Bloods and bone profile (rule out leukaemia, ITP)
Fundoscopy (retinal haemorrhages)
Who should be contacted in cases of suspected non-accidental injury?
Senior colleagues
Named doctor for child protection
Social services
Consider contacting the police (Child Abuse Investigation Team)
Consider contacting Mutli-Agency Safeguarding Hub (MASH)
What are the differences between diplegic, hemiplegic and quadriplegic cerebral palsy?
Diplegic: both legs and arms are involved, legs are affected more than arms, associated with periventricular leukomalacia and preterm babies, do NOT tend to have severe learning difficulties/epilepsy
Hemiplegic: affects one side of the body, arms more than legs
Quadriplegic: most severe form, all four limbs are severely affected, associated with learning difficulties, epilepsy and swallowing problems
What are some features of innocent murmurs?
Asymptomatic
Systolic
Louder during fever and exercise
Vary with respiration and posture
What counts as precocious and delayed puberty?
Precocious - Girls < 8, Boys < 9
Delayed - Girls > 13, Boys > 14
Which investigations might be used for delayed puberty?
Pubertal staging (Tanner) Accurate height and weight measurements Bone age Gonadotrophin levels Visual field examination CT/MRI head scan Karyotype
Which scoring system is used to assess the severity of croup?
Westley croup score
