Paeds 6 Flashcards by Guthrie Ruby

Which antibiotics are used to treat meningococcal sepsis?

Community: IM benzylpenicillin
Hospital: IV ceftriaxone

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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

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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

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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

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What should be monitored whilst a patient is receiving treatment for anaphylaxis?

Blood pressure
Pulse
Respiratory function

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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)

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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)

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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

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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List some conditions that are associated with Down syndrome.

Coeliac disease 
Hypothyroidism
Alzheimer's disease 
Epilepsy 
Hearing and visual defects

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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

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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

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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