Paeds ICM Flashcards
Differences in adults and paediatrics blood results?
Haemoglobin
WBC
ALP (slightly higher in infants; <400IU/L)
Similarities in adults and paediatrics blood results?
Platelets
INR
CRP
D-dimer
Why is urea level lower in children?
Urea is a protein that comes from muscle mass.
When babies are born, they have very low levels of muscle but more subcutaneous fat. So low protein levels.
Urea will increase when babies grow and be active.
Under 12 months:
urea < 5.5mmol/L
Adults:
ureas 2.0-7.8mmol/L
Creatinine increases with muscle mass. It reaches adult range at the age of 12.
What is a newborn blood spot test (Guthrie card)?
Spots of blood sample are taken at/by day 5 of life (or day 8 if baby had transfused blood) using a heel-prick test.
Detects for life changing conditions, for e.g.:
- cystic fibrosis (immunoreactive trysinogen)
- sickle cell disease (high-powered liquid chromotography)
- congenital hypothyroidism (TSH)
- 6 types of inherited metabolic disorders
* Galctosemia
* Maple Syrup Disease (MSUD)
* medium chan acyl-coenzyme A dehydrogenase defienceicy (MCADD)
* Phyenylketonuria (PKU)
* Homocystinuria
(HSU)
* Glutaric Acidaemia Type 1 (GA1)
* Isovaleric Acidaemia (VA)
Positive test can be treated early, improving baby’s health and, in some cases, preventing severe disability or even death.
Types of paediatric needles and cannulas when taking blood?
Lower the gauge number, larger the needle.
Child sizes:
24G
22G
20G
Neoflon (brand name) -yellow cannula; used in neonatal
Other blood tests?
Capillary blood gas
- quick, minimally invasive, heel-prick
- useful if worried about pH, pCO2.
-not good for pO2
Other phlebotomy techniques?
Drip from needle or cannula
Butterfly needle in bigger kids
Scalp veins in babies
What to consider when deciding on paediatric investigations?
Will doing the test CHANGE your management?
Risk vs benefit?
Can it be avoided?
How to minimise invasive/traumatic experience?
Common presentations in paediatrics?
Breathing difficulties
- high RR
- SOB
- cough
- increase in work of breathing
Fever
- temp > 37.5deg
GI changes
- diarrhoea
- vomiting
Rash
Differential diagnosis for breathing difficulty?
Lower respiratory tract infection
Asthma
Pneumothorax
Blunt/penetrating trauma
Toxin ingestion
Airway obstruction
Investigations for breathing difficulty?
Check airway is clear before considering other IVx.
Breathing concern (x-ray, blood tests, capillary blood gas)
Differential diagnosis for fever, reduced feeds, and irritability?
Viral URTI
Teething
Bacterial infection e.g. UTI
Reflux
Investigations for fever, reduced feeds, and irritability?
Fever in < 5months old:
- urine MC&S
- FBC
- CRP
- Blood culture
- CXR
- Stool culture (age < 3months + diarrhoea)
- Lumbar puncture
- U&Es (dehydrated, jaundice)
- LFTs (dehydrated, jaundice)
When can you do CXR in children?
Age < 3months + respiratory signs
Age > 3months
- any ‘red’ flags
- fever of unknown source AND 1+ ‘amber’ flags + temp >39deg and WBC >20
If a 2 month old presented with fever, what must you consider?
Reduced consciousness
Floppy
Parents think their child is ‘not quite right’
Possible sepsis or meningitis?
Consider meningitis in any child with fever and associated symptoms.
Start abx immediately for sepsis.
When to consider lumbar puncture in children?
All pts with any ‘red’ flags
Age < 1year and ‘amber’ flags
Classic meningitis signs?
Neck stiffness
Bulging Fontanelle
High-pitched cry/Irritable
Decreased level of consciousness
Convulsive status epilepticus
Management of suspected UTI and fever in a child?
Send urgent urine MC&S and refer to specialist if:
- age < 3months + fever
Urine dipstick
if age > 3months
How to obtain urine sample?
Clean catch urine (CCU) sample
- Sterile container/catching method
- sterile boric acid container
- potty cleaned with boiled hot water to sterilise
- urine collection bag - Encourage micturition
- gentle pressure over bladder
- hydration
Management of urine dipstick results?
+ve leukocyte AND +ve nitrate
→start abx for UTI, send urine for culture
+ve leukocyte AND -ve nitrate
→start abx for UTI if good clinical evidence, send urine for culture
-ve leukocyte AND +ve nitrate
→start abx for UTI, send urine for culture
-ve leukocyte AND -ve nitrate
→ don’t start abx tx, explore other causes for illness
When to send urine culture?
Age > 3 months
Dipstick +ve leukocyte OR nitrite
Serious illness
Suspected upper UTI (aka pyelonephritis)
Recurrent UTI
Not improving after 1-2. days of tx (and no previous urine sample)
When to consider imaging in UTI?
USS KUB routine (within 6 weeks)
- if age < 6months
- recurrent UTI
- looking for structural issues
USS KUB during acute infection
- if age < 6months AND recurrent UTI
- atypical UTI any age
What is atypical UTI?
Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Septicaemia
Failure to respond to abx in 48hours
Non- E-coli infection
What is recurrent UTI?
2+ episodes of acute pyelonephritis
1 episode pyelonephritis + 1+ cystitis (lower UTI)
3+ episodes cystitis/lower UTI
Differentials for diarrhoea and vomiting of 4 year old girl?
Gastroenteritis
Traveller’s diarrhoea
Food poisoning
Bowel obstruction
Appendicitus
Septicaemia
When to consider stool MC&S IVx for children?
Consider if:
- recent travel abroad
- diarrhoea > 7days
- want to rule out gastroenteritis
Definitely send a stool culture if:
- suspect sepsis
- blood or mucus in stool
- immunocompromised pt
What must you do before starting antibiotics for sepsis?
Take a blood culture
What must you check for before giving IV fluids?
Electrolytes and glucose
Sodium
Potassium
Chloride
Creatinine
This will indicate what else you need to give with the IV fluid.
What does blanching rash mean?
Rash disappears when pressed on.
Differential diagnosis for non-blanching red/pink rash spots over legs and buttocks in a 3 year old?
Viral illness
Niessera meningitidis
Henoch Schonlein Purpura (HSP)
ITP
Leukaemia or lymphoma
Other infections (Strep pneumonia, H influenza)
IVx for purpuric rash?
FBC
Coagulation screen
CRP
Glucose
Blood gas
Blood MC&S
N meningitidis PCR
When should you do CT head in a child?
CT head if:
- GCS <10
- focal neuro
- fluctuating consciousness
Reasons for CT within 1 hour?
Suspect non-accidental injury (NAI)
Post-traumatic seizure (no PMHx of epilepsy)
GCS <14
1 year old and GCS <15
GCS <15 -2hrs after injury
Skull fracture or tense fontanelle
Focal neurological deficit
Age < 1year: bruise, swelling, laceration >5cm on the head
Witnessed loss of consciousness (LOC) > 5mins
Amnesia >5mins
Abnormal drowsiness
≥ 3 discrete episodes of vomiting
Dangerous mechanism of injury
If pt has one of the following from above second section, then observe for 4 hours.
