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Phase 3a > paeds ILA > Flashcards

paeds ILA Flashcards

1
Q

what is a septic screen?

A
  • blood culture - septicaemia (other bloods to consider = FBC, U&E, CRP, blood gas, coagulation profile, acute phase reactants ESR and CRP)
  • urine culture
  • stool swab
  • CSF - LP unless contraindicated
  • chest XR if indicated
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2
Q

why is a septic screen performed?

A

To identify the cause of infection – because in children often the come in with a temperature with no focus

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3
Q

how would bacterial meningitis show in the CSF?/

A
  • cloudy and turbid
  • opening pressure would be elevated
  • WBC elevated >100cell/uL
  • low glucose level (<40% of serum glucose level)
  • protein level will be elevated
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4
Q

what are the common causes of meningitis in newborns and in older children?

A

newborns: listeria monocytogenes, E.coli, Group B streptococci

Older children: Neisseria meningitides, haemophilia influenza type B

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5
Q

how would viral (aseptic meningitis present in the CSF?

A
  • appearance - clear
  • opening pressure - normal or elevated
  • WCC - elevated (primarily lymphocytes)
    glucose level - normal
    protein level - elevated (>50mg/dl)
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6
Q

if there was predominantly polymorphonuclear leukocytes/neutrophils in the CSF what would it suggest?

A

bacterial meningitis

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7
Q

if it was predominantly lymphocytes in the CSF what would it suggest?

A

viral meningitis

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8
Q

if there was a HSV meningitis what would you see that was different to CSF in other viral meningitis?

A

the glucose may be low where as usually it is normal

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9
Q

what are the causes of viral meningitis?

A 
herpes simplex virus 
enterovirus 
varicella zoster virus 
mumps
HIV
adenovirus
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10
Q

what would you see in CSF of someone with fungal meningitis?

A 
appearance - cloudy or clear 
opening pressure elevates 
WBC elevated 10-500 cells/uL
glucose low
protein elevated
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11
Q

what are the causes of fungal meningitis?

A

cryptococcus neoformans

candida

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12
Q

hoe would TB meningitis show on CSF?

A

appearance - opaque, if left to settle it forms a fibrin web
opening pressure elevated
WBC - elevated - early PMNs and then mononuclears
glucose level - low
protein level - elevated

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13
Q

The microbiologist rings to confirm a CSF white cell count of 500 with no red cells. The cells are predominantly neutrophils. CSF glucose is low and CSF protein raised. Gram film shows gram negative diplococci.
Later, Jon becomes hypotensive with a delayed capillary refill time, and develops tachycardia and a purpuric rash.
diagnosis?

A

meningococcal septicaemia with meningitis

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14
Q

what is the immediate management of meningococcal septicaemia with meningitis?

A 
ABCDE approach 
A - airway 
B - breathing 
C - circulation, IV access, bloods, fluid bolus, antibiotics
D - disability - AVPU
E - environment - temp and glucose
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15
Q

if a child presents with meningococcal septicaemia shock what fluids would you prescribe?

A

20mls/kg 0.9% sodium chloride fluid bolus over 10 mins

if no improvement then repeat but this can lead to pulmonary oedema

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16
Q

what fluid bolus would you give in trauma or DKA?

A

10ml/kg 0.9% sodium chloride over 10 minutes

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17
Q

what antibiotics should be given for meningococcal septicaemia?

A

third gen cephalosporin e.g. IV ceftriaxone
it is able to cross the blood brain barrier and it is a broad spectrum antibiotic with activity again gram positive and negatives to cover most likely organisms

if under 3 months give cefotaxime

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18
Q

what causes the purpuric rash in meningitis?

A

they are caused by bleeding underneath the skin
caused by DIC
consumptive coagulopathy
bacteraemia leads to widespread thrombosis in microvassaculature, platelets being used up and clotting factors not being produced by liver which leads to bleeding tendancy

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19
Q

what measures should be taken to stabilise and manage a patient with meningococcal septicaemia?

A

airway and breathing management - intubation and ventilation
circulation - fluid bolus/fluid management
vasoactive agents - vasosupressors and inotropic agents

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20
Q

how would meningitis be spread?

A

exchange of respiratory secretions

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21
Q

what is the first line treated that is recommended to reduce the risk of meningitis in those who have been in close contact with someone who has had it?

A

prophylactic treatment with rifampicin or ciprofloxacin to eradicate nasopharyngeal carriage - for meningococcal
flu vaccination for those with Hib infection

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22
Q

what is classified as close contact when conisdering prophylaxis for meningitis?

A

those who have prolonged close contact with the case in a household type setting during seven days before the onset of the illness
e.g. living/sleeping in same household, pupils in same dorm, boyfriend/girlfirend, uni students sharing kitchen in halls

23
Q

when should rifampicin be avoided?

A

people with severe liver disease
should try to be avoided in those who are on medication for epilepsy

  • it is fine in breast feeding
24
Q

what are the side effects of meningococcal prophylaxis?

A

Side effects of ciprofloxacin – common – diarrhoea, dizzieness, headache, nausea and vomiting.
Side effects of rifampicin – hepatitis, orange urine and tears, interaction the with contraceptive pill, flu like symptoms.

25
Q

Laura, a two year old, presents to her general practitioner with a two month long history of malaise, pallor and reduced appetite. She has occasional febrile episodes, associated with a pink rash, and with a persistent complaint of soreness in her left thigh. Despite walking at the age of 13 months, she is now reluctant to weight bear. Her birth and development history show no concerns and all her immunisations are up to date.

what aspects of clinical examination are important?

A

full clinical examination - particularly CVS, euro, gastro, skin
fundoscopy - to check for uveitis
height and body weight

26
Q

Laura, a two year old, presents to her general practitioner with a two month long history of malaise, pallor and reduced appetite. She has occasional febrile episodes, associated with a pink rash, and with a persistent complaint of soreness in her left thigh. Despite walking at the age of 13 months, she is now reluctant to weight bear. Her birth and development history show no concerns and all her immunisations are up to date.

low grade fever and generalised cervical lymphadenopathy, walks with a limp but no discomfort - rest of examination pretty much unremarkable.

DD??
what further tests would you want to perform?

A

transient synovitis - very common
infection (osteomyelitis, septic arthritis)
malignancy (leukaemia, lymphoma, neuroblastoma)
connective tissue disorder (SLE, RA)
juvenile idiopathic arthritis

Bloods
Xray/USS of limb
echo

27
Q

what is juvenile idiopathic arthritis?

A

Systemic onset – rash, temp
Oligoarthritis (less than 4 joints) JIA more common – more common in girls
When you are thinking about if a child has JIA then test for their ANA +ve because in increases their risk of chronic anterior uveitis.
there will be raised ESR
JIA - rash that comes on with temp and inflammation of the synovium

28
Q

in children with JIA who is common to develop uveitis?

A

girls
under 7 years, especially if under 4 years
oligoarticular subtype
antinuclear antibody (ANA) positive on blood tests

29
Q

how is JIA managed?

A

it a chronic childhood disease so needs an MDT
NSAIDs for early therapy - pain relief, anti-inflammatory and anti pyretic

Longterm - DMARD (disease modifying anti-rheumatic drug - methotrexate
2nd line - TNF alpha inhibitors e.g. infliximab

alternatives - intra-articular corticosteroid injections - if only a few joints affected, systemic corticosteroids, cytokine modulators

teams involved - paediatric rheumatologist, nurses, physics, OTs, social workers, paediatric opthalmologist, dietician, school lesion workers, GP, child psychology

30
Q

Jirou, a three year old boy presents with a seven day history of high fevers. He has now developed red eyes, a rash and is complaining of a sore mouth and throat.
On examination he appears miserable and unwell with a diffuse maculopapular rash mainly on his torso. He has bilateral injected conjunctiva, red cracked lips and a strawberry tongue. He has a unilateral 3cm x 2cm cervical swelling, and swollen reddened palms.

DD?

A

Scarlet fever – group A beta haemolytic strep
Measles
Toxic shock syndrome caused by staphylococcal toxins
Staphylococcal scolded skin syndrome – fluid filled blisters
Kawasaki disease

31
Q

what is Kawasaki disease and what criteria are used to diagnose it?

A

Kawasaki disease- a systemic vasculitis, common in children of a Japanese origin

Criteria
the presence of a fever for five days plus four of the five criteria constitutes Kawasaki disease
MY HEART
M- mucosal involvement - dry lips and strawberry tongue
H - hands and feat with oedema and desquamation
E - eyes - non-perulent conjunctivitis
A - adenopathy - unilateral, cervical
R - rash usually truncal and pleomorphic
T temp non remitting for at least 5 days

32
Q

what is the management of Kawasaki disease? and complications of the treatments?

A

IV Immunglobulin in the first 10 days and aspirin (to reduce risk of thrombosis)

IVIG- anaphylaxis, renal failure, headache, myalgia, N&V
Aspirin - reyes, bleeding/bruising, GI upset

children with giant coronary aneurysms may require long term warfarin

33
Q

what further investigations would you perform for Kawasaki disease?

A

echo - to look for coronary artery aneurysm
magnetic resonance angiography
cardiac catheterisation and angiography

34
Q

what is the long term prognosis of Kawasaki disease?

A
  • usually an acute, self limiting illness,
  • overall mortality is less than 0.05%
  • if left untreated it can be associated with significant morbidity and mortality
  • IVIG immediately improves outcome
35
Q

what is the emergency management of an unwell child with 5% dehydration?

A

A - intubation if needed
B- 100% oxygen
C - perfusion, blood sample, HR, BP, fluids

Blood investigations

36
Q

what would be suggestive of DKA and so not to give normal fluid bolus?

A

if the child had been drinking a lot and peeing a lot

37
Q

child is 5% dehydrated with DKA - what fluids do you give them?

A

only give fluid bolus if necessary - 10mls/kg 0.9% sodium chloride

deficit: assume 5% deficit if pH >7.1, assume 10% deficit if pH below 7.1 - give deficit fluids over 48 hours
10% deficit - 100mls/kg
5% deficit 50mls/kg

DKA reduced maintenance volume rues
<10kg - 2ml/kg/hour
10-40kg - 1mls/kg/hour
>40 kg - 40mls/hour

*ensure all fluids contain potassium chloride apart from bolus

38
Q

in someone with DKA when should you start insulin

A

1-2 hours after fluid administration
0.05-1 unit/kg/hour
monitor - cap blood glucose, vital signs, fluid balance, level of consciousness

39
Q

some one with DKA, their blood glucose is now <14, how do you manage?

A

if ketones <3: 0.9% NS, glucose 5%, KCL 20mmmol in 500ml and maintain or reduce insulin 0.05 unit/kg/hour

ketones >3: glucose 10%, KCL 20 mol in 500ml and maintain insulin at 0.05-0.1 unit/kg/hour

40
Q

what are the complications of DKA management?

A

hypoglycaemia, hypokalaemia, hpoxaemia, pulmonary oedema

cerebral oedema is a rare but potentially fatal complication - avoid rapid fluid and electrolyte replacement

41
Q

what are the symptoms of DKA?

A

increased thirst, polyuria, recent unexplained weight loss or excessive tiredness along side any of the following symptoms

  • nausea and vomiting
  • abdominal pain
  • hyperventilations
  • dehydration
  • decreased level of consciousness
42
Q

10 day old neonate with TSH very high? what is the likely diagnosis?

A

congenital hypothyroidism

43
Q

what are the most likely causes of congenital hypothyroidism?

A

world wider - iodine deficiency
in the uk - dysgenesis thyroid gland defects - a missing or ectopic or poorly developed thyroid gland
consanguineous (cousins) (dyshormonogeneis) - a problem with the hormone production line

44
Q

how can you distinguish between dygenesis and dyshormonogenesis causes of congenital hypothyroid?

A

radioisotope and USS examination

45
Q

what is the screening for congenital hypothyroid and what has this helped prevent?

A

Guthrie test

prevents cretinism - stunted mental and physical growth

46
Q

what does the Guthrie test screen for?

A

congenital hypothyroidism
sickle cell disease
CF
inherited metabolic diseases

47
Q

how is congenital hypothyroidism managed?

A

thyroxine - levothyroxine

48
Q

what are the differentials for an unwell neonate (collapsed and shocked)?

A 
sepsis/infection 
congenital heart defects
surgical emergencies 
inborn errors of metabolism 
congenital adrenal hyperplasia
49
Q

what would you see on investigations for CAH?

A 
hyponatremia 
hyperkalemia 
hypoglycaemia 
acidosis 
elevated hydroxyprogesterone 
rapid ACTH stimulation test 
plasma renin-aldosterone
50
Q

how would a baby girl with CAH present?

A

ambiguous genitalia

51
Q

could CAH be managed antenatally?

hoe is CAH managed subsequently?

A

dexamethasone

glucocorticoid (hyrdrocortisone) and mineralocorticoid (fludrocortison) with sodium chloride supplementation

52
Q

how do males with CAH present?

A

they usually present with a neonatal salt losing crisis - usually within the 1st 4 weeks of life

53
Q

long term complication of meningitis (always comes up in exams)

A

SENSORINEURAL DEAFNESS

Phase 3a (41 decks)

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