Paeds Ix/Mx Flashcards
What ix to perform when suspecting DKA?
Beside:
- General and abdo exam (acetone smell on breath, Kussmaul)
- GCS
- Obs: look for signs of dehydration or hypovolaemic shock
- Weight
- Urine dip for glucose and ketones
Bloods:
- VBG: metabolic acidosis, high anion gap
- Ketones, glucose
- FBC
- U+E: low Na, high K
- Blood culture
Later on = consider screen for other autoimmune: coeliac, Addison’s, thyroid
Mx of DKA?
Initial:
- ABCDE (if reduced consciousness / vomiting may need NG tube)
- Call senior
- Fluid bolus (10ml/kg if non-shocked, 20ml/kg if shocked)
- Calculate fluid requirements (maintenance + deficit + 40ml KCl)
- 1-2 hrs after starting infusion -> Insulin infusion
Once stable:
- Intense monitoring including catheter for fluid input and output
- Glucose and ketones every hour
- VBG, electrolytes - If declining: senior review, ITU
- Once glucose drops <14: add 5% dextrose to fluids
Follow-up:
- MDT: paediatric endocrinologists, specialist nurse, dietician, psychologist , GP and advise parents to liase with schools
- Seen in clinic
- Insulin regimens, glucose monitoring, diet modification
- Leaflets (Diabetes.org.uk)
- Care plan for school for hypogyclaemia
DDx for DKA?
- Addisonian crisis
- UTI
- Gastroenteritis
- Hypoglycaemia
Important Qs to ask when considering appendicitis?
Precipitants: funny foods, recent resp illness, history of constipation
Central periumbilical colicky pain → shift to localised and constant RIF pain
Nausea, vomiting
Anorexia
Bowel movements, passing urine
TRIAD (Low fever, RIF pain, N+V)
Ix for appendicitis?
ABCDE approach
Bedside:
- Basic obs
- Abdo exam
- Urinalysis (if female 12+ UPT as well)
Bloods:
- WCC, CRP, BR, amylase
- Cross match, clotting = prep for surgery
Ultrasound if doubt over diagnosis or for complications e.g. abscess, perforation, mass
Can use the alvarado score to determine the likelihood of appendicitis
If clinical signs present however investigations are negative can perform diagnostic laparoscopy and proceed to appendicectomy if indicated
What are some specific signs to look out for in appendicitis?
Rovsing: palpation of LIF causes pain in RIF
Psoas: pain on hip extension (retrocaecal appendix)
Cope: pain on hip flexion and internal rotation (close to obturator internus)
DDx for appendicitis?
Pyelonephritis, UTI
Mesenteric adenitis: higher fever, systemic features: headache, photophobia - More generalised tenderness, no guarding, preceding URTI, lymphocytosis
Meckel’s diverticulitis -> infected, intussusception, volvulus
Gynae related - Ectopics + Ovarian cysts
Mx of appendicitis?
Progressive condition hence repeated observation + clinical review every 4h
Medical: NBM, NG tube, IV fluids, analgesia, antiemetics, IV antibiotics (cef and met)
If generalised guarding consistent w perforation - fluid resus + IV Abx given prior to laparotomy
Surgical emergency: laparoscopic appendicectomy
- With peritoneal lavage if perforation
Follow-up in clinic
Complications of appendicits v complications of appendicectomy?
Perforation -> peritonitis, ischaemia, sepsis, death
Abscess
Appendix mass
Bleeding, infection, pain and scars, damage to bowel and surrounding organs, risks of anasthetics and VTE
What are the key questions to ask in a patient when suspecting intussusception?
Episodic colicky abdo pain: screaming, drawing legs up, pale around mouth
Vomiting: may be bilious
Mucus / blood in stool (redcurrant jelly)
Late: abdo distension and shock → peritonitis
Birth history: delayed meconium passage
What are the main DDx for intussusception?
- Colic
- Volvulus
- Polyps
- Meckel’s Diverticulum
- Inflamed appendix
- Lymph nodes
- Ileal duplications
- Tumours
What is the mx of intussusception?
ABCDE approach
Medical: NBM, IV fluid resus, NG, analgesia, IV antibiotics
Interventional:
Rectal air insufflation (contrast enema)
CI: peritonitis, perforation, clinically unstable, shock (75% success)
Surgical reduction last line (notify paeds surgical team if above signs present + give broad spectrum abx)
If recurrent: investigate for pathological lead point e.g. Meckel’s diverticulum
Key questions to ask in a hx of tonsilitis?
Fever Cough, sore throat Rash, headache, drowsiness SOB / trouble breathing Adequate hydration, passing urine Previous episodes
Dx for tonsilitis?
Infectious mononucleosis, EBV
Acute epiglottitis
Retropharyngeal abscess
Ix for tonsilitis?
Bedside: Basic obs, ENT exam (checking for redness of tonsils + exudate, assessing cervical lymph nodes) – using the CENTOR Criteria to assess for likelihood of strep throat + checking for any signs of dehydration (also look to exclude scarlet fever – look for any rough rash, red strawberry tongue
If these are negative can consider further tests like urinalysis to look for antistreptolysin O titre and also blood tests to look for other causes of infection (including FBC, CRP, U+Es and blood cultures)
Mx for tonsilitis?
Advice: Ensure adequate fluid intake, eating soft foods
Analgesia: paracetamol/ ibuprofen, salt-water water gargling, lozenges and Difflam spray – can keep them off school until they’re feeling better to return
Use CENTOR criteria to determine the likelihood of bacterial + abx need:
• 1 point for: fever >38, no cough, LN, exudate, age 3-14 years
• 0-1: home and safety net
• 2-3: consider rapid antigen test for strep
• 4-5: antibiotics - Phenoxymethylpenicillin PO QDS for 10 days, Macrolide if allergic, Avoid amoxicillin = maculopapular rash if EBV
Hospital admission may be indicated if dehydrated and cannot swallow, have signs of clinical dehydration, quinsy, systemic illness or suspected rare causes such as diptheria or Kawasaki
If recurrent episodes occur (7+ in one year, 5/y for 2y or 3/y for 3y – referral to pediatric surgical team may be required for a tonsillectomy)
Questions to ask in epilepsy hx?
About the seizure
• Did anything happen before
• During: LOC, tongue biting, incontinence, cyanosis, jerky movements, how long for
• Post-ictal: how long to come around, drowsiness, confusion, weakness
Other:
• Predisposing events: unwell, fever, head injury
• FH of epilepsy
• FLAWS, headaches for SOL
Ix for epilepsy?
ABCDE approach
Bedside:
• Physical exam: general, neuro, cardio, look for skin lesions (Tuberous sclerosus or NF-1)
• Obs: fever, GCS
• Bloods: FBC, CRP, U+E, Capillary glucose level, prolactin, LP if considering infection like meningitis
• ECG: arrhythmias and long-QT
EEG (after 2nd tonic clonic seizure)
MRI brain imaging – if 1st seizure in children <2y, focal seizures or no response to 1st line anti-epileptics
Urgent referral to first fit clinic if suspect epilepsy
DDx for epilepsy?
Epilepsy: tendency for unprovoked seizures
SOL, meningitis, hypoglycaemia
Febrile convulsions
Congenital: neurocutaneous syndrome
Advice to give parents of children w epilepsy?
Alert school
Take video of next time
If happens again: protect from injury (move harmful objects) but do not restrain / put anything in mouth
Avoid unsupervised swimming or bathing until diagnosis
Specialist epilepsy nurse review
Mx of epilepsy?
GP referral –> Urgent referral of all patients having 1st epileptic seizure to neurologist, safety net –> seek help if another seizure happens before the referral
MDT: Pediatric neurologists, specialist epilepsy nurse (provide education and lifestyle advice to families), school should be made aware and psychologists
Conservative:
• Education: How to recognise a seizure, keep a diary with a record of things that may have triggered seizures to avoid, being careful in situations where a seizure could lead to injury eg. showers instead of baths, around traffic and heights and with hot / electrical equipment
• Support: Psychological help to adjust to condition, aiming to promote independence + confidence + Support groups such as epilepsy action can help with this
Pharmacological: Anti-epileptic drugs considered, after diagnosis (2 or more seizures)
• Generalized: sodium valproate first line, Lamotrigine / Carbamazepine (if F) - Side effects: increased appetite, weight gain, hair loss, CI if childbearing age
• Absence: Ethosuximide / Sodium Valproate
• Myoclonic: Sodium Valproate (or Levetiracem or Topiramate)
• Tonic or Atonic: Sodium valproate (or Lamotrigine + specialist referral)
• Focal: carbamazepine first line - Side effects: neutropenia, hyponatremia, enzyme inducer, rash
Tertiary care:
• Ketogenic diets - Low carbohydrates, fat-based
• Vagal nerve stimulation - Sometimes called the pacemaker of the brain
• Epilepsy surgery – only if well localized structural cause
• Cannabidiols may be used in rare cases in clinical trials undertaken
Ix of West Syndrome?
ABCDE approach
Bedside:
• Physical exam: general, neuro, cardio, look for skin lesions (Tuberous sclerosus or NF-1)
• Obs: fever, GCS
• Bloods: FBC, CRP, U+E, Capillary glucose level, prolactin, LP if considering infection like meningitis
• ECG: arrhythmias and long-QT
EEG – showing hypsarrhtmia in 2/3 of children
CT - diffuse or localised brain disease in 70% e.g. tuberous sclerosis
Mx of West Syndrome?
MDT approach: Pediatric neurologists, psychologists and school should be made aware in order to have a EHCP plan in place
Pharmacological:
• 1st Line – Vigabatrin (anti-seizure) & Prednisolone
• ACTH (hormonal therapy can also be used)
Mx of Febrile Convulsions?
Most are self-limiting
• Protect from injury, do not restrain, recovery position after
• Manage fever with paracetamol / ibuprofen, manage fluid intake
• Seek help if worsening symptoms / worried
• (Buccal midazolam if 5+ mins) – if 10 mins after seizure has’nt stopped / ongoing twitching + another seizure before regaining concioussness –> call an ambulance
Complex seizure defined as: • Prolonged >15 mins • Focal / partial in onset • Recurrence in same illness or within 24 hours • Incomplete recovery at 1 hour
Need hosp assessment by pediatrician if: • Complex seizure • Atypical features / indicators of CNS infection (vomiting, meningism) • <18 months • Focal neuro deficit
Follow up:
• Appointment with GP routine developmental assessment as developmental delay can be associated w/ risk of developing epilepsy
What advice should be offered to parents of a child with febrile convulsions?
30% chance of recurrence
Call ambulance if lasts >5 mins
Usually self-limiting
Majority of children have normal growth and development
One in three will have another febrile convulsion, Future risk of epilepsy is low
Increased future epilepsy risk if
• Complex seizure
• Positive FH of epilepsy
• Neuro abnormality or delayed development
What investigations are required for children w febrile convulsions?
ABCDE approach
Obs - Fever, HR, RR, BP
Physical exam: infection focus, exclude rash, neuro exam (normal), CV to rule out arrhytmia + any injuries sustained by seizure
Glucose
What ix in acute asthma?
Initial: • Examination, signs of resp distress • Obs including oxygen sats, temp • PEFR if >5 • ABG • Sputum sample if productive cough, Consider CXR
Determine severity of attack
Confirmatory tests of asthma diagnosis e.g. spirometry, FEV1 reversibility with bronchodilator, FeNO, asthma diary with diurnal variation of PEFR, skin prick for allergies, bloods (eosinophilia, IgE)
DDx for acute asthma?
- Foreign body inhalation
- Multiple trigger wheeze
- Resp infection
- Hyperventilation due to anxiety: normal PEFR, no wheeze
Mx of mild-moderate acute asthma?
Mx as OP = inhaled SABA through spacer
One puff of Salbutamol, every 30 seconds, max 10 puffs
Consider oxygen if sats <94%
Mx of moderate-severe acute asthma?
- Oxygen if sats <94% usually nasal cannulae + BURST therapy: back to back nebulisers
a. Salbutamol 5mg, every 20 mins - If refractory: add
nebulisers w/ salbutamol if that doesn’t work nebulizers w/ Ipratropium bromide - Steroids: oral prednisolone for 3 days
- IV Hydrocortisone – if this doesn’t work SENIOR HELP
- Monitor PEFR, oxygen sats
- Monitor ECG (tachycardia) and electrolytes (low K with bronchodilators)
- If not responding, 2nd line
i. Senior help
ii. IV MgSO4 – also acts as anti-HTN so monitor BP over 20 minutes
iii. IV salbutamol
iv. IV aminophylline (not given if pt already on theophylline)
v. ITU and intubation (call ITU, anesthetics and ENT – if requirement for Cricothyrotomy)
When to admit patients w asthma?
After inhaled bronchodilators
• Severe or life-threatening attack
• No adequate clinical response: still SOB, tachypnoea
• Signs of exhaustion e.g. normalising / rising CO2
• Reduced oxygen sats <92%
• Also if premature or significant medical hx
Discharge when
• Stable on using inhaled SABA less than 4 hourly (continue at home)
• PEFR >75%
• Oxygen >94%
What other things to look out for in patients w asthma?
- Antibiotics if infection
- Follow up with GP within 2 days: inhaler technique, asthma action plan for school
- Advise about PEFR monitoring and to seek advice if worsening = safety net
- Inhaler technique, which types to use when
- If parental smoking: advise about stopping
What are the key questions to ask about in acute asthma hx?
Dry cough, worse at night
SOB, wheeze
Precipitants: cold, exercise, recent illness, travel
Previous exacerbations, ITU admissions
Current meds, recent meds, adherence
Smoking, pets, allergies, atopy
Effect on school, play, sleep
Family history
What ix for whooping cough?
- Cardioresp exam
- Basic obs
- Nasopharyngeal aspirate or nasopharyngeal swab – PCR testing / bacterial culture to confirm infection <3w
Mx of whooping cough?
Admit if:
• < 6 months old or acutely unwell
• Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis)
• Significant complications e.g. seizures, pneumonia
Macrolide antibiotic: azithromycin or clarithromycin (2nd line – Co-trimoxazole)
Advice = Rest, adequate fluid intake + paracetamol / ibuprofen for symptomatic relief, avoid school for 48h after abx or 21d after cough started if not treated
Supportive: fluids, paracetamol, rest + macrolide prophylactically for close contacts
Notifiable disease
What are the key questions in a bronchiolitis hx?
Cough, sputum
SOB
Wheezy sounds
Runny nose, fever
Eating and drinking
Passing urine, stools
Playing as usual / more drowsy
Risk factors: • Prematurity, RDS • Underlying lung disease e.g. CF • Congenital heart defects • Down’s syndrome
DDx for bronchiolitis?
Viral induced wheeze = whenever get virus, causes wheeze
• Same as bronchiolitis
• But in Bronch: children usually <1 and unresponsive to steroids/dilators
Pneumonia
Ix for bronchiolitis?
ABCDE approach
Physical exam, resp, look for signs of dehydration, resp distress (raised RR, intercostal and subcostal recessions, nasal flaring or cyanosis)
Obs especially oxygen sats + Consider CXR and blood gas if resp failure suspected
Test for RSV via nasopharyngeal swab and PCR if child 1-2 (possibly VIW)
Consider CXR and blood gas if resp failure suspected
What mx for bronchiolitis?
Admit if:
• Apnoea
• Feeding 50-75% of normal
• Persistent sats <92% on air
• Severe resp distress / central cyanosis (E.g. grunting, marked recession, tachypnoea >60)
• Lower threshold for admission if (<3m, CLD + premature <32w)
Supportive management:
• Regular obs
• Paracetamol / ibuprofen for fever
• Oxygen if <92% - Consider optiflow (nasal), CPAP if impending resp failure
• Adequate intake – Oral or NG / orogastric tube if poor feeding
Infection control = isolate
What advice should be offered to parents of children with bronchiolitis?
Usual course: 3-5 days worsening, 3 days same, 3 days getting better, most will fully recover in 2w
Encourage regular fluid intake – small + frequent
Viral cause: RSV, consider parainfluenza, influenzae
Prophylaxis: Palivizumab for preterm high risk babies (preterm, downs, congenital HD)
DDx for ADHD?
- Conduct disorder
- Depression, anxiety
- Mania
Ix for children w ADHD?
This is likely to be ADHD but I’d like to refer patient to specialist for diagnosis
Assessment by child psychiatrist, paediatrician and educational psychologist
Questionnaires:
• Strength and Difficulties Questionnaire
• Conner’s Rating Scale
• Completed by child, parents and teachers
Info from school: reports, interview teachers
Physical exam • Height, weight, BMI • BP • Motor coordination Lipids, ECG = before meds
Consider hearing test
Mx of children w ADHD?
MDT approach including OT
Bio-psycho-social approach
<5y:
•Psycho-education w/ dietary advice (10w watchful waiting + food diary to see what influences hyperactivity)
•Referral to ADHD focused parent training group (Webster Stratton) – can be done whilst waiting on diagnosis Behavioural mx (praise + reward + rules w/ realistic expectations)
•Making environmental modifications to reduce distractions
> 5y:
•Psycho-education w/ dietary advice (10w watchful waiting + food diary to see what influences hyperactivity)
•Referral to ADHD focused parent training group (Webster Stratton) – can be done whilst waiting on diagnosis Behavioural mx (praise + reward + rules w/ realistic expectations)
•Making environmental modifications to reduce distractions eg. teaching assistants at school + regular breaks when doing work
•Meds:
•Stimulants e.g. Methylphenidate (Ritalin), first line
o Can cause appetite suppression → weight loss, insomnia
o Long term: weight gain, obesity
o Monitoring – Height (6m), weight (3m <10y then 6m), HR + BP (6m)
•Atomoxetine, second line
o Can cause appetite suppression and ECG abnormalities
Improve concentration and reduce impulsivity
Drug holidays recommended to prevent growth retardation
Consider CBT if medication helps but there is still significant morbidity
Questions to ask in ADHD?
- Does the child act the same at home and in school?
- School performance including concentration, dyslexia, learning disability
- Social interactions and friends
- Fidgety
- Tics/twitches, aggression, antisocial behaviour
- Disobedience
- Reckless / risky behaviours like crossing road without looking
- Clumsy, accident-prone
What questions should be asked in children w Coeliac?
- Faltering growth
- Abdo distension
- Vomiting: contents, blood
- Change in stools: diarrhoea / constipation, blood, mucus, steatorrhoea (pale, smelly)
- Adequate hydration and passing urine
- Irritability, fatigue: not playing as normal
- Rash
- Diet and weaning
- Specific triggers / foods
- Breastfed / formula
- Development milestones
- FH of coeliac (strong genetic component)
- Social history: known to social worker
DDx for children w/ failure to thrive?
- Coeliac
- Hypothyroidism
- Neglect
- Chronic diarrhoea: toddler’s diarrhoea (preschool child, undigested veg, improves with age), Giardia infection
- Lactose intolerance
What ix for children w Coeliac?
Bedside:
• Physical exam: buttock wasting, abdo distension
• Growth chart to identify growth stunting
• Obs
Bloods: FBC, Ferritin, U+E, TFT (assc w/ thyroid disease), LFTs, B12 + D, Ca, glucose (assc w/ T1DM)
Serology:
• Antibodies: anti-TTG IgA, anti-endomysial IgA - if positive then arrange biopsy
• Measure IgA to ensure no false negatives
Stool:
• MCS to exclude infectious causes, ova and cysts for Giardia
• Faecal fat tests
Definitive: duodenal biopsy on and off gluten diet (Villous atrophy, crypt hyperplasia, increased lymphocytes)
Mx of children w Coeliac?
MDT: Paediatric gastroenterologists, GP, refer to dietician, School nurses, school and psychologists
Diet advice: no gluten = wheat, rye, barley
Warn about risks: malabsorption, cancer
Consider calcium, vitamin D and iron supplements
Screen for associated autoimmune diseases e.g. thyroid, type 1 diabetes
GP: monitoring
• Weight, height, BMI
• Anti-TTG every 3 months then yearly once normalised
Consider bone scan for osteomalacia / osteoporosis
Dapsone topical antibiotic for dermatitis herpetiformis
