Paeds peer teachings Flashcards
Breathless (L to R) congenital defects
VSD PDA ASD
Cyanotic (R to L) congenital defects
Tetralogy of fallot Transposition of the great arteries
Pulse in PDA
Bounding
Treatment of PDA
NSAIDs or surgical ligation
4 components of tetralogy of fallot
Pulmonary stenosis VSD Overriding aorta Right ventricular hypertorphy
Signs and symptoms of tetralogy of fallot
Severe cyanosis, HY hypercyanotic spells on exercise, crying and defecating. Ejection systolic murmur Clubbing
Management of tetralogy of fallot
Surgery at 6 months, close VSD and relieve pulmonary outflow obstruction
How does transposition of the great arteries work
Pulmonary artery and aorta swap.
Signs and symptoms of transposition of great arteries
Presents at 2 days with severe cyanosis (after PDA closes)
Management of transposition of the great arteries
Prostaglandin infusion to maintain PDA Surgical- atrial sepstostomy
Cardiac outflow obstruction in a well child
Pulmonary or aortic steonsis
Cardiac outflow obstruction in a . sick child
Coarctation of the aorta
Describe pulmonary stenosis
Pulmonary valve leaflets partially fused together, obstructs RV outflow
Signs and symptoms of pulmonary stenosis
Asymptomatic. Ejection systolic murmur and palpable thrill
Where will the ejection systolic murmur be heard in pulmonary stenosis
Left upper sternal edge
Where will the ejection systolic murmur be heard in pulmonary stenosis
Right upper sternal edge
What does bile stained vomit suggest
Intestinal obstruction
What does haematemesis suggest
Pepti ulceration Gastritis Oesophageal varices
What does projectile vomiting suggest
Pyloric stenosis
What does abdominal pain on movement suggest
Surgical abdomen- appendicitis
What does blood in the stool suggest
Intussusception Gastroenteritis
What does severe dehydration suggest
Severe gastroenteritis Diabetic ketoacidosis Systemic infection
What are headache or seizures a red flag for
Raised intracranial pressure
What is failure to thrive a red flag for in a vomiting infant
GORD Coeliac disease
Blood results for a vomitting child
Hypokalaemic Hypochlroaemic Metabolic alkalosis Dehydration
Gold standard test for pyloric stenosis
Test feed
How does a test feed work
NG tube insertion and aspiration to empty the stomach, small feed of dioralyte. Examiners fingers placed just below the liver edge- olive mass palpable indicates a stenosed pylorus
How do you treat pyloric stenosis first line
Calculate and commence maintenance fluids
What is the surgery for pyloric stenosis
Ramstedts pyloromyotomy
What are the three components of fluids
Bolus (severe dehydration), maintenance (as nil by mouth), replacement (to replace ongoing NG losses)
GORD symptoms
Recurrent regurgitation, feeding difficulties, arching of back and neck, sore throat
Investigation for GORD
pH impedance study, 24 hour pH probe
Management of GORD
Smaller and more frequent meals, feed thickeners, optimise position
Symptoms of cows milk protein intolerance
Abdominal pain, eczema, flatulence, bloody stools, diarrhoea or constipation
Investigation of cows milk protein intolerance
Skin prick or specific IgE antibody testing
Management of cows milk protein intolerance
Cows milk elimination diet, hypoallergenic infant formula, mother to avoid cows milk
Symptoms of intestinal obstruction
Billous vomiting, constipation, abdominal pain
Investigation of intestinal obstruction
Ultrasound, abdominal X ray, contrast study
Treatment of intestinal obstruction
Surgical intervention
Symptoms of vomiting caused by gastroenteritis
Diarrhoea and vomitting and abdominal pain
Symptoms of vomitting caused by UTI
Isolated vomitting
Symptoms of vomitting caused by meningitis
Also altered responsiveness
Investigation of vomiting caused by infection
Find the source of infection: cultures, urine dipstick, lumbar puncture
What three things are needed for a fluid prescription
Fluid constituents and bag size (500mL) Rate of administration (mL/hr) Signature of the prescriber
How do you estimate the weight of a child
(Age +4) x 2
What questions do you want to ask before you prescribe fluids
Weight? change in past 24hr Fluid input and output in past 24hr? Fluid status? Recent bloods?
What type of fluid do you give normally for maintenance
NaCl 0.9% + Dextrose 5% + KCl 10mmol
What is an upper limit for girls fluids in 24 hr
2 litres
What is an upper limit for boys fluids in 24 hr
2.5 litres
fluid requirement for 0-10kg
100mL/kg
fluid requirement for 10-20kg
50mL/kg
fluid requirement for above 20kg
20mL/kg
How to calculate percentage dehydration if weights not known
clinical assessment
How to calculate percentage dehydration
well weight (kg) - current weight/ well weight x100
How do you calculate the fluid defecit (mL)
%dehydration x wieght x 10
What percentage dehydration will someone with increased thirst but no others signs of dehydration be
Less than 5%
If a child is dehydrated but no shock what do you assume the % dehydration to be
5
Red flags of dehydration
Unwell or deteriorating Altered responsiveness Sunken eyes Tachycardia Tachypnoea Reduced skin turgor
Signs of clinical shock
Decreased LOC Pale or mottled skin Cold extremeties Weak peripheral pulses Prolonged cap refill time Hypotension
What percentage dehydration is someone in shock
8-10%
What fluid is in fluid boluses
Sodium Chloride at 0.9% at 20ml/kg
When might you need a 10ml/kg bolus
Diabetic ketoacidosis Trauma Primary cardiac pathology e.g. heart failure
Do you include boluses in total fluid requirement calculations
No
What should you do if youve given more than 3 boluses
Call for paediatric intensive care support in case the child deteriorates into pulmonary oedema
What fluid do you give to neonates
10% dextrose
How much do you give in first day of life
50
how much do you give in second day of life
70
how much do you give in 3rd day of life
90
how much do you give in 4th day of life
110
how much do you give in 5th day of life
130
How do you add electrolyte support from day 2 onwards in fluid support of neonates
3mmol Na, 2mmol K
Name the causes of wheeze
Asthma Bronchiolitis Viral induzed wheeze Pneumonia
Name the causes of stridor
Croup Epiglottitis Bacterial tracheitis Diptheria Laryngomalacia Inhaled foreign body Angioedema Anaphylaxis
Signs of respiratory distress
Cyanosis Tracheal tug Subcostal and intercostal recessions Hypoxia Tahcypnoea Wheeze (Stridor, head bobbing)
Presentation of pneumonia
Cough, fever, tachypnoea, chest recession, nasal flaring, head bobbing, hypoxia, hypotension, confusion, shock
Which is the most common cause of pneumonia
Streptococcus pneumonia
What pneumonia occurs in prevaccinated and neonates
Group B strep
What x ray findings would make you think the pneumonia was caused by staphylococcus aureus
Pneumatoceles (round air filled cavities) and consolidations in multiple lobes
Which pneumonia occurs in prevaccinated/ unvaccinated children
Haemophilus influenza
What organism is to blame if the child gets pneumonia and also erythema multiforme
Mycoplasma pneumonia
What is the most common and one other viral cause of pneumonia
RSV is the most common Influenza can also cause
Which children get more viral pneumonia
Under 2s
Investigations for pneumonia or sepsis
Chest Xray Blood cultures and sensitivities FBC Sputum cultures and throat swabs Viral PCR Capillary blood gas
Neonates pneumonia treatment
IV broad sprectrum antibiotics
Older children pneumonia first line
Amoxicillin
Older children second line treatment for pneumonia
Erythromycin
What do you add on to pneumonia treatment if associated with influenza
Co amoxiclav
Why do you add in erythromycin to pneumonia treatment
Covers the atypical pneumonia
Presentation of acute asthma attack
Progressively worsening shortening of breath, signs of respiratory distress, tachypnoea, expiratory wheeze, reduced air entry
What is an ominous sign in an acute asthma attack
Silent chest
Signs of moderate asthma attack
SpO2 >92 no clinical features of severe asthma
Signs of a severe asthma attack
SpO2 <92 Too breathless to talk or feed Heart rate over 140 Resp rate over 40 Use of accessory neck muscles
Signs of a life threatening asthma attack
SpO2 <92 Silent chest Poor respiratory effort Agitation Altered LOC Cyanosis
What is the limits on how many puffs of salbutamol you can have in an acute attack
1 puff every 30-60s, up to a max of 10
What are the first 4 steps in acute asthma management
- supplementary high flow oxygen 2. nebulised salbutamol 3. nebulised ipratropium bromide 4. oral prednisolone
What can you give IV in an acute asthma attack
Hydrocortisone Salbutamol Aminophylline Magnesium sulphate
What should the peak flow be in an asthma patient be after treatment, before going home
Over 75%
What can salbutamol cause
Tachycardia, hypokalaemia and tremor
What are the other things that need doing during an acute asthma attack
Call anaesthetist and intensive care unit Intubation and ventilation Prescribe reducing routine of salbutamol Finish course of pred Safety net info, 1 week GP follow up Written asthma action plan
What is the atopic triad
Asthma Eczema Hay fever (and food allergies)
What are the 1st 2nd 3rd line treatments of asthma in an under 5
SABA- Salbutamol Low dose corticosteroid LTRA- oral montelukast
What is the treatment regime for asthma in an older child
SABA Low dose CSI LABA- Salmeterol Medium dose CSI LTRA High dose CSI
Questions for the asthmatic child
What are your symptoms When do you get them Worse at night or morning How often do you use your blue inhaler Have you been hospitalised before Has your exercise tolerance reduced Is it worse in the cold What seems to trigger them Do you have hayfever or allergies Family history
Symptoms of anaphylaxis
Urticaria, itching, swelling of lips, tongue, eyes. Wheeze, stridor, SOB, tachycardia, abdo pain, collapse, hypotension
Management of anaphylaxis
ABCDE, oxygen, IV fluids, IM adrenaline, hydrocortisone IV and antihistamines oral
How often can you repeat IM adrenaline
After 5 mins
What should you measure in anaphylaxis
Tryptase
Presentation of viral induced wheeze
2yo, cold like symptoms, fever, runny nose and an expiratory wheeze
Cause of viral induced wheeze
RSV or rhinovirus Small amount of oedema and narrowing leads to a proportionally larger restriction in airflow
What makes you think viral induced wheeze not asthma
Under 3 No atopic history Only occurs during viral infections
Treatment of viral induced wheeze
Supplementary oxygen Salbutamol and inhaled corticosteroids and montelukast
Bronchiolitis cause
Winter borne viral URTI in under 2s, most common RSV
2 key symptoms of bronchiolitis
Wheeze and inspiratory crackles
Pathology of bronchiolitis
Mucus production and inflammation results in airway narrowing and alveoli collapse
Diagnosis of bronchiolitis
Nasal swab
Chest X ray findings in bronchiolitis
Broken ribs, flattened diaphragm, atelectasis (sac collapse)
Red flags for bronchiolitis presentation
Premature, downs or CF Less than 3/4 of normal milk intake Dehydration signs Oxygen sats below 92 Moderate to severe resp distress
Treatments for bronchiolitis
Consider NG feeds and IV fluids High flow humidified oxygen CPAP
What is palivizumab
Monoclonal antibody against RSV
Who can get palivizumab and how often
Monthly CF, premature, chronic lung disease, immunodeficient kids
Monitoring for bronchiolitis
Capillary blood gas (T2 Resp failure) O2 % (over 92)
Presentation of laryngotracheobronchitis
6mnths-6yrs Stridor, barking cough and coryzal
Causative organism in croup
Parainfluenza virus
Pathology of croup
URTI causes oedema in the larynx
Key symptoms of croup
Barking or seal like cough Stridor/ hoarse voice
Treatment of croup
Dexamethasone 0.15mg/kg Oxygen Nebulised budesonide and adrenalin
What shouldnt you do
Examine the throat
Presentation of acute epiglottitis
Foreign child comes in drooling, unable to speak, inspiratory stridor. Sitting upright and leaning forwards helps.
Causative organism of acute epiglottitis
Haemophilus influenza b
Signs and symptoms of acute epiglottitis
Drooling, sore throat, dysphagia, stridor, fever, septic
What does laryngoscopy show in acute epiglottitis
Beefy red stiff oedematous epiglottis
What does a lateral x ray of the neck show in acute epiglottitis
Thumb sign
Treatment of acute epiglottitis
ITU- Nasotracheal intubation. IV ceftriazone and dexamethasone
Which drug for close contact prophylaxis for haemophilus influenza b
Rifampicin
Presentation of laryngomalacia
6 month old infant, intermittent chronic stridor worse on feeding and crying. No other signs of respiratory distress
Pathology of laryngomalacia
Congenital. Supraglottic larynx causes partial airway obstruction. Inspiratory stridor when larynx flops across the airway
What is an omega shape epiglottis on bronchoscopy suggestive of
Laryngomalacia
What is the treatment for laryngomalacia
Leave Should resolve within 18 months
What is the presentation of whooping cough
No vaccine. Coryzal, violently coughing so much it vomits, gasps, inpiratory whoop. Goes blue. Worse at night. 100 day cough
Causative organism of whooping cough
Bordetella pertussis
What does bordetella pertusis look like under the microscope
Gram negative cocobacilli
Diagnosis of whooping cough
Per nasal pharynx swabs and culture for pertussis Anti-pertussis toxin IgG
Treatment for whooping couhg
Part of the 6 in vaccine Erythromycin
When is the 6 in 1 vaccine given
2, 3, 4 months and 3-5 years
Complications of whooping cough
Bronchiectasis and pneumothorax
Which specific mutation causes cystic fibrosis
delta F508
What causes cystic fibrosis
Autosomal recessive Cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
Key signs and symptoms of cystic fibrosis
Thick pancreatic and biliary secretions Thick airway secretions (=bacterial colonisation) Absence of the vas deferens Meconium ileus
What is meconium ileus
Not passing meconium within 24 hours, causing abdominal distension and vomiting
Presentation of cystic fibrosis
Salty tasting baby Nasal polyps Finger clubbing Failure to thrive Foul smelling, floating poos
Later presentation of cystic fibrosis
recurrent lower respiratory tract infections, failure to thrive or pancreatitis
What is the gold standard for cystic fibrosis diagnosis
Sweat test
How else can cystic fibrosis be tested for
Newborn blood spot testign Genetic testing for CTFR gene by amniocentesis or CVS
How do you treat pseudomonas colonisation
Nebulised antibiotics (tobramycin) and oral ciprofloxacin
How do you treat staph aureus colonisation
Prophylactic flucoxacillin
