Paeds revision lectures Flashcards
What is a seizure?
An abnormal surge of electrical brain activity.
Clinical phenomena resulting from abnormal and excessive excitability of the neurones of the cerebral hemispheres
What is epilepsy?
2 or more unprovoked epileptic seizures
What are the symptomatic causes of seizures?
Infection (meningitis/encephalitis)
Metabolic disturbance (hypoglycaemia and calcaemia, hyperammonaemia)
Trauma
Vascular (haemorrhage/stroke)
Toxins (iatrogenic- recreational or prescribed)
What investigations would you do in epilepsy?
EEG (normal does not exclude epilepsy and abnormal does not mean epilepsy)
MRI (particularly in focal seizures or if they have other neurological deficits)
Potentially metabolic bloods, LP, Urine
Genetics
What is the main useful thing about an EEG?
Classifying the epilepsy after it has been diagnosed
What are the differential diagnoses of seizures in infants ?
Bengign sleep myoclonus Benign myoclonus of infancy reflux Shuddering attacks Self gratifications Benign paroxysmal upgaze Spasmus nutans
What are the differential diagnoses of seizures in early childhood?
Breath holding attcks Reflex anoxic seizures Daydreaming Tics Stereotypies Syncope Parasomnias Shuddering attacks Tantrums Movement disorders Vertigo type syndromes
6 months old. Episodes of shaking head when excited, not with it. Normal development Normal examination Diagnosis?
Shuddering attack
18 months old
Lies on floor, stiffens up, crosses legs, starts in high chair.
Flushed, looks happy.
Normal development and normal examination
Diagnosis?
Self gratification
14 year old girl Feels hot, dizzy Vision closes in, goes black Collapses Can't hear what's going on, can't move Ok after a couple of minutes. Diagnosis?
Syncope
13 year old girl.
Night time episodes of shaking - all four limbs, rhythmic, unresponsive, sometimes gets up, confused.
Video - brief repetitive jerks of arms/hands
Diagnosis?
Clonic seiures
What are the classifications of epilepsy?
Tonic Clonic (normally repetitive) Tonic-clonic Myoclonic (often occurs in isolation) Atonic Absence Epileptic spasm
Summary of childhood absence epilepsy?
Starts age 4-7 years
Frequent absence seizures - 5-15 seconds, abrupt offset/onset, precipitated by hyperventilation, multiple times a day
Usually otherwise normal
What is the characteristic ECG in absence epilepsy?
Characteristic ECG - 3Hz spike/wave
What is the prognosis of absence epilepsy?
Good response to medication
Most outgrow in puberty 10% have generalised tonic clonic seizures in adulthood
Summary juvenile myoclonic epilspsy?
Starts usually 12-16 years
More common in girls
Myoclonic seizures
Can occur with absence and general tonic-clonic seizures
Summary genetic generalised epilepsy?
Idiopathic GTC alone Age of onset variable over 5 years old Occur in the morning Investigate - photosensitivity Treat - sodium valproate
How do you treat epilepsy?
None
Rescue medication - buccal midazolam
Regular medication - depends on seizure type and syndrome
Ketogenic diet
Epilepsy surgery - resective; corpus callosotomy
When should you not prescribe sodium valproate?
For girls of childbearing age (after periods start).
Unless it is a last resort.
Need to go on a pregnancy prevention programme
Summary febrile seizures?
Not epilepsy 6 months - 6 years 5% of children have one Seizure assocaited with fever (rate of rise) Usually GTC and less than 5 minutes Risk of epilepsy in later life - 2-5%
What is a complex febrile seizure?
Duration over 15 mins
Focal
Occurs within same illness
What’s in a septic screen?
Blood cultures MC&S CXR LP Throat swabs/skin swabs (FBC/CRP)
Why would you do blood cultures?
Bacteraemia/sepsis
What is sepsis
Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure and death
What can cause sepsis?
Anything: bacterial, viral, fungal, parasitic
What are the red flags for sepsis
Inappropriate tachycardia
Temperature <36 or >38.5
Altered mental states (sleeping, irritability, lethargic, floppiness)
Reduced peripheral perfusion/ prolonged cap refil/ reduced urine output
What is bacteraemia?
Presence of bacteria in the blood stream - not sepsis
What are the important causes of bacteraemia in neonates?
Group B strep
E. coli
Listeria
Coagulase negative staph (if they have complex neonatal history)
What are the important causes of bacteraemia in infants/young children
Strep pneumonia H influenza Staph aureus Group A strep Neisseria meningitidis Gram negative organisms (E.coli)
What are the important causes of bacteraemia in adolescents?
Neisseria meningitidis
Staph aureus
Group A strep
Strep pneumonia
What are the important causes of bacteraemia in adolescents?
Neisseria meningitidis
Staph aureus
Group A strep
Strep pneumonia
What are the clinical features of UTI in infants and young children?
Fever Lethargy Vomiting/diarrhoea Poor feeding Failure to thrice Prolonged jaundice Sepsis Ferile convulsions
What are the clinical features of UTI in older children?
Dysuria Frequency Fever ± rigors Lethargy, reduced appetite Vomiting/diarrhoea Abdominal (loin) pain Febrile convulsions (<6 years) Incontinence/enuresis
What would you find on dipstick of UTI?
Protein, white cells, nitrates
What would you investigate for and how after a UTI?
Underlying structural abnormalities - US
Renal scarring - DMSA (radioisotope scan)
Vesico-ureteric reflux - MSUG (micturating cystourethrogram)
How long do you wait to do a DMSA scan after an infection and why?
3 months otherwise the infection would cause a false positive
What is the main organism that causes epiglottis?
HiB
What is the main organism that causes bacterial thracheitis?
Staph aureus
What is the main organism that causes pneumonia in neonates?
Group B strep
E.Coli
What is the main organism that causes pneumonia in young children?
RSV Strep penumonia H. influenza Staph aureus Chlamydia trachomatis
What is the main organism that causes pneumonia in older children?
Strep pneumonias
Mycoplasma pneumoniae
Staph aureus
TB
How would you treat empyema
Chest drain
Urokinase
Prolonged antibiotics
Consider underlying immune deficiency
What is the main organism that causes meningitis in neonates?
Group B strep
Gram negative organisms
Listeria monocytogenes
What is the main organism that causes pneumonia in young children?
Neisseria meningitidis
Strep pneumniae
H influenza
Name a gram negative diplococci
Neisseria meningitidis
Name a gram positive diplococci
Strep pneumonia
Name a gram negative coccobacilli
H influenza
How do you treat septic arthritis?
Surgical drainage and antibiotics
How do you treat osteomyelitis?
Antibiotics
US is best imaging for in the joint, why?
Great for excluding infection
Both sides
Is there an effusion?
Is there a subperiosteal abscess?
MRI is best imaging for in the bone, why?
Gold standard
Especially for complex cases
BUT may involve GA/sedation
What are the main things to look for in septic arthritis?
Non weight-bearing Pyrexia >38.5 WCC >12 ESR >40 CRP >20
What are the clinical tests for DDH?
Barlow: subluxes/dislocates a hip posteriorly
Ortolani: relocates a dislocated hip
What is the time difference between acute and chronic diarrhoea?
14
Causes of acute diarrhoea?
Infection - viral (rotavirus, noravirus, enterovirus), bacterial (salmonella, shigella) or protozoal
What is haemolytic uraemic syndrome (HUS) triad?
Anaemia, uraemia, multisystem disease
What organism causes HUS?
E.Coli O157
What organs can cause of chronic diarrhoea?
Normally intestinal but can be liver or pancreas as well
6 features of colitis?
Diarrhoea Cramping lower abdominal pain Urgency Tenesmus (feeling like there's more stool to come) Nocturnal stooling Mucus and blood
What are the causes of colitis?
Infective
Inflammatory
Other
What are the infective causes ?
Viral - enterovirus
Inflammatory - crohns, UC
Other - allographs (transplant from others)
12 year old
Lethargy and diarrhoea for 3 months
Since holiday in Greece where she had D&V
Vomiting settled, diarrhoea hasn’t, she started to feel unwell.
Developed perianal disease, what investigations?
Stool MC&S
If bloods are abnormal, might be helpful, if normal, not that helpful
Faecal calprotectin (raised with any cause of rectal bleeding, so not specific)
Calprotectin
Produced by immune cells, involved in inducing apoptosis in unhealthy cells.
What is Crohn’s disease of the mouth called?
Orofacialgranulomatosis
What are the things specific to Crohn’s?
Mouth to anus
Skip lesions
Transmural
Strictures and perforations
What are the things specific to UC?
Colon only
Confluent disease
Uniform disease (all ulcers look the same)
Superficial inflammation
Toxic megacolon with perforation (only cause of perforation in UC)
What is toxic megacolon?
UC for over 7cm
In school aged children >6cm
Any younger than that >5cm
What are the causes of toxic megacolon?
UC
C.Diff
Immunocompromised
What are the stages of treatment of colitis in IBD?
Induction of remission (steroids) and maintenance of remission (5-aminosalicylates)
How do you induce remission in small bowel disease?
Liquid nutritional therapy
How do you treat IBD remission?
Steroids then steroid sparing agents (azathioprine)
How do you treat poor disease control?
Biological agents (anti-TNF) (infliximab and adalimumab)
How do ou tret terminal ileitis?
TI resection and right hemiclectomy
How do you treat unresponsive Crohn’s colitis?
Sub-total colectomy
What are the causes of chronic diarrhoea due to small bowel disease?
Coeliac disease
Post enteritis syndrome (lactose intolerance temporarily)
What are the features of small bowel diarrhoea?
No colitic features
Abdominal pain is central, poor appetite, nutritional deficiencies (mainly iron and calcium)
Steatorrhoea, lactose malabsorption (depending on cause)
What 4 things happen when coeliacs ingest gluten?
- Gluten taken up by dendritic cells and presented on HLA DQ2
- Forms a complex with matrix TTG
- Recognised by TH1 cells, produce IFN-gamma and TNF alpha and IL-15
- Recruits B cell binds to TTG-gluten-APC construct, makes anti-TTG (stimulated to class switch by IgA by TH1 cell)
What are the histological features of coeliac disease?
- Villous atrophy
- Crypt hypertrophy
- Intraepithelial lymphocytosis
- Infiltration of lamina propria
What are the pancreatic causes of diarrhoea?
All the causes of chronic pancreatitis
CF
Rare paediatric diseases (congenital pancreatic atresia)
What is trypsin?
Protease enzyme
What are the symptoms of diarrhoea due to pancreatic exocrine insufficiency?
Fat malabsorption - failure to thrive and catastrophic weight loss
Fat soluble vitamin deficiency : ADEK (eyes, bones, nerves and bleeding)
Measure exocrine function by faecal elastase
Signs of acute pancreatitis?
Grey Turner or Cullen’s sign (rare in children)
Clinic features of acute pancreatitis
Severe dyspepsia, epigastric pain, sepsis, shock
SE of prednisolone
Eyes: glaucome, cataracts
CVS: cardiomyopathy, HTN, post surgery or infarct dehisence
MSK: proximal myopathy, stunting, osteoporosis
Brain: depression, mania, poor sleep
Skin: bruising, striae, fat redistribution
Pancreatitis, avascular across of femoral head
Infection: latent TB
