PANCE Prep- Inpatient Pediatrics Pearls Flashcards
1
Q
Normal urine output
A
1.0-2.0 cc/kg/hour
2
Q
Describe fluid requirements calculations
A
100/50/20 rule
-100 cc/kg/day for first 10kgs;
-from 10 to 20 kg, additional 50 cc/kg/day;
-over 20 kg, 20 cc/kg/day for each additional kg.
-Divide total daily fluid by 24
to get cc/hr.
Example: 8 kg patient-> 8 x 100 = 800 cc/day = 33 cc/hr
13 kg patient -> (10 x 100) + (3 x 50) = 1150 cc/day= 48 cc/hr
3
Q
Describe fluid requirement calculations on an hourly rate
A
4/2/1 rule (to calculate hourly rate)
- 4 cc/kg/hour for first 10 kg;
- from 10-20 kg, additional 2 cc/kg/hour;
- over 20 kg, give 1cc/kg/hour for each additional kg.
Example: 8 kg patient -> 8 x 4 = 32 cc/hr
23 kg patient -> (10 x 4) + (10 x 2) + (3 x 1) = 63 cc/hr
4
Q
Describe caloric requirements
A
- for patients < 10kg, 100-120 kcal/kg/day (ill or premature infants may have increased caloric need)
- for older patients who are taking the majority of their calories as solid foods, we do not generally calculate caloric intake, unless a calorie count is being done.
5
Q
Describe the calories found in breast milk
A
20kcal/ounce = 20kcal/30 cc = 0.67 kcal/cc
6
Q
What are types of cow milk based formulas
A
- Similac
2. Enfamil Premature
7
Q
What are types of soy based formula
A
- Isomil
2. Prosobee
8
Q
What are types of Elemental based formulas
A
- Pregestimil
- Nutramigen
- Tolerex
- Vivonex
9
Q
What are types of Premature infant formulas
A
- Special Care
2. Enfamil Premature
10
Q
What is a lactose free formula
A
- Lactofree
11
Q
Describe the weight loss and gain of an infant
A
- Infants should regain their birth weight by 10-14 days of age (after losing up to 10% of birth weight).
- Infant gains 1 ounce (30 grams) per day.
- Weight doubles by 5 months,
- triples by 1 year,
- quadruples by 2 years.
- Length doubles by 1 year,
- triples by 13 years.
12
Q
Common microbes that cause UTIs
A
Gram Neg. Rods
- E. coli
- Pseudomonas
13
Q
Common microbes that cause GI diseases
A
Anaerobes
- C. Diff
- Bacteroides fragillis
14
Q
Common microbes that cause Skin, Pneumonia, AOM
A
Gram Positive Cocci
- S. pneumoniae
- S. pyogenes (GAS)
- MSSA
- MRSA
GN Cocci
5. N. gonorrhoeae
15
Q
What is bronchioloitis
A
inflammation of the bronchioles due to neutrophil infiltration
-MC in children 2 month-2 y/o after viral infections (RSV and adenovirus)
16
Q
persistent alveolar exudates–> inflammation and scarring (FIBROSIS) of the bronchioles AND alveoli
A
Cryptogenic Organizing Pneumonia (COP)– previously called BOOP (bronchiolitis obliterans with organizing pneumonia)
*looks like pneumonia but doesn’t respond to antibiotics
17
Q
Most common cause of bronchioloitis
A
RSV (50-70%)
18
Q
Risk factors for broncholitis
A
- 2months-2y/o
- exposure to cig smoke
- lack of breastfeeding
- premature (<37wks)
- MC in fall and spring**
19
Q
Associated Complications of bronchiolitis
A
- Otitis media w/ S. pneumonia
2. asthma later in life
20
Q
SX of bronchiolitis
A
- Fever
- URI sx 1-2 days
- THEN resp. distress (wheezing, tachypnea, nasal flaring, cyanosis, retractions +/- rales)
- poor feeding
*likely to deteriorate 48-72 hours after cough onset
21
Q
How do you dx bronchiolitis
A
- CXR: hyperinflation, peribronchial cuffing
- nasal washing using monoclonal Ab testing
- Pulse ox single best predictor of disease in children***
22
Q
Tx of bronchioloitis
A
- Supportive: humidified O2 (MAINSTAY OF TX) delivered by mask, IV fluids, acetaminophen/ibuprofen for fever, +/- mechanical ventilation if severe
* *Nasal suctioning and hydration! - Meds play a limited role***- +/- B agonists (albuterol), +/- nebulized racemic epi (if albuterol not effective)—– Corticosteroids NOT indicated unless hx of underlying reactive airway disease
- Ribavirin +/- administered if severe lug or heart disease or in immunosuppressed pt.
23
Q
How can you prevent bronchioloitis
A
- Good hand washing- RSV is highly contagious and is transmitted via direct contact w/ secretions and self inoculation by contaminated hands
- Palivizumab prophylaxis may be used in high risk groups
24
Q
What is the most sensitive indicator of LOWER airway disease
A
tachypnea
25
What is croup?
inflammation secondary to acute viral infection of the upper airway (vocal cords or trachea)--> subglottic larynx/trachea swelling
-MC in 6months-6y/o
26
What is the most common cause of croup?
Parainfluenza!
| Others: adenovirus, RSV,
27
Signs of Croup
1. Barking cough (seal-like)
2. Stridor (inspiratory and expiratory worse w/ crying)
3. hoarseness
4. dyspnea (worse at night*)
5. +/- other URI sx preceeding or concurrent
6. fever
28
How do you dx croup
1. R/O epiglottitis and FB aspiration
2. CLINICAL DX
3. CXR: steeple sign (subglottic narrowing of trachea)**
29
How to manage mild Croup
1. Cool humidified air mist
2. Hydration
3. Dexamethosone oral or IM (provides sign. relief as early at 6hrs after single dose)
* *1mg/kg/d for 3-5 days
4. O2
30
How do you classify mild, mod, and severe croup
Mild: no stridor at rest, no resp. distress
Mod: stridor at rest w/ mild-mod retractions
Severe: stridor at rest w/ marked retractions
31
How to manage mod Croup
1. Dexamethasone PO or IM
2. supportive tx (humidified air, hydration)
3. +/- Nebulized epi
4. SHOULD OBSERVE 3-4hrs after intervention for rebound resp. distress
32
How to manage severe Croup
1. Dexamethasone
| 2. Neb epi
33
What is whooping cough
highly contagious Brodetella pertussis infection
| -MC in kids <2y/o
34
What are the pertussis phases
1. Catarrhal phase: URI sx 1-2 weeks (MOST CONTAGIOUS IN THIS PHASE)
2. Paroxysmal phase: severe paroxysmal coughing fits w/ inspiratory whooping, +/- post cough emesis: 2-4 wks
3. Convalescent phase: resolution of cough (up to 6wks)
35
How do you dx pertussis (whooping cough)
1. PCF of nasopharyngeal swab (gold standard)
| 2. lymphocytosis (60-80% lymphocytes of diff., WBC count elevated as high as 50,000
36
Tx of pertussis
1. Supportive is mainstay
2. O2 and nebulizers
3. Abx- Macrolides, Erythomycin or Bactrim if allergic to macrolides
37
Complications of pertussis
1. Pneumonia
2. Encephalopathy
3. otitis media
4. sinusitis
5. seizures
6. apnea or cerebral hypoxia
7. subconjuctival hemorrhage due to increased pressure from coughin
38
MC cause of CAP and what does its gram stain look like?
- strep pneumoniae
- Gram + cocci in pairs
(other common causes: H. influenza, Staph. Auerus, Morazella, kelbsiella)
39
MC cause of CAP in someone w/ underlying pulmonary disease* (COPD*, bronchiectasis, CF)
and what does its gram stain look like?
Haemophilus influenza
**2nd MC cause of CAP
also- M. catarrhalis
Gram neg. Rods (bacilli)
40
MC cause of atypical pneumonia or walking pneumonia and what does its gram stain look like?
Mycoplasma pneumoniae-- eps. <40y/o
Lacks cell walls** (does not respond to beta lactams)
41
MC cause of pneumonia is school aged kids and what does its gram stain look like?
Mycoplasma pneumoniae
-and Chlamydophilia, and viral
Clinical: pharyngitis, ear infection, (BULLOUS MYRINGITIS) URI sx
42
MC cause of pneumonia due to water supply, air conditioners and what does its gram stain look like?
Legionella pneumonia
* no person to person transmission
* GI sx (N/V/anorexia, hyponatremia)
Intracellular GNR
43
MC cause of pneumonia often seen after viral illness (ie. flu) and what does its gram stain look like?
Staphylococcus aureus
Gram positive cocci in clusers
44
MC cause of pneumonia often seen in IVDU and what does its gram stain look like?
Staphylococcus aureus
Gram positive cocci in clusers
45
MC cause of pneumonia that causes severe illness in alcoholics and what does its gram stain look like?
Klebsiella pneumonia
(and other)
GNR (bacilli)
46
MC cause of pneumonia in debilitated, chronic illness, aspirators and what does its gram stain look like?
Klebsiella pneumonia
GNR (bacilli)
47
What pneumonia is associated w/
| CXR: CAVITARY LESIONS
Klebsiella pneumonia
*esp. RUL
48
MC cause of ASPIRATION
Anaerobes ( in out pts- typically oral flora)
GNR in inpats or chronically ill
49
Aspiration pneumonias are MC found where
R lower lobe (anerobes)
50
MC cuase of pneumonia in immunocompromised (ie. HIV, neutropenic, s/p transplant, CF, bronchiectasis) and what does its gram stain look like?
Pseudomonas aeruginosa
GNR- produces slime coat
51
MC cause of hospital acquired pneumonia
GNR: pseudomonas
| and MRSA
52
MC cause of pneumonia in infants and small children
viral- RSV and parainfluenza
53
MC cause of viral pneumonia in adults
Influenza
54
MC cause of viral pneumonia in transplant recipients or HIV
CMV
55
Who gets pneumocystis jirovecii pneumonia (PCP)
compromised host (fatigue, dry cough, dyspnea on exertion, O2 desat w/ ambulation)
*Fungal pneumonia
56
What fungal/parasitic pneumonia is associated w/ Mississippi and Ohio river Valley soil contaminated w/ Bird and bat droppings
Histoplasma capsulatum
57
Sx of typical pneumonia
1. fever
2. productive cough w/ purulent sputum
3. RIGORS**- eps. S. pneumoniae
4. tachycardia/tachypnea
58
Sx of atypical pneumonia
1. Low grade fever
| 2. Extrapulmonary sx*- myalgias, malaise, HA, N/V/D
59
PE findings of typical pneumonia
Signs of consolidation:
1. bronchial breath sounds
2. dullness on percussion
3. increased tactile fremitus, egophony
4. crackles (insp)
60
PE findings of atypical pneumonia
*often normal
| +/- crackles or rhonchi
61
What do you do/suspect if someone presents with:
| ear pain, BULLOUS MYRINGITIS, red pharynx, persistent nonproductive cough
Mycoplasma PNA
-send serum cold agglutinins
62
Legionella pneumonia is associated with:
1. GI sx
2. Elevated LFTs
3. Hyponatremia
63
What PNA is associated with:
| CXR: abscess formation
S. aureus** (or Klebsiella, anaerobes)
64
What PNA is associated with Bullous myringitis
mycoplasma pneumonia
65
```
PNA sputum (gram stain/culture) reveals:
Rusty, blood tinged
```
Strep pneumonia
66
```
PNA sputum (gram stain/culture) reveals:
Currant jelly
```
Klebsiella
67
DX workup of pneumonia
1. CXR (+/- CT scan)-- CXR lags behind clinical improvement
2. Sputum (gram stain/culture)
3. PE- dull Percussion, INCREASED fremitus, bronchial, EGOPHONY breath sounds
68
What does percussion sound like in Pneumothorax or obstructive lung disease
HYPERRESONANCE
| dull in pneumonia and pleural effusion
69
Empiric Tx of CAP outpatient
Macrolide (Clarithromycin or Azithromycin) or doxycycline is first line***
70
Empiric tx of CAP inpatient
B lactam + macrolide (or doxy) OR broad spectrum FQ
71
Empiric tx of CAP in ICU
B lactam + macrolide
| OR broad spectrum FQ + B lactam
72
Empiric tx of hospital acquried pneumonia (pseudomonas infection risk)
Anti-pseudomonal B lactam and anti-pseudomonal AG or FQ
* Add vancomycin if MRSA suspected
* Add Levofloxacin or Azithromycin if Legionella is suspected
73
What Abx do you add if you suspect legionella pna or MRSA pna
legionella: levofloxacin or azithromycin
MRSA: vancomycin
74
B-lactam Abx used in PNA (CAP inpatient or ICU)
Cefriazone or Unasyn
75
Anti-Pseudomonal B-lactams used in PNA (hospital acquired)
Pip/taz or Cefepime
76
What are Respiratory fluoroquinolones (used in PNA- CAP Inpt, ICU)
Levofloxacin, Moxifloxacin
**Cipro is NOT A respiratory FQ
77
What are aminoglycosides used in PNA (HAP)
Gentamicin, Tobramycin
78
What Vx is used to prevent pneumonia
PCV13 (prevnar): given at 2, 4, 6 months, and 12-15 months
*those 2y/o-64 w/ chronic dz OR +65 y/o also get Pneumovax (PSV23)
79
___ is the number 1 organism in pneumonia in children 3w-4y, ___ should be considered in 2-12w who are usually afebrile, __ cause a significant amount of pneumonia in children <5y, although up to 30% of these kids will have a ___ too
__ >5yo
S.Pneumo (3wks-4yo)
chlamydia (2-12 wks)
Viruses (<5yo)--> 30% have secondary bacterial infection
mycoplasma >5yo
80
What PNA is associate w/:
| CXR: peribronchial cuffing or interstitial infiltrates
viral pneumonia
81
These CXR findings are commonly associated w/ what pneumonias:
1. Lobar
2. diffuse, patchy infiltrate, multi-lobar
3. interstitial pattern
4. cavitary lesions
1. Lobar- Strep pneumo
2. diffuse, patchy infiltrate, multi-lobar- S. aureus, H. influ
3. interstitial pattern- Mycoplasma, legionella
4. cavitary lesions- Klebsiella, pseudomonas, TB
82
How do you tx Active TB infection
```
RIPE
Rifamin (RIF)
Isoniazid (INH)
Pyrazinamide (PZA)
Ethambutol (EMB)
(OR Streptomycin instead of EMB)
```
* tx for 6 months at least
* no longer considered infectious 2wks after initiation of therapy
83
What is asthma
REVERSIBLE hyperirritability of tracheobronchial tree--> airway inflammation and bronchoconstriction
84
Describe the 3 main components (pathophysiology) of asthma
1. Airway hyperreactivity- IgE mediated (extrinsic- allergen or intrinsic- viral infection, meds (BB, ASA, NSAID, ACEI), exercise, emotional)
2. Bronchoconstriction/airway narrowing: SmM constriction, bronchial wall edema, mucus section
3. Inflammation: secondary to cellular infiltrate, cytokines, and histamine
85
Obstruction in bronchoconstriction is characterized by:
1. decrease expiratory airflow
2. increased airway resistance
* V and Q mismatch
86
What is Samters Triad
1. Asthma
2. Nasal polyps
3. NSAID/ASA allergy
87
Classic asthma triad of symptoms
1. Dyspnea
2. Wheezing
3. Cough (esp. at night)
*if silent chest= no air exchange= severe!
88
How can you dx asthma
1. PFTs (Gold standard)
2. Bronchoprovacation test (Methacholine challenge test)
3. Peak Expiratory Flow rate (PEFR)
89
PFTs of asthma will show
1. Decreased FEV1
| 2. Decrease FEV1/FVC
90
What is the best and most objective way to assess asthma exacerbation severity and patient response in ED
Peak expiratory flow rate (PEFR)-- best to obtain baseline before tx
<40% = severe obstruction
PEFR> 15% from initial attempt = response to tx
-Normal 400-600
91
Describe how you classify asthma
Rule of 2's
1. use of albuterol or rescue 2 or more times a week= Mild persistent
2. Nocturnal Sx over 2x/month= Mod. persistent
3. Sx all the time= severe persistent
4. less than 2x week= intermittent asthma
92
Describe PFTs of intermittent, mild, mod, and severe asthma
1. intermittent: FEV1 >80% predicted, FEV1/FVC nl
2. mild: FEV1 >80% predicted, FEV1/FVC nl
3. mod: FEV1 60-80% predicted, FEV1/FVC reduced by 5%
4. Severe: FEV1 <60% predicted, FEV1/FVC reduced by >5%
93
Describe recommended management of intermittent, mild, mod, and severe asthma
1. intermittent: SABA prn
2. Mild: Saba prn + LD ICS
3. Mod: SABA prn + LD ICS + LABA or Increase ICS to MD
4. Severe: SABA prn + HD ICS + LABA +/- Omalizumab
94
What is Omalizumab
anti-IgE Ab (inhibits IgE inflammation)
| *used in severe, uncontrolled asthma
95
Types of:
1. SABA
2. LABA
3. ICA
4. LT inhibitors
5. Anticholinergics
1. SABA: albuterol, terbutaline, epi
2. LABA: Salmeterol, Formoterol
3. ICA: Beclomethasone, Flunisolide, Triamcinolone
4. LT inhibitors: Montelukast (singular)
5. Anticholinergics: Ipratropium (atrovent)
*LABA/ICS combo: Symbicort, Advair diskus
96
How to SABA and LABAs work?
B2 agonists
| Bronchodilator, decrease bronchospasm
97
Asthma drug of choice for long term persistent chronic management asthma
ICS
98
When are leukotriene modifers helpful in tx of astham
asthmatics w/ allergic rhinitis/ASA inducted asthma
99
SE of B2 agonists
1. B1 cross reactivity: tachycardia/ arrhythmias, muscle tremors
2. CNS stimulation
3. hypokalemia
100
Management of acute asthma exacerbation
1. 2-4 puffs of SABA via MDI/spacer or neb
2. Repeat x3 q 20 min
3. Oral corticosteroids 2mg/kg/d
101
Hospital evaluation for asthma exbaceration
1. CXR (1st time wheezers, failure to improve w/ tx)
2. PEFR pretx- <40% =severe
3. ABS for sick pts PEFR <35%
4. EKG if cardiac condition
102
Tx of asthma exacerbation
1. cardiac monitor (given 2ry tachycardia, HTN and palps)
2. Pulse OX
3. BP monitoring
4. IV access if mod/severe
5. B-agonist (albuterol) neb X3 (or 2-4 puffs)
6. + Atrovent (ipratropium-anticholinergic)
* continuous B2agonist for 1 hr if no better
7. Steroids: 2mg/kg/d max at 60mg or 40-60mg for adults OR IV 125mg methylprednisolone
8. +/- Magnesium sulfate, 1-2 mg IV
9. +/- Heliox (80% helium, 20% Ox) - decreases airway resistance
10. +/- intubate if increased PCO2, decreased PO2, AMS,
103
Indications to discharge asthma pt
1. feel better, not hypoxic, clear lungs
2. PEFR >60%
3. DC on B2 agonist, oral steroids 4-5 d.
4. FU in 1-3 days with PCP
104
how to interpret GFR and albumin
60+ = normal
below 60= kidney disease/poor functioning
below 15= failure
elevated albumin = kidney disease bc it is not being filtered out (should just be found in blood)
105
Children receiving continuous albuterol nebulization are at risk of transient:
1. hypokalemia,
2. hypophosphatemia, and
3. hypomagnesemia.
*Although these decreases are rarely of clinical importance in children, we suggest measuring serum electrolytes daily in all patients receiving continuous albuterol,
106
Causes of Metabolic Acidosis with an Elevated Anion Gap
MUDPILERS (too much acid or little bicarb)
```
Methanol
Uremia
DKA/alcoholic KA
Propylene glycol
Isoniazid, infection
Lactic acidosis
Ethylene Glycol
Rhabdo/Renal failure
Salicylates
```
107
Causes of Metabolic Acidosis with NO Anion Gap
HARDUPS (too much acid or little carb)
```
Hyperalimentation (artificial nutrients)
Acetazolamide
Renal tubular acidosis
Diarrhea
Uretero-Pelvic shunt
Post Hypocapnia
Spironolactone
```
108
Causes of acute respiratory acidosis
CHAMPP *causes of hypoventilation
```
CNS depression (drugs/CVA)
Hemo/pneumothorax
Airway obstruction
Myopathy
Pneumonia
Pulmonary Edema
```
109
Causes of metabolic alkalosis
CLEVER PD- little acid or too much bicarb
```
Contraction
Licorice
Endo (Cushings, Conn)
Vomiting
Excess Alkali
Post-hypercapnia
Diuretics
```
110
Causes of respiratory alkalosis
CHAMPSS- causes of hyperventilation
```
CNS disease
Hypoxia
Anxiety
Mech ventilators
Progesterone
Salicylates
Sepsis
```
111
Cellulitis is most commonly caused by what organisms
S. auerus*
| Group A beta hemolytic streptococus (GABHS/S. pyogenes)
112
LOCAL clinical manifestations of cellulitis
Macular erythema (flat margins, NOT sharply demarcated)
- swelling
- warmth
- tenderness
113
Special types of cellulitis
1. Erysipelas: MC cause GABHS
| 2. Lymphangitis: spread of infection via lymphatic vessels
114
Well demarcated margins of cellulitis, intensely erythematous (St. Anthony's fire) most commonly on the face or skin w/ impaired lymphatic drainage
Erysipelas (mc cause GABHS)
115
Tx of cellulitis
Cephalexin or dicloxacillin X 7-10 days
(Clindamycin or Erythromycin if PCN allergic)
* If you suspect MRSA:
- IV vancomycin or linezolid OR
- Oral: Bactrim (2nd best PO for MRSA but doesn't cover strep well)
116
How do you tx cat bite cellulitis
Amoxicillin/clavulante
| doxy if PCN allergic
117
MC cause of cat bite cellulitis
Pasteurella multocida
118
How do you tx dog bite cellulitis
Amoxicillin/clavulante
119
How do you tx human bite cellulitis
Amoxicillin/clavulante
120
How do you tx a wound through a tennis shoe? What organism must you cover for?
Ciprofloxacin (covers pseudomonas)
121
MC cause of Osteomyelitis
S. aureus*
122
salmonella osteomyelitis is pathognomonic for ___
sickle cell disease
123
Sources of osteomyelitis
1. Acute hematogenous spread: MC route in children
| 2. Direct inoculation: s/p trauma, surgery, prosthetic joint
124
Clinical manifestations of osteomyelitis
1. gradual onset of sx (days to weeks)- signs of bacteremia: high fever, chills, malise
2. Local: inflammation, pain over bone, decrease ROM
3. Refusal to weight bare
125
Labs/Dx test for osteomyelitis
1. increased WBC
2. increased ESR (if ESR is normal, osteo. is unlikely)
3. MRI (most sensitive test in early dz- CT for surgical planning)
4. Bone aspiration: gold standard**
5. Radiographs: shows bone infection but +/- up to 2 weeks after sx onset
- early: soft tissue swelling and PERIOSTEAL REACTION, Lucent areas of cortical destruction
- Advanced/chronic: SEQUESTRUM (segments of necrotic bone and new bone formation)
126
TXof acute osteomyeltits
Abx 4-6 wks (at least 2 wks via IV) +/- debridement
127
MC organism of newborn osteomyelitis
GBS, Gram neg.
128
MC organism of osteomyelitis in someone older than 4 months
S. aureus
MSSA or MRSA
129
MC organism of osteomyelitis from a puncture wound
Pseudomonas
130
MC organism of osteomyelitis in someone w/ sickle cell dz
salmonella
131
TX of osteomyelitis in someone older than 4 months
MSSA: Nafcillin or oxacillin or Cefazolin
(clindamycin or vancomycin if PCN allergy)
MRSA: Vancomycin
132
TX of osteomyelitis in someone w/ sickle cell dz
3rd generation cephalosporin or FQ (Cipro* or levofloxacin)
133
TX of osteomyelitis from a puncture wound
Ciprofloxacin (pseudomonas)
134
XR: periosteal reaction of bone shaft
| -w/ lucent areas of cortical destruction
Osteomyelitis
135
What is the criteria for sepsis
```
SOFA: infection + 2 or more:
(BAT)
1. sBP 100mmHg or less
2. AMS <15
3. Tachypnea (RR 22/min or greater)
```
136
How can you assess for multiple organ dysfxn w/ sepsis
```
CPKBNP
Cardiac/ MAP/vasopressors
Pulmonary
Kidneys: creatinine
Bilirubin
Neuro
Platelet count
```
137
Risk factors for sepsis
1. 65+
2. ICU
3. bacteremia
4. immunocompromised/ asplenic
5. prior hospitalization
6. diabeteic
7. PNA
138
Work up of Sepsis
1. CBC w/ diff
2. CMP (hyperglycemia?)
3. Lactate (>2?)
4. Blood cultures x2
5. Coags: PT, PTT
6. ABGs
7. UA?
8. CXR: if pulm (also get sputum culture)
9. CT if GI or menigitis
10. LP
139
Tx of sepsis
ABCs! (RESTORE PERFUSION AND GIVE ABX ~1HR OF PRESENTATION)
1. 2 large bore IVs w/ fluid resuscitation
2. Cardiac monitoring and VS q 15 min
3. Abx: Vancomycin (G+ and MRSA coverage) + Cefepime (G-) +/- Pip/taz for pseudomonal coverage
4. Acetaminophen for fever
140
how can you assess nuchal rigidity
1. Kernig sign: have the person lie flat on the back, flex the thigh so that it is at a right angle to the trunk, and completely extend the leg at the knee joint.
2. Brudzinski's sign: flex the pts neck and severe neck stiffness causes the patients his and neck to flex
141
What is the workup for a fever of unknown source in a neonate 28 days or less?
* nee full septic w/u if temp of 38C or 100.4
1. CBC
2. Blood cultures
3. Gram stain
4. UA
5. Urine culture
6. LP with CSF analysis and gram stain
7. CSF culture
8. +/- CXR if resp. sx: cough, rhinorrhea, tachypnea, WOB, abnormal breath sounds,
9. +/- stool culture: if diarrhea
*Need IV abx
142
Criteria for low risk for SBI in an infant 29 days +
1. WBC between 5-15K (cannot be neutropenic)
2. Bands not greater than 1.5 (cannot have leukocytosis)
3. Band/neutrophil ratio of <0.2 (no left shift)
4. U/A <10 wbc/hpf, negative gram stain
5. CSF (if obtained) <8 wbc/hpf, negative gram stain
6. CXR negative (if obtained)
7. stool gram stain <5wbc/hpf (if obtained)
143
What is the workup for a fever of unknown source in an infant 29-90 days old?
* nee full septic w/u if temp of 38C or 100.4
1. CBC
2. Blood cultures
3. Gram stain
4. UA
5. Urine culture
6. LP with CSF analysis and gram stain
7. CSF culture
8. +/- CXR if resp. sx: cough, rhinorrhea, tachypnea, WOB, abnormal breath sounds,
9. +/- stool culture: if diarrhea
144
Tx if infant 29-90day old meet the low-risk criteria for SBI, consider
Ceftriaxone 50mg/kg IV/IM
145
Work up for fever of unknown source in an infant 3-36 months
102. 2 F
1. UA
2. urine gram stain
3. Urine cultures: only for the select population of: girls <24 months, uncircumcised boys <12 months and circumcised boys <6 months
4. A CXR, if indicated by symptoms or exam and a blood c/s based on risk of bacteremia
5. blood cultures
146
*Use parenteral antibiotics for FWS awaiting cultures, preferrably ____*
Ceftriaxone
147
Causes of prolonged fever
1. TB
2. Lymphoma and Leukemia
3. Juvenile Idiopathic Arthritis
4. Endocarditis
5. CMV, EBV
6. Malaria
7. Hyperthyroidism, Ectodermal dysplasia
8. Kawasaki’s disease
148
Symptoms of Kawasaki's
```
Crash and Burn
C-conjunctivitis
R- rash on body
A- arthritis (join pain)
S- strawberry tongue (red and swollen)
H- Hands skin peeling
AND
BURN- uncontrolled high fever persisting longer than 5 days
```
149
Clinical manifestations of appendicitis
1. anorexia
2. periumbilical pain/epigastric pain
3. RLQ pain
4. N/V
150
PE Signs specific for appendicitis
1. Rovsing sign: RLQ pain w/ palpation
2. Obturator sign: RLQ pain w/ internal and external hip rotation w/ flexed knee
3. Psoas sign: RLQ pain w/ right hip flexion/extension (raise leg aginst resistance)
4. McBurneys point tendernesss: 1/3 the distance from anterior sup. iliac spine and navel
151
How do you dx appendicitis
CT
US
Leukocytosis**
152
Risk factors for UTI
1. sex
2. spermicidal use
3. pregnancy: progesterone and estrogen
4. Vesicourethral reflux
5. Newborns with fever of unknown origin
6. DM
7. catheters
8. dysfunctional voiding
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Common cause of UTI
1. E. coli (MC- 80%)
2. Staph. saprophyticus: especially in sexually active women
3. other GN uropathogens: proteus, enterobacter, klebsiella, pseudomonas
4. Enterococci with indwelling cath
154
Gram negative uropathogens
1. E. coli
2. proteus,
3. enterobacter,
4. klebsiella,
5. pseudomonas
155
Sx of pyelonephritis
1. fever
2. tachycardia
3. flank/back pain
4. CVA tenderness
5. N/V
156
How do you dx cystitis
UA w/
1. pyuria* (>5WBC/hpf)
2. + leukocyte esterase
3. Nitrites (90% bacteria causing)
4. Hematuria
5. +/- cloudy urine
6. increase pH with Proteus
7. WBC casts with pyelonephritis
8. Dipstick: + leukocytes esterase, nitrites, hematuria, WBCs (WBC casts w/ pyelo)
9. Urine culture (definitive dx)
157
Describe a positive urine culture w/ a clean catch specimen
10^5 (100,000)
*epithelial (squamous cells)= contamination
158
Management of uncomplicated cystitis
1. increase fluid intake
2. void after sex
3. pyridium (phenazopyridine- bladder analgesic)
4. Nitrofurantoin (Macrobid) 100 BID x 5-7days
5. FQ: Cipro 250mg BID x3days
6. trimethoprim-sulfamethoxazole double strength (bactrim-DS) BID x3 days
159
Do not use pyridium (phenazopyridine- bladder analgesic) no longer than ___ due to:
no longer than 48 hrs due to increased SE:
1. methemoglobinuria
2. hemolytic anemia
160
Tx of Complicated cystitis
1. FQ (Cipro) PO or IV
| 2. AG x 7-10 days
161
Tx of cystitis in pregnancy
tx 7-14 days w/ amoxicillin or nitrofurantoin
162
Tx of pyelonephritis
FQ (Cipro) PO or IV, aminoglycosides x 14 days
163
Tx of pediatric febrile UTI
* infants < 2 m/o should be hospitalized and undergo a full septic w/u due to risk of bacteremia or urosepsis)→ treated with 2 antibiotic regimen given IV
- Outpatient treatment: Second/Third generation cephalosporins (cefprozil, cefdinir (QD), cefixime (QD), and IM ceftriaxone) X10 days
164
Tx of pediatric uncomplicated cystitis
- Initial antibiotic regimens for 2-13 y/o (cephalosporin regimens mentioned in Febrile UTI);
- 13 y/o + trimethoprim-sulfamethoxazole (Bactrim) or cephalosporin
- Treatment duration 5-7 days
- Educate sexually active girls about method of birth control as spermicide is a risk for UTI
165
Who needs VCUG imaging after UTI
1. all febrile pediatric UTI
2. non-febrile pediatric UTI: <3/o F w/ first UTI and all girls with recurrent
3. Feverile and non-febrile UTI: all males, poor growth, hx of urologic abnormalities, FH of renal disease
166
the most common types of urinary tract malformations
1. vesicoureteral reflux (VUR)
2. ureteropelvic junction (UPJ) obstruction
3. Posterior urethral valves (PUVs)
167
What is vesicoureteral reflux (VUR)
the abnormal flow of urine from your bladder back up the tubes (ureters) that connect your kidneys to your bladder.
168
What is Posterior urethral valves (PUVs)
extra flaps of tissue that have grown in his urethra, the tube that leads from the bladder to the tip of his penis.
-These extra flaps of tissue block the normal flow of urine, which can damage organs such as the bladder and kidneys
169
what is reteropelvic junction (UPJ) obstruction
an obstruction of the flow of urine from the renal pelvis to the proximal ureter
