Peadiatrics Flashcards
Acute epiglottitis: cause
H influenza type B
Acute epiglottitis: vaccine
Hib (H influenza type B)
Acute epiglottitis: Sx
-rapid onset
-high temperature
-generally unwell/toxic
-stridor
-drooling of saliva
-muffled sound
-‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
Acute epiglottitis: complication
airway obstruction
Acute epiglottitis: Dx
- direct visualization by the senior
- Lateral neck Xray: thumb print sign -swelling of the epiglottis
Acute epiglottitis: Mgmt
NOTE: if suspected do NOT examine the throat due to the risk of acute airway obstruction
1. Call anesthetist/ENT -secure the airways -endotracheal intubation
2. Oxygen
3. IV antibiotics
Croup: alternative name
Laryngotracheobronchitis
Croup
Characterized by stridor which is caused by a combination of laryngeal oedema and secretions.
Croup: causative organism
Parainfluenza viruses
Croup: age group
infants to toddlers (6 months to 3 years)
Croup: features
stridor
barking cough (worse at night) -hint
fever
coryzal symptoms
Croup: mild Sx
Occasional barking cough
No audible stridor at rest
No or mild suprasternal and/or intercostal recession
The child is happy and is prepared to eat, drink, and play
Croup: moderate Sx
Frequent barking cough
Easily audible stridor at rest
Suprasternal and sternal wall retraction at rest
No or little distress or agitation
The child can be placated and is interested in its surroundings
Croup: severe Sx
Frequent barking cough
Prominent inspiratory (and occasionally, expiratory) stridor at rest
Marked sternal wall retractions
Significant distress and agitation, or lethargy or restlessness (a sign of hypoxemia)
Tachycardia occurs with more severe obstructive symptoms and hypoxemia
Croup: Dx
- Usually diagnosed clinically
- chest x-ray: a posterior-anterior view - subglottic narrowing ‘steeple sign’
Croup: admission criteria
- Mod-severe croup
- < 6 months of age
3.known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome) - uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
Croup: Mgmt
-a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
-prednisolone is an alternative if dexamethasone is not available
Croup: Emergency treatment
-high-flow oxygen
-nebulized adrenaline
Croup: prognosis
Natural resolution (complete recovery)
Nocturnal enuresis
the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
Normal continence: age group
usually by 3-4 years of age -day and night
Nocturnal enuresis: Types
- primary (the child has never achieved continence) 2. secondary (the child has been dry for at least 6 months before)
Primary enuresis (daytime plus >2 years of age: Mgmt
Refer to sec care or enuresis clinic
Primary enuresis (only night time plus >5 years of age plus <2 times/week : Mgmt
Reassurance
Primary enuresis (only night time plus >5 years of age plus >2 times/week : Mgmt
Long term:
1. enuresis alarm
2. reward system
Short term:
1. Desmopressin
If 2x long and short term tx -still bedwetting -> sec care or enuresis clinic
Secondary enuresis: Mgmt
Refer to pediatrician
Secondary enuresis: Causes
-Child abuse or emotional upset due to change of the environment e.g. addition of new member in the house, change of school/day care etc
-constipation
-diabetes mellitus
-UTI if recent onset
Nocturnal enuresis: Mgmt in a glance
A. general advice
-fluid intake
-toileting patterns: encourage to empty bladder regularly during the day and before sleep
-lifting and waking
B. reward systems (e.g. Star charts)
NICE recommend these ‘should be given for agreed behavior rather than dry nights’ e.g. Using the toilet to pass urine before sleep
C. enuresis alarm generally first-line for children have sensor pads that sense wetness high success rate
D. desmopressin particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family
Vesicoureteric reflux (VUR)
The abnormal backflow of urine from the bladder into the ureter and kidney - dilatation of pelvicalyceal system - recurrent UTIs - renal scarring - renal failure
Pathophysiology of VUR
Congenital abnormality of insertion of ureters in the urinary bladder (displaced laterally, entering the bladder in a more perpendicular fashion than at an angle) -can be seen on ultrasound
VUR: Possible presentations
A. antenatal period: hydronephrosis on ultrasound
B. recurrent childhood urinary tract infections
C. reflux nephropathy - chronic pyelonephritis secondary to VUR - renal scar may produce increased quantities of renin causing hypertension
VUR: Dx
A. initial:
Ultrasound
B: Gold standard:
Micturating cystourethrogram (not done >3 years of age)
C: recurrent UTI with suspected renal/parenchymal damage:
DMSA - Technetium scan -can be booked in 4-6 months after the acute UTI
VUR: Mgmt
A: Low dose abx prophylaxis (mostly trimethoprim)
B. If Tx failed or parenchymal damage -surgery (ureter reimplantation)
Neck lumps:
lateral neck mass -non translucent
Branchial cyst
Neck lumps:
lateral (along or near sternocleidomastoid) neck mass- translucent
Lymphangioma
Neck lumps:
ant midline neck mass- painless, mobile, moves up with tongue protusion
Thyroglossal cyst
Neck lumps:
midline neck mass- moves up with swallowing
Goiter
Neck lumps:
Fluctuant lump that transilluminate usually evident at birth
Cystic hygroma
Neck lumps:
Pulsatile lateral neck mass which doesn’t move on swallowing
Carotid aneurysm
Neck lumps:
Pulsatile lateral neck mass which doesn’t move on swallowing
Neck lumps:
midline lump in the neck that gurgles on palpation
ass with dysphagia, regurgitation, aspiration and chronic cough
more common in older men
Pharyngeal pouch
Neck lumps:
Rubbery, painless lymphadenopathy,
associated with night sweats and splenomegaly
Lymphoma
Neck lumps: Mgmt
Initially: U/S
If suspicious: FNAC
Asthma: severe attack
SpO2 < 92%
PEF 33-50% best or predicted
Too breathless to talk or feed
Heart rate
>125 (>5 years)
>140 (1-5 years)
Respiratory rate
>30 breaths/min (>5 years)
>40 (1-5 years)
Use of accessory neck muscles
Asthma: life threatening
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
Asthma: Moderate
2-5 years of age
SpO2 > 92%
No clinical features of severe asthma
Asthma: Moderate
>5 years of age
SpO2 > 92%
PEF > 50% best or predicted
No clinical features of
severe asthma
Acute asthma: Mgmt-mild to moderate
Bronchodilator:
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy:
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days
Acute asthma: Mgmt-severe to life threatening
transferred immediately to hospital.
PEFR
all children >5 years of age
Asthma: Mgmt <5 years
newly diagnosed
Short-acting beta agonist (SABA)
Asthma: Mgmt <5 years
Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
SABA + an 8-week trial of paediatric MODERATE-dose inhaled corticosteroid (ICS)
Asthma: Mgmt <5 years
next step
SABA + paediatric low-dose ICS + leukotriene receptor antagonist (LTRA)
Asthma: Mgmt <5 years
next step
Stop the LTRA and refer to an paediatric asthma specialist
Asthma: Mgmt 5 -16 years
almost same as in adults
Maintenance and reliever therapy (MART)
A form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
Paediatric low dose ICS
<= 200 micrograms budesonide or equivalent
Paediatric mod dose ICS
200 micrograms - 400 micrograms budesonide or equivalent
Paediatric high dose ICS
> 400 micrograms budesonide or equivalent
Silent chest: Mgmt
intubation
acute asthma exacerbation: Mgmt
O2
Salbutamol neb (back to back)
Ipratropium neb (can be mixed with B agonist)
steroids (oral or IV hydrocortisone)
acute asthma exacerbation: Mgmt
next step if sx still not improving
Senior consultation
IV salbutamol
IV MgSO4
IV aminophyline
Acute asthma:
child develops SOB, tachypnea and drowsiness even after O2 and salbutamol
Cap gas -ABG -to look for resp acidosis
Sudden onset
coughing
choking
stridor
vomiting
Foreign body
Laryngoscopy
congenital abnormality
presents at 4 weeks of age
stridor
Laryngomalacia
Travel Hx
Watery diarrhea
foul -smelling stools
weight loss
flatulence
bloating
Sx >10 days
Giardiasis
Giardiasis: Dx
stool for ova and parasite
ELISA/PCR
Giardiasis: Mgmt
Metronidazole
personal hygeine
Came back from 3rd world country e.g. Kenya
watery diarrhea
abdo cramping
E. Coli (traveler’s diarrhea)
Self limited - 72 hours
Hx of travel
High grade fever >40
headache
body aches
bloody diarrhea
Campylobacter jejuni
bloody diarrhea
Campylobacter jejuni
Shigella
Salmonella
MCC diarrhea in peads
Rota virus
Gastric infection -diarrhea
areflexia
weakness
GBS
Diarrhea
Renal impairment
Hemolysis
HUS-hemolytic uremic syndrome
Diarrhea
RUQ pain
Entamoebae Histolytica
amoebiasis
H/o long term abx use
Diarrhea
Clostridium difficile (Pseudomembranous colitis)
Clostridium difficile (Pseudomembranous colitis): Mgmt
oral metronidazole or oral vancomycin
Diarrhea after eating poultry
Salmonella
sudden onset diarrhea just after eating
Staphylococcus aureus (toxin)
Bed ridden patient
diarrhea
stony hard stool on PR exam
Fecal impaction
Toddler (6 months to 2 years)
minor injury -fever -pain
vigorous crying
turns blue
hold breathing
then LOC: 1-2 mins
rapid recovery
Blue breath holding spells
reassurance
Toddler (6 months to 2 years)
minor injury -fever -pain
attempt to cry
turns pale
hold breathing
may have jerky movements/upward deviation of eyes
no tongue biting
then LOC: 1-2 mins
rapid recovery
White breath holding attacks
or Reflex anoxic seizures
or Reflex asystolic syncope
Breath holding spells: Mgmt
Reassurance
Check ferritin
Tx iron def if present
child in a recovery position usually for 1-2 mins
5 week old child
pale stools
dark urine
low weight for age
hepatomegaly
biliary atresia
biliary atresia: Dx
LFT -raised conjugated bilirubin
biliary atresia: Mgmt
Surgery
Jaundice in the first 24 hours
always pathological.
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
Jaundice in the neonate from 2-14 days
More common
physiological
more commonly seen in breastfed babies
Jaundice after 14 days or 21 days if premature (prolonged): screening tests
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs
Jaundice after 14 days or 21 days if premature (prolonged): Causes
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
jaundice is more common in breastfed babies
mechanism is not fully understood but thought to be due to high concentrations of beta-glucuronidase → increase in intestinal absorption of unconjugated bilirubin
prematurity
due to immature liver function
increased risk of kernicterus
congenital infections e.g. CMV, toxoplasmosis
8 week child
FTT
pale urine
yellow stool
hepatomegaly
vomiting
poor feeding
Galactosemia
jaundice >14 days
constipation
protruding tongue
cold mottled skin
hypoactive
floppy muscles
FTT
flat nose
widely set eyes
Hypothyroidism
Thyroxine up to 2 years of age
4-8 years old boy
late walker >18 months
Gower sign pos
proximal m weakness
waddling gait -cant run
raised CK levels
some resp/cardiac manifestation
X linked recessive
Duchene Muscular Dystrophy
DMD
Duchene Muscular Dystrophy
DMD: Dx
Raised CK
Muscle biopsy
Genetic testing -obligatory after m biopsy
Duchene Muscular Dystrophy
DMD: muscle biopsy
mutation defect in dystrophin protein in the straited muscle
X linked recessive
DMD
Hemophilia
Autosomal dominant
Huntington’s disease -anticipation
Neurofibromatosis
Autosomal adult kidney disease
BRCA 1 gene -incomplete penetrance
Autosomal recessive
Cystic fibrosis
Sickle cell anemia
CAH -21 hydroxylase def
Thalassemia
Autosomal Dominant:
If one parent is affected
50% chance of a child -affected
25% chance of a grandchild -affected
Autosomal recessive:
If both parents are carriers
25% chance of a child -affected
50% chance of a child -carrier
X linked recessive:
if mother is a carrier
50% chance of a male child to be affected
No gastric bubble
Jejunal atresia
single gastric bubble
gastric/pyloric atresia
double bubble sign
duodenal atresia
malrotation
volvulus
triple bubble sign
Jejunal atresia
sudden onset bilious vomiting in neonate
Xray -double bubble sign
bleeding PR
malrotation/volvulus
malrotation/volvulus: Dx
Abdominal Xray
Barium enema
malrotation/volvulus: Rx
ABCDE
NG decompression
Refer to pediatrics
Laparotomy/resection
3-8 weeks neonate usually male and first born
projectile non bilious vomiting
constipation or dehydration +/-
hypochloraemic, hypokalaemic alkalosis
palpable mass in the upper abdodmen
Pyloric stenosis
Pyloric stenosis: Dx
U/S: Thickened pylorus
Pyloric stenosis: next or urgent step
Check K+ levels
Pyloric stenosis: Tx
correct dehydration and electrolyte abnormality
NGT
Ramstedt pyloromyotomy
-6-18 months child usually a male child
-paroxysmal colicky abdominal pain
-inconsolable crying
-knees up
-turn pale
-vomiting
-bloodstained stool - ‘red-currant jelly’ - late sign
-sausage-shaped mass in the right upper quadrant
Intussusception
Intussusception: Dx
U/S: target sign or doughnut sign
Intussusception: Tx
-Air insufflation: air enema
-if fails : barium enema
-if fails or signs of peritonitis -surgery (laparotomy)
Male child -2-3 y/o
painless bleeding PR
Meckel’s diverticulum
Meckel’s diverticulum: Rule of 2s
2% of the population
2 feet from the ileocaecal valve
2 inches long
Meckel’s diverticulum: complication
rectal bleeding:
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction:
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Meckel’s diverticulum: Dx
‘Meckel’s scan’ -radioisotope scan uses 99m technetium pertechnetate, which has an affinity for gastric mucosa
mesenteric arteriography- in more severe cases e.g. transfusion is required
Definitive Dx: Laparotomy
Meckel’s diverticulum: Tx
Surgical resection
painful bleeding PR
Intussusception
volvulus
RNA paramyxovirus
Measles
Measles: incubation period
spread by aerosol transmission
infective from prodrome until 4 days after rash starts
incubation period = 10-14 days
Measles: Sx
3 C’s
conjunctivitis
coryza
cough
High grade fever 105
Koplik spots
diarrhea -10%
No cervical LN enlargement
Koplik spots
typically develop before the rash
white spots (‘grain of salt’) on the buccal mucosa
Measles: rash
starts behind ears then to the whole body
discrete maculopapular rash becoming blotchy & confluent
desquamation that typically spares the palms and soles may occur after a week
often itchy
Measles: Dx
IgM antibodies can be detected within a few days of rash onset
Measles: Mgmt
mainly supportive
admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
Measles: complications
otitis media: the most common complication
pneumonia: the most common cause of death
encephalitis: typically occurs 1-2 weeks following the onset of the illness)
subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
febrile convulsions
keratoconjunctivitis, corneal ulceration
diarrhoea
increased incidence of appendicitis
myocarditis
Measles: Mgmt of contacts
if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection)
this should be given within 72 hours
Rubeola
Measles
German Measles
Rubella
-maculopapular rash from face and downwards
-low grade fever
-enlarge LN -occipital, cervical, postauricular
-Forschheimers’s spot on the soft palate
Rubella
Rubella: Mgmt
supportive
difference between rubella and measles
In rubella:
- enlarge LN
- spot on soft palate and not buccal
Roseola infantum
Roseola
Sudden onset high grade fever
non itchy rash starting from chest and legs and then spread to the rest of the body
Roseola
Erythema infectiosum
fifth disease
parvo virus B19
bright red rash on cheeks or rest of the body -slapped cheek appearance
itchy esp. if involves feet and soles
Erythema infectiosum
painful ulcers on tongue
grey blisters on hand and feet
Hand foot mouth disease
Hand foot mouth disease: causative organism
Coxsackie virus
all viral rashes: Mgmt
Supportive tx
Reassurance
if:
photophobia
rash
neck rigidity
Meningitis
suspected UTI in >3 months old baby
Urine dip
leucocyte esterase and nitrites are negative on urine dip
no abx
no urine MCS
leucocyte esterase or nitrites or both are positive on urine dip
abx and send urine MCS
