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