Pediatrics Flashcards
Labs / Signs with increased risk for bacterial source
Procalcitonin
CRP
Fever > 38.5 C rectally
ANC > 4000 with elevated PCT or > 5200 without
Assessment of fever in 8-21 day old (well-appearing only)
urinalysis
lumbar puncture
labs (can include inflammatory markers)
Consider HSV risk
Assessment of fever in 22-28 day old (well-appearing only)
UA
Blood culture
Inflammatory markers
- If UA negative AND abnormal IMs - do LP
- If normal IMs, MAY do an LP
- If Normal CSF 1) Going home: give antibiotics/antivirals. Observe at home and reassess in 24 hrs.
2) In hospital: MAY give antimicrobials. Observe.
If no source identified, stop antimicrobials and d/c home.
Assessment of Fever in 29-60 day old, well appearing
If NOT CLINICAL RSV BRONCHIOLITIS
Urinalysis, blood cultures and IMs.
- If increased IMs, send urine culture. MAY perform LP.
- If IMs Normal: positive urine, treat. If negative urine, observe closely at home, f/u in 24-36 hours.
Most common bacteria for 0-28 days
Group B Strep
Klebsiella
E Coli
Listeria
Chlamydia
Gonorrhea
Most common bacteria 1-3 months
Strep Pneumo
Neisseria
E Coli
H Flu
Most common bacteria > 3 months
E Coli
Strep Pneumo
Neisseria
Empiric Treatment in the Infant
Ampicillin, Cefotaxime (or Gentamycin) + Acyclovir if concerns for HSV
Rochester Criteria for Low Risk infants
WBC 5-15
Abs bands < 1500
UA < 10 WBC/HPF
Stool < 5 WBC / HPF
Colic Definition (Wessel Criteria)
Crying > 3 hrs / day, 3 days / week for at least 3 weeks
Differential Dx for Colic
C - Corneal abrasion, constipation, congenital anomalies
A - Anal fissure, appendicitis
N - iNtussusception, iNfection
T - Tourniquet
F - Formula intolerance, foreign body eye
A - Abuse
R - Recent immunization (pertussis)
T - Testicular torsion
Jaundice Causes (<24 hours)
ABO incompatibility
Sepsis
Conginital TORCH infections
- Toxoplasmosis
- Other: Syphillis,Varicella and Parvo
- Rubella
- CMV
- HSV
Birth Trauma
Jaundice Causes 2-3 Days
Physiologic (most common cause)
Jaundice Cause 3 days - 1 week
Infection
Congenital Infections
Congenital disease in bilirubin metabolism
Jaundice Causes > 1 week
Breast milk
Breast feeding
Biliary Atresia
Congenital hepititis
Red cell diseases (G6PD, sickle, spherocytosis)
Hemolysis due to drugs
Hypothyroid
Metabolic abnormalities
Signs of Kernicterus
Extensor rigidity
Tremor
Loss of suck reflex
Lethargy
Seizures
Progression of Jaundice
Head
Torso
Lower
Generalized
Risk factors for phototherapy
Prematurity
ABO incompatible
Sepsis
Clinical instability
ALTE Def’n
Acute, otherwise unexplained change in breathing leading to apnea or pallor / cyanosis, limpness or rigidity or an episode of choking/gagging
ALTE Workup and Mgmt
Glucose
Electrolytes
ECG
Infectious w/u if indicated
Inpatient mgmt if:
- Recent ALTE in preceding 24 hrs
- Sick appearing
- Signs of abuse
- FMHx
- Congenital abnormalities
Bronchopulmonary Dysplasia
Receive O2 in first 28 days of life
Repeated injury/inflammation
Risk Factors: prematurity, PPV, genetic predisposition
Signs/Symptoms: Resp distress, hypoxia, tachypnea, adventitious sounds or decreased air entry
CXR: Hyperinflation with cystic areas or fibrosis.
Tx:
- Supportive, O2 and suctioning.
- Trial inhaled bronchodilators
- IV fluids
- Admit
Pleural Effusion DDx in Peds
Transudative:
-Cirrhosis
-Nephrotic Syndrome
-CHF
-hyponatremia
Exudative:
-Infection
-Neoplasm
Cystic Fibrosis Presentation
Frequent lung and sinus infections
Pancreatitis
FTT
CP - due to pleurisy, pneumonia, pneumothorax
SOB due to LRTI or aspergillosis
Constipation/obstruction/ppancreatitis, chole, GERD
Cystic Fibrosis Dx
Meconium Ileus in newborn
Sweat Chloride
For exacerbations:
- Antibiotics: Inhaled and oral
- Pulmonary hygiene
- Steroids for bronchospasm
- Pulmonology Consult
Asthma Risk Factors for Badness
Previous ICU, previous intubation, low SES, multiple admissions in last year, comorbidities
Wheezing Differential
Asthma
Anaphylaxis
Bronchiolitis
Pneumonia
Cardiac wheeze / pulmonary edema
Foreign body
Bronchiectasis
Neoplasm
Vocal cord dysfunction
PRAM Score
Wheeze
Scalene retractions
Suprasternal Retractions
Air entry
Oxygen saturation
Mild < 4
Moderate 4-7
Severe >7
Asthma Mgmt
Initial:
Mild (PRAM 1-3): Ventolin Q1
Moderate (4-7): Salbutamol 20 min x 3 then Q1H + Dex (up to 2 dose)
Severe (8-12)
- Dex 0.6 mg/kg to max 12 mg
- < 20 kg Salbutamol 5 puffs (2.5 mg neb) q20 x 3 and Ipratropium 4 puffs (250 mcg neb)
- >20 kg Salbutamol 10 puffs (or 5 mg neb), Atrovent 8 puffs (500 mcg nebs)
*Atrovent ONLY in the first 3 hrs.
- Assess perfusion. IV access as needed.
- If impending resp failure give MgSO4 50 mg/kg (max 2g over 20 mins) with IV bolus (20 mg/kg)
- High flow nasal canula
- CPAP 5 to max 10 cm H20
- IV hydrocort 8 mg/kg (max 400 mg)
- Can trial IV salbutamol or epi 0.01 mg/kg to max 0.5 mg IM.
Impending respiratory failure: PRAM 12 + lethargy, cyanosis, decreasing resp effort, with increasing pCO2
Asthma D/c
Discharge 4 hrs after dex if PRAM < 4 and not required puffers x 2 hrs.
On d/c 4 puffs Q4 hrs x 24 hrs
D/c with ICS
Croup (laryngotracheobronchitis)
Upper airway obstruciton
- most common by Parainfluenza (COVID)
- Children < 3 usually
Differential:
- FB, subglottic stenosis, bacterial tracheitis, epiglottitis
XR: steeple sign
Use Wesley Score
Tx: Oral dexamethasone, 0.6 mg/kg. Nebulized epinephrine
Humidified O2
- Trial Heliox
- If ETT required, 0.5 size smaller.
- Admit if ongoing stridor
Bacterial Tracheitis Features and Mgmt
Age < 3
Preceded by viral illness
Toxic appearing
XR: Tracheal narrowing with rough appearance
If can get IV without causing resp distress, the administer ceft + vanco
RPA features and mgmt
Children < 4. Potential space infection between esophagus and spine.
- Hoarse voice, drooling, neck pain, trismus
Dx: Lateral neck (in extension)
- C2: > 7mm
- C6: > 14mm at C6 (21 mm in adults)
Bronchiolitis features and mgmt
Virus: RSV, HMNV, COVID
Typical: 1-2 days URI then cough, wheeze, tachypnea
Hypoxia possible
Apnea possible in premature infants
Ddx: Pneumonia, asthma, FB
Dx: Clinical. RAT for admission cohorting only
CXR only if very sick / ICU
Tx: Suction, supplemental O2.
- Consider hypertonic saline nebs
- Admission for resp distress, hypoxia, comorbidities or apnea present
- Complications dehydration and acute respiratory failure
Age Criteria: < 2 yrs, really < 1 years.
NO Nebulized Ventolin
Can try Epinephrine
Risk Factors for severe bronchiolitis
Age < 7 weeks
< 34 week prem
Chronic cardiac / respiratory illness
HR > 180
RR > 80
O2 sat < 88%
D/c if:
Mild distress
Hydrated
Sats > 90%
Mom/Dad Happy
RSV usually peaks at 4-7 days.
Distal Radius Acceptable Angulation
Bayonet apposition acceptable if > 50% overlap
If < 5 yrs 20 degrees
5-10 yrs, 15 degrees
> 10 10 degrees? Review slide
Greenstick # Mgmt
Requires splinting and ortho follow-up
Bowing Fracture / Plastic Deformity MgMt
Requires reduction, will not remodel
Elbow Injury - Supracondylar Features and Mgmt
Look for sail sign ant/post
Anterior humeral line should pass through the medial 1/3 of capitellum
Radio-capitalar line - done the radius bisects the capitellum in all views
Should not see a posterior fat pad ever!
Assess NV status in all
Median nerve (anterior interosseous branch) most commonly injured (Ok sign)
Can have radial nerve as well
Gartland Classifications
1 - undiscplaced
2 - Obvious # line with displaced distal fragment but intact posterior
3 - Complete displacement (no reduction unless hand is pulseless)
Mgmt: Posterior slab with ortho follow-up
Elbow Injury - Ossification order
Capitellum
Radial head
Internal
Trochlea
Olecranon
External
Toddler’s #
Stable #
Immobilize for comfort
Stable - no # line
REVIEW THIS
Fall, refusing to ambulate / limp
Salter Harris I of fibula Mgmt
Ankle bracing alone is ok.
Low Risk Ankle Fractures
Salter Harris I
Salter II
Avulsion
Weber A / Through malleoulus
Tilleaux (Salter Harris III of distal tibia)
Transition fracture
Growth plate fuses medial to lateral
Ortho referral in ED.
+ posterior malleolus = triplane #
Pelvic Avulsion #
Acute onset with forceful movement
Locations:
- Ischial tuberosity
- Greater trochanter
- Less Trochanter
- AIIS
- Symphysis Pubis
- Iliac Crest (abdo muscles)
- ASIS
SIDS Risk Factors
Prone sleeping
Co-sleeping
Mother that smokes
Young maternal age
Soft surfaces sleeping
Prematurity
Too hot
Male
FMhx
Management of Increased ICP
Elevated Head of Bed
Avoid hypotension / hypoxia / hypercarbia
MAP > 60
IV Mannitol (1 g/kg) or IV 3% NS (2-6 ml/kg)
Pediatric Cervical Spine Injury - Indications for Imaging
Focal Neuro deficit
Torticollis with trauma hx
Altered Mental Status
High speed injury
Major torso injury concomitantly
Age < 8 - can use plain films as initial imaging.
Age > 8 more likely.
- NEXUS criteria can be applied to rule out.
Pediatric Thoracic Trauma Signs
Tachypnea, tachycardia, hypotension, abnormal auscultation or external trauma
Chance Fracture and Associated Injuries
Chance fracture is an unstable spine fracture that typically occurs at the thoracolumbar junction. It is a horizontal fracture extending from posterior to anterior through the spinous process, pedicles, and vertebral body
Mechanism - flexion/distraction
Associated with duodenal perforation, mesenteric injuries or bladder ruptrue.
Pediatric Airway Normal Resp rate
10-60.
If < 20 in age < 6 then worry re: fatigue
List 5 Reasons Infants Desaturate Rapidly Under Anesthesia
Increased O2 Consumption
Decreased number of alveoli
Decreased FRC
increased dead space ventilation
Increased ventilatory rate
Risk of Anesthesia for Recent URI
Can result in airway hyperreactivity for up to 8 weeks
Increased rusk of perioperative complications including breath holding , desaturation, coughing, laryngospasm and bronchospasm
Anesthesia considerations for peds OSA
20% increased in postop respiratory morbidity after T&A and blunted CO2 response with increased opioid sensitivity
Laryngospasm mgmt
Jaw thrust and high flow 02 for partial
Succinylcholine 0.1 mg/kg + IV atropine 20 mcg/kg
- If no IV then 3-4 mg IM
Biomarkers for SBI / IBI in peds
Procalcitonin
ANC > 4
Temp > 38.5
CRP
Procalcitonin + ANC OR CRP (If negative no LP, if + then LP)
Temp + ANC + CRP then LP
22-28 days: No LP required if markers negative. Can consider discharge
- If positive markers must do LP and admit
Vitals in pediatrics
Memory aid:
1-3-5-7-9
6-5-4-3-2
Age RR HR
1 60 160
3 50 150
5 40 140
7 30 130
9 20 120
Minimal BP
Neonates: 60 mmHg
1-12 months: 70 mmHg
>1 = 70 + 2x age in years.
Pediatric Assessment Triangle
Appearance
- Tone, interactive/irritable, consolable, look/gaze, speech or cry
Breathing
- Head position, Bobbing, Nasal flaring, grunting, indrawing / retractions
Circulation
- Cap refill, pallor, petechiae, cyanosis, mottling
Red flags for non-accidental trauma
Story inconsistent
Bruises in pre-cruising infants
Patterns injury or injury to ears, inner thighs, neck, groin
Posterior oropharynx bruising.
Posterior rib #
Fractures in non-ambulatory child
injury not in keeping with mechanism endorsed
Simple vs Complex Febrile Seizure
Simple:
- < 15 mins
- Single in 24 hours
- No focality, GTC
- Between 6 months - 5 years
1/3 will have 2nd seizure, usually within the year.
Risk of epilepsy 1-2 vs 0.5-1% if seizure
6 causes of fever and petechiae
1) N. Meningiditis
2) HSP
3) DIC
4) ITP
5) Toxic shock syndrome
6) Leukemia
7) Necrotizing fasciitis
8) VAsculitis - SLE
9) HIV
10) Pneumococcemia
11) Endocarditis
Diagnostic criteria for Toxic Shock Syndrome
Fever > 38.9
Hypotension
Orthostatic syncope
Erythroderma
Desquamation (after 1-2 weeks, not helpful(
Multisystem involvement (3 or more):
- GI
- Muscular (elevated CK or myalgias)
- Mucous membranes
- Renal
- Hepatic
- Hematologic - thrombocytopenia
- CNS: Disorientation without focal findings
Negative cultures for other bacteria, rocky mountain spotted fever, measles, leptospirosis
Differential for stridor
Supraglottic:
- Epiglottitis
- Myriad congenital with craniofacial abn
- Foreign body
- RPA
- Tonsillar hypertrophy
Glottic (biphasic)
- laryngomalacia
- vocal cord paralysis, cyst
- laryngeal web
- foreign body
- papillomas
Subglottic:
-subglottic stenosis
- tracheiitis
- mediastinal mass
- croup
- FB
- tracheomalacia
XR findings in croup
Thumbprint sign
Thickened aryepiglotic folds
Lack of air in vallecula
Dilated hypopharynx
Normal
How to do jet insufflation
14 G angiocath over needle into the cricoid membrane - directed caudally
- Attach to 3 cc syringe
- Connect adapter for 7.0 tube the bag
Differential for pneumonia in peds
Bad XR . interpretation
Pulmonary disease:
- Dysplasia
- CF
- Bronchiectasis
- Atelectasis
- ARDS
Cardiac Disease
- CHF
Blood Vessels:
- AVM
- PE
- Sickle cell infarction / acute chest
Bronchi/oles:
- FB
- Aspiration
-Chemical exposure
When to get XR in respiratory disease in child
Fever, unilateral lung findings, tachypnea, hypoxia
CF complications
Pumonary infections and bronchiectasis
Pancreatic insufficiency
Malabsorption - vitamin deficiency and osteoporosis
Diabetes
Infertility
Causes and stages of Whooping Cough
Bordetella Pertussis
Stages:
1) Catarrhal stage, 1-2 weeks of typical URTI symptoms
2) Paroxysmal Stage
- Severe paroxysms of staccato cough x 1-2 weeks
- 2 to 4 weeks
3) Convalescent stage
- Gradually resolving over 2-4 weeks
Mgmt: Azithromycin, Septra
- Does not treat infection / reduces transmission
Tetralogy of Fallot anatomy
VSD
Low lying aorta
RV outflow obstruction
RVH
Cyanotic and Acyanotic Heart Lesions
Cyanotic:
- Increased Pulmonary Markings
*Transposition of the great arteries
*TAPVR
*hypoplastic Left Heart
*Truncus Arteriosus - Decreased Pulmonary Markings
*Tetralogy of Fallot - Severe pulmonic stenosis
*Tricuspid atresia
*Pulmonary atresia
*Hypoplastic RH
Acyanotic:
- Increased Pulmonary Markings
*VSD
*ASD
*Patent DA - Decreased Pulmonary Markings
*Aortic Stenosis
*Aortic Coarctation - Pulmonic Stenosis
Ductal dependent cardiac lesions
Acyanotic: aortic stenosis, coarctation, HLHS
Cyanotic: Tetralogy, Pulmonic stenosis, Tricuspid atresia, HRHS, TGA, TA
Complications of PGE1 - Prostaglandin
Apnea
Seizures
Bradycardia
Fever
Flushing
Decreased platelet aggregation
Tet Spell Mgmt
Calm child
Knees to chest
Supplemental O2
Fentanyl / Morphine
IV Fluids / Bicarb
HSP etiology and complications
IgA vasculitis, usually onset after a viral URTI
- Joint pain
- Painful, palpable purpura
- Hematuria
- AKI
Complications:
- Intussusception
- GI bleeding
- Renal failure
- Testicular torsion
- Hypertension
- Cellulitis / infection of purpura
Causes of constipation in children
Drugs: opioids, anticholinergics, aluminum containing antacids
Neurogenic: Hirschsprungs, CP, spinal cord injury, duchenne MD
Endocrine / Metabolic: CF, hypoK, hyper or hypoCa2+, hypothyroid, DM
Anatomic: Atresia, volvulus, imperforate anus
DDx Priapism
Low flow: Ischemic, painful, “limb” threatening”
- Drugs (cocaine)
- Sickle cell
- Malignancy - lymphoma, leukemia
High Flow (Non-ischemic, non-painful)
- Trauma, AVM
Neurogenic
Testicular torsion assessment
Testicular or flank pain
Swelling
High Riding
Nausea and vomiting
Twist score
-Swelling (2 pts), hard (2 pts), high riding, loss of cremasteric reflex,
UTIs in kids < 2 years
If < 2 month:
- Admit and IV abx with Amp and cefotxime
- Kleb and E.coli
2-24 months
- Assume all are upper tract disease
- PO cefixime is first line.
- tx 7-10 days
>2 yrs
- If no systemic symptoms, treat as simple with 3 day course of Abx.
Types of HUS
Primary - atypical HUS
- Complement mediated
Secondary - typical HUS
- Usually associated with EHEC
- Renal failure, uremia, hemolyis, thrombocytopenia
DDx for hematuria
Intrarenal:
- Stones
- PSGN
- AIN
- Pyelonephritis
- PCKD
- Renal vein or artery thrombosis
Extrarenal:
- Cystitis
- Trauma
- Meatal stenosis
- Exercise
- Mestruation / rectal bleeding
- Epididymitis
6 causes of nephrotic syndrome
Renal failure with hypoalbuminemia and edema
- PSGN
- Lupus
- Scleroderma
- IgA nephropathy
- HUS
- HSP
- Goodpasture’s
- MPA
- Alport syndrome
Primary and most common is minimal change disease!
Indication of surgical repair in clavicle fracture
Open
Skin tenting
NV injury
Fractures with > 100% displacement
Pathologic fracture
1-2-3 rules
1 and 3 pieces are odd fractures
2 - up to 2 cm of overlap allowed
Approach to elbow XR
Effusion
Lines - anterior humeral and radiocapitellar
Boney Cortex
Ossification centres
Watch all 3 views.
Baumann’s angle: Angle between humeral axis and lateral physis
Supracondylar Fracture complications
NV injury. AIN
Brachial artery
Volkmann’s Ischemic contracture:
- Fixed elbow flexion, forearm pronation, wrist flexion, MCP extension, IP flexion
Brachial artery thrombosis
Malunion: cubitus varus
Monteggia vs Galleazzi
MUGGER
Monteggia: Fracture of ulna with dislocation of radial head
- Needs ORIF
Galeazzi: Fracture of distal 1.3 of radius with DRUJ injury
Risks for DDH
Female
Breach presentation
Family Hx
First born
Oligohydramnios
10 Causes of hip pain in child
Infection: Septic arthritis, osteomyelitis, myositis
Inflammatory: TS, JRA, Rheumatic fever
Trauma: Fracture or overuse
Metabolic: Hemophilia, sickle cell
Neoplasm: leukemia, osteogenic / sarcoma, metastatic disease
Miscellaneous: LCP, SCFE
Septic arthritis vs Transient Synovitis
Septic - younger 6-24 months
- ++ pain with passive ROM
- Appear sick
- Limp or refusal to walk
- Erythema, warmth and swelling of joint. If hip, usually flexed, abduction and external rotation
Knee»_space;> Hip incidence
- Most common cause if MSSA/MRSA
- Gonococcal
WBC > 50,000 ++ likely
TS: Older, age 3-9 years
- Dx of exclusion
- Limited pain with passive ROM
Kocher Criteria:
- Fever > 38.5
- Inability to WB
- ESR > 40 or CRP > 20
- WBC >12
Pathogens for septic arthritis by age
< 2 months: GBS, s aureusm gram negatives bacilli or N gonorrhoeae
2 months -5 years: MSSA, MRSA, S. pneumonia, S. pyogenes, Kingella kingae, H Flu
>12 S aureus, N. gonorrheae
Sickle - Salmonella
