Pediatrics Flashcards
Newborn Management
First 30 seconds
First 30 seconds stimulating
- rub with towel, suction MOUTH then NOSE
- At thirty check pulse and breathing
Indications for PPV
Pulse under 100 or breathing difficulties (gasping, apnea)
Primary apnea
no breathing but is corrected by stimulation in first 30 seconds
Secondary apnea
not corrected in the first thirty seconds, treated by PPV
APGAR
1, 5, 10? Appearance Pulse Grimace Activity Respiration
TX for Pulse below 100? Below 60?
<100: PPV
<60: Chest compressions 3:1 with breaths, check at 60 seconds, then epinephrine through umbilical vein catheter
Meconium Aspiration Syndrome, when to worry
Meconium passed in utero
Meconium present but vigorous (pulse >100) : simple suction
Patient not vigorous, endotracheal suctioning / ventilatory support
Newborn Exam
Head - fontanells open, ok for some molding, look for cephalohematoma/caput succedaneum
Ears / eyes - red reflex
Nose / mouth - cleft lip / palat
Clavicles - breaks
Chest - heart / lung sounds. PDA not heard right away
Abdomen - masses
GU - Male / femal genitalia. Patent anus, sacral dimple
Extremities - ortalani / barlow maneuvers
Neuro - reflexes
Umbilical cord
2 arteries, 1 vein
Maternal Labs that could change post partem care
GBS
HIV
Hep B
Transient tachypnia of the Newborn
Delayed clearance of lung fluid
Often seen with C sections
Wet hyperexpanded CXR
can last 24-48 hours
Treat with O2 or CPAP
Respiratory Distress Syndrome
Usually surfactant def causing atelectasis
Usually in premature babies / those with perinatal distress
CXR shows low lung volumes with granular pattern
If severe: give surfactant and mechanical ventialtion
Infectious Etiologies by Age
Under three months:
Ecoli
GBS
Listeria
3months - 5years
Hflu
Niseria
S Pneumo
6year - Adult
Niseria
S Pneumo
Antibiotics for < 1month vs >1month
<1 month:
Cefotaxime
ampicillin
> 1 month:
Ceftriaxone
Vancomycin
CTX - hyperbilirubinemia <1m
How to dx Asthma
PFT showing dec FEV1 over FEV that improves with bronchodilator OR
Normal PFT that is reduced with methacholine challenge
Asthma Management - initial and order of addition
Remove pets, mold, dust mites, cigarrets, mold other allergen triggers from house.
LTA can be added anytime.
SABA
ICS (low then high)
LABA
Oral steroids
Asthma; acute exacerbation tx
Albuterol / Iprotropium (duonebs)
IV steroids
Epi and Magnesium if escalation
Bronchiolitis
usually under 2
Viral infec (usu RSV)
Looks like asthma BUT no help from bronchodialator
Obstruction is from sloughed epithelial cells
DX with rapid antigen / nasopharingeal swab
under 3 months, under 90% spo2, immunodef all get hosp
Give Palivuzumab for prevention
CF
Prenatal screening
How it may present: Failure to thrive, meconium illius, freq resp infections, infertile, malnourished
Manage with pancreatic enzyems and agressive tx of psuedomonas with lung infections.
life expec is 40 years
Lung diseases in pedatric patient DDX
Forign body aspiration
Viral URI bacterial URI Bronchiloitis (under 2) PNA asthma Consider CF
Physiologic vs Pathologic Jaundice
Physiologic
- onset first week
- < 10% direct (conjugated)
- not elevating more than 5/day
- resolves by day 10
Pathologic
- onset under 24 hours
- > 10% direct (Conjugated)
- lasts over 2 weks
Workup for yellow baby
First check Bili
-direct (>10% conjugated) —-> HIDA scan/Hepatic US, Sepsis / metabolic eval
-indirect (<10% conjugated) —–>
Coombs test (Rh or ABO incompat)
Hgb (if high could be late cord clamping)
Retic count ( High in hemolysis / hemmorhage)
Reabsorbtion ( hemmorhage vs breasmilk jaundice vs breastfeeding jaundice)
Breast FEEDING Jaudice vs Breast MILK jaundice
Breast feeding Jaundice
- under 7 days
- slow transit, increased reabsorbtion
- unconj (indirect)
- increase feeds
Breast milk jaundice
- over 7 days
- Milk inhibits an enzyme
- Conjugated (direct)
- temporary substitute formula
Asthma DX with Frequency
Intermittant - Under 2dayyime sxs/wk or nightime/2month
Mild Persistant - 2-6/wk or over 2 nightime sxs /month
Moderate Persistant - daily or >1 nightime / month
Severe - multiple daily or frequent nocturnal sxs
Refractory - PO steroids
Encephalitis
Inflamation of brain parenchyma
Meningitis
Inflamation of meningis
-Kernig / brudzinski signs
-
FAILS
Pneumonic used to decide if LP is safe
FND AMS Immunodef Lesion Seizure
If they fail, get BCX, ABX and a CT scan
If no, do LP, then ABX and CT
if CT shows mass - HIV or TOXO (get Abs / test for each)
CSF findings
Lymphocytes - viral. Get HSV PCR , IV acyclovir
Polys (inc prot, low sug) - Bacterial - give Vanc, CTX, steroids +/- amp
Inc prot, normal sug = Guillon barre?
Not bacterial - Crypto, RMSF, Lyme, TB, Syphilis
Fever:
Under 1 month
1-3months
3months - 3 years
Under 1 month
-CBC, BCX, UCX, LP with chest radiogrpah and admit
Urine
Bcx, Lumbar px
1-3months
-same, LP is a maybe , CXR is a maybe
3months - 3 years
-LP not needed
TX for anaphalaxis
Epinephrine
H1/H2 blockers
Epi pen at D/C
Urticaria
WHat is it
What do you see
TX
Mast cell degranulation - causes
erythema and wheals
TX
2n gen H1 antihistamines (ranitidine, fexofenadine)
Avoid agent
Angioedema
WHat is it
TX
Mast cell degranulation (same as urticaria but deeper)- causes swelling in lip airway and GI tract
INtubate if needed
FFP given if C1 esterase inhib defect suspected
Allergic Rhinitis
Difference between seasonal and perenial
PE findings
TX
PE
venous congestion under eyes (allergic shiners)
Nasal Mucosa will be pale and bogy. maby polyps
Oropharynx may have cobblestoning
TX
Identify and avoid triggers
Intranasal - (antihistamins, steroids)
Oral meds : antihistamines, leukotriene antagonisnts
ALlergic conjunctivitis
Exam:
TX
PE
Ocular prurutus
Conjuctival redness discharge
TX
Avoid triggers
artificial tears (barrier)
Medicated eye drops (mast cell stabalzierz / h1 blockers)
Atopic dermatitis (eczema)
What is it What causes it Who gets it What do you worry about TX
Scaley skin
Who typically gets it? younger children on extensor surfaces (flexors on adults)
Cause - environmental / food exposure
Worry; Can become infected if severely excoriated
Emollients / moisterizers. steroids for exacerbations
Food allergies
Which are often outgrown?
Which ar persistant?
Presentation
TX
Note: breast feeding
Grown out of: wheat, eggs, soy and milk
Persistant - nuts / fish
Presentation: could be pruritis
or Vomiting/diarrhea OR anaphalaxys
TX - epi pen
Stop mom from eating offending food while breast feeding
Baby emisis
Usually is
Something to keep in mind
Must find out if ____
Usually “Spitting up” - smaller vome, non projectile, formula colored
Always keep head trauma from abuse as casue in mind
If it is billious vomiting or not
Causes of billious vomiting
First step in workup
DDX Duodenal atresia annular pancrease Malrotation / volvulus Intestinal atresia
First step
Babygram
Causes of non billious vomiting
Pyloric stenosis
TE fistula
BRUE: what does it stand for
What is it
TX
Brief Resolved Unexplained Event
Definition: < 1year old and <1 min duration with any change in: color tone breathing responsiveness.
TX: If over in any any of these catagories, do work up
Otitis Media
What is it
What causes it
Exam finding/
DX
TX
inf of middle ear
Cuased by resp bugs
(S pnumo, H flu, Moroxella Catarhalis)
Exam findings:
Tense immobile membrane
relief with puling the pinna
TX - Amoixicillin
recure: amoxicillin + clavulonic acid.
Penicillin allergic: ceffdinir if no anaphalctic hx, azithro if there is
Mastoiditis
What is it
inc risk of:
Look for:
What to do:
Mastioid air cell infection
Inc risk with tympanoplasty (for pseudomonas)
Look for swelling behind the ear, and anteriorly rotated ear
Get surgical eval
Otitis Externa
What is it
Causes
Common bug
TX
Education
Infection of skin in ear canal
Swimmer (pseudomonas)
Casued by trauma, Staph aurius
TX - topical abx and steroids
Education - dry ears after swimming and showering
Sinusitis
What is it
Presentation
When to presume bacterial?
When to get XR?
TX if bacterial
What is it : Infection of nose and sinuses
Presentation: Purulent nasal discharge, sensitive sinuses
When to presume bacterial?
- above 10 days
- Fever above 39
- Purulent / facial pain for 3-4 days
When to get XR? if -
- -refractory or recurrent to look for anatomical cause
- -Eval for forign body if young*
TX
caused by URI bugs, so give Amoxicillin / clavulonic acid
NO AZITHRO (why?)
Cold
main cause
How long to wait
Rhinovirus
do nothing unless over 10 days
Pharyngitis
HX
Exam findings
Centor cirteria?
If pharyngitis + enlarged spleen
conjunctivities
rash on palms and souls
IF GAS (group A strep)
TX
Causes
HX - Sore throat
pain on swallowing
Exam findings
Centor cirteria - to decide on next step for patient. Definitly swab someone 5-15 years old. Do not swab under three years old.
If pharyngitis + enlarged spleen, get EBV panel
If pharyngitis + conjunctivitis - adenovirus
Pharyngitis + rash on palms and souls - cocksackie
If GAS- could cause reumatic fever. Must treat. Wont stop PSGN
TX - amoxicillin / clavulonic
What are the CENTOR criteria
Acronym
When you see sxs of step pharingitis, it is to see if a swab is needed
CENTOR!
Cough absent +1
Exudate or swelling on tonsils + 1
Nodes: Tender/ swollen anterior nodes + 1
Temp >38 +1
OR Age
+1 if 3-14 OR
-1 if over 45
2 - maybe
3 or more: strep test with culture
Epistaxis
Most common cause
Normal nosebleed will:
TX:
Exam once it clears
Most common cause- digital trauma
Normal nosebleed will:
be unilateral, last under 30 min
TX: Cold compress, lean forward, pressure
Consider cauterizing with silver nitrate
Exam once it clears: look for forEign body / something anatomical
failure to pass meconium
TImeline
Causes of FTPM (failure to pass meconium)
First step
Timeline : over 48 hours
Causes :
Imperforate Anus
Meconium Illius
Hrischsprungs
Get X ray
Constipation in baby / todler
Causes
two high, two low
Causes: Voluntary constipation duodenal atresia Voluvulus Intestinal atresia
Medication induced
Mg, opiates
Metabolic induced
(Hypercalcimia, hypermagnesemia,
Hypoglycemia, hypokalemia)
Describe each:
Epidural Hematoma
Subdural Hematoma
Cerebral contussion
Epidural Hematoma - trauma to side of head, LOC, lucid interval, coma. CT - lense shape
Subdural Hematoma- trauma or shaken baby. Coma, child stas in it. Concave or crescent shaped
Cerebral contussion - desceleration injuries, LOC - CT shows puncteate intracerebral hemmohrages
When to use:
Rear facing seat in the back seat
Booster seat
Read facing in back - o-2
Booster - after 2, untill 4’9” - usually 8-12 years old
Concussions
things to ask about
Mild vs Severe
Any tingling, numbness, weakness?
any LOC? How long?
Any headache? Worse or better?
Can you remember everything?
Mild concussion
- No FND
- under 60 sec LOC
- None/ improving headache
- No amnesia
-Observe / send home
Severe concucssion
- FND
- over 60 seconds passed out
- retrograde / anterograde amnesia
CT / admit
Always stepwise return to play, stop playing current game
SIDS
How to prevent
Children under 1 year, highest incidence in first 3 months.
Sleep on back
Dont share bed
Stop smoking
Failure To Thrive
What is it. What goes first.
DDX
Organic
non organic
Kid falls off growth curve. Weight first, then hight, then head circ.
DDX
Organic
- Genetic (CF)
- cardiac dz
- pyloric stenosis
- GERD
Non-organic (more common)
-wrong formula
-improper feeding technique
CHECK Formula, Feeding, Frequency
Important things to discuss to prevent trauma
Car seat (back backwrds till 2, then booster untill 4'9") Then seatbelts Trampolines Guns Fence pools Swimming
