Pediatrics Flashcards
APGAR criteria
appearance pulse grimace activity respiration
APGAR: appearance
0 = blue/pale 1 = acrocyanosis 2 = pink
APGAR: pulse
0 = absent 1 = <100 2 = >100
APGAR: grimace
0 = absent 1 = lots of stim 2 = with stim
APGAR: activity
0 = absent 1 = flexion 2 = resist extension
APGAR: respiration
0 = absent 1 = irregular 2 = strong
primary neonatal apnea path
understimulation
C-section
primary neonatal apnea pt
no respirations from the start
primary neonatal apnea dx
clinical
primary neonatal apnea tx
stimulate baby
suction
secondary neonatal apnea path
uncertain
secondary neonatal apnea pt
baby was breathing then stops
secondary neonatal apnea dx
ensure patent airway
secondary neonatal apnea tx
PPV
neonatal dyspnea causes
TTN
RDS
TTN path
self-limiting
C-sections
TTN pt
near-term
grunting
TTN dx
hyperextended
wet
TTN tx
PPV
RDS path
developmental
deficient surfactant
RDS pt
premature
perinatal distress
RDS dx
hypoextended
atelectasis
RDS tx
intubation and surfactant
newborn hypoglycemia path
risk factors
- LGA, infant DM mother
- small gestational age, IUGR
newborn hypoglycemia pt
jitteriness, tremors, lethargy, poor feeding
newborn hypoglycemia dx
every babe gets a glucose check
newborn hypoglycemia tx
if sx = IV glucose
if asx = feed
newborn hypoglycemia f/u
sepsis
bronchopulmonary dysplasia path
decrease surfactant = RDS
prolonged damage = scarring
bronchopulmonary dysplasia pt
increase O2 demands
FiO2 required >28d
lung-protective strats
bronchopulmonary dysplasia dx
xray = ground-glass opacities
bronchopulmonary dysplasia tx
surfactant (post-birth)
steroids (pre-birth)
bronchopulmonary dysplasia f/u
BPD is to RDS (peds) as DPLD is to ARDS (adult)
retinopathy of prematurity path
neoangiogenesis gone awry
Increase FiO2
retinopathy of prematurity pt
premature infant requiring O2
retinopathy of prematurity dx
eye exam (all premies)
retinopathy of prematurity tx
laser
retinopathy of prematurity f/u
glaucoma
intraventricular hemorrhage (NICU) path
highly vascular ventricles
labile pressures
intraventricular hemorrhage (NICU) pt
premie...asx increase ICP (fontanelles)
intraventricular hemorrhage (NICU) dx
cranial doppler (all premies)
intraventricular hemorrhage (NICU) tx
decrease ICP…shunts, drains
intraventricular hemorrhage (NICU) f/u
intellectual disability, seizures
necrotizing enterocolitis path
dead gut
necrotizing enterocolitis pt
premie…bloody BM
necrotizing enterocolitis dx
xray = pneumatosis intestinalis
necrotizing enterocolitis tx
NPO, IV abx, TPN
necrotizing enterocolitis f/u
surgery
imperforate anus path
VACTERL
imperforate anus pt
no hole on inspection (+/- fistula)
never first temp rectally
imperforate anus dx
visual inspection
cross-table xray
imperforate anus tx
mild = repair now severe = colostomy, repair before toilet training
imperforate anus f/u
Vertebra - u/s sacrum Anus - x-ray Cardiac - echo TE Fistula - x-ray with coiled tube Esophageal atresia - xray with coiled tube Renal - VCUG Limb - xray
meconium ileus path
cystic fibrosis
meconium ileus pt
FTPM and…
no prenatal care (undocumented)
meconium ileus dx
x-ray = dilated loops, gas-filled plug
water-soluble contrast (gastrograffin enema)
meconium ileus tx
water-soluble contrast (gastrografin enema)
meconium ileus f/u
meconium peritonitis = perf
ADEK vitamins
pancreatic enzymes
short stature
hirschsprung’s path
failure of neuron migration = distal colon
absent inhibitor neurons = no relaxation
Hirschsprung’s pt
case 1 (90%): FTPM, explosive stool with DRE case 2 (10%): chronic constipation with overflow incontinence
Hirschsprung’s dx
x-ray: good bowel = dilated; bad bowel = normal
if FTPM: contrast enema
if constipation: anorectal manometry -> increased tone
best = biopsy = absent neurons
Hirschsprung’s tx
surgery
voluntary constipation path
embarrassment or pain
cognitive impairment
voluntary constipation pt
toilet training OR school-aged child
constipation with overflow incontinence
encopresis
voluntary constipation dx
clinical
voluntary constipation tx
bowel regimen (stool softener, motility) disimpaction under anesthesia if necessary
unconjugated bilirubin
lipid soluble
can cross BBB
kernicterus
NO urinary excretion
conjugated bilirubin
water soluble
cannot cross BBB
NO kernicterus
urinary excretion
physiologic jaundice
onset >/= 72h
bilirubin increase <5/d (slow)
D. bili <10% total
resolves in 1wk (term) or 2wks (preterm
pathologic jaundice
onset <24h
bilirubin increase >5/d (fast)
D. bili >10% total
resolves in >/= 1wk (term) or >/= 2wks (preterm)
Crigler-Najjar
NO UDP-glucouronyltransferase
Type 1 die, Type II have unconjugated bili (very rare)
Gilbert’s
decrease UDP-glucuronyltransferase unconjugated bili (mc of these diseases)
Dubin-Johnson
problem with excretion
conjugated hyperbilirubinemia
black liver
Rotor
looks like Dubin-Johnson
conjugated, no black liver
problem with storage
breast-feeding jaundice
< 7d of life
not enough feeding, slowing of gut, increase bili reabsorption
increase feed frequency
breast milk jaundice
> 10d of life
enzyme inhibition by mother’s milk; insufficient conjugation
phototherapy (if needed) and continuation of breast feeding OR supplement with formula x1wk
neonatal jaundice path
unconjugated causes kernicterus
conjugated implies structural lesion
neonatal jaundice pt
baby will be yellow
neonatal jaundice dx
transcutaneous sensor (screen) bilirubin level (diagnostic)
neonatal jaundice tx
if unconjugated: use BLUE LIGHT
if conjugated: evaluate for cause
tracheoesophageal fistula path
+/- fistula
+/- atresia
mc type C (blind pouch of esophagus with fistula from distal esophagus to trachea)
tracheoesophageal fistula pt
nonbiliary emesis day 0
bubbling, gurgling
TE fistula dx
NG tube coils on xray
TE fistula tx
parenteral nutrition
NG tube suction
surgery
pyloric stenosis path
hypertrophy of pylorus
gastric outlet obstruction
pyloric stenosis pt
2-8wks, normal feeds -> projectile
usually a boy
* olive-shaped mass
* visibel peristaltic waves
pyloric stenosis dx
BMP = decrease Cl, decrease K, increase Bicarb u/s = donut sign
pyloric stenosis tx
FIX ELECTROLYTES FIRST = IVF
pyloromyotomy
malrotation path
failure of rotation
malrotation pt
normal uterine course
no polyhydramnios
no down syndrome
malrotation dx
x-ray = double bubble with NORMAL gas pattern beyond
upper GI series
malrotation tx
NGT decompression
surgery
malrotation f/u
volvulus; ischemia
duodenal atresia path
failure to recannulate the duodenum
duodenal atresia pt
+ polyhydramnios
+ down syndrome
duodenal atresia dx
x-ray = double bubble AND no gas beyond
duodenal atresia tx
surgery
annular pancreas path
failure to recannulate the esophagus
annular pancreas pt
+ polyhydramnios
+ Down syndrome
annular pancreas dx
x-ray = double bubble AND no gas beyond
annular pancreas tx
surgery
intestinal atresia path
vascular compromise
intestinal atresia pt
mom = cocaine use
NO down syndrome
intestinal atresia dx
x-ray = double bubble with multiple air-fluid levels
intestinal atresia tx
surgery for baby
confront mom
intestinal atresia f/u
short-gut
congenital diaphragmatic hernia path
bowel in chest
hypoplastic lungs
congenital diaphragmatic hernia pt
scaphoid abdomen
pulmonary distress day 0
bowel sounds in chest
congenital diaphragmatic hernia dx
x-ray (babygram)
congenital diaphragmatic hernia tx
cardiopulmonary stabilization
pulmonary surfactant
surgical repair
gastroschisis path
extrusion of bowel
NO membrane
gastroschisis pt
RIGHT of midline NO membrane (loose bowel)
gastroschisis dx
clinical
gastroschisis tx
silo
gastroschisis f/u
fluid shifts big problem
omphalocele path
extrusion of bowel
intact membrane
omphalocele pt
MIDLINE YES membrane (contained sac)
omphalocele dx
clinical
omphalocele tx
silo
omphalocele f/u
fluid shifts but not as fast
exstrophy of the bladder path
bladder through the skin
exstrophy of the bladder pt
MIDLINE defect
wet with urine
red or shining
no bowel seen
exstrophy of the bladder dx
clinical
exstrophy of the bladder tx
surgically
biliary atresia path
failure of the biliary tree to recanalize
biliary atresia pt
persistent or worsening jaundice at 2kws
direct hyperbili
biliary atresia dx
u/s = absence of ducts
HIDA scan after phenobarb = no contrast in GI
biliary atresia tx
surgical (hepatoportoenterostomy)
biliary atresia f/u
fatal if not corrected
neural tube defects path
genetic syndromes
FOLATE deficiency
failure of the caudal neural tube to fuse
NTDs pt
occulta: tuft of hair only
meningocele: extrusion of meninges without cord
myelomeningocele: extrusion of meninges with cord
NTDs dx
prenatal \+ AFP screen \+ u/s in utero no prenatal care \+ visual inspection
NTDs tx
surgery
NTDs f/u
chiari type II with myelomeningocele
hydrocephalus can lead to learning disabilities
cleft lip/cleft palate path
failure of growth and fusion of the underlying structures
cleft lip/palate pt
spectrum: lip through uvula
spectrum: superficial through transmural
spectrum: unilateral, bilateral, midline
cleft lip/palate dx
clinical
cleft lip/palate tx
surgically
cleft lip/palate f/u
cosmetic deformity
failure to thrive from inability to latch (feed)
developmental milestones: 2 mo
gross motor: lift head
fine motor: tracks past mid
speech: coos
social: social smile
developmental milestones: 4 mo
gross motor: roll over
fine motor: clumsy clap
speech: laughs, squeals
social: looks around
developmental milestones: 6 mo
gross motor: sit up
fine motor: rakes
speech: babbles
social: stranger anxiety
developmental milestones: 1 yr
gross motor: walk
fine motor: pincer grasp
speech: 1-word
social: separation anxiety
developmental milestones: 2 yr
gross motor: steps
fine motor: -
speech: 2-word
social: 2-step commands
developmental milestones: 3 yr
gross motor: trike
fine motor: circle
speech: 3-word
social: -
developmental milestones: 4 yr
gross motor: hop
fine motor: cross
speech: 4-word
social: -
developmental milestones: 5 yr
gross motor: skip
fine motor: triangle
speech: 5-word
social: -
vaccines
MMRV HepA/B DTaP HiB pneumococcal meningococcal HPV flu
FTT
head circumference: last to go
height: lost between
weight: first to go
organic causes of FTT
genetic (CF)
cardiac disease
pyloric stenosis
GERD
non-organic causes of FTT
formula
feeding
frequency
red flags of abuse: injury
suspicious shape
suspicious location
severity
red flags of abuse: child
injured infant
comfort from nurses
comfort from staff
safety to prevent trauma
car seats booster seats seatbelts NO trampolines eliminate guns fence pools
safety for SIDS
sleep on back
don’t share beds
smoking cessation
vaccine contraindications: egg allergy
nothing made with eggs except:
- influenza *US IM flu no longer made with eggs
- yellow fever
vaccine contraindications: immunocompromised or pregnant
no live vaccines
- MMRV
- live attenuated flu (IN)
vaccine contraindications: anaphylaxis
never get that vaccine again
vaccine contraindications: ok to give vaccine again if…
prior local reactions, current illness or fever, family history of ____, autism fear
hep B vaccines
Mom: + Baby: Hep B Ig and Hep B Vax NOW
Mom: - Baby: Hep B within 2 mo
Mom: ? Baby: Hep B NOW, check mom’s HBsAg
DTaP vaccine
kids get 5 doses: - 3 doses in 1st year - 2 doses between 1-4y Td (booster) or Tdap at least once in adolescence and q10y need 3 total doses lifetime
Hib vaccine
disease does not confer immunity in those <2y so give Hib vax
does not cover nontypeable
Hib causes epiglottis and meningitis
MMRV vax
vax and booster before school (1 and 4)
pneumococcal vax
two types: 23 and 13 valent
complete 13 as infant, add 23 if + risk factors
to all immunocompromised and asplenic pt
meningococcal vax
to everyone vs. meningitis…
required for college and military
HPV vax
all boys and girls 9-26
prevents cancer
Hep A/B vax
2 doses for A
3 doses for B
pick up where you left off
Flu vax
everyone. period.
healthcare workers before winter months
given annually
managing a wound with < 3 lifetime DTaP doses (or unknown)
clean: Tdap
Dirty: Tdap + TIG
timing doesn’t matter if <3 lifetime doses
managing a wound with >/= 3 lifetime DTap doses
clean:
- > /= 10y : Tdap
- < 10y : Home
dirty: - > /= 5y : Tdap
- < 5y : home
- NO TIG needed if >/= 3 lifetime doses
pertussis
catarrhal stage (inconspicuous) paroxysmal phase (coughing spells, whoops) resolution phase (regular cold symptoms)
diphtheria
grey pseudomembrane in oropharynx
airway, antibiotics, antitoxin
tetanus
dirty wound, lock jaw, spasms
TIG (block toxin) and toxoid (vaccinate)
lethal dose < immune dose
tube, sedate, MTZ
varicella
no pox parties -> vaccinate instead
kids get MMRV = no chickenpox
adults, no “v” = shingles = varicella @ 60
HPV
boys and girls aged 9-26
does prevent cancer
does not increase sex, STI, pregnancy, etc
rotavirus
oral
contraindicated in intussusception
1st degree burn
epidermis only
+ pain, + erythema
2nd degree burn
epi + dermis
+ pain, + blisters, + erythema
3rd degree burn
through dermis
white and painless with surrounding 2nd deg burns
Parkland formula for burns
%BSA x kg x 4
- 2nd and 3rd degree only
- 50% in 8hrs; 50% in 16hrs
rule of nines for burns
head: 9 + 9 = 18 front thorax: 9 + 9 = 18 back thorax: 9 + 9 = 18 Arms: L = 9; R = 9 = 18 Legs: 9 + 9 + 9 = 27 genitals: 1
epidural hematoma
temple trauma
+ LOC with lucid interval
biconvex ‘lens’
subdural hematoma
major trauma or abuse
+ LOC, no lucidity
concave ‘crescent’
cerebral contusion
major trauma
+ LOC
punctate hemorrhage
head trauma prevention
helmets: in sports and on bikes car safety: - rear facing car seat 0-2y - booster seat until 4'9" and 8-12y/o - seat belts in every car for everyone, every seat eliminate trampolines - nets, soft ground, water don't count
drowning prevention
limit access: locked gates surrounding all pools
supervision: near tubs, pools, and tanks
flotation: use life jackets, NOT arm floaties
up risk: too young to know; too drunk to remember (adolescents)
gun and chemical safety
best: eliminate them from the home
OK: keep them out of reach - store up high; keep them locked in a safe or locked cabinet, do not depend on ‘child proof’ lids
guns: ammo stored separately from weapon; store guns unloaded
severity of concussion to treatment: mild:
FND: none LOC: <60sec HA: none, improving amnesia: none No CT d/c home
severity of concussion to treatment: severe
FND: positive LOC: >60sec HA: persistent or worsening amnesia: retrograde or anterograde CT scan observe in house
treatment for concussion regardless of severity
step-wise return to play
sleep -> go to school -> homework -> practice -> play
abuse vs. neglect
abuse: + sxs, intentional, active
neglect: - sxs, absence, passive
risk factors for abuse: child
intellectual disability
premature birth
physical disability
cognitive disability
risk factors for abuse: parental
those who were abused
single parent
young parent
low SES
how to spot abuse: fractures
skull or clavicle
femur, especially spiral
rib fractures in infants
different stages of healing
how to spot abuse: bruises
different stages of healing
how to spot abuse: burns
feet, ankles (dunk)
buttocks only (dunk)
punctate circular burns (cigarettes)
how to spot abuse: sexual
any STD in any child ever
vaginal or anal trauma
how to spot abuse: behavior
not crying in the presence of a parent
running from caregiver
receiving comfort from healthcare provider rather than caregiver
what to do if you suspect abuse: certainty
certainty is NOT required
what to do if you suspect abuse: the family
tell the family why you are doing it and that you are required by law to do so
what to do if you suspect abuse: the child
hospitalize the child if no safe alternative exists
what to do if you suspect abuse: the abuser
separate abuser from child if obvious
separate parent-child unit from a common abuser
what to do if you suspect abuse: behavior
offer resources and support that allows families and caregivers to understand disease process, provide emotional, economic, and physical support
what to do if you suspect abuse: CPS
must report
ALTE definition
frightened observer plus any combination of:
- change in color: red, blue, or pale
- change in muscle tone: hypertonic or hypotonic
- change in respirations: choking, gagging, or apnea
features by etiology: seizures
eye deviation, limb-jerking
features by etiology: infection
temperature instability
fussy baby
features by etiology: cardiac
difficulty with feeding
murmur
FTT
features by etiology: abuse
evidence of trauma
femur, skull fracture
BRUE definition
< 1 y/o + < 1 min duration + …
- change in color: red, blue, or pale
- change in muscle tone: hypertonic or hypotonic
- change in respirations: choking, gagging, or apnea
- change in responsiveness
low risk BRUE
no history no physical no CPR 1st time, non-recurring age, term > 60d age, preterm >32wk GA AND >/= 45wk PC action: reassurance only
high risk BRUE
hx suggestive of disease physical suggestive of dz CPR performed multiple, recurring not old enough action: NO SET WORKUP, go after workup based on history and physical
SIDS prevention
back to sleep
don’t share a bed
smoking cessation
flatten occiput
erythema infectiosum path
parvovirus 19
erythema infectiosum pt
slapped-cheek rash
erythema infectiosum dx
clinical
erythema infectiosum tx
none
erythema infectiosum f/u
aplastic crisis in sickle cell
hydrops fetalis if in utero
measles path
measles virus (paramyxovirus)
measles pt
cough, coryza, conjunctivitis, Koplik spots
fever AND rash
- starts on face, spreads to extremities
measles tx
supportive (ppx vaccinate)
measles f/u
subacute sclerosing panencephalitis
rubella path
rubella
rubella pt
fever BEFORE rash
starts on face, spreads to toes
prodrome of lymphadenitis
rubella tx
supportive (ppx vaccinate)
rubella f/u
congenital: heart, deafness, cataracts
roseola path
HHV-6
roseola pt
fever BEFORE rash (>104)
starts on trunk, spreads outward
roseola f/u
febrile seizures
varicella chickenpox path
varicella zoster
varicella chickenpox pt
widespread
vesicles on erythematous base
different stages of healing
varicella chickenpox tx
supportive, antivirals for teens and those with lung issues (ppx vaccinate)
varicella chickenpox f/u
shingles
varicella shingles path
reactivated varicella, non-vaccinated adults
varicella shingles pt
pain precedes rash
vesicles on an erythematous base
does NOT cross midline
confined to a dermatome
varicella shingles tx
antiviral if immunocompromised (ppx vaccinate)
varicella shingles f/u
postherpetic neuralgia
mumps path
mumps virus
mumps pt
bilateral swelling
orchitis in pubertal males
mumps dx
clinical
mumps tx
vaccinate