Peds Flashcards
hypoglycemia threshold in newborns
< 2.8 up to 48 hrs
then 3.3 on third day of life
then 4-8
febrile infant 0-28 days CPS algo
febrile infant CPS 29-60 days algo
empiric abx for febrile infant
what qualifies as fever in infant
RECTAL temperature >= 38 at home or in hosp
SBI and IBI
SBI: serious bact infection = UTI, bacteremia, meningitis, pneumonia,
IBI: invasive bact infection = bacteremia & meningitis
who do the CPS algorithms apply to?(febrile infants)
well-appearing infants ≤90 days old with a documented history of fever, defined as any rectal temperature ≥38.0°C, taken
by a caregiver or HCP at home or in a clinical setting
risk factors that increase liklihood of SBI/IBI in febrile infants?
Commonly accepted risk factors
* History of prematurity (gestational age <37 weeks)
* Prior hospitalization or prolonged newborn nursery course
* Chronic medical conditions, chromosomal abnormality, or
technology dependence
* Known or suspected immunodeficiency
* Recent antibiotic exposure
* Any focal bacterial infection (e.g., cellulitis, omphalitis,
osteoarticular infection)
febrile infants < 90 days with which virus are actually more likely to have concomitant bact infection?
rhinovirus
how to handle viral symptoms or confirmed viral infection in young febrile infants?
even in the presence
of respiratory symptoms or a documented viral pathogen,
the initial diagnostic evaluation should follow the age-based
recommendations above
when to definitely think of HSV in febrile infants?
seizure, ELEVATED ALT, maternal HSV
basically, if covering for meningitis, cover for HSV with IV acyclovir
how to think of infants with hypothermia?
basically, any temp < 36 should be treated the same as a fever in infants <90 days
why is rectal temp the standard?
Axillary, oral, or tympanic measurements are inaccurate for core temperature in infants
definition of colic
rule of 3’s. crying 3 hours, 3 days per week for 3 weeks
2 times neonatal jaundice is always pathologic
in first 24 hrs of life and conjugated
Ddx of colic
NNJ: causes of conjugated hyperbili
BILIARY OBSTRUCTION, sepsis, TORCH infections (look them up), genetic/metabolic abn
NNJ: causes of unconjugated hyperbili
physiologic, breastmilk, hemolysis, trauma from birth
why order DAT in NNJ
r/o hemolysis in an unconjugated hyperbili
most common viral cause of diarrhea?
norovirus
bilious emesis in young infant is _____________ until proven otherwise
malrotation with volvulus
Levels of dehydration chart
dx and mgmt of malrotation/volvulus?
dx: abdo xray (cannot exclude and so still need to consult if suspicious)
mgmt: IVF, NGT, emergent surgical consult
Hirschsprung disease:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
Tracheoesophageal fistula:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
Meckel’s Diverticulum:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
Malrotation with volvulus:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
pyloric stenosis:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
Necrotizing eneterocolitis:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
Intussusception:
congen or acquired:
pathphys:
age group:
s/s:
dx:
mgmt:
peak age of incidence of wilms tumor
3-4 years
presenting s/s wilms tumor?
how to dx?
-painless abdo or mass effect when large
-hematuria
-hypertension
dx on u/s
pediatric UTI RF?
female, uncircumcised male, Caucasian, infants, sexually active
s/s of UTI based on age: neonates, 1-2, >2
neonate: sepsis, fever
1-2: vomiting, fever, irritable
>2: more typical UTI symptoms: LUTS, suprapubic pain, fever and vomiting with pyelo
how to interpret bag urine sample?
useful if negative as r/o UTI,
if + need to confirm with cath or midstream; generally if < 2 need to be cath’d
midstream usually can be done if child is potty trained
peak ages of peds testicular torsion?
NEONATES and adolescents
all male children with abdo pain or isolated vomiting need what exam?
GU to r/o torsion
primary vs secondary vs communicating hydroceles
primary: congenital excess fluid in scrotum, resolves by 1 yoa
secondary: reactive fluid collection secondary to infection, trauma, tumor, torsion –> treat underlying problem
communicating: excess scrotal fluid as a result of inguinal hernia –> refer for elective gen surg
most common cause of acquired peds renal failure?
glomerulonephritis
causes of peds
post infectious, especially strep (throat or skin); HSP, HUS, SLE
when does glomerulonephritis after infection, how does it present?
1-2 weeks after infection, presents as painless hematuria, HTN, +/- edema (if it causes nephrotic syndrome)
what is, what causes nephrotic syndrome
excessive proteinuria
can be primary (eg MCD) or secondary (HSP, SLE, HIV, GN)
how does nephrotic syndrome present?
most commonly age 2-6, presents as bilateral edema (periorbital, pedal etc), add to dx in eye puffiness
HUS triad
MAHA; thrombocytopenia; anemia
HUS most common cause
E coli O157
HUS vs DIC on lab work
coag studies will be normal in HUS
how does HUS present?
prodrome of bloody diarrhea,
Most kids with urololithiasis have one of two abn?
Anatomic gu abn
Metabolic abn leading to hypercalcemia
how do neonates and small children increase CO?
HR only, cannot really increase SV
when do ductus arteriosus and foramen ovale close functionally?
15 hours and 3 months respectively
age and characteristics of Still’s murmur
age 2-6, 1/6-3/6, early systolic murmur LLSB/apex, louder when supine
what is the basic mechanisms of cyanotic heart lesions?
R –> L shunt, which mixes deO2 with O2 blood
Cyanotic heart lesions - the 5 Ts
tricuspid atresia
truncus arteriosus
total anomalous pulmonary venous return
Tetrology of Fallot
transposition of great arteries
4 components of tetrology of Fallot
3 presentations phenotypes of CHD
which ones generally benefit from prostaglandins?
shock (grey), CHF (pink), cyanotic (blue)
grey for sure, as usually duct dependent systemic circulation
blue usually, as duct dependent pulmonary cirulation
when to give prostaglandin in crashing neonate?
initial mgmt of crumping neonate
3 heart lesions that are definitely duct dependent?
critical AS, coarctation, hypoplastic left heart syndrome
what is dose of prostaglandin? what do you need to be ready to do?
dose = 0.05 mcg/kg/min
need to be ready to intubate
what are tet spells? how to manage them?
= rt sided outflow obstruction leading to R->L shunt through a VSD, lead to hypoxia and acidosis. present like tachypnea, cyanosis
treatment is to increase pulmonary blood flow by increasing preload.
admin 100% o2, calm the child by placing in parents arms and flex the childs knee to chest to increase venous return,
if this doesnt work give morphine to act as pulm vasodilator
Cyanotic lesion, name a few, name clinical presentation and general mgmt
Shock lesion, name a few, name clinical presentation and general mgmt
HF lesions, name a few, name clinical presentation and general mgmt
basic mechanism of shock lesions?
poor left sided CO
basic mechanism of CHF lesions?
L –> R shunt
what are the cardiac complications of kawasaki?
coronary aneurysms, myocarditis, pericarditis , pericardial effusion, valve disease, arrhythmias
concerning historical features for pediatric chest pain?
exertional
syncope
famhx SCD
famhx/pmhx marfasns
pmhx kawasaki
lupus
cocaine use
recent URI
pericarditis vs myocarditis, ecg and trop, in peds (similar to adult)
peri: normal trop, classic ECG findings (same as adults, name them)
myo: often trop elevated, ECG –> low voltage or non-specific ST changes,
Ddx peds CP,
Note peds specific considerations
RF for serious cause of pediatric syncope
-mid exertion
-absence of prodrome
-triggered by loud noise or while swimmign (?long QT)
-famhx cardiac dz
what are breath holding spells
typicall 6-18 months, intense crying, then holds breath, becoems cyanotic and loses conciousness, can have ome myoclonic jerking, episodes resovle rapidly and require no intervention
most common cause of pediatric bradycardia? other causes
hypoxia
other: cardiac abn, hypothermia, raised ICP, meds
ECG characteristic of SVT
narrow complex, regular
no beat to beat variation,
rate > 220 in infant and >180 in children
discuss PALS brady algo
discuss PALS tachy algo
causes of pediatric SVT?
50% idiopathic, then accessory pathway (AVRT/AVNRT), then WPW syndrome and CHD can happen
what age do duct dependent lesions typically present?
second week of life
how does congenital adrenal hyperplasia present?
females: ambiguous genitalia
males: normal genitals, salt wasting (loss of sodium)
lethargy, vomiting, poor feeding, poor weight gain, hypovolemic shock
usually present around 2 weeks
stress dosing glucocorticoids? who and how?
for pts on chronic steroids. give 2-3X their daily dose when infection or stress from illness
one life threatening cause of persistent new born hypoglycemia?
CAH, give hydrocort 25 mg IV stat
when to suspect inborn errors of metabolism?
vomiting, lethargy, encephalopathic, acidosis or alkalosis, hypoglycemia.
these can present at any age, depending on the specific issue
what is eczema herpeticum?
eczema with superimposed HSV infection, vesicular rash in area of previous eczema
measles clinical picture and tx?
fever and rash with 3 C’s (cough, coryza and conjunctivitis) AND koplik spots (white pin point spots on white background)
tx: supportive
what is german measles
AKA rubella, immunity conferred by MMR
sx: low grade fever, rash, postauricular adenopathy,
mild course, except very severe if congenital infection which often leads to fetal viremia and birth defects
Roseola. Age and clinical presentation
6m to two years
High fever for 3-5 days, then rash when fever leave for 1-2 days
Roseola. Age and clinical presentation
6m to two years
High fever for 3-5 days, then rash when fever leave for 1-2 days
Erythema infectiosum
Parvovirus B19
4-15 years of age
3 day prodrome: Coryza, fever, HA then slapped cheek rash
Who should be concerned about parvovirus B19
Pregnant women, should see pregnancy dr if exposed
Chicken pox: virus, and symptoms
Varicella zoster
Fever precedes rash 2 days
Rash starts at hairline, often involves MM, dew drops on a rose petal at various stages of healing
Chickenpox treatment
Healthy, less than 12 supportive
Healthy older than 12 - oral antivirals
Immunocompromised- IV acyclovir
Pregnant- VZIG (note can cause severe fetal complications at birth or during pregnancy )
molluscum: presentation, virus, mgmt
virus: poxvirus
presentation: asymptomatic, flesh coloured, umbilicated papules
mgmt: ntohing
HFMD: presentation, virus, mgmt
cocksackie
usually kids <5, fever, painful lesion on mouth, buttocks, hands/soles
mgmt: supportive usually, can give magic mouthwash (not lidocaine conaining)
2 possible complications of HFMD?
myocarditis (2%)?? seems high
dehydration
scarlet fever presentation? mgmt?
sore throat and fever, then strawberry tongue, sandpaper rash and pastia lines (non blanching, linear erythema in skin folds)
anti staph abx for 10 days (PREVENTS RHEUMATIC FEVER, NOT GOMERULONEPRHRITIS)
staph scalded skin syndrome: presentation? mgmt?
usually under 5 yrs,
general erythema, no MM involement, + Nikolsky sign (although it is NOT SJS/TEN);
tx with anti staph abx
toxic shock syndrome: 2 organisms and mechanism
strep and staph
mech= colonization by a pathogen that produces endotoxins
general vibe of Juvenile Idopahthic arthritis
-joint pain and swelling longer than 6 weeks
-elevated crp, sometimes mild white count
-NSAIDs for first line tx
HSP presentation, prodrome?
prodrome = URI
palpable purpura, joint pain, abdo pain, hematuria
HSP mgmt and complications
mgmt = supportive, unless severe abdo pain, GIB or nephritis
complications: intussusception, nephrotic syndrome
what is the leading cause of acquired peds heart dz?
kawasaki
how does kawasaki cause heart issues?
it is a vasculitis, affects all small and med vessels, including coronary arteries which can elad to aneursym
diagnostic criteria for Kawasaki
5 or more days of fever
AND 4/5:
conjunctivitis
rash
erythema/edema
adenopathy (cervical)
mucous membrane involvement
treatment for kawasaki?
admission, IVIG, high dose ASA
caveat to diagnostic criteria for kawasaki?
not all pts will meet the criteria, consider the dx in anyone with fever for 5 or more days and two of the criteria
When do rheumatic fever symptoms develop in relation to GAS infection?
Within 2-3 weeks
5 major criteria (Jones) for rheumatic fever?
Carditis
Polyarthritis
Chorea
Erythema migranatum
Subcutaneous nodules
Causes of seizures in kids
Simple vs complex febrile seizure
Causes of seizure by age: neonatal, <6 yrs, <6 yrs
1st, 2nd and 3rd line meds in peds seizures
1st: lorazepam 0.1mg/kg, midaz 0.1 mg/kg IV or 0.2 mg/kg IM, diazepam 0.5 mg/kg PR
2nd: keppra 60mg/kg or fosphenytoin 20mg/kg
3rd: propofol, ketamine etc
In neonates: phenobarbital 20mg/kg
Preferred agent in neonatal seizures, including first line for status?
Phenobarbital 20mg/kg loading dose at 1 mg/kg/min
Indications for LP in ?febrile seizure
Symptoms of meningitis, considered for for an infant 6-12 months who is not immunized against h flu and strep pneumonia, and considered for kids who have been pre treated with abx
When is LP not needed in febrile seizure:
Well appearing, simple feb seizure, vaccinated child over 6 months with no signs of meningitis
Two blood tests in epileptic with typical seismology, otherwise well pt
Blood glucose
ASM levels if relevant
Big difference between peds and adult
Migraine?
Often bilat in peds
Peds headache causes: serious vs benign, list a bunch
One rare cause of neonatal seizures that will not respond to typical ASM?
Pyridoxine deficiency
Are neonatal seizures usually benign or serious?
Neonatal ones, are usually serious, although benign aetiologies exist
A few blood tests to order in ?IEM for neonatal seizures
Ammonia, pH (?anion gap), urine ketones, lactate
Ddx of limp in peds
4 features of septic arthritis in peds?
fever, inability to weight bear, elevated wbc, elevated CRP/ESR
what is leg calve perth? typical age for it?
idipathic AVN of proximal femur
age 2-12
dx of leg calve perth
-xrays, especially frog leg of hips.
- looking for crescent sign ( subchondral lucency and collapse)
- if normal xrays, but high suspicion, get mri/refer
SCFE: demo, patho, dx, mgmt
-obese boys,
-displacement of prox femur on its ball (ice cream cone slips relative to ice cream)
-dx is radiographic
-mgmt: non weight bearing, ortho referral
what is klein sign?
looks for SCFE, draw a line along superior border of fem neck and it should intersect fem head)
most common cause of hip pain in young children (3-6)?
transient synovitis
dx and mgmt of transient synovotis
dx of exclusion, need xrays and bw to r/o other causes (esp septic joint),
mgmt is nsaids and joint rest
Don’t necessarily need to tap joint
2 methods for nursemaids reduction
hyperpronation: pronate elbow while holding it in extension
supination: supinate and flex elbow while putting pressure on radial head
nursemaids mechanism and path
radial head subluxation where it slips under annular ligament, mechanism is inline traction on extended elbow
age usually <5
Salter-Harris classification
S: straight across = 1
A: Above the physis =2
L: beLow the physis =3
T: through and through =4
R: ruined physis = 5
Bowing deformity aka plastic deformaiton
deformation without cortical disruption
should d/w ortho as they often dont remodel and can cause functional/cosmetic impairment
greenstick fracture
where one cortex is broken, but other is intact, usually from axial compression with twisting
buckle fracture aka torus fracture
from axial compression
there is a bulge or buckle on the side of the compressive force
common age and mechanism for supracondylar elbow fractures?
> 8, usually hyperextension mechanism
ossification of peds elbow, by age
CRITOE, starts at 1 yoa and then counts up by two
what fat pad is always pathologic? what is a sail sign?
posterior fat pad is always pathologic
sail sign is abn large anterior fat pad
most common elbow ossification centre to be avulsed?
“I”, internal (medial epicondyle)
most common nerve injury in supracondylar elbow fracture?
anterior interosseous nerve (make “OK” sign to test)
most common type of clavicle fracture?
midshaft
monteggia fracture is?
mgmt?
proximal ulnar fracture, with dislocation of radial head
isolated ulna # is rare in children, if seen need ti image elbow to r/o monteggia
mgmt: closed reduction with splinting with ortho consult
galeazzi fracture is?
mgmt?
radial shaft # with DRUJ dislocation .. mgmt is surgical
young children with leg pain but no fracture on standard xrays should have what xray for what dx?
oblique xray to look for toddlers fracture
what is a toddlers fracture?
mgmt?
non-displaced spiral fracture of distal tibia, resulting from low energy torsion
mgmt = full leg cast (but ortho dependent), some say splint or short leg cast
Definition of BRUE
Brief resolved unexplained event
= infant <1 yr, having one or more of: cyanosis, pallor, absent/decreased/irregular breaths, hyper or hypotonia, or aLOC
With return to baseline after the event and have reassuring history and physical
Ddx of BRUE- think of common benign and serious pathologies
What is periodic breathing
Rapid irregular breathing interspersed with pauses, almost all pre term and most term infants will do this before 2 months of age
Think through BRUE algorithm
How is safe apnea time different in children?
It’s shorter. They have higher O2 demand and decreased reserve therefore may need to bag while waiting for induction meds to kick in
Don’t need to do it every time, but need to anticipate needing bvm
Anatomic consideration in peds airway and bow to deal with them
Name 6
What age is surgical cric cutoff?
10-12
Equipment for needle cric?
Age <12
12 g (or 14 g) angiocath!
End piece of size 7 ett
And 3mL syringe
Then just do bvm, forget jet ventilation
When to use uncuffed ETT?
If 3.0 or smaller. Basically only for premies. Everyone else, including term newborns get a cuff
ETT size estimator for peds?
(Age/4)+4
Formula for depth of ett in kids?
tube size x3
Why do you need to gently inflate peds ETT cuffs?
To prevent ischemic damage to trachea, can inflate just enough to prevent cuff leak (auscultate neck while inflating cuff slowly while also delivering a breath)
Consideration for managing pediatric peri-intubation hypotension
Give fluid bolus before induction (almost always helpful, especially if tubing for resp failure or sepsis)
Consider push dose pressors if severely hypotensive. Would personally be hesitant for push dose in kids, could consider epi or norepinephrine infusion if anticipating hypotension
Should you pre treat with atropine in peds rsi?
Tints says no. Have it ready if needed, usually the Brady is from hypoxia which you should be fixing
Peds vent settings: tidal volume, peep, RR
Why is BVM often successful in epiglotitis or RPA or other upper airway infections?
Bc PPV helps to stent open the airway
Contraindications to IO
Overlying infection
Exposed bone
Underlying fracture
Structural bone d/o eg OI
Landmarks for peds IO: prox tibia, distal tibia and distal femur
Prox tib: 2 cm below tibial tuberosity
Distal tibia: just above med malleolus
Femur: 2 cm above distal femur in midline
Age of UVC placement
Less than 7-10 days
Vein vs artery in UVC placement?
1 vein, 2 arteries. Vein is bigger and thin walled
what do breath holding spells look like? age they occur?
6 months to 5 years
intense emotion, followed by apnea, colour change, loss of consciousness, tone changes, lasting less than 1 minute
parents often describe seziure
ddx of breath holding spells
seizure, syncope, arrhythmia, apnea
history will differentiate
of note: colour change precedes any seizure like activity in breath holding rather than other way around
what causes bronchopulmonary dysplasia
supp o2 and mechanical vent in neonatal period
how does bronchopulmonary dysplasia usually present to the ED? how to manage?
acute exacerbation of chronic lung dz, usually triggered by viral resp infection, presents with hypoxia, tachypnea, resp distress
mgmt is supportive, trial bronchodilators/steroids
how much pleural fluid can be detected on cxr?
50 mL with blunting of costophrenic angle
prevalence of cystic fibrosis among caucasians?
1:2500, very rare in non-whites
how is cystic fibrosis diagnosed?
usually caught on newborn screen. dx is chloride sweat test
pathophys of cystic fibrosis
imparied chloride transport, resulting in thick & dry secretions which lead to chronic inflammation and infection in the resp and GI systems
THNK frequent resp infections
aside from resp what body system is most affected with cystic fibrosis?
GI
what specific bug should you cover in CF patients with pneumonia?
all the usuals + PSEUDOMONAS
apart from resp infections, what is other resp complication in cystic fibrosis?
heomptysis or massive pulm hemorrhage from the chronic inflammation
triggers for asthma flare?
URI, cold weather, exercise, irritants (cigs, wildfires etc), allergens
RF for severe asthma exacerbation
prev ICU admission, intubation, multiple admissions in past year, low SES, other medical comorbs
asthma exacerbation severity by peak flow?
need to know pts baseline
mild <70% predicted
moderate 40-60
severe <40
in reality, use PRAM in peds exclusively
initial vent settings in peds asthma
Vt 6-10 mL/kg, PEEP 5, I:E 1:3 with continuous ventolin nebs
epiglottitis organisms?
classically hemophilus influenza (HiB), since vax its mostly staph and strep
s/s of epiglottitis
abrupt onset and rapid progression of: drooling, sore throat, “hot potatoe” voice,
+/- stridor
mgmt of epiglottis
minimal intervention. do not try and visualize the throat unless can be done without agiatation/tongue blade etc
arrange for airway in OR with double setup, unless necessary loss of airway, can try BVM first then, tracheal intubation or FONA prn. be prepped for airwya while awaiting OR
only get IV if needed for airway mgmt unless pt is ++ chill
in terms of other mgmt: IV abx/fluids only if IV access can be secured without too much irritation/agitation as this will make hasten airway loss
keep them with parent, try some blow o2 etc.
xray finding epiglottitis
lateral neck xray will show swollen epiglottis (aka thumbprint sign)
croup viruses
classically parainfluenza, but also RSV, covid, rhino
croup ddx
foreign body aspiration,
epiglottis
bact tracheitis
RPA
subglottic stenosis
laryngomalacia (in newbs)
hemangiomas
xray finding of croup
steeple sign on soft tissue neck xray
what is bacterial tracheities
a severe form of laryngotracheobronchitis (aka croup) caused secondary bacterial infection leading to ++ purulent material in trachea
s/s of bacterial tracheitis
-prodromal viral infection
-fever
-stridor
-toxic appearance
-little/no response to croup treatment
xray findings bact tracheitis
subglottic narrowing and shaggy/rough appearing trachea
treatment of bact tracheitis
similar to epiglottitis
recent croup in toxic appearing child is what dx?
bact tracheitis
RPA s/s
fever, sore throat, hoarse voce, drooling, torticollis, neck pain/stiffness
what is a toxic appearance infant
pale or cyanotic,
lethargic or inconsolably irritable.
tachypnea
tachycardia
poor capillary refill.
xray finding in RPA, how to get xray specifically?
lateral neck xray in extension/inspiration. looking for soft tissue widening anterior to the cervical vertebrae (1/3rd the size of the vert)… if + or unsure get CT
Peritonsillar abscess s/s
sore throat, unilat tonsillar swelling with deviated uvula to contralateral side, +/- trismus, drooling, ear/neck pain
mgmt of pta
dexamethasone, ABX, aspirate or I&D and refer to ENT
Whooping cough organism
Bordetella pertussis
Stages of pertussis
Catarrhal stage: cough, conjunctivitis, Coryza (1-2 weeks)
Paroxysmal: paroxysms of cough, with whooping cough post tussive emesis is common
Convalescencent: chronic symptoms
Tx of pertussis
Azithro,clarithromycin, septra
Ix of pertussis, including cxr, wbc and diagnostic test
Cxr can have shaggy right heart border or be normal (often normal)
Wbc can be very elevated like 60s
Dx test is NP swab for pcr
s/s bronchiolitis
age usually <2, URI symptoms +/- fever with wheeze +/- resp distress
bronchiolitis tx
supp o2, nasal suctioning, intermittently check o2. +/- epi neb or hypertonic neb
HFNC or NPPV are good to try and avoid mech vent
how long does bronchiolitis last? what is most common organism
bronciolitis symptoms peak around 5 days, overal illness (eg cough) can last symptoms for 2-4 weeks
RSV
Children with lower lobe pma may have cc of?
Abdo pain
Pma organisms vibe, by age
Diffuse interstitial infiltrates or peribronchial cuffing suggest what ethology of pma (2)
Viral
Mycoplasma pneumonia
Risk factors for apnea in bronchiolitis that indicate admission
Age < 1 month
Preterm and corrected age <2months
High or low RR
Low birth weight
Reported apneic episodes
peds pma abx
also consider azithro or doxy if suspicion for atypicals, ie suggestive xray or non-response to initial tx
Age demo for SIDS
Unexplained death <1 year, 90% occur < 6 months
Etiology of SIDS
Unclear, maybe suffocation maybe immature reflexes/immature response to rising co2 or falling o2
<5% of cases are from child abuse
RF for sides
NEXUS is validated to what age?
older than 8
are c spine injuries more or less common in peds?
far less
is abdo trauma more or less common in peds
more
consideration in mgmt when putting a kid <8 in c spine precautions?
need to elevate torso to avoid flexing neck. can use towel roll etc.
rule for evaluating peds c-spine?
NEXUS if older than 8, pecarn c-spine for anyone under 18
what is considered raised ICP?
> 20 mmHg
what type of scalp hematoma is worrisome in children < 2
non frontal, more likely to have ICH
vital sign findings of raised ICP in peds
bradycardia, bradypnea, HTN
peds mgmt of raised ICP
neuro surg consult and CT head
-HOB to 30 deg
-remove tight fitting neck stuff
-head midline
-very mild hypoventilation: CO2 30-35 if ETT (this is if ICP is raised, if serious tbi aim for normal co2)
-keep MAP at least 60
- hypertonic 3 mL/kg max 250 as a bolus, no infusions
-mannitol 1g/kg (can decrease MAP)
run through peds primary survey
PRBC initial dose in peds trauma
10- 20mL/kg
pecarn: over 2 and under 2
How to estimate peds hypotension
Age 1-10, anything less than 70+ (2xage)
Peds vital sign physiologic differences when responding to stress
Hypotension is late finding, HR increases first
Also tidal volume is fixed. Tachypnea occurs instead of deeper breaths
Hyperglycaemia is common after poly trauma just leave it. Hypoglycaemia can also occur, needs to be treated
When to give TXA in paediatric trauma. What is the dose?
Give if within three hours of injury and bleeding. Or any patient requiring blood transfusion from hemorrhage.
Dose is 20 mg per kilogram max 2 g loading dose +/- infusion
General MTP value for kids?
If anticipating they will need more than 40 mL/kg of blood
Mgmt of hemm shock in peds?
Generally similar to adults. However, they seem to be more capable of handling crystalloid. Give one to 220 ML per KG bones then transitioned to PRBCs 10 to 20 ML per KG repeat PRN.
MTP if needing more than 40 mg per kilogram of blood.
FAST in peds vs adults?
It’s less reliable as a neg predictive value in kids
How long can it take pulmonary contusions to evolve on cxr and clinically?
Over 4-6 hrs
Mgmt of pulm contusion
Supportive, lung protective ventilation
Thoracotomy (surgical, not ED) in Peds chest trauma?
> 20mL/kg output on initial insertion,
4ml/kg/hr output,
Need for ongoing blood products
Minimum Acceptable urine output in sick infant/toddler
At least 3 in 24 hrs. Volume less important than actually
Making urine
Pecarn blunt abdo trauma ct rule, 5 criteria a gate need for CT
Reasons to get a CT in blunt abdo trauma in peds
%age of successful non op mgmt in pediatric solid organ injuries from trauma
> 95%
Peds blunt trauma: microscopic hematuria as an isolated finding, what to do?
Nothing! Common after blunt trauma, if not other findings can ignore
Gross hematuria= different story
Panc enzymes is peds pancreatic injury from trauma
Neither sensitive nor specific. Tricky dx to make as ct isn’t great either
Serial exams and serial enzymes could be considered
ED thoracotomy indications in children
No role in blunt traumatic arrest
Consider it in with penetrating injury if arrest in trauma bay or in ambulance <10 mins
Approach to blunt traumatic arrest
Deempshzise cpr although keep doing it
Get definitive airway
Manage major external bleeding
Decompress chest
Assess for cardiac tamponade
Administer blood
If none of these work, can likely pronounce death
Why sometimes need to observe kids for a few hours with blunt abdo trauma even if ct is normal?
B/C hollow viscus injuries are difficult to dx. So if high index of suspicion, don’t send home
peds anaphylaxis algo? include doses
peds anaphylaxis dispo
adjuncts in peds anaphylaxis
-steroids: no
-bronchodilators: only if wheeze
-antihistamines: cetirizine or other non-sedating for cutaneous symptoms only
-inhaled epi: if signs of upper airway obstruction eg stridor that persist after lower airway obs
peds astma tx according to PRAM score, include doses and dispo
PRAM score
peds asthma dispo
generally observe for 2 hours from initial therapy (also another slide on this)
steroids for home in asthma?
can do one more oral dose of dex for the following day, if more severe exacerbation do it.
all should get an ICS with rescue as well.
how long do symptoms of bronchiolitis last vs over illness
symptoms of bronchiolitis peak around 5 days, over all illness can last 3 weeks or so
treatments do’s and don’ts of bronchiolitis? what one med can you try?
bronchiolitis dispo
bronchiolitis is usually first wheeze in pt under what age?
2 years
how to calculate TBSA in peds?
Lund-browder diagram or size of child palm is 1% (note dont include superficial thickness burns in calc ie 1st degree)
pediatric burn fluid resus formula?
2-4 mL/kg/hr half over 8 hours and other half over 16 hours. target out .5-1 ml/kg/hr (0.5 is fine in kids > 30 kg)
also add maintenance with 421 rule using D5NS
peds 421 rule
D5NS
4/kg for first 10
2/kg for next 10
1/kg thereafter
croup grading and mangement and dispo
croup criteria for d/c and admission
peds DKA mgmt (doses, monitoring etc)
signs of cerebral edema in peds DKA, mgmt of cerebral edema in peds DKA
one extra consideration in peds gastro, esp if under 2 and looking unwell?
check a POC glucose
one med to give in peds gastro? dose?
zofran ODT
8-15 kg –> 2 mg
13- 30 kg 4 mg
> 30 kg 8 mg
signs and mgmt of severe gastro?
also can do NG rehydration if cant get IV access
mgmt of mild to mod dehydration in pesd gasto
general presentation of intusseception
most common age 5-10 months, most cases under 2 yrs
4 signs/symptoms with good LR for peds bacterial meningitis
Bulging fontanelle, seizures, neck stiffness, decreased feeds
Does being afebrile r/o meningitis in kids < 90 days?
NO! If they look toxic or have other signs of it, work them up
Is it common for neonates to have stiff neck with meningitis
Nope, therefore work them up if febrile or ill appearing
CSF interpretation in peds ?meningitis
ABCD’s of critical neonate resus
after ABCDs, what 5 body systems to think of in critical neonate
list 10 red flags for NAI in peds
lower age limit for ketamine?
contraindicated in less than 3 months
when to pre treat with ondansetron in peds prosed?
if >5 and using ketamine
baserman ketamine prosed method?
1.5 mg/kg IV push over 60 seconds in one syringe. have second syringe with 0.75 mg/kg for smaller aliquots, ie 10-20 mg at a time
IN fentanyl and midaz dosing? max mL/nare
fentanyl 1.5 mcg/kg, midaz 0.3 kg/kg, give fent first. dont usually give midaz mono as it burns.
max 1 mL/drug/nare
peds severe sepsis resus algo?
peds status epi algo?
Most common childhood cancer
ALL
Signs of pediatric leukemia
Constitutional symptoms, bone pain, night pain, easy bruising, bleeding, epistaxis, hepatosplenomegaly, adenopathy
Tests to order if concerned re leukemia?
CBC, lytes, extended lytes, coags, peripheral smear, liver enzymes, LDH
Common CBC findings in peds leukemia
Almost all will have some CBC abnormality (anemia, thrombocytopenia, leukocytosis or leukopenia) very few will actually have an extremely elevated wbc
3 questions to ask if a newborn to determine if ongoing NRP is needed?
Term
Tone
Crying
When to use nrp vs pals?
NRP is truly for newborns who have just delivered. Ie still transitioning to breathing air. If they code after a day or even a few hours use pals
How long to wait to clamp cord in sell appearing neonate
1 minute
Walk through first 60 seconds of NRP
What is MR SOPA steps ?
When to use it?
Use while doing PPV to ensure adequate ventilation. If you’re getting adequate chest wall rise, don’t need to use this
What pressure to start PPV in NRP
PIP 20 to start, can go to max of 40
PEEP 5
What is the time frame to PPV in NRP
Make decision at 60 seconds
Need to have timer going!
Question to ask yourself when doing PPv in NRP?
Is there chest wall rise
If not Mr sopa (do two things at a time and trial for 5 breaths) and then ventilate for 30 seconds before checking HR again
How many breaths per minute in NRP?
what ratio of doing compressions?
40-60 bpm “breathe baby breathe baby”
3:1 ratio “1 and 2 and 3 and breathe”
Chest compression trigger in NRP
Rate of compression
Depth of compressions
Trigger: HR < 60 and 30 seconds of good ventilation
3:1 comp to breath “1 and 2 and 3and breathe”
1/3 AP diameter of chest
Dose for endotracheal epi in NRP or PALS
0.1 mg/kg
Steps for treatment of tension pneumo in neonate
Use 20 gauge 1 inch angio cath, local if time permits, insert cath at nipple level in anterior axillary line. Connect to 3 way stop cock and aspirate air out with 20 cc syringe
what age do you start doing Heimlich maneuver?
> 1 yr of age
how to deal with the choking but infant (<1 yr)
back blows and chest compressions (alternating 5 and 5)
ratio of compression to breaths in:
a) NRP
b)PALS
nrp = 1:3
PALS: 2 rescuer 15:2 or 3:2 if 1 rescuer
in ED get advanced airway
where to check pulse in NRP vs infants vs older children
NRP: umbilical stump
infant: brachial
older children: femoral/carotids
how is CPR different in an unconscious choking kid
same, except check mouth when giving breaths. ?tube em and try o push fb into rt lung?
?use glidescope and try and suction something out
pediatric glucose, rule of 50
D5 –> give 10 mL/kg
D10 –> give 5 mL/kg
D50 –> 1 mL/kg
younger infant or neonates use d10
dose of epi in peds code: IV/IO and ETT
IV/IO= 0.01 mg/kg
ETT: 0.1 mg/kg
meds that can be given via ETT
LEAN
lido
EPI
atropine
Naloxone
ETT dose for non-epi meds is twice the IV/IO dose
EPI is 0.1 mg/kg and is the only one studied
dose of peds atropine
0.02 mg/kg IV/IO (double
formula for estimating pediatric weigth by age
in reality use Broselow or an app or pt best guess but
ARGALL formula: (age + 2) *3
compression rate for PALS
at least 100
initial joules in peds cardioversion vs defibrillation
CV: 0.5 J/KG, then double it for subsequent
defib: 2 J/kg, then double for subsequent, makes 10 J/kg
PALS: tachy with a pulse svt vs vt
Which kids get a 10 mL/kg bolus?
Neonates and those known CV disease
what %age of pediatric pts with isolated vomitting had an enteric pathogen identified?
50%!
