Peershare Flashcards
neonatal resus
- warm baby under lamp
- dry as quickly as possible (helps stimulate breathing)
- calculate APGAR score
- delayed umbilical cord clamping
paeds life support
- look, listen, feel
- shout for help
- open airway
- 5 rescue breaths
- check for circulation (infants = brachial/femoral pulse, children = femoral pulse)
- 15:2 chest compressions to rescue breaths
* chest compressions 100-120/min
* 1/3 of AP dimension of chest - infants = two thumb encircling technqiue
* children - compress lower 1/2 sternum
APGAR
assessed at 1, 5 and 10 mins
* appearance (skin colour) 0 = blue, 1 = peripheries blue, 2 = pink
* pulse 0 = absent, 1 = <100bpm, 1 = >100bpm
* grimace (response to stimulation) 0 = no response 1 = little response/aggressive stimulation for cry, 2 = strong response/crying
* activity (tone 0 = absent/floppy, 1 = flexed arms/legs, 2 = active/flexes and rists extension
* respiratory effort 0 = absent, 1 = slow/irregular/gasping, 2 = strong, regular, crying
def: caput succedaneum v caphalohaematoma
caput - crosses suture lines, collecting on scalp outside periosteum
caused by traumatic/prolonged/instrumental delivery
ablle to cross suture lines
no treatment - resolves in few days
cephalohaematoma - bloo dbetween skull and periosteu,
does not cross suture lines
traumatic subperiostel haematoma
resolves in few months with no treatment
risk of anaemia/jaundice should be monitored until resolves
causes: hypoglycaemia neonates
- preterm <37 weeks
- IUGR
- GDM
- maternal diabetes
- hypothermia
- neonatal spesis
- inborn errors metabolism
- nesidioblastosis
- Beckwith-Wiedemann syndrome
def: nesidioblastosis
nesidioblastosis and insulinoma are disorders of the endocrine pancreas causing endogenous hyperinsulinemic hypoglycemia
def: Beckwith-Weidemann syndrome
condition that affects many parts of the body
classified as an overgrowth syndrome
affected infants are larger than normal (macrosomia)
some may be taller than their peers during childhood
BWS has various signs and symptoms, including a large body size at birth and taller-than-average height during childhood, a large tongue, and hypoglycemia (low blood sugar). In some children with BWS, parts of the body, such as the ears, may grow abnormally large, leading to an asymmetric or uneven appearance
def: hypoglycaemia neonates
?<2.6mmol/L
common even in term babies - can be hypoglycaemic for first 24 hrs but no sequelae
presentation: hypoglycaemia neonates
autonomic: hitteriness/irritable/tachypnoea/pallor
neuroglycopenic: poor feeding/sucking, weak cry, drowsy, hypotonic, seizures
other fx: apnoea, hypothermia
rx: hypoglycaemia neonates
asymptomatic = wncourage feeding and monitor
symptomatic/v low = admit to NICU and 10% dextrose IV
causes: IUGR
- smoking, alcohol, or illicit drug use
- infection: cytomegalovirus, German measles (rubella), toxoplasmosis, or syphilis
- some seizure treatment
- lupus, anemia, or clotting problems
- hypertension
problems: preterm birth
- RoP
- necrotising enterocolitis
- RDS
pathophys: NEC
part of bowel = necrotic
presentation: NEC
- intolerance to feeds
- vomiting (green bile)
- unwell
- distended tender abdomen
- absent bowel sounds
- blood in stool
ix: NEC
bloods - FBC for WCC< CRP, blod gas = metabolic acidosis) and blood culture ?sepsis
AXR - dilated loops of bowel, bowel wall oedema (thickened walls), pneumatosis intestinalis (gas in bowel wall), pneumoperitoneum and gas in portal veins
rx: NEC
- NBM
- IV fluids
- TPN
- NG tube - drip and suck
- Abx
surgical emergency - may require temporary stoma
complications: NEC
- perforation
- peritonitis
- shock
pahtophys: RoP
- retinopathy of prematurity
- abnormal development of blood vessels in retina
- normal development stimulated by hypoxia - triggered by supplemental O2
ix: RoP
screen premature babies
rx: RoP
stop new vessel growth
1st line = transpupillary laser photocoagulation to halt and reverse neovascularisation
cryotherapy ot intravitreal VEGF inhibitors
surgery if retinal detachment
complications: RoP
scarring
retinal detachment
blindness
pathophys: RDS
commonly occurs before 32 weeks when lungs start to produce lung surfactant
* inadequate surfactant
* high surface tension with alveoli
* atelectasis (lung collapse) since more difficult for alveoli and lungs to expand
* inadequate gas exchange
* hypoxia and hypercapnia causing respiratory distress
ix: RDS
CXR = ground glass appearance
rx: RDS
antenatal maternal steroids (dexamethasone) with ? premature labour
- intubation and ventilation if severe
- endotracheal surfactant via endotracheal tube
- CPAP via nasal mask
- supplementary O2 to maintain 91-95% sats
complciations: RDS
short term:
* pneumothorax
* infection
* apniea
* IVH
* pulmonary haemorrhage
* NEC
long term:
* chronic lung disease of prematurity
* RoP
* neurological/hearing/visual impairment
presentation: RDS
- tachypnoea >60RR
- increased wob - chest wall recession (sternal and subcostal indrawing) and nasal flaring
- expiratory grunting in order to create positive airway pressure during expiration and maintain functional residual capacity
- cyanosis if severe
drug: keep duct open
prostoglandin E (alprostadil)
drug: close duct
ibuprofen/indomethacin
acute asthma: management
33 92 CHEST
PEF <33% predicted
sats <92%
cyanosis, hypotension, exhaustion, silent chest, tachycardia SEVERE
moderate - >50% PEF, >92% sats, no clinica; fx of severe asthma
severe - 33-50% PEF, <92%, HR >125, RR >30, use of accessory muscles
life-threatening - <33%, <92% sats, CHEST, altered consiousness, poor respiratory effort
acute asthma: 2-5 y
moderate - >92% sats, no clinical features of severe
severe - <92% sats, HR >140, RR >40, use of accessory muscles
life-threatening - <92%, cyanosis, hypotension, exhaustion, silent chest, tachycardia, agitation, poor respiratory effort, altered consciousness
rx: acute mild-moderate asthma
give 1 puff every 30-60 seconds of B2 agonist (salbutamol) using spaced or <3y close fitting mask
max 10 puffs
if symptoms not controlled - go to hospital
steroids given in exacerbation for 3-5 days (prednisolone PO)
rx: severe-life-threateneing asthma
call senior + anaesthetics
OSHIT ME
oxygen (<94%)
salbutamol (B2B)
hydrocortison IV
ipatropium bromide (B2B)
theophyline (aminophyline) IV
magnesium sulfate IV
escalate
rx: asthma
SABA - salbutamol
add ICS - beclomethasone
then LABA or LTRA - salmeterol or monetleukast and SABA
ddx: stridor
larygnomalacia
bronchiolitis
croup
acute epiglottitis
inhaled foreign body
cause: bronchiolitis
RSV
presentation: bronchiolitis
usually <1yr (most common <6months) but can occur up to 2 years
coryxal symptoms - runny nose, sneezing, mucous in throat, watery eyes
signs of respiratory disress
dysnoea
tachypnoea
poor feeding
<39 fever
apnoeas
wheeze and crackles with harsh breath sounds on auscultatiomn
signs: respiratory distress
tachypniea
accessory muscle (sternocleidomastoids, abdominal and intercostal muscles)
intercostal and subcostal recessions
head bobbing
nasal flaring
tracheal tug
cyanosis
abnormal airway noises
wheezing (usually expiratory)
grunting (ehaling with glottis sclosed increases positive end-expiratory pressure)
stridor (high pitched inspiratory noise)
typical course: bronchiolitis
starts as URTI with coryzal symptoms
can get better spontaneously, those who don’t tend to develop chest symptoms following coryzal symptoms
symptoms usually worse day 3/4 and last 7-10 days
full recovery within 2-3 weeks
more likely to get viral induced wheeze in childhood
when to admit: bronchiolitis
- under 3 months
- pre-existing conditions like prematurity, Down’s or CF
- <50% intake
- clinical dehydration
- RR>70
- O2 <92%
- moderate to severe respiratory distress
- apnoeas
- parents concerned unable to manage at home
rx: bronchiolitis
ensure adequate intake (can be oral/NG or IV fluids)
saline nasal drops and nasal suctioning
supplementary oxygen
ventilatory support if needed
little evidence for neb saline, bronchodilators, steroids or antibiotics
ventilatory support
high-flow humidified oxygen (adds PEEP to maintain airway at end of expiration
CCPAP (higher and more controlled pressures than high flow)
intubation and ventilation
rx: palovozumab
monoclonal antibody targeting RSV given monthly injection as prevention against bronchiolitis caused by RSV
given to high risk babies such as ex-premature babies adn those with congenital heart disease
viral induced wheeze v asthma
VIW: presenting before 3 years old
no atopic hx
occurs only during viral infection
diagnosis: asthma
apirometry with reversivke testing (over 5y)
direct bronchial challenge test with histamine or methacholine
FeNO - fraction exhaled nitric oxide
peak flow variability (keep diary for 2-4 weeks)
cause: croup
parainfluenza virus
presentation: croup
6m - 2y
* increased WOB
* barking cough
* hoarse voice
* stridor
* low grade fever
rx: croup
PO dexamethasone 150microg/kg
can be repeated after 12 hours
severe stepwise approach:
* oral dexamethasone
* oxygen
* nebulised budesonide
* nebulised adrenaline
* intubation and ventilation
mild = withut stridor or significant indrawing = oral dex
moderate = stridor and chest wall indrawing but NO agitation = neb budesonide or high dose oral dex
severe = stridor and indrawing and agitation/lethargy = neb adrenaline and ?PICU
cause: acute epiglottitis
HiB
presentation: epiglotittis
LIFE THREATENING EMERGENCY
* rapid onset
* unwell child
* sore throat
* stridor
* drooling
* tripod position
* high fever
* difficulty or painful swallowing
* muffled voice
* scared quiet child
* septic unwell appearance
ix: epiglotittis
SHOULD NOT BE PERFORME WHEN ACUTELY UNWELL
lateral XR should thumbprint sign (soft tissue shadow that looks like a thumb pressed into trachea)
presentation: inhaled foreign body
- coughing
- choking
- vomiting
- stridor
- previously well
- rapid onset
presentation: pneumonia
- cough (typically productive)
- high fever (>38.5)
- tachypnoea
- increased WOB
- lethargy
- delirium (acute confiusion)
chest signs: pneumonia
bronchial breath sounds
focal coarse crachles
dullness to percussion
causes: pneumonia
bacterial - strep pneumonia (most common), group A strep and GBS if pre-vaccinated
viral - RSV most common or parainfluenza
ix: pneumonia
consolidation on CXR
sputum cultures, viral PCR and blood cultures if ?sepsis
rx: pneumonia
amoxicillin 125 (up to 1)
250mg up to 4 and 500mg up to 17, 3/day for 5 days
can add clarithromycin/erythromycin for atypical covre
cause: tonsilitis
group A strep (strep pneumoniae) = MOST COMMON
haemophilus influenzae
moraxella
staph aureus
presentation: tonsilitis
fever
sore throat
painful swallowing
peak 5-10 and 15-20 y
poor oral intake, headache, vomiting, abodominal pain non-specific in younger children
examination: tonsilitis
red, inflamed tonsils
+/- exudate
always eaxmine tympanic membranes and cervical lymph nodes
scoring: tonsilitis
feverPAIN score
score 1 point for each (maximum score of 5)
Fever (during previous 24 hours).
Purulence (pharyngeal/tonsillar exudate)
Attend rapidly (within 3 days after onset of symptoms)
Severely Inflamed tonsils
No cough or coryza
CENTOR
each scores 1 point, max 4
1. fever >38
2. tonsilar exudates
3. absense of cough
4. tender anterior cervical lymph nodes
rx: tonsilitis
if CENTOR 3+ or feverPAIN 4+ ?antibiotics or if immunocompromised or other co-morbidity e.g hx rheumatic fever
penicillin V for 10 days 1st line
clarithromycin in pen allergic
complications: tonsillitis
chronic tonsilitis
peritonsilar abscess = quinsy
scarlet fever
otitis media
rheumatic fever
post-streptococcal glomeruloneohritis
post-streptococcal reactive arthritis
additional symtpoms to tonsilitis: quinsy
trismus - unable to open mouth
voice changes “hot potato voice” - thick, muffled voice
swelling and erythema beside tonsils
cause: quinsy
group A strep
HiB or staph aureus
rx: quinsy
incision and drainage
?dexamethasone
cause: scarlet fever
group A strep (strep pyogenes) produces exotoxin
presentation: scarlet fever
- red-pink, blotch, macular rash
- rough sandpaper
- starts on trunk and spreads outwards
- red, flushed cheeks
- fever
- lethargy
- flushed face
- sore throat
- strawberry tongue
- cervical lymphadenopathy
rx: scarlet fever
notifiable disease - tell public health
pen V for 10 days
kept off school until 24 hours after starting abx
complications: scarlet fever
post-strep glomerulonephritis
acute rheumatic fever
cause: otitis media
strep pneumoniae most common
can be haemophilus influenzae
moraxella catarrhalis
staph aureus
presentation: otitis media
ear pain
reduced hearing (can be with effusion causing glue ear)
general URTI symptoms - fever, cough, coryzal symptoms, sore throat and feeling gnereally unwell
can cause balance issues
examination: otitis media
normally tympanic membrane = peraly grey, translucent and slightly shiny
otitis media = red, bulging, inflamed
may have discharge if perforated
rx: otitis media
refer and admit if <3m with temp >38 or 3-6m and temp >39
most resolve without abx
mainly resolve within 3 days
give analgesia
can give immediate abx in aptients with significant co-morbidities, are systemically unwell or immunocompromised
children <2y with bilateral otitis media or with otorrhoea (discharge)
delayed perscription - can be collected after 3 days if symtpoms persist/worsen
first line - amoxicillin for 5 days or clarithromycin in pen allergic
complications: otitis media
otitis media with effusion
perforated eardrum
mastoiditis
asbcess
hearing loss
recurrent infx
cause: whooping cough
bordetella pertusis(gram -ve)
presentation: whooping cough
starts with mild coryzal symptoms
low grade fever
mild cough
more severe coughing fits after 1+ weeks
sudden recurring attacks of coughing with cough free periods between
paroxysmal cough - coughing fit until patient completely out of breath then large, loud inspiratory whoop when coughing ends
may have apnoeas
may cough so hard - faint/vomit/pneumothorax
diagnosis: whooping cough
nasal PCR testing or bacterial culture
if cough been 2+ weeks present - aanti-pertussis IgG can be tested in 5-16y
rx: whooping cough
notifiable disease
supportive care
macrolide (azithro, calrihro, erythromycin) may be beneficial in first 21 days or in vulnerable pts
co-trimoxazole alternative
close contacts given prophylactic abx if vulnerable (pregnancy, unvaccinated infants, healthcare workers in contact with those people)
symptoms typically resolve within 8 weeks
complication: whooping cough
bronchiectasis
inheritance: CF
autosomal recessive
chromosome affected: CF
chromosome 7 delta-F508
codes for cellular chloride chnnels
consequences: CF
- thick pancreatic and biliary scretions - blocks ducts (lacking digestive enzymes such as pancreatic lipase in digestive tract)
- low volume thick airway secretions (bacterial colonisation) and susceptibolity to airway infections
- congeniuital bilateral absence of vas dferens in mals (male infertility)
diagnosis: CF
screened in heel prick test
gold standard test = sweat test
genetic testing for CFTR gene during pregnancy by amnicemtesis or CVS
pathognomonic sign: CF
meconium ileus
in around 20% of babies with CF, meconium thick and sticky causing it to obstruct the bowel causing meconium ileus
meconium not passed in 24hrs, abdominal distension and vomiting
symptoms: CF
- chronic cough
- thick sputum production
- recurrent respiratory tract infection
- loose greasy stools (steatorrhoea) due to lack of fat digesting lipase enzymes
- abdominal pain and bloating
- child tastes particularly salty when they kiss them (concentrated salt in sweat)
- failure to thrive
signs: CF
- failure to thrive on growth charts
- nasal polyps
- finger clubbing
- crackles and wheeze
- abdominal distension
common colonisers: CF
- staph aureus
- psudomonas aeruginosa
prophylaxis: CF
flucloxacillin (staph aureus)
sweat test: CF
pilocarpine applied to skin on patch and electrodes placed on skin
causes skin to sweat and sweat absorbed with lab issued gauze and sent to lab to test for chloride concentration
>60mmol/l = diagnostic
pseudomonas rx: CF
nebulised tobramycin
ciprofloxacin
pseudomonas rx: CF
nebulised tobramycin
ciprofloxacin
rx: CF
- chest physiotherapy for secretions
- excercise imporves respiratory fnx and helps clear secretions
- high calorie diet due to malabsorption, high resp effort, coughing etc
- CREON tablets for pancreatic insufficiency
- prophylactic flucloxacilin
- treat chest infections when they occue
- bronchodilators
- vaccinations
monitoring: CF
every 6 months
* aputum cultures
* diabetes
* osteoporosis
* vit D deficiency
* liver failure
life and QoL: CF
improving life expectancy - meadian 47 years
surgical causaes: abd pain
- intussusception - colicky, non-specific pain REDCURRANT JELLY STOOL
- appendicitis - central abd pain spreading to R iliac fossa
- bowel obstruction - absolute constipation, vomiting, pain and distension
- testicular torsion - sudden onset, unilateral testicular pain N+V
red flags: abd pain
- persistent/bilious vomiting
- severe chronic diarrhoea
- fever
- rectal bleeding
- weight loss/failure to thrive/faltering growth
- dysphagia (difficulty swallowing)
- nighttime pain
- abd tenderness
ix: red flag abd pain
- FBC - anaemia = IBD or coeliac disease
- raised inflammatory markers (ESR or CRP) = IBD
- raised anti-TTG or anti-EMA antibodies = coeliac
- raised faecal alprotectin = IBD
- positive urine dipstick = UTI
content of vomit: abd pain
food/milk = GORD or pyloric stenosis
bilious = malrotation or intussusception or Hirschprung’s/meconium ileus if badly obstructed
aetiology: GORD
- contents of stomach reflux through lower oesophageal sphincter into oesophagus/throat/mouth
- in babies immaturity of LOS allow contents to reflux more easilt - normal in infants and usually improves within 1 year for 90% patients
presentation: problematic GORD
usually <8wks
* chronic cough
* hoarse cry
* distress/crying or unsettled after feeding
* reluctance to feed
* pneumonia
* poor weight gain
red flags: vomiting
- not keeping down any feed
- projectile/forceful vomiting
- bile stained
- haematemesis/melaena
- abdominal distension
- reduced consciousness, bulging fontanelle or neurological signs - meningitis or raised ICP
- blood in stools
- respiratory symptoms
- signs of infection
- rash, angioedema
- apnoeas
rx: GORD
explanation, reassurance and practical adive in simple cases:
* small, frequent feeds
* burping regularly to help milk settle
* not over-feeding
* keep baby upright after feeding
more problematic:
* gaviscon mixed with feeds
* thickened milk (carobel)
* ranitidine (H2 receptor blocker)
* anti-reflux formulas
* omeprazole where ranitidine is inadequate PPI if feeding diffulties/distressed/faltering growth
def: sandifer’s syndrome
rare condition causing brief episodes of abnormal movements assoc. with GORD
infants neurologically normal
key features:
1. torticollis - forceful contraction of neck muscles causing twisting of neck
2. dystonia - abnormal mscle contractions causing twisting movements, arching of back or unusual postures
def: pyloric stenosis
hypertrophy of the pylorus (ring of smooth muscle between stomach and duodenum)
after feeding = increase peristalsis to push food to duodenm and eventually becomes so powerful causes food to project up oesophagus and projectile vomit
features: pyloric stenosis
presents in first few weeks of like (4-6weeks)
* thin
* pale
* hungry
* failing to thrive
olive mass on examination
projectile, non-bile stained vomit
blood gas shows hypochloric metabolic alkalosis since baby vomiting hydrochloric acid from stomach
ix and rx: pyloric stenosis
abd USS diagnosis or test feed
laparoscopic pylotoyomy (Ramstedt’s operation - incision made in pylorus)
excellent prognosis
symptoms: mesenteric adenitis
URTI preceeds sore tummy
rx: mesenteric adenitis
conservative
def: coeliac disease
- autoimmune condition where exposure to gluten causes immune reaction creating inflammation in small intestine
- usually develops early childhood but can start at any stage
- auatoantibodies created in response to gluten targetting epithelial cells of intestine - anti-TTG (transglutaminase) and anti-EMA (endomysial)
- inflammation affects small bowel mainly jejunum and causes atrophy of intestinal villi causing malabsorption
presentation: coeliac
- failure to thrive
- diarrhoea
- fatigue
- weight loss
- mouth ulcers
- anaemia (secondary to iron
presentation: coeliac
- failure to thrive
- wasting of buttocks and distended abdomen
- diarrhoea
- fatigue
- weight loss
- mouth ulcers
- anaemia (secondary to ironnand B12 deficiency)
association: coeliac disease
T1DM - any new T1DM should be tested for coeliac disease, even if unsymptomatic
auto-antibodies: coeliac disease
anti-TTG - tissue transglutaminase IgA
EMA - endomysial IgA
diagnosis: coeliac disease
patient remains on gluten diet
check total IgA to exclude IgA deficiency
* raised anti-TTG ab
* raised anti-EMA (diagnosis if cymptomatic and raised anti-TTG and this)
endoscopy and intestinal biopsy show
* crypt hypertrophy
* villous atrophy (flat duodenal biopsy)
1 = symptomatic + markedly raised anti-TTG + raised anti-EMA
2 = asymptomatic + raised anti-TTG + duodenal biopsy
rx: coeliac disease
lifelong gluten-free diet
associations: coeliac disease
- T1DM
- thyroid disease
- primary biliary cirrhoses
- Down’s syndrome
- autoimmune hepatitis
complications: untreated coeliac
- vitamin deficiency
- anaemia
- osteoporosis
- ulcerative jejunitis
- non-hodgkins lymphoma
def: intussusception
- bowel invaginates/telescopes into itself
- thickens size of bowel and narrows lumen
- causes palpable mass in abdomen and obstruction
- often 3 months to 2 years
presentation: intussusception
- often a preceeding viral infection
- severe, colicky abdominal pain
- pale, lethargic and unwell child
- redcurrant jelly stool
- RUQ sausage shaped mass on palpation
- vomiting
- intestinal obstruction
ix: intussusception
target/doughnut sign on USS
rx: intussusception
- air enema/rectal air insufflation
- surgery required if unsuccessful or if peritonitis - bowel becomes gangrenous or perfed bowel
complications: intussusception
- obstruction
- gangrenous bowel
- perforation
- death
def: cow’s milk allergy
- hypersenstivity to protein in cow’s milk
- affecting infants and children under 3
- IgE mediated (type I hypersensitivity - happens rapidly)
- can alsobe non-IgE mediated (happening over time)
- DIFFERENT TO LACTOSE INTOLERANCE (sugar not protein)
presentation: cow’s milk allergy
- usually <1 when weaned from breast milk to formula or foods containing milk or breastfed babies with mums consuming milk products
GI:
* bloating and wind
* abdominal pain
* vomiting
* diarrhoea (mucous)
* reluctant to feed/feeds little and then is sick/unsettled after feed
allergic general symptoms:
* urticarial rash
* angio-odemea
* cough/wheeze/sneezing/watery eyes
rx: cow’s milk protein allergy
- skin prick testing can support if IgE mediates
- trial avoiding cow’s milk
- Regular monitoring of growth and nutritional status (including faltering growth or excessive weight gain).
- Advice on a cow’s milk-free diet including hypoallergenic infant formulas and suitable substitute foods if complementary feeding (weaning).
- Advice on performing a cow’s milk elimination trial and home reintroduction, and follow-up.
- If there is a clear improvement in symptoms, arrange a home reintroduction of cow’s milk into the mother’s or infant’s diet to confirm the diagnosis of non-IgE-mediated cow’s milk allergy.
- hydrolysed formulas (neocate)
- Trial of milk ladder every 6 months from age 1
- should grow out of it by 2-3 if intolerant
def: Meckel’s diverticulum
- most common cause of paediatric massive PR bleed
- ileal remnant of suct
- technetium scan = increased uptake by ectopic gastric mucosa and ?laparoscopic examination for diagnosis
- tx: surgery
def: malrotation
- comgenital abnormality
- small intestine lies mainly on RHS abdomen with caecum in RUQ
- presents in first 3 days of life with intestinal obstruction
- Ladd bands obstructing duodenum/volvulus
presentation: malrotation
- bilious vomiting
- abdominal pain
- tenderness/peritonitic/ischaemic bowel
ix and tx: malrotation
- urgent GI contrast studdy and USS
- surgical correction (Ladd’s procedure)
def: Hirschprung’s disease
- congenital condition where nerve cells of myenteric plexus absent in distal bowel and rectum (Auerbach’s plexus)
- stimulates peristalsis of large bowel
- absent parasympathetic ganglion cells in end section of colon
- aganglionic section constricts and causes obstruction
associations: Hirschprung’s
- family hx
- Down’s
- neurofibromatosis
presentation: Hirschprung’s
- delay in passing meconium
- chronic constipation since birth
- abdominal pain/distension
- vomiting
- failure to thrive and vomiting
def: Hirschprung’s Associated Enterocolitis (HAEC)
inflammation and obstruction of intestine presenting 2-4 weeks of birth with fever, abdominal distension, diarrhoea and fx sepsis
can lead to toxic megacolon and bowel perf
rx: HAEC
urgent antibiotics
fluid resus
decompression of obstruction
rx: Hirschprung’s
- AXR
- rectal biopsy to confirm diagnosis - absence of ganglionic cells
- fluid resus
- surgical removal of aganglionic cells definitive mx
def: biliary atresia
- congenital condition
- section of bile duct narrowed or absent causing cholestasis and preventing excretion of conjjugated bilirubin
presentation: biliary atresia
significant jaundice (high levels conjugated bilirubin))
persistent jaundice >14 dys in term babies and >21 days prem
ix: biliary atresia
conjugated bilirubin raised
raised GGT
diagnosis confirmed with cholangiogram (ERCP or operative)
rx: biliary atresia
Kasai hepatoenterostomy
causes: intestinal obstruction
Hirschprungs
meconium ileus
oesophageal atresia
duodenal atresia
intussusception
imperforate anus
malrotation with volvulus
presentation: intestinal obstruction
persistent vomiting (may be bilious(
abdominal pain and distension
failure to pass stools or wind (absolute constipation)
abnormal bowel sounds - tinkling/high pitched or absent
diagnosis: intestinal obstruction
AXR
dilated loops of bowel
absence of air in rectum
rx: intestinal obstruction
nil by mouth
drip and suck (Ng tube)
IV fluids
def: meconium ileus
delayed passage meconium (>24 hours)
often CF
abdominal distension
ix: meconium ileus
AXR no fluid level as meconium viscid
PR contrast studies may dislodge plugs and be therapeutic
rx: meconium ileus
PR contrast
NG N-acetyl cysteine
surgery
def: oesophageal atresia
associated with tracheo-oesophageal fistula
polyhydramnios
may present with choking, cyanotic spells following aspirations
VACTERL
def: infantile colic
common and benign
<3months
bouts of excessive crying and pulling up of legs
worse in evening
signs/symptoms: appendicitis
- central abdominal pain initially moving to RIF
- tenderness in McBurney’s point
- Rovsing’s sign
- loss of appetite
- N+v
- guarding
- rebound and percussion tenderness
diagnosis: appendicitis
- clinical presentation and raised inflammatory markers
- ?CT scan
rx: appendicitis
appendicetomy
viral cause: gastroenteritis
rotavirus
norovirus
(adenovirus less common and more subacute diarrhoea)
bacterial cause: gastroenteritis
- e-coli 0157 shiga toxin
- campylobacter jejuni
- shigella
- salmonella
- bacillus cereus
- stash aureus
- giardiasis
features: ecoli 0157 shiga toxin gastroenteritis
- abdominal cramps
- bloody diarrhoea
- vomiting
- shiga toxin destroys blood cells and leads to haemolytic uraemic syndrome (HUS)
- abx increases risk of HUS
features: campylobacter jejuni gastroenteritis
- “travellers diarrhoea”
- gram negative bacteria spiral shaped
- raw/improperly cooked pultry/untreated water/unpasteurised milk
- incubation 2 to 5 days - symp resolve within 3-6 days
- abdominal cramps
- diarrhoea (often bloody)
- vomiting
- fever
azithromycin or ciprofloxacin if severe
features: shigella
- faeces contaminated drinking water/swimmin pools/ food
- incubation 1-2 days
- symtpoms resolve usually around 1 week without treatment
- blood diarrhoea, abdominal cramps and fever
- shiga toxin - HUS
- severe = azithromycin or ciprofloxacin
features: salmonella
- eating raw eggs/poultry
- incubation 12 hours to 3 days
- symptoms usually resolbe within 1 week
- watery diarrhoea
- ?mucus and blood
- abdominal pain and vomiting
- abx only in severe cases guided by stool culture and sensitivities
features: bacillus cereus
- gram +ve rod
- inadequately cooked food
- fried rice
- toxin cereulide causes abdominal cramping and vomiting within 5 hours of ingestion
- watery diarrhoea
- symptoms usually resolve within 24 hours
features: giardiasis
- parasite
- pets, farmyard anuimals
- cysts from stools of affected animals contaminate food/water
- feaecal-oral transmission
- chronic diarrhoea
- stool microscopy diagnosis
- metronidazole
principles: gastroenteritis rx
- barrier nursing
- infection control
- child stays off school for 48 hours after symtpoms completely resolve
- sample of stool for microscopy, culture and sensitivities
- fluid challende
- rehydration solutions
- may require IV fluids
- light reintroduction of food
complications: gastroenteritis
- reactive arthritis
- lactose intolerance
- IBS
- guillain-barre
presentation: constipation
- less than 3 stools pepr week
- rabbit sropping stools
- hard stools difficult to pass
- staining and painful passage of stools
- overflow soiling
- hard stools palpable in abdomen
- abdominal pain
- holding babnormal posture - retentive posturing
def: encopresis
- faecal incontinence - not pathological until 4 y
- sign of chronic constipation
- rectum stretched and looses sensation
- large hard stools remain in rectum and loos sools bypass and leak out
rare causes: encoparesis
- spina bifida
- hirschprung’s disease
- cerebral palsy
- abuse
- etc
lifestyle factors: constipation
- habitually not opening bowels
- low fibre diet
- poor fluid intake and dehydration
- sedentary lifestyle
red flags: constipation
- not passing meconium
- neurological signs (esp lower limbs)
- vomiting
- ribbon stool (anal stenosis)
- abnormal anus
- abnormal lower back/buttocks
- failure to thrive
- acute severe abdominal pain/bloating
rx: constipation
correct any reversible factors - good hydration and high fibre diet
start laxatives (movicol first line)
faecal impaction may require disimpaction (high dose laxatives at first)
encourage and praise going to toilet (schedule visits, bowel diary, star charts)
features: chron’s IBD
NESTS
* no blood or muscous
* entire GI tract
* skip lesions on endoscopy
* terminal ileum most affected and transmural (full thickness) inflammation
* smoking RF (don’t set the nest on fire)
wight loss strictures and fistulas
features: UC IBD
CLOSE UP
* continuous inflammation
* limited to colon and rectum
* only superficial mucosa affected
* smoking protective
* excrete blood and mucus
* use aminosalicylates
* primary sclerosing cholangitis
presentation: IBD
- perfuse diarrhooea
- abdominal pain
- bleeding
- weight loss
- anaemia
- may be systemically unwell during flares with fevers, malaise and dehydration
extra-intestinal manifestations: IBD
- finger clubbing
- erythema nodosum
- pyoderma gangrenosum
- episcleritis and iritis
- inflammatory arthritis
ix: IBD
faecal calprotectin raised
CRP raised
** endoscopy with biopsy = gold standard **
rx: Chron’s
- first line = steroids - oral pred or IV hydrocortisone
- ?enteral nutrition
- immunosuppressant - methotrexate, infliximab, azathiprine
rx: UC
mild-moderate:
first line = aminosalicylate
second line = steroids
severe:
IV hydrocortisone
aminosalicylate to maintain remission
ileostomy ot J-pouch definitive management
def: macule
<1cm circumcised flat area of discoloration
def: patch
larger flat area of discoloration
def: papule
raised palpable area (small <1cm)
def: plaque
large raised disc lesion
def: nodule
palpable lesion >1cm
o
def: vesicle
small blister <0.5cm
def: bulla
blister >0.5cm
def: pustule
blister with visible pus
def: purpura
red/purple non-blanching discoloration secondary to extravasation of red cells
def: petechiae
purpuric area <2cm
def: talangiectasia
dilated, visible small blood vessels
def: wheal
itchy papule
pigmented lesion: ABCDE
asymmetry
border (irregular/redular)
colour
diameter
evolution of lesion
cause and presentation: measles
- measles virus spread by respiratory droplets
- fever and coryzal symptoms with conjunctivitis
- symptoms start 10-12 days after exposure
- Koplik (grey/white spots) on buccal muscosa appear 2 days after fever = pathognomonic
rash: measles
- starts behind ears typically and spreads to face 3-5 days after fever
- Koplik spots in buccal mucosa
rx: measles
- self resolving 7-10 days later
- isolated until 4 days after symptoms resolve
- notifiable disease
complications: meaasles
- pneumonia
- diarrhoea
- dehydration
- encephalitis
- meningitis
- vision loss
- hearing loss
- death
cause and presentation: scarlet fever
- group A strep association - usually tonsilitis
- caused by exotoxin produced by strep pyogenes
- red-pink blotchy macular rash with rough sandpaper skin starting on trunk and spreading outwards
- often have red, flushed cheeks
- fever/lethargy/flushed face/sore throat/strawberry tongue, cervical lymphadenopathy
rx: scarlet fever
penicillin V for 10 days
pen allergy: azithro 5 days or clarithro 10 daays
notifiable disease
kept off school until 24hrs after starting abx
complications: scarlet fever
post-strep glomerulonephritis
acute rheumatic fever
cause and presentation: rubella
- highly contagious spread by respiratory droplets
- symptoms start 2 weeks after exposure
- milder erythematous macular rash starting on face and spreading to rest of body
- rash lasts 3 days
- associated with mild fever, joint pain and sore throat
- lymphadenopathy behing ears and back of neck
rx: rubella
- supportive and self limiting
- notifiable disease
- stay off school at least 5 days after rash appears
- avoid pregnant women
complications: rubella
- thrombocytopenia
- encephalitis
- congenital rubella syndrome - triad = deafness, blindness and congenital heart disease
cause and presentation: slapped cheek syndrome/fifths disease/erythema infectiosum
- parvovirus B19
- mild fever, coryza and non-specific viral symptoms (muscle aches and lethargy
- after 2-5days rash appears rapidly as diffuse bright red rash on both cheeks
- few days later reticular (net like) mildly erythematous rash affecting trunk and limbs appears that can be raised and itchy
rx: slapped cheek
- self-limiting
- rash and syptoms fade over 1-2 weeks
- plenty of fluids and analgesia
- no longer infectious after rash formed
- no need to stay off school
complications: slapped cheek
- immunocompromised and pregnancy or haematological condition
- requrie serology testing to confirm diagnosis - FBC and reticulocyte for aplastic anaemia
- aplastic anaemia
- encephalitis/meningitis
- pregnancy complications inc foetal death
*
cause and presentation: roseola infantum
human herpesvirus 6 and less commonly 7
* patietns present 1-2 weeks after infection with high fever (up to 40) comes on suddenly
* lasts for 3-5 days and disappears suddenly
* may be coryzal, sore throat and swollen lymph nodes
* when fever settles, rash appears for 1-2 days of erythematous macular rash on arms, trunk and face - not itchy
* do not need to take off school and oftern recover within 1 week
febrile convulsions
cause and presentation: hand, foot and mouth
- coxsackie A virus
- incubation 3-5 days
- starts with URTI - tiredness, sore throat, dry cough, fever
- 1-2 days later ulcers on mouth, blistering red spots on body and hands (palms) and feet (soles) (esp tongue) may be itchy
rx: hand, foot and mouth
- supportive
- adequate fluid intake
- simple analgesia
- resolve 7-10days
- highly contagious - avoid sharing towels/bedding
- wash hands and careful handling nappies
complications: H,F&M
- dehydration
- bacterial superinfection
- encephalitis
isolation: infectious diseases
rubella - 5 days after rash appears
scarlet fever - 24 hours after starting abx
measles - 4 days after symptoms resolve
chicken pox - once all lesions have crusted over
cause and presentation: chickenpox
- VZV
- widespread, erythemaous, raised, vesicular, blistering lesions
- starts on trunk or face and spreads outwards affecting whole body over 2-5 days
- fever first symptoms
- itch
- general fatigue and malaise
infectivity and complciations: chickenpox
- highly contagious and spread through direct contact with lesions or through respiratory droplets
- bacterial superinfection
- dehydration
- conjunctival lesions
- pneumonitis
- encephalitis (presenting with ataxia)
- after infection virus can lie dormant in snsory dorsal root ganglion cells adn cranial nerves - reactivate in later life as shingles or Ramsay Hunt syndrome
chickenpox and prgnancy
- pregnant women not immune need VZV immunoglobulins
- chickenpox before 28 weeks can cause developmental problems in foetus - CONGENITAL VARICELLA SYNDROME
- chickenpox near delivery can lead to life threatening neonatal infection and treated with VZV immunoglobulins and aciclovir
rx: chickenpox
- usually mild and self limiting
- DO NOT GIVE NEUROFEN - increases risk of necrotising fascitis
- aciclovir if immunocompromised, over 14 and adults presenting within 24 hours or neonates
- itching relieved with calamine lotion and chlorphenamine
- complications like encephalitis require admission
- patients kept off school and avoid pregnant women until lesions dry and crusted over (around 5 days)
