PEM - CVS, environmental, surgical, neonatal, trauma Flashcards
CVS, environmental, genitalia, neonatal, trauma
Major trauma activation criteria
Mechanism:
- Motorcyclist, cyclist or pedestrian impact > 30 km/hr
MVA > 60 km/hr
- Ejection, roll over, fatality in same vehicle or extraction > 30 min
- Fall > 3 m or twice childs height
- Explosion and suspected inhalation burns
Injury
- Serious or suspected serious injuries to head, neck or torso
- Injury to 2 or more body areas
- Burns > 20 %
- Two or more long bone fractures
- Evisceration, severe crush injury, amputation, suspected spinal injury or pelvic fracture
Signs
- RR < 10 or > 30
- SBP < 75 mmHg
- GCS 15
- O2 sat < 90%
Interventions - Intubation, airway manoeuvres, assisted ventilation, chest decompression Failure to control bleeding Interhospital transfer Significant comorbidity
Circulating blood volume of
- neonate
- infant
- child
- adult
- neonate 85-90 mls/kg
- infant 75-85 mls/kg
- child 70-75 mls/kg
- adult 65-70 mls/kg
Indications for CTB in paediatric head injury
Definite (RCH)
- Signs of base of skull fracture
- Focal neurological deficit
- Suspected open or depressed skull fracture
- Any GCS < 8 or GCS persistently < 13
- Suspected NAI
- Seizures > 2 min post impact
Consider - persistent headache, irritability, confusion or drowsiness
Central cord syndrome: causes and deficits
Hyperextension injury.
Motor deficit arms > legs, distal > proximal
Variable sensory change
Indications for CT abdomen in paediatric trauma
- Abdominal tenderness / peritonism
- Reduced conscious state and high risk of injury
- External evidence of abdominal injury (bruising, handlebar injury, haematoma)
- Positive FAST, falling HCT or elevated LFT
- Macroscopic haematuria
Describe fluid therapy in burns
Indication > 20% BSA - Resus: Parkland formula: BSA burnt x weight (kg) x 4 = mls of resus fluid to be given over 24 hrs, half in first 8 hrs (from time of injury) - Maintenance fluid - Subtract any resus boluses. Aim, urine output 0.5-1 ml/kg/hr
Indications for paediatric burns unit admission
Required
- Partial thickness burns > 20%
- Full thickness burns > 5-10%
- Smoke inhalation or airway burn suspected
- Child abuse suspected
Consider
- Burns to hands, feet, face, perineum or joints
- Other concern: age < 12 months, parental coping
- Comorbidity
- Other significant injuries
Indications for tetanus toxoid or immunoglobulin
Toxoid:
- < 3 doses, uncertain, > 10 yrs since vaccination, or 5-10 years with large / contaminated wound
- At risk: 9-11/13 yrs and > 16-18 yrs
Immunoglobulin: < 3 doses or uncertain with large/dirty wound. HIV positive. 250 IU if < 24 hrs, 500 IU if > 24 hrs.
Characteristics of a benign paediatric murmur
Asymptomatic (no chest pain, breathlessness, cyanosis)
Systolic, short
Soft
Well localised.
Serious differentials for paediatric chest pain
Pneumothorax, PE Arrhythmia, Cardiomyopathy Myocarditis Coronary arteritis (kawasaki) Ingested FB (button battery)
Cyanotic heart disease - 5 causes
Transposition of great arteries Tetralogy of fallot Total anomalous pulmonary venous return Truncus arteriosus Tricuspid atresia (pulmonary atresia, hypoplastic LV)
Findings in Tetralogy of Fallot
VSD
Overriding aorta
Pulmonary stenosis (subpulmonary)
RVH
Causes, timing and treatment of duct dependent cardiac lesion
Causes - pulmonary atresia / stenosis - Transposition of great arteries - coarctation of aorta, interrupted aortic arch - critical aortic stenosis - hypoplastic left heart 1-3 weeks of age
Management
- Prostaglandin E1 infusion, 5-60 ng/kg/min.
- End organ perfusion: IV fluid bolus, adrenaline, optimise Hb
- PEEP (offload LV)
- Reduce O2 demand: support breathing, reduce fever
Management of tetralogy spells
Aim: increase PVR and decrease Pulmonary Blood flow.
- knees to chest
- O2
- Morphine / fentanyl / ketamine (abort crying, reduce tachypnoea).
- inrcrease preload 5-10 mls/kg IV saline
Then PICU/cardio: propranolol/esmolol, metaraminol.
Causes of acyanotic cardiac disease
Increased pulmonary blood flow: VSD, ASD, PDA, AV canal
Ventricular outflow obstruction: coartation of aorta, aortic stenosis, pulmonary stenosis
Causes, timing and treatment of congestive heart failure
VSD, PDA, congenital arrhythmia or valve disease
4-12 weeks of age.
Post viral cardiomyopathy 3-6 months.
Management
- oxygen
- diuresis
- support ventialtion
- inotropes (adrenaline if hypotensive)
Acute rheumatic fever diagnostic criteria
Modified Jones criteria
- 2 major criteria
- 1 major and 2 minor criteria
- Preceding GAS infection (positive throat swab, elevated/rising ASOT)
Major manifestations
- Heart: Carditis
- Joint: polyarthritis, aseptic monoarthritis, arthralgia (very high risk only)
- Brain: Chorea
- Skin: erythema marginatum, subcutaneous nodules
Minor manifestations
- Fever
- ESR > 30 (Aus) or CRP > 30
- Heart: Prolonged PR
- Joints: monoarthralgia (high risk) or polyarthralgia (NZ, lower risk)
Diagnostic criteria for infective endocarditis
Modified Duke criteria
- definite: 2 major criteria, 1 major and 3 minor, 5 minor criteria
- Possible: 1 major and 1 minor, or 3 minor
- Rejected: clear alternative diagnosis, or resolution with antibiotic therapy for 4 days
Major
- typical microorganism (strep viridans/bovis, HÁČEK, staph aureus) in 2 cultures or one of coxiella
- positive cultures > 12 hours apart of typical organisms, or for skin contaminant organisms 3 cultures
- Evidence of endocardial involvement
- Echo confirming IE (intracardiac mass, periannular abscess, partial dehiscence of valve)
- New valvular regurgitation on echo
Minor
- Predisposing factor, history of IVDU or Congenital heart disease
- Fever > 38
- Vascular phenomenon - arterial emboli, pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage conjunctival haemorrhage, Janeways lesions
- Immunological phenomenon - GN, oslers nodes, Roth spots, RF positive
- Positive blood cultures / serology not meeting major criteria.
Antibiotic management of infective endocarditis
Community acquired:
Benzylpenicillin Q4H
Flucloxacillin 50mg/kg to 2g Q4H
Gentamicin 4-6 mg/kg stat
Hospital acquired / prosthetic valve / MRSA:
Vancomycin 1.5g IV BD
Gentamicin 4-6 mg/kg IV
Diagnosis of Kawasaki Disease
Fever of 5 days, without other cause, plus
4 of:
- bilateral bulbar conjunctival injection
- Enanthem: dry/cracked/injected lips, oropharyngeal injection, strawberry tongue
- Rash: polymorphous
- Peripheral changes: erythema or oedema of Palms/soles, desquamation in 2/3rd week
- Cervical adenopathy (one node > 1.5 cm diameter)
Treatment of Kawasaki disease
IVIG 2g/kg over 10-12 hrs
Aspirin 3-5 mg/kg/day
Possible methyprednisolone 2mg/kg.kday in 3 doses
Differential diagnosis of ataxia developing flaccid paralysis
Snake bite Pesticide exposure Toxins / poisons (antiepileptic, lead) Tick bite paralysis ADEM, GBS
Factors associated with poor prognosis in drowning
Duration of hypoxia
-Duration of submersion (>5 min = poor)
-Time to institution of effective CPR (>10-20 min poor)
-Time to first spontaneous gasp
Response to resuscitation
-Arrive conscious in ED - excellent outcome
-Lack of response, coma on arrival to ED - poor outcome
-GCS 5 or less on arrival to ED - dismal outcome
-Lack of pupillary response in ED (unless severe hypothermia).
-25 min of ALS, if non-hypothermic, without response,- poor outcome (but case reports of long donwtimes)
Complications of hypothermia
Cardiac arrhythmia / arrest Haematological - platelet dysfunction, thrombocytopaenia, DIC Pulmonary: pneumonia, PO, ARDS Infection: immune complex supression Renal: ATN, rhabdomyolysis GIT: pancreatitis Biochemical / metabolic derrangements.
Management of anaphylaxis
Remove allergen Lay child down Administer adrenaline: 0.01 mls/kg of 1:1000 (10 mcg/kg) - maximum 0.5 ml - repeat in 5 min if not improving Adrenaline infusion 0.05 - 5 mcg/kg/min - 1 ml adrenaline 1:1000, in 1L saline, at 5 mls/kg/hr (0.1 mcg/kg/min) IV fluid bolus 20 mls/kg saline
Risk factors for fatal anaphylaxis
Adolescence
Nut and shellfish allergy
Poorly controlled asthma
Delays to administration of adrenaline / emergency services
Preexisting cardiac and respiratory conditions
Causes of PUO (>10 days)
Juvenile idopathic arthritis, IBD, Malignancy
Infection
- Viral syndromes (EBV)
- LRTI, CNS, Bone
- TB, abscess, endocaridtis, enteric (typhoid fever)
- Kawasaki disease
Antibiotic cover for meningitis
3rd generation cephalosporin
Plus
- age < 2 months: benzylpenicillin (GBS, listeria)
- Penicillin-resistant pneumococci: vancomycin 15mg/kg (to 500mg) IV Q6H
Contact prophylaxis for neisseria meningitidis or haemophilus influenza
Rifampicin. Neisseria - 10mg/kg BD, Influenza - 20mg/kg daily
Antibiotics for pre-septal cellulitis
Amoxycillin/clavulanate, 22.5 mg/kg amoxycillin PO BD
Flucloxacillin and ceftriaxone if IV
Antibiotics for peritonitis
Ampicillin/amoxycillin 50mg/kg IV Q6H
Gentamicin 7.5mg/kg (360mg) < 10 yrs, or 6mg/kg > 10 yrs
Metronidazone 15mg/kg (1g) stat, then 7.5mg/kg IV Q8H
Antibiotics for pyelonephritis or UTI < 6 months
Benzylpenicillin 60mg/kg Q6H
Gentamicin 7.5mg/kg (360mg) if < 10yrs, or 6mg/kg IV if > 10 yrs.
Antibiotics for epiglottitis
Ceftriaxone 50mg/kg IV
Add dexamethasone
Management of otitis media
Red flags: OAM in only hearing ear, cochlear implant, indigenous child. Immunosupressed.
No red flags - analgesia for 48 hrs
Red flags / immunocompromised / very unwell / not improving at 48 hrs:
- amoxycillin 30-45 mg/kg/dose BD for 5 days
Ongoing in 48 hrs with abx: change to amoxyclav
Amoxyclav if amoxycillin in last 30 days or history of resistance.
Antibiotic management of pneumonia
Amoxycillin 25 mg/kg (500 mg) PO Q8H
add: benzylpenicillin 60mg/kg (2g) IV Q6H if moderate
Severe: flucloxacillin 50mg/kg IV Q6H and cephalosporin
Antibiotics for necrotising fascitis
Vancomycin 15mg/kg IV Q6H
Meropenem 25 mg/kg IV Q8H (1g)
Clindamicin 15mg/kg IV Q8H (600mg)
Sepsis < 2 months - causative agents
GBS E. coli and gram negatives Listeria Haemophillus influenza Plus: strep pneumoniae, neisseria meningitidis, staph aureus, GAS
Sepsis < 2 months - treatment
Benzylpenicillin 60mg/kg IV Q12H / 6H (1-4 weeks) / 4H
3rd generation Cephalosporin
Skin: Flucloxacillin 50mg/kg IV Q12H (first week) / 8H (1-4 weeks) / 6H (>4 weeks)
Abdominal: Amoxycillin/ampicillin 50mg/kg IV AND Gentamicin 5mg/kg IV (<1 week) then 7.5mg/kg AND Metronidazole 15mg/kg IV
Sepsis > 2 months - causes
Strep pneumoniae N. meningitidis S. Aureus Group A strep Gram negatives
Sepsis > 2 months - treatment
Flucloxacillin 50mg/kg IV Q6H (2g)
Cephalosporin 3rd gen
Central line or suspected MRSA: Vancomycin (alt to flucloxacillin)
Gram positive TSS: Add clindamicin and IVIG
Febrile neutropaenia
Piperacillin / Tazobactam 100mg/kg (4g) IV Q6H
AND
Amikacin 22.5 mg/kg (1.5g) IV daily (< 10 yrs) / 18mg/kg > 10 yrs
Add vancomycin 15mg/kg IV (500mg) Q6H for line infection
Differntial diagnosis acute scrotum
- Testicular torsion, adolescent and neonates, abnormal lie.
- Torsion of appendix testis, upper pole tenderness, blue dot. few days.
- Epididymoorchitis. Infants and 10-12 yr olds.
- Idiopathic scrotal oedema. Scrotal skin thickened.
- Testicular tumours. Scrotal enlargement + trauma.
- Irreducible inguinal hernia.
- Testicular rupture.
- Acute hydrocele. Intercurrent illness - increase peritoneal fluid. Not painful.
Causes of erythroderma
Causes
- Inflammatory: psoriasis, eczema, pityriasis, diffuse cutaneous mastocytosis
- Ichthyoses
- Immudeficiency: SCID, DiGeorg,GVHD
- Drug Reaction
- Metabolic: acrodermatitis enteropathica, organic acidemia
- Infection: staph scalded skin, staph toxic shock, syphilius , HSV
Causes of collapsed neonate
THEMISFITS
Trauma Heart disease Endocrine - CAH, hypothyroidism Metabolic - BSL Inborn errors of metabolism Sepsis Formula mishaps Intestinal catastrophe - volvulus, NEC, intusussception Toxins Seizures
Presentation and management of congenital adrenal hyperplasia
ambiguous genitalia (F) or enlarged penis (M)
1-2 weeks of age with salt loosing crisis.
Hyponatraemia, hypkerkalaemia and hypoglycaemia.
IV hydrocortisone - 5mg/m2 Q8H
Causes of neonatal seizures (after 48 hrs)
- CVA: extra-axial, periventricular, sinovenous thrombosis
- Biochemical: hypoglyaemia, hypocalcaemia, hypernatraemia
- Meningoencephalitis: bacterial (GBS, E coli, listeria, Staph), viral (HSV, enterovirus)
- Withrdrawal (opioid, SSRI)
- NAI
- Inborn errors of metabolism
- Seizure syndromes: benign and malignant
- Malformations/tumours
Differential of neonatal seizures and differentiating features
Benign sleep myocolonus: during sleep, not stimulus sensitive, UL>LL, bilateral or unilateral
Jitterinesss: symmetrical, stimulus sensitive, no eye movements, supressible.
Management of neonatal seizures
Phenobarbitone 20 mg/kg IV or IM
Levitiracetam 20mg/kg IV BD
Intubation & midazolam - 0.15 mg/kg over 5 min, infusion 60-400 mcg/kg/hr
Phenytoin 15-20 mg/kg IV over 30 min
Pyridoxine 100 mg IV if unclear cause not responsive to other therapies
Indications for neuroimaging in seizures
- focal seizure
- 3rd line antiseizure medicine
- children < 6 months
- signs of raised ICP
- bleeding disorder / anticoagulation
- not returned to baseline mentation
Medications and dosing in neonatal resus:
- adrenaline
- naloxone
- dextrose
- saline
Adrenaline 0.1-0.3 mls/kg 1:10,000 (10 mcg/kg)
Naloxone 0.1 mg/kg IV or IM
Dextrose 10% slow IV, 2 mls/kg
Saline 10 mls/kg over 5 min
