PEM - neuro, opthal, ENT, dental, radiology, renal, resus Flashcards
Causes of Raised ICP
Increased CSF fluid
- decreased absoprtion (Obstruction, communicating)
Swollen contents
- infection: meningitis, encephalitis
- Cerebral oedema: metabolic, vasogenic, ischaemic, axonal injury
- Increased venous pressure: venous sinus thrombosis
Space occupying lesion: tumours, haematoma, absess/cyst
Decreased volume: depressed skull fracture
Simple febrile seizure, characteristics
- generalised tonic-clonic
- < 10 min
- Complete recovery in 1 hr
- not reoccuring in same illness
Management of seizure
> 5 min seizure / unknown length
Monitoring, BSL
Benzodiazepine - midazolam 0.1 mg/kg IV/IM (0.3mg/kg buccal)
5 min - repeat benzodiazepine
5 min - levetiracetam 40 mg/kg IV (max 3g) over 5 min
5 min after infusion - phenytoin IV 20mg/kg over 20 min, max 50mg/min
5 min after infusion - intubation
Dose of midazolam in seizures
- 1 mg/kg IM / IV
0. 3 mg/kg IN / Buccal
Predictors of ICU admission in diagnosis of muscular weakness
- bulbar palsy
- Vital capacity < 20 mls/kg
- > 30% reduction in vital capacity
- Flaccid quadriparesis
- Rapidly progressive weakness
- Autonomic cardiovascular instability
Guillian-Barre: clinical findings
Motor weakness
Absent reflexes
Ascending pattern.
Cranial nerve abnormalities
Predictors of intubation in Guillian Barre
Vital capacity <= 20mls/kg
Max insp pressure <= 30 cmH2O or exp pressure <= 40 cmH2O
Tidal volume < 5 mls/kg
Sustained increase of pCO2 > 50
Rising RR or O2 requirement.
Increased accessory muscle use or paradoxical diaphragm movements.
Features of infantile botulism and treatment
Exposure to honey. Bulbar palsy, descending. lack of facial expression.
No antibiotics.
BabyBIG (botulism IG)
NG feeding
Respiratory support
Features of transverse myelitis
Flaccid paralysis –> increased tone.
Sensory level (often midthoracic)
Back pain, neck stiffness / fever.
Bladder / bowel disturbance
DDx of ataxia
Post-viral acute cerebellar ataxia - dysarthria, hypotonia
Poisoning - altered consciousness and vomiting
Tumours - posterior fossa, paraneoplastic
Trauma - NAI, concussion
Metabolic - BSL, Na, Ammonia, B12, IEM
Infectious - CNS, larbrynthitis
Vascular - stroke, vasculitis
Immune - MS, ADEM
Absence of red reflex
large retinal detachment
large vitreous haemorrhage
dense cataract
retinoblastoma
Distinguishing features of orbital cellulitis
Systemic features, sinusitis
Red eye
Painful eye movements / diplopia
Proptosis
Neonatal conjunctivitis management and differential
Swab
IV ceftriaxone (Gonorrhoea, 24-48 hrs)
PO azithromycin or erythromycin (Chlamydia 5-14 days)
Other - staph/strep (D5-7) or HSV
DDx:
congenital nasolacrimal duct obstruction (not red / inflamed)
How do you identify keratitis, causes and management
Corneal opacity, without overlying epithelial defect.
Pain, erythema, photophobia and reduced visual acuity
+/- hypopyon
Staph/strep Pseudomonas (contact lenses) Fungi (garden trauma) HSV (dendritic) Varicella (skin rash)
Mx: ophthalmologist for scrapings prior to abx
Indications for referral in eyelid trauma
Bite trauma Involves lid margin Medial 1/3 of eyelid Levator aponeurosis (proptosis) Orbital fat exposed Significant tissue loss
Indications for antibiotic treatment in otitis media
Only 1 hearing ear
Indigenous
Cochlear implant
Otherwise well child without improvement at 2-3 days
Consider (other sources suggest)
- age < 2
Useful numbers and otitis media treatment
- NNT with antibiotics to reduce pain
- NNH with antibiotics
- NNT to prevent 1 mastoiditis
- NNT 20
- NNH 10
- prevent mastoiditis NNT 5000
Indications to antibitoics in tonsilitis
Indigneous australia, maori / pacific islander
Personal or FHx rheumatic heart disese
Immunosupressed
Aged >= 4 yrs
Intercostal catheter size in child
4 x ETT (age / 4 + 4)
Red flags for organic illness in acute behavioural disturbance
Fever
Clouded consciousness
Fluctuating mental state
Behaviour - personality change, sleep disturbance
Speech - muddled, fragmented
Perception - illusion, visual or tactile hallucinations
Paranoid ideation
Medications for acute behavioural disturbance in adolescents
Hyperaroused - quetiapine 5mg/kg
Psychotic, agressive or agitatied - olanzapine < 40 kg 5mg, > 40 kg 10 mg
Droperidol 0.1-0.2 mg/kg (max 10mg) IM, Repeated at 15 min
Medications for acute behavioural disturbance in pre-adolescent
PO
Quetiapine 5-10 mg/kg PO (max 10mg/kg in 24 hrs)
Olanzapine < 40 kg 2.5-5mg, > 40 kg 5-10 mg single dose
Risperidone 0.02-0.04 mg/kg (max 2mg) one dose.
Parenteral Sedation
Droperidol 0.1-0.2 mg/kg IM (max 10mg), repeat in 15 min
15 min still unsettled
Midazolam 0.1-0.2 mg/kg IM or IV
Ketamine 4mg/kg IM or 1mg/kg IV
Avoid benzos - disinhibition without sedation in this group (autism / behavioural disturbance)
Emergency medicine role in sexual assault
Recognition Treatment of physical injury Consider toxicology screening Sexual Assault Service referral Medical - emergency contraception - antibiotic / antiviral Child protection
Indications for medical admission in eating disorders
Arrhythmia Or QTc > 450 msec BP - SBP < 80 por postural drop >= 20 C - HR < 50, postural HR increase >= 30, Dehydration Electrolyte - K < 3 Hypothermia < 35.5
Weight < 75% predicted or rapid LOW
Eating disorder behaviour out of control.
Causes of Upper GI bleeding
Maternal: swallowed blood, NSAID Neonate: - trauma - vascular malformation Young child - oesophagitis All - gastritis and erosions, PUD - Mallory Weiss tear - bleeding disorder - duplication cyst - Oesophageal varicies - drug induced ulcers / NSAIDS (adolescent)
Causes of lower GI bleeding
Swallowed maternal blood Enterocolitis (necrotising, ischaemic, protein sensitive) Gastroenteritis Obstruction Congenital (duplication, vascular malformation, Meckels) Anal fissure Medical (HUS, vascular, IBD) Polyps, haemorrhoids, rectal prolapse
Management of oesphageal variceal bleeding
PPI
IV Vitamin K 2-10 mg
Ceftriaxone
IV somatostatin / octreotide 1 mcg/kg IV bolus (50mcg), then infusion
GI foreign bodies that should be removed
At presentation
- any oesophageal FB
- button battery > 20 mm and < 6 yrs
- > 5 cm (3 cm < 12 months) object
- sharp object
Button battery
- high risk (<6 yrs or > 15 mm) _ repeat x-ray in 4 days to localise
- low risk repeat x-ray in 10-14 days.
AXR findings consistent with intussusception
Absence of air in RUQ
Intracolonic mass / cresent sign
No air/fluid level in caecum
fistal obstruction with dilated small bowel
free air - riglers sign (double wall), football sign
Red flags in gastroenteritis
< 6 months of age high fever bilious vomits significant abdominal pain absence of diarrhoea blood in vomit / stool reduced consciousness
What is rapid NG rehydration prescription
25 mls/kg/hr ORS over 4 hrs (up to 300 mls/hr), then increase to 6 hrs)
Red flags for constipation
Fever Vomiting Bloody diarrhoea Failure to thrive Abdominal distention Anal canal stenosis delayed meconium passage polydipsia/polyuria
Differential diagnosis and key features for paediatric haematuria
Post strep GN - preceeding GAS infection (throat, skin) Rash / arthritis - HSP, SLE Diarrhoea +/- petehiae - HUS Travel - schisosomiasis / TB Abdominal mass - wilms tumour
Features of haemolytic uraemic syndrome
Thrombotic microangiopathy
Haemolytic anaemia - schisocytes, raised LDH, low haptoglobin, raised bilirubin. reticulocytosis microangiopathic - thrombocytopaenia Negative coombs Normal coagulation Urinalysis - haematuria / proteinuria
Diagnostic criteria for HSP
Palpable purpura
Normal platelet count / coagulation
one or more of
- abdominal pain
- arthralgia / arthritis
- renal involvement (proteinuria / haematuria)
- histopath - leucoclastic vasculitis with IgA deposits (GN)
