pg 28 Flashcards
¸What is the clinical examination of meningitis?
• Inspect: Fever, rash, unwell
• Meningisim:
o Neck stiffness: Hands on occiput sides (near ears), Rotate head,
Chin to chest, hold it there for 10 secs. (Assessing for resistance
to movement).
o Brudzinski sign: Flexion of the neck with child supine causes
flexion of the hips and knees.
o Kernig sign: Bend their knee with your hands on hamstrings and
the other supporting the thigh. Straighten: Positive if there is hamstring spasm or back pain, or flexion of the opposite leg on
extension.
o Papilledema and fontanelles.
o Focal neurological signs
Kawasaki disease
CP:
o High fever (> 5 days and difficult to manage)
o Strikingly miserable
o Non-purulent Conjunctivitis, strawberry tongue, lip cracking
o Hand and foot swelling, erythema, rash or peeling
o Inflammation of BCG scar.
Kawasaki disease
INVX
o Inflammatory markers
o Cardiac ECHO
Kawasaki disease
TX:
o IVIG
o High dose aspirin
o +/- Warfarin
o +/- Immunosuppression
Outline the UK immunisation schedule?
Birth: BCG, HB (if high risk) • 1 month: HB (If at risk) 2-3-4 months: HB (If at risk), 5 in one (DTAP, POLIO, HIF), PCV, Rota, and MEN-B. • 1 yr: MMR, HIB/MENC, MEN b, PCV, Hib • 3 yrs: MMR, 4 IN one (remove Hib) • 2-7: Flu shot each year. • 12-13 girls: HPV • 14 yrs: MENC ACWY, 3 in one
immunodeficiency syndromes
CP:
o Recurrent infections (Ear, sinus, lung, skin)
o Severe infections (Bone, brain, sepsis)
o Prolonged complicated infections
o Failure of antibiotics to clear infection
o Prolonged or recurrent diahorrea with Failure to thrive
o Deep sited and skin abscesses.
o Reactions to live vaccines
o Prolonged warts
o Opportunistic infections (candidiasis)
immunodeficiency syndromes
INVX:
o FBC with WBC differential
o IG levels and IgG subsets
o Compliment levels
o Special tests and genetics
immunodeficiency syndromes
Mgt:
o Anti-microbial prophylaxis
o Anti-biotic treatment
o Screen for end organ damage
examination findings in atopic child?
- Mouth breathing
- Allergic salute
- Swollen and pale inferior turbinate
- Allergic conjunctivitis with Dennie-Morgan folds and discoloration
- Atopic eczema
- Chest hyperinflation and Harrison sulcus
clinical features,
of food
hypersensitivity?
- 6% of children are affected.
- Allergic (Cow milk protein allergy)
o IgE-mediated:
Onset within 2 hours
Mild: Urticaria and itchy skin & facial swelling.
Severe: Wheeze, stridor, abdominal pain, vomiting and
diarrohea, Shock and collapse.
o Non-IgE: beyond 2 hrs. GI symptoms. - Non-allergic (Transient lactose intolerance).
Diagnosis of food
hypersensitivity?
Skin prick test (Most useful); wheel > 8 mm. Blood IgE
levels. Gold standard: Supervised food challenge.
Management of food
hypersensitivity?
Food avoidance with dietician advice (Traces,
Alternatives and nutritional deficiency avoidance). Written management
plan, carry epipen all the time. (Technique and expiry date).
Prognosis of food
hypersensitivity?
Egg and milk resolve but nut and fish do not.
What should the child with severe eczema be screened for?
Egg allergy (40%) with skin prick or blood test.
clinical presentation of hay fever?
- Conjunctivitis
- Rhinitis
- Chronic nasal congestion sleep disturbance and impaired day time
behaviour and concentration - Aden hypertrophy: Snoring, sleep apnoea, irritability and somnolence
during the day. - Chronic cough
- Sinusitis
- Eczema, asthma
How is hay fever managed?
2nd G antihistamine, topical steroid, cromogylcate, Monteleukast, decongestants (< 7 days) Allergen immunotherapy
How is urticaria classified and treated?
- Acute: Hours (drug), days (viral)
- Chronic > 6 weeks
- Physical
- NSAIDS-induced
- C1 esterase inhibitor deficiency (just angioedema)
What is the prognosis and management of insect bite allergy?
- Mild: Local swelling
- Moderate: generalised urticaria
- Severe: Anaphylaxis.
- Mild-moderate => Reassurance
- Severe: Carry epipen.
Stridor is
Upper airway obstruction inspiratory
Wheeze is
Lower airway
Expiratory
causes of tonsillitis?
What is the treatment?
Viral, EBV, Strep-A
Penicillin for 10 days in strep A
What is Scarlet fever?
• GAS bacteria
• Fever => Tonsillitis, sand-paper rash, flushed cheeks with peri-oral
sparing, strawberry tongue.
• TX: penicillin V
• Complications: Glomerulonephritis and rarely RF
causes of acute
otitis media?
o Mostly viral (RSV, Rhino)
o Bacterial: Pneumococcus, non-typable H.Flu, Moraxella
complications of acute
otitis media?
Meningitis
Mastoiditis
treatment of acute
otitis media?
Regular analgesia, Amoxicillin if still unwell after 2 days
Antibiotics marginally shorten the duration of pain but does not prevent hearing loss
What is Glue ear?
What is the treatment?
A cause of hearing loss and subsequent speech and language delay.
OM with effusion => Conductive hearing loss on audiometry (after 4
years), dull retracted TM on tympanometry.
TX: Grommets, adenoidectomy
indications for Tonsillectomy?
Severe recurrent OM
Peri-tonsillar abscess (quinsy)
indications for Adenotonsillectomy?
OME => hearing loss
OSA (Absolute indication)
child with
stridor
DDX
o Croup o Acute epiglottitis o Bacterial Tracheitis o Inhaled foreign body o Anaphylaxis o Recurrent/ chronic (Laryngomalycia)
child with
stridor Management
o O2
o Nebulised steroids +/- Adrenaline +/- Call Anaesthesia.
o Observe SATS
o Do not examine the throat
Acute epiglottitis
Hib, < 6 yrs, over hours, Toxic child with high
fever, muffled voice, soft whispering stridor and drooling.
Call for help (anaesthesia, senior paediatrician, ENT surgeon) Intubate and transfer to ICU Blood cultures IV cefuroxime for 5 days Rifampicin prophylaxis for contacts
Croup
Parainfleunza virus, 2nd year, over days.
Croyza =>
severe parking cough, hoarse voice, harsh rasping stridor.
Nebulised steroids, warm moist air, observe
What is bacterial Tracheitis (Pseudomembranous croup)?
Just like epiglottitis
Caused by staph
bronchiolitis cause
RSV in 80% of cases
bronchiolitis features
Dry wheezy cough + Resp distress
bronchiolitis investigations
Oximetry, ABG, CXR
bronchiolitis Mgt steps
humidified O2 from head box + monitor for apnoea+/- fluids (NG or
IV).
Admission criteria: Apnoea, Sats <90, PO intake < 75%, severe resp
distress.
What is bronchiolitis obliterans?
Recurrent cough and wheeze, if caused by
adenovirus
prevention of bronchiolitis?
Palivizumab to high risk PREMS (NNT= 17)
DDX of acute respiratory distress in infants?
- Bronchiolitis
- Viral wheeze
- Pneumonia
- HF
- Foreign body
- Anaphylaxis
DDX of wheeze?
- Viral episodic
- Multiple trigger
- Asthma
- CF
- Chronic aspiration
- Recurrent anaphylaxis
Chronic Asthma Sx
Cough, wheeze, breathlessness, chest tightness o Episodic o Non-viral riggers o Diurnal (worse at morning and night) o Response to bronchodilators
Chronic Asthma signs
o Polyphonic expiratory wheeze
o Harrison sulcus (chronic airway obstruction)
o Atopy
Chronic Asthma investigations
o Spirometry
o Serial Peak flow
o Skin prick
Chronic Asthma tx steps 1-5
1: SABA PRN
2: + inhaled steroids (200-400) (from now on can use LTRA)
3: + LABA, up steroids (800) (From now on can use SR
theophylline)
4: Up steroids (1600)+ carry steroid card, refer if < 5 yrs.
5: + PO steroids
Acute asthma assessment
A
A: Appearance and awareness:
o Normal consciousness => Not life-threatening
o Can speak => Not severe
Acute asthma management Moderate
o Inhaled salbutamol (up to 10 puffs)
o PO prednisolone (1-2 mg/g, up to 40)
Acute asthma assessment
B
B: Breathing/ Beak flow
o RR: Poor guide
o Recessions: Intercostal => Accessory muscles => poor effort
(life-threatening)
o Auscultation => Wheeze => silent (life threatening)
o BF: > 50, < 50, < 33
Acute asthma assessment C
C: Circulation/ colour
o Tachycardia: better than tachypnea, affected by B agonists.
o Hypotension-Arrhythmia: Life-threatening.
o Cyanosis: life-threatening.
o Sats (< 92% = severe or life-threatening).
Acute asthma management Severe and life threatening:
o High flow O2
o Nebulised Salbutamol/ Ipratropium
o Steroids: IV hydrocortisone
Acute asthma management
If no response:
Consider (IV SABA, MgSo4, theophylline)
ICU, intubation and mechanical ventilation, CXR, ABG
Acute asthma management
If response:
TX for 4 hrs
Discharge on steroids (1 week)
Review meds, technique,
F/U
Acute asthma management
If response:
TX for 4 hrs
Discharge on steroids (1 week)
Review meds, technique,
F/U
different types of inhalers and how do you choose them?
MDI (with spacer for all children)+ face mask if < 2
Powder inhaler
Breath actuated MDI (simpler)
Nebuliser (if O2 needed, at home in brittle asthma)
Bordetella pertussis
PC
Dx
Paroxysmal cough + inspiratory whoop or apnoea => Vomiting
Culture from pre-nasal swap, blood film (lymphocytosis)
What is persistent cough? What is the DDX?
Cough lasting > 8 weeks or not improving > 4 weeks
Recurrent URTI
Certain infections RSV, pertussis, mycoplasma, TB), asthma,
CF,
inhaled foreign body, bacterial bronchitis, Aspiration (reflux),
habit cough
pneumonia causes
Strep-B => RSV => Pneumococcus.
pneumonia Sx
URTI => Cough, fever, anorexia, lethargy, unwell, localised
chest or abdominal pain, or neck stiffness (peritoneal irritation,
bacterial)
pneumonia Signs
Tachypnea (the most sensitive sign), Nasal flaring, chest indrawing, crackles
Classical (rare): Bronchial breathing, dullness, decreased breath
sounds and sats.
pneumonia INVXL
CXR, bloods, Nasopharyngeal aspirate, Oximetry
pneumonia Mgt:
o Admit if (grunting, recurrent apnoea, sats < 92%, inability to
maintain PO intake)
o O2, IV fluids, analgesia, Amoxicillin.
o If fever persists despite 2 days of antibiotics => suspect pleural
collection (CXR: blunting of the costovertebral angle) => US
guided drainage and fibrinolysis.
o No follow-up unless there is lobar collapse or atelectasis (CXR in 1 month).
Cystic fibrosis Pathophysiology = Thick secretions
Genetics:
Class 2 mutation; Change in F508; defective CFTR folding;
never makes it to surface. Lumicaftor (increases number that makes it to surface).
Class 3 and 4: defective function, G551D, use potentiator (Ivacaftor)
possible clinical examination findings in CF patients?
o Chest hyperinflation o Harrison’s sulcus o Coarse inspiratory crepitation o Expiratory wheeze o Chest infection o Clubbing
What is PCD, Kartagners syndrome?
o Recurrent chest infections => Bronchiectasis
o Chronic Ear infections
o CE: Situs inversus.
o DX: cilia examination from nasal brush
o TX: Chest physio, ENT follow-up and antibiotics
What are the indications of tracheostomy in children?
o Narrow upper or lower airways o Neuromuscular weakness o Need for long-term o Weaning of o Airway protection
sleep disordered breathing causes:
o Adenotonsillar hypertrophy o Severe obesity o Down syndrome o Cerebral palsy o DMD
sleep disordered breathing Mgt:
o Night oximetry
o Sleep study
o Night CPAP
o Adenotonsillectomy
sleep disordered breathing
Symptoms:
o Loud snoring o Witnessed apnoea o Sleep disturbance and restlessness o Day-time sleepiness or hyperactivity o Learning and behavioural problems o Faltering growth
What are the methods and indications of long-term ventilation?
BiPAP
CPAP via facemask or nasal mask
tracheostomy
Indications: BPD, NMD
