Pg 5 - Flashcards
How do you measure Cap refill?
5 secs of blanching pressure. Prolonged if > 2 secs to return
What is AVPU scale?
• Assesses the level of consciousness in children.
• A= Alert, V= responds to Voice, P= Responds to Pain, U=
Unresponsive
What is the most common cause for CPR in children?
Hypoxia secondary to respiratory or neurogenic shock.
In the seriously injured child what are the additional steps to ABC?
• Cervical spine: manual in-line stabilisation, followed by head blocks
and straps (no routine collar anymore)
• Deal with catastrophic haemorrhage before ABC
What are the underlying mechanisms in respiratory failure?
• Decreased alveolar ventilation, diffusion impairment, intra-pulmonary
shunting, and ventilation-perfusion mismatch.
• Causes hypoxemia, tissue hypoxia and hypercapnia => CO2 narcosis.
• Severe respiratory distress may lead to exhaustion and respiratory
arrest.
What are the indicators of respiratory distress in a child?
Moderate:
- Tachycardia
- Tachypnea; RR>50
- Nasal flaring
- Use of accessory muscles
- Sternal and subcostal recessions
- Head retraction
- Inability to feed.
What are the indicators of respiratory distress in a child?
Severe:
- Cyanosis
- Getting tired
- Reduced level of consciousness
- Sat <92 despite O2 therapy
- Rising PCO2
What are the steps of supportive measures in respiratory distress child?
- O2 needed if sats below 92%
- Nasal cannula or face mask
- CPAP or BiPAP with NIV
- Intubation and mechanical ventilation in ICU
What are the indications of intubation and mechanical ventilation in
respiratory failure?
- Severe respiratory distress
* Progressive NM weakness. E.g. GBS
What are the clinical signs of shock?
Early compensated:
• Tachypnea
• Tachycardia
• Dehydration (Pale mottled cold skin, decreased skin turgor, sunken
eyes and Fontanelles, Core-peripheral T gap > 4, decreased urinary
output)
What are the clinical signs of shock?
Late decompensated:
- Acidotic (Kaussmal breathing).
- Bradychardia
- Severe dehydration (Absent urine output)
- Hypoxemia: Blue peripheries
- Hypercapnia: Confusion
Outline fluid resuscitation in shock, both initial and maintenance?
v• 20 mls/ Kg of 0.9% IV crystalloid saline, repeat twice to transfer to
PICU
• Maintenance 100ml/ 10 Kg/ 24 hrs. (First 10), 50 ml/ 10 Kg (Next 10).
So anyone above 15 already has 1500 mls. 20 mls/ Kg for subsequent
Kg.
What is sepsis and what are its clinical features?
• SIRS+ Infection focus
Sx
Signs
• Symptoms: Fever, poor feeding, irritability, lethargy+ infection focus.
• Signs: Tachypnea, tachycardia and hypotension, Rash, shock and
multi-organ failure
What is sepsis 6?
- Take 3 (Blood cultures, lactate, urine output)
* Give 3 (IV Antibiotics, IV fluids, O2 to keep stats > 94%)
What is the ER management of anaphylaxis?
• Adrenaline auto injector
• Call ambulance (High flow O2, resuscitation fluids, IM or slow IV
Chorphenamine and hydrocortisone +/- salbutamol. Monitor: Sats and
BP, ECG.
What are the management steps for status epilepticus?
- Buccal midazolam
- IV lorazepam
- Re-assess diagnosis and call for help
- Iv phenytoin
- IV phenobarbital
- PR paraldehyde
- Induction of anaesthesia via thiopental
What are the neuroprotective measures if there is raised ICP?
• Tilt head 20-30 • Intubate and ventilate, monitor CO2 and Oximetry, Hypothermia and keep BP normal high. • Restrict fluids • Mannitol
What are the components of GCS?
• Eye (4): Open, demand, pain, None
• Verbal (5): Speaks, words, sounds, cry, mute.
• Motor (6): Move, localisepain, flex to pain, Decorticate, decerebrate,
none
What are the pupillary signs in coma?
• Unilateral dilatation: Expanding lesion, pontine herniation, 3rd nerve
palsy.
• Bilateral dilatation: Severe hypoxia, hypothermia, and post-ictal.
What is BRUE and how it is managed?
One or more of the following that happens and resolve suddenly in previously
well child.
• Cyanosis or pallor
• Absent, decreased or irregular breathing
• Change in tone (increased or decreased)
• Altered level of responsiveness.
When does SIDS peak and what are its risk factors?
• 2-4 months
• Infant (Small prem boy who was sick yesterday, environmental
(Sleeping prone, swaddled on a billow, near mother in a hot room,
Parents (young couple with low education and income who smoke and
drink in an overcrowded house).
What are the main congenital infections?
What are their clinical
features?
How are they diagnosed?
o TORCH.
o Growth restriction, Microcephaly, CHD and PDA, eye and ear
defects, hepatosplenomegaly and haematological, Blueberry
muffin rash.
o Maternal serconversion, Fetal: CVS, amniocentesis, PCR, baby:
fluid samples.
What is the most common congenital infection?
What is the most
common complication?
o CMV
o Sensorineural hearing loss and other neurodevelopmental
disabilities
What are the main steps for intra to extra uterine life
transmission?
o Lung expansion => reduced pulmonary vascular resistance =>
Increased Left atrial filling => Closure of foramen ovale, DA =>
Establishment of adult circulation
What are the main components of Apgar score?
Heart rate > 100 Respiratory effort = strong cry Muscle tone: Well flexed, active Reflex irritability: Cry and cough Colour: Pink
What are the main steps in neonatal resuscitation and what are the extra measures taken for preterm babies?
o Clock, dry, stimulate, o Assess and REASSESS: o Tone, breathing and HR (The most important; check each 30 secs; should be above 60) o Airway: o Breathing: Failed intubation? DOPE: • Displaced, Obstructed, Patient, Equipment o Circulation: CPR (3:1); 90 compressions: 30 ventilations. o Disability: Avoid hypothermia: o Drugs: Centrally (Umbilical venous catheter); Adrenaline, Volume supports.
What is the cause and Mgt and complications of meconium aspiration syndrome?
o Cause: Distress of term or post-term baby.
o Mgt: Lung inflation > suction => CPAP
o Complications: Chemical/ bacterial pneumonitis, pulmonary
hypertension.
What are the diagnostic tests, risk factors and Mgt of DDH?
DX: Barlow: Adduct and down to dislocate Ortolani: Abduct and up to relocate Positive finding is a palpable clunk. Hip US
RF:
Female, Breech, BW > 4.5, FHX, NMD
Mgt:
Refer to orthopaedics
Splinting in abduction
DDX for tense fontanelles
Crying, High ICP (hydrocephalus), meningitis (late).
DDx for absent red reflex
Cataract,
retinoblastoma,
glaucoma
DDx for increased/ decreased femoral pulses?
Increased FP: PDA
Reduced FP: Coarctation
What is the most common benign neonatal rash?
Erythema toxicum: Transient urticarial rash with central white papules. Mainly on trunk but change location
What is the difference between nevus flammenus and strawberry
naevus?
o Flammenus= Port-wine stain= stork bite: red macula on face; may need laser
o Strawberry = Cavernous haemangioma = Raised lesion, grows
until 15 months hen regresses, may need topical or po propranolol
Innocent murmur management in a
neonate?
Measure upper and lower limb BP, measure pre-ductal
(right hand) and post-ductal (left hand) sats. Urgent
ECHO.
positional, Soft, Systolic, asymptomatic, LSB
Reassure and FU
What is the most common congenital anomaly and what is its prevalence?
CHD (7%)
Significant murmur management in a
neonate?
Measure upper and lower limb BP, measure pre-ductal
(right hand) and post-ductal (left hand) sats. Urgent
ECHO.
What are the tests used in newborn hearing screening?
o Initial: otoacoustic emissions (OAE); cochlear function
o Then: auditory brainstem response (ABR).
How is CHD screened for in the newborn?
o Pre-ductal (right hand) oximetry
o Identifies duct dependent circulation (shock after 1-2 days)
o Keep duct open by PG
When is the heel-prick test performed? What does it screen for?
o Within 5-7 days. o Congenital hypothyroidism o CF (high IRT => DNA) o 6 IEM: § MSUD § MCAD § PKU § HCU § Isovaleric academia § Glutaric aciduria type 1
What are the causes of HIE?
o Antenatal: Placenta, cord, maternal, fetal
o Labour: Asphyxia (Only if) Acidosis in labour Needed resuscitation Born with HIE features Multi-organ failure No ante or post natal cause identified other
o Post-natal: Kernicterus, IEM
What are the clinical manifestations of HIE?
o Mild: Irritable, hyperventilation, Staring eyes.
o Moderate: seizure, hypotonia, feeding problems.
o Severe: Refractory seizures, multi-organ failure.
What is the Mgt and prognosis of HIE?
Therapeutic hypothermia:
Rectal T at 33 for 3 days for those 36 weeks onward with
M-S HIE (NNT = 8)
Supportive and monitor by amplitude-integrated EEG (confirm
encephalopathy and monitor seizures).
Mild => Recover.
Moderate => Can recover. Severe => CP
What are the types of neonatal extra cranial haemorrhage?
o Caput: Under skin, crosses sutures
o Cephalohaematoma: Between bone and peri-ostium, confined
by sutures, usually parietal and has soft centre
o Chignon: Oedema and bruising from Ventouse delivery.
o Sub-aponeurotic (Sub-galeal) bleeding: Can cause shock.
What are the common problems encountered by pre-term infants?
o RDS o NEC o IVH o Metabolic o Hypothermia o Hypotension and PDA o Haematological o Sepsis o Jaundice o Nutrition o RoP
RDS & pneumothorax RF Clinical presentation DX Mgt
RF: Pre-maturity, CS, DM
Presentation: Resp distress (Cyanosis, apnoea, recessions, tachy), => Pneumothorax if : increased O2 requirements,
decreased chest movements and breath sounds on the affected
side.
DX: CXR; ground glass appearance => Transillumnation
(pneumothorax)
Mgt: Decompression by chest drain (PNX). Surfactant X 2 (by endotracheal tube, CPAP) (RDS)
What are the features and TX of PDA:
Increased O2 requirement and difficulty weaning of mechanical ventilation. o Bounding pulses o Machinery murmur o Active precordium o TX: Ibuprofen => Ligation
What are the principles of O2 therapy in infants?
o Use air if Term
o Use 21-30% O2 if pre-term
Sats > 95% RoP
Sats < 91% NEC
What are the types of newborn venous access and what are their
specific indications?
o Peripheral IV: Routine
o Umbilical venous: Resuscitation, PREM, Hyper-osmolar
o Umbilical artery: BP monitoring, frequent blood gas analysis
NEC
RF Clinical presentation DX Mgt Comp
RF: PREM, formula-fed.
CP: Abdominal distension, bile-stained vomiting, PR bleeding
+/- peritonitis
DX: X-Ray, trans illumination
Mgt: Supportive or surgery (perforation)
Comp: Peritonitis, sepsis, strictures, malabsorption
What is the IVH?
How is it classified?
Bleeding in the germinal matrix (floor of lateral ventricles, above
caudate nucleus), may extend into the ventricles or brain
parenchyma.
Grade 1: Bleeding in GM
Grade 2: Blood in ventricles
Grade 3: Ventricular distension
Grade 4: Parenchymal bleed
what is peri-ventricular leukomalacia
inflammation => cysts and loss of white matter => Diplegic cerebral palsy
DX: Head US.
Complications: CP (PVL, Grades 3-4), hydrocephalus
Retinopathy of prematurity? What is the treatment?
Vascular proliferation at the junction of vascularised and nonvascularised
retina => Fibrosis => detachment and blindness.
TX: Anti-VEGF and laser
causes of neonatal jaundice?
< 24 hrs: Haemolysis (ABO: O mum and A baby, Rh,
Polycythaemia, Bruising, G6PD, HSC),
congenital infection
24h-2 W: Physiological, breast milk
> 2 W: Conjugated (Physiological, breast milk). Unconjugated >25 (Bile duct obstruction, neonatal hepatitis).
What is the treatment of neonatal jaundice?
Hydration and Phototherapy => Intensive phototherapy
=> IVIG
=> Exchange transfusion (if severe) => Phenobarbital (very rarely).
What are the main considerations in neonatal assessment?
o SGA WRT
S: Severity (Transcutaneous Bilimeter, blood sample). >
17 mg/dl is pathological
G: Gestation: PREM?
A: Age of Oncet: < 1 day or after 7-10: worrisome
W: Well? Sepsis? Dehydration?
R: Risk factors (Haemolysis, infection, Hepatitis, biliary obstruction) • FBC, blood film, DCT, blood types. • Sepsis work-up, MSU for UTI • Congenital infection screen • Urinalysis for reducing substances (Galactosemia) • A1AT • HIDA scan • CF sweat test
T: Treatment needed? Plot on gestation specific chart
and monitor change velocity to predict severity.
respiratory distress in infants
Signs:
Tachypnea Tachycardia Increased work of breathing • Accessory muscles • Sub-costal and intercostal recessions • Sternal retractions Nasal flaring Expiratory grunting Cyanosis
respiratory distress in infants
Causes:
Transient tachypnea of the newborn RDS, Pneumothorax Pneumonia Aspiration (Meconium, milk) CHD Diaphragmatic hernia. HIE
What are the most common causes of neonatal sepsis?
o Early onset:
Time: < 48 hours.
Source: Ascended from birth canal (GBS, E-COLI) or
through placenta (Congenital infection, Listeria).
CP: pneumonia and sepsis. Listeria: Typically meconium
stained liquor and rash.
Mgt: Septic screen, CXR => IV amoxicillin and gentamicin
+/- CSF => Ceftriaxone
What are the most common causes of neonatal sepsis?
o Late-onset:
Time: > 48 hours
Source: Nosocomial (CoNS and G-)
CP: Non-specific
Mgt: Same: TX: IV Fluoxacillin + gentamicin
What are the indications for Intrapartum antibiotics prophylaxis for GBS?
Previous infant with GBS disease Urine/ blood isolate Pre-term labour Pyrexia in labour PPROM and Prolonged ROM > 18 hrs
What are the causes of neonatal strokes?
o HIE o CP o Hypoglycaemia o Meningitis o Vascular (Ischemia, haemorrhage) o Malformations
What are the causes, embryology, complications and Mgt of cleft
lip and palate?
o Causes:
Inherited (polygenic)
Syndromes (Chromosomal)
Maternal anti-convulsants
o Lip: failure of frontonasal and maxillary fusion
o Palate: Failure of palatine and nasal processes fusion
o Complications: Feeding and OM
o Mgt: Lip: Closed at 3 M. Palate: Closed at 6-12 months
presentation of oesophageal atresia?
o Absent stomach pubble on antenatal scan
o Constant drooling, salivation
o Feeding: cough, chock, Cyanosis and aspiration
o Continuous suction => surgical repair
small bowel obstruction
causes
presentation
Mgt
o Causes: Duodenal atresia (DS), volvulus.
o CP: Bile-stained vomiting, absent meconium, abdominal
distension.
large bowel
obstruction
causes
o HSP disease (DS)
o Rectal atresia
