Secondary care Flashcards
How does slowing of growth velocity show on a growth chart?
gradient decreases and doesn’t follow centile lines
What tests should be done if growth velocity slows?
renal
liver
thyroid
bone age
What is constitutional delay?
condition that causes a temporary delay in growth and height. It’s the most common cause of delayed puberty in both sexes
short stature relative to parents heights (but often parents took longer to grow too)
delayed bone age
puberty starts later than usual
If falling off growth chart at young age - what should you look for?
dysmorphic features
parents + siblings growth
developmental milestones
?NAI
What tests should be done if poor growth and no signs of puberty at 13?
FSH
LH
TFTs
IGF-1
genetics
bone age
Turner’s karyotype
XO
Turner’s internal features
horseshoe kidney
aortic arch defects (coarctation, bicuspid aortic valve)
underdeveloped ovaries
can have absent uterus
should investigate with abdominal USS
Why should rescue breathe be done first in a child in cardiac arrest?
more likely to be caused by a respiratory issue
SSSABC for paediatric BLS
safety
stimulate
shout for help (2222)
airway
breathing (check carotid same time)
circulation
Describe how to do chest compressions in a child
1 finger breadth above xiphoid sternum
1 hand on chest
100-120bpm
compress chest ~5cm (1/3 of AP chest diameter)
Ratio of chest compressions:rescue breaths in children
15:2
Rate of rescue breaths in child <1y
25/min
every 2s
Rate of rescue breaths in child 1-8y
20/min
every 3s
Rate of rescue breaths in child 8-12y
15/min
every 4s
Rate of rescue breaths in child >12y
10-12/min
every 5-6s
How to do painful stimulus infant
do not shake baby
painful stimuli = pull hair
How to open airway in an infant
put head in neutral position
Which pulse is best to check in a neonate in an emergency ?
brachial
What pressure should infant bag valve mask be set to for resuscitation?
40 cm H2O
How to do chest compressions in infant
1 finger breadth above xiphoid sternum
2 finger compressions (either onto chest or wrap around infant and use thumbs - encircling technique)
100-120bpm
4cm depth (1/3 of AP chest wall)
How to manage choking child
encourage to cough if they can
keep reassessing
shout for help
lean forward/place across lap
5 back slaps - reassess between each
5 abdominal thrusts - reassess between each
unresponsive = start CPR
How to manage choking infant
shout for help
keep head neutral
thumb + fingers around chin, head down
5 back slaps between shoulder blades - reassess between each
turn baby over
5 chest thrusts (as if doing CPR) - reassess between each
unresponsive = start CPR
How to treat severe viral-induced wheeze?
asthma protocol
When to use inhaler or nebuliser in asthma attack in children?
if need oxygen –> use nebuliser
if not needing oxygen –> use inhaler + spacer
If a child/infant is groaning what could this suggest?
airway compromise
How can poorly controlled maternal diabetes cause a small foetus?
placental insufficiency due to diabetes causing vascular damage
How can poorly controlled maternal diabetes cause a large foetus?
hyperglycaemia
What drugs cause small babies?
nicotine
cocaine
alcohol
What does symmetrically growth restricted mean?
whole body not growing (not a specific body part)
What drives growth in the foetal stage?
intrauterine environment
What drives growth in the infant stage (0-2)?
nutrition-dependent
what drives growth in childhood (pre-puberty)?
hormone-dependent (GH)
What drives growth in the pubertal period?
hormone-dependent (sex hormones)
Causes of poor growth (general)
malnutrition
psychosocial
chronic ill health
iatrogenic
skeletal abnormalities
syndromes
hormones
When is the length of a child measured?
when a child cannot stand
What age is head circumference measured until?
2 years
How is bone age determined?
XR of wrist
examine ossification centres
different areas ossify at different rates
What does mid-parental height estimate?
what centile child should be growing on
What is adult height predictor used for?
predicts adult height from current centile
When should children be referred based on growth charts?
unexplained short stature
growth velocity lower than expected
height crosses >2 centile lines
if child at risk of poor growth
What should polyhydramnios make you consider?
GI issues of baby
What should oligohydramnios make you consider?
renal/urology issues in baby
Septic screen components (infant)
urine culture
blood culture
CSF culture
blood gas (capillary)
FBC
U&Es
CRP (can take 12h to rise)
Why can PCR be better than culture for CSF if antibiotics have already been started?
culture will likely be negative after antibiotics
PCR can still be positive
How many wet nappies is normal in a baby?
6 or more a day
If a GP is concerned about meningococcal septicaemia, what should be done before sending to hospital?
IM benzylpenicillin
Kawasaki disease features mnemonic
fever for >5 days and 4/5 of:
CREAM
conjunctivitis (non-exudative)
rash (polymorphous, non-vesicular)
edema or erythema (of hands and feet)
adenopathy (cervical)
mucosal involvement (erythema or fissures or crusting)
Complication of kawasaki disease
coronary artery aneurysm
can rupture
can remain lifelong —> needs follow up
Kawasaki disease management
high dose aspirin
IVIg
response = fever goes down
What is bronchiolitis?
inflammation of small airways
If a child presents with severe bronchiolitis on day 1 - what should you do?
admit
likely to get worse as normally runs 7-10 days
When to admit patients with bronchiolitis
low sats
early presentation (as will worsen)
feeding <50% normal
signs of resp distress
parental concern
TORCH infections
toxoplasma
other agents: syphilis, parvovirus B19, varicella zoster, listeria
rubella
cytomegalovirus
herpes-simplex 2
Why are TORCH infections important?
a group of diseases that can be passed from a mother to her foetus during pregnancy or childbirth
What age is classed as a non-mobile child?
<12 months
What is a skeletal survey?
whole body xray
looks for fractures - particularly in different healing stages
What sign can be seen in shaken baby syndrome?
retinal haemorrhages
Risk factors for maltreatment of child
young parents
domestic violence
drug/alcohol abuse
mental health problems
learning disability
poverty
isolated parents
Key factors in history which may suggest child maltreatment
delayed presentation
incompatible history (eg. mechanisms not fitting injury)
inconsistent history (different stories from different people or changing story)
How can you tell if a CT is a contrast CT?
aorta white in contrast CT as contrast in aorta
How long can the thymus be seen on xray for?
up to 5y it can be prominent enough to see - can be mistaken for consolidation
How can you tell the difference between venous and arterial umbilical lines on xray?
venous goes up towards liver
arterial goes down towards iliac arteries
What pneumonia in children can cavitate?
staphylococcus aureus
How is right middle lobe pneumonia seen on xray?
consolidation in middle of lung
obscures right heart border
Complication of staph pneumonia
pneumatocoele
Which part of the lungs do viral and bacterial infections affect?
bacterial normally affect alveoli –> causes consolidation on CXR
viral normally causes bronchial oedema
Signs of RDS on CXR
ground-glass shadowing
air bronchograms
What neonatal lung conditions can have pleural effusions?
transient tachypnoea of the newborn
neonatal pneumonia
NOT respiratory distress syndrome
How can pneumothorax be seen in xray of baby?
deep sulcus sign
clear heart border
What can cause a bilateral pneumothorax?
open heart surgery through sternotomy
What test should be done in suspected diabetes insipidus?
paired urine and plasma osmolality
What test can help rule out diabetes insipidus?
water deprivation overnight
morning urine osmolality >750 excludes DI as they are able to concentrate their urine
Which diabetes insipidus subtype is more common?
cranial
(AVP-D)
What liver blood test can be raised in vitamin D deficiency?
ALP
Vitamin D deficiency bone group results
hypocalcaemia
hypophosphataemia
What is the effect of PTH on phosphate?
PTH makes you lose phosphate in urine
What is ALP indicative of (bone-wise)?
osteoblastic activity
high ALP = high bone turnover
What distinguishes graves from other causes of hyperthyroidism?
eye involvement
What is the main risk of propylthiouracil?
hepatotoxic
Can carbimazole be given in pregnancy?
no - teratogenic
What ages suggest precocious puberty?
<8 in girls
<9 in boys
What is the first sign of puberty in girls?
breast bud development
Order of puberty
thelarche (breast)
adrenarche (adrenals - hair, odour)
growth spurt
menarche (menstruation)
What is the first sign of puberty in boys?
increased testicular volume
What hormones can be tested to assess if someone is in puberty?
FSH
LH
What endocrine problem happens in turner’s syndrome?
hypergonadotrophic hypogonadism
What ages are the cutoffs for delayed puberty?
no signs of puberty by:
- 13 in girls
- 14 in boys
Normal ketone levels
<0.6
DKA ketone levels
> 3
How does exercise affect glucose levels in diabetic people?
short anaerobic exercise = risk of hyperglycaemia
long aerobic exercise = makes you more insulin-sensitive therefore risk of hypoglycaemia, may need to reduce insulin beforehand
HbA1C target for children with diabetes
48-53
checked 3 monthly
What type of allergy will have a negative skin prick test?
non-IgE allergy
more of a delayed picture
Can cows milk protein come out in breastmilk and affect a child with CMPA?
yes - small amounts can be expressed in breast milk
What increases the risk of a child developing CMPA?
FH of atopic eczema, allergic rhinitis, asthma, food allergy
What other allergies often co-occur with peanut allergy?
pea
soya
chickpeas
lupin
(because peanut is a legume)
What does FeNO testing test?
fraction expired nitric oxide
eosinophils give off nitric oxide
therefore higher levels suggests more eosinophils in airways
How many wet nappies a day is normal?
5-8
What colour of vomit is pathological?
green –> bilious –> rule out GI obstruction
How much milk should a baby consume in a day?
150 ml/kg/day
How can you treat reflux in babies?
smaller volume feeds
thicker feeds
gaviscon (add to milk –> thickens it)
omeprazole
normally settles as baby grows and sphincter tightens
When can you get temporary lactose intolerance?
in gastroenteritis
How can you treat CMPA in babies?
extensively hydrolysed formula
amino acid base formula
When does pyloric stenosis present?
6-8 weeks
How does Hirschsprung’s present?
not passing meconium
big, bulky poo
constipation
What caused pyloric stenosis?
narrowed + elongated pylorus
milk not leaving stomach so vomits back up
Signs of pyloric stenosis
projectile vomiting
olive on abdominal exam
visible peristalsis after feed
What blood gas abnormality can be present in pyloric stenosis?
hypochloraemic metabolic alkalosis
Pyloric stenosis definitive management
laparoscopic pyloromyotomy
What causes lack of femoral pulses on NIPE?
coarctation of aorta
left heart obstructive lesions
Differential for bronchiolitis
heart failure
What is a gallop rhythm suggestive of?
heart failure
What murmur does a VSD cause?
pansystolic murmur
Types of VSD
muscular
perimembranous
What sign may be present in babies with heart failure?
congestive hepatomegaly
What murmur does PDA cause?
continuous machinery murmur
How does PDA cause pulmonary oedema?
left to right shunt
increased blood flow to lungs
pulmonary oedema
What can close a PDA?
indomethacin
What can keep a PDA open?
prostaglandins
VSD surgery approach
midline sternotomy (as hole in side heart)
PDA surgery approach
thoracotomy (as hole outside heart)
What heart defect is associated with Down’s syndrome?
AVSD
How does heart failure occur in AVSD?
due to left to right shunt
What is Eisenmenger’s syndrome?
ASD or VSD allows left to right shunt
causes pulmonary hypertension
when pulmonary pressure>systemic pressure, shunt reverses
blood then bypasses lungs causing cyanosis
Define heart failure
delivery of oxygen to peripheral vascular bed insufficient to meet metabolic needs
Signs of heart failure in babies/children
breathlessness with feeding
exercise intolerance
excessive sweating
cold, clammy hands and feet
faltering growth
Triad of HF signs in children
tachypnoea
tachycardia
hepatomegaly
What is a lower preductal spo2 suggestive of?
transposition of the great arteries
What does survival of TGA babies depend on?
patency of atrial shunt and ductus arteriosus
give prostaglandins to maintain patent shunts
TGA surgery
arterial switch surgery
RV hypertrophy on ECG signs
L axis deviation
QRS large in L leads
LV hypertrophy on ECG signs
R axis deviation
QRS large in R leads
What heart abnormality is associated with William’s syndrome?
aortic stenosis
Why can children with aortic stenosis not do strenuous exercise?
cardiac output cannot meet metabolic needs
What cardiac abnormality is associated with Noonan’s syndrome?
pulmonary stenosis
Most common secondary cause of hypertension in children?
renal
Major defects in tetralogy of fallot
pulmonary stenosis
right ventricular hypertrophy
overriding aorta
ventricular septal defect (large)
Tetralogy of fallot CXR sign
boot-shaped heart
Triggers of tet spells at home
waking up
straining on potty
feeding
crying
tantrums
pain/fever/dehydration
Triggers of tet spells in hospital
fear/stress
venepuncture
anaesthesia/intubation
cardiac catheter
cold, fast or irritant central fluids
Tet spells presentation
rapid deep inspirations (paroxysmal hypoxaemia)
irritability/prolonged crying
increased cyanosis
severe - limpness, hypoxic seizure, collapse/death
disappearance of heart murmur
Why does pulmonary stenosis murmur disappear in a tet spell?
all blood shunted from right to left
not much blood going through pulmonary artery
What to do if a child is having a tet spell?
calm + comfort
bring knees up to chest
most episodes will self resolve (>5mins = 999)
let cardiology team know
Management of tet spell in hospital
oxygen to achieve baseline spo2
sedate = morphine 0.1-0.2mg/kg IM
fluid bolus
beta blockade = esmolol IV stat/propranolol
vasoconstrictors = noradrenaline/phenylephrine, avoid adrenaline
Wolff-parkinson white ECG
short PR interval
wide QRS
delta wave
HOCM ECG signs
LVH
T wave inversion v5 +v6
What direction are T waves normally in v5 and v6?
upright
Red flags that increase likelihood of cardiac cause for chest pain
congenital heart disease hx
exertional syncope
exertional cardiac-type chest pain
hypercoagulable or hypercholesterolaemic state
FH of sudden death <35y, young ischaemic heart disease, inherited arrhythmias (eg. long QT or brugada)
ICD in situ
connective tissue disorders
history of cocain/amphetamine use
What to look out for when assessing paeds ECG?
PR interval
delta wave
QT interval
upright T wave V1?
ST elevation V1-3?
T wave inversions V4-6?
excessive R or S wave?
partial RBBB?
ventricular ectopics?
When is a prominent thymus on CXR considered normal?
up to to 5 years
CXR findings of viral infection
peri-bronchial markings increased - not consolidation
large volume lungs
Name 4 medical lung diseases of the neonate
respiratory distress syndrome
transient tachypnoea of the newborn
meconium aspiration
neonatal pneumonia
Respiratory distress syndrome complications
alveolar rupture with pneumothorax, pneumomediastinum
pulmonary interstitial emphysema
What causes transient tachypnoea of the newborn?
delayed clearance of intrauterine pulmonary fluid
What increases risk of transient tachypnoea of the newborn?
caesarean section or precipitous (quick) vaginal delivery
(thoracic squeeze of normal vaginal delivery will clear 30% of pulmonary fluid)
Most common cause of neonatal pneumonia
group B streptococcus
Major risk factor for neonatal pneumonia
premature rupture of membranes
How can you distinguish neonatal pneumonia from RDS?
neonatal pneumonia can have pleural effusion - RDS will not
Name some congenital lung abnormalities
congenital diaphragmatic hernia
congenital lobar emphysema
congenital pulmonary airway malformation
bronchopulmonary sequestration
What is bronchopulmonary sequestration?
a portion of lung has no normal connection with tracheobronchial tree
supplied by anomalous artery - usually arising from aorta
How can pneumothorax be seen in CXR of neonate?
deep sulcus sign (unusually sharp and lucent costophrenic angle)
sharp right heart border
What is pulmonary interstitial emphysema?
complication of RDS and its treatment (assisted ventilation)
results from alveolar rupture and subsequent dissection of air along the peribronchial and perivascular structures
linear lucencies radiation from hilar regions into lung
Polyuria bloods
glucose
U&Es
bone profile
thyroid profile
paired urine + plasma osmolality
Define epileptic seizure
sudden, excessive and/or hypersynchronous electrical activity in brain’s neurons, typically self-limiting
Define non-epileptic seizure
results from different mechanisms from epileptic seizures eg. brain temporarily starved of oxygen as in simple faints and cardiac arrhythmias or psychological factors
How does juvenile myoclonic epilepsy present?
genetically determined
myoclonic jerks on awakening
generalised tonic clonic seizures
typical absences
Juvenile myoclonic epilepsy management
avoidance of precipitating factors
sodium valproate
clonazepam for myoclonic jerks
phenobarbitone
levetiracetam
What drugs are contraindicated in juvenile myoclonic epilepsy?
vigabatrin
tiagabine
carbamazepine
Sodium valproate side effects
weight gain
liver toxicity
decreased platelets
pancreatitis
Carbamazepine side effects
rash
blood dyscrasias
dizziness
diplopia
Lamotrigine side effect
steven johnson syndrome
Topiramate side effects
weight loss
language dysfunction
kidney stones
glaucoma
Levetiracetam side effects
irritability
agitation
How much buccal midazolam can a child have in 24 hours in community?
one dose of a pre filled syringe
must be brought to hospital after
What is a simple focal seizure?
maintains consciousness
What is a complex focal seizure?
loses consciousness
Describe West syndrome
infantile spasms
hypsarrhythmia
intellectual disability
characteristic salaam spells
Aetiologies of West syndrome
perinatal hypoxia
tuberous sclerosis
metabolic causes
West syndrome treatment
steroids
vigabatrin
Describe childhood absence epilepsy
idiopathic
strong FH
F>M
starts 4-10y
lasts 5-30s
abrupt start + stop
rhythmic 3Hz bilateral synchronous symmetric spike wave discharge
Childhood absence epilepsy treatment
ethosuximide
valproate
lamotrigine
carbamazepine is contraindicated
Describe BCECT
benign childhood epilepsy with centrotemporal spikes
more often during sleep
brief simple, partial, hemifacial motor seizures
blunt high voltage centrotemporal spikes
normally no treatment
all patients will eventually enter remission
What is the main role of anti-epileptic drugs?
prevent further seizures/status epilepticus
What is CSE?
convulsive status epilepticus
>5 mins seizure
