Topic list Flashcards
Classification of pneumonia
Typical bacteria, atypical bacteria, viral
Based on inflitrate: lobar, bronchopulmonary, interstitial
Based on place of acquisition: community-acquired or hospital acquired.
Symptoms of pneumonia
– fever, weakness, lethargy.
– cough, tachypnea, wheezing, dyspnea, cyanosis
– vomiting, diarrhea, abd. pain
– convulsions, apathy, restlessness
– tachycardia, cardiac decompensation
Specific symptoms of pneumonia based on pathogens
Unproductive cough: viruses, M. pneumonia, C. pneumonia
Herpes labialis: S. pneumonia
Erythema multiforme: M. pneumonia
Characteristics and differences in typical-, atypical-, and viral pneumonia
Atypical bact. > 5y, all seasons, mild fever, gradual, unproductive cough, dyspneavery rare.
Typical bact all ages, winter, sudden, high fever, dyspnea frequent, productive cough, creptiation at ascul., alveolar inf. on x-ray, common w. pleural effusion
Atypical viral: all ages, winter, sudden, high fever, unproductive cough, dyspnea frequent, interstital inf. on x-ray, not typical w. pleural effusion
Age related pathogens
Newborn: GBS, staph. aureus
1-3 mo: RSV, chlam. trachomatis, S. pneumonia
3mo - 5y: RSV, S. pneumonia
>5y: M. pneumonia, Chl. pneumonia
Diagnosis of pneumonia
– Lab: incr. WBC, decr. neutrophils, increased ESR and CRP.
– Imaging: CXR (empyema, pulm. abscess and PTX suggests bacterial origin) and US
– Specific testing: hemoculture (in suspected bacterial pneumonia), mycoplasma and chlam. testing (in suspected atypical bact.), Rapid antigen test (in suspected viral, e.g. RSV)
Treatment of pneumonia
Mild lower RTI in young children and infants do not require ab treatment.
Bacterial pneumonia emperical treatment:
– Mild: < 5y = amoxicillin, >5y = macrlide
– Severe: 0-6mo = cefotaxime + ampicillin, > 6mo = II and III gen. cephalosporins (cefuroxime, cefotaxime + macrolide.
Prevention: vaccination
What is cystic fibrosis?
Genetic autosomal recessive disorder, CFTR gene mutation. Chloride channel disorder leading to dysfunction of exocrine glands. It’s a multiorgan disease affecting reproductive tract, sinus, lungs, sweat gl., liver, pancreas and GI tract
Most common symptoms of cystic fibrosis
Respiratory (90% of CF patients)
Respiratory symptoms of CF
– Irreversible lung injury
– Cough, bronchitis, PTX, fibrosis, cor pulmunola, respiratory failure
What happens with chloride in CF
Decreased uptake of Cl in sweat glands, increased uptake in mucous membranes.
(increased NaCl in sweat of babies, but thick sticky secretions in mucous membranes)
Diagnosis of CF
Sweat test (high Nacl), Guthrie screening test, genetic testing
Define obstructive bronchitis
Swelling or inflammation of the main airways (bronchi) of the lungs
Etiology of obstructive bronchitis
– Common cold
– Acute asthma exacerbation
– Viral bronchiolitis
– Foreign body aspiration
– Acute bronchitis
– Croup
– Tracheomalacia
– CF
Pathophysiology of asthma bronchiale
Respiratory hyperactivity –> Incr. cap. permeability and histamine release –> incr. gland secr. and proliferation –> decreased airflow due to airway narrowing and hyperinflated + collapsed alveoli –> insufficient ventilation
Symptoms of asthma
Cough, wheezing in expiratory, dyspnea, chest tightness
Treatment of asthma
Acute:
– SABA: salbutamol, terbutaline
– SAMA: ipratropium
Chronic:
– 1st line: Inhaled corticosteroids (budesonide, fluticasone)
– 2nd line: bronchodilation: LABA (formoterol, salmeterol)
Define acute subglottic laryngitis
Pseudocroup. Inflammation of tissues in subglottic space +/- tracheobronchial tree.
Pathogens of pseudocroup (acute subglottic laryngitis)
Parainfluenza virus, RSV
Common symptoms of pseuodocroup
Commenly starts at night and resolves suddenly.
– Inspiratory stridor, hoarsness, barking cough.
Treatment of pseudocroup
Mild – cold humidified air, fluid intake, rectal steroids
Moderate – hospital admission, epinephrine inhalation, systemic glucocorticoids
Severe – same as moderate + ICU admission
What is the croup score?
Score based on inspiration, stridor, cough, retraction + nasal flaring and cyanosis.
mild = 1-2 p
moderate = 3-5 p
severe = 6-10 p
Alarming signs of CNS diseases
– Acute encephalopathy
– Signs and symptoms on increased intracranial pressure
– Meningeal signs and symptoms
Signs and symptoms of increased intracranial pressure
Cushing’s triad:
1. bradycardia
2. irregular respiration
3. increased blood pressure
Signs of increased intracranial pressure in infants
Bulging of the fontanelle, setting-sun eyes, irritability
Meningeal signs and symptoms
Nuchal rigidity, Brudzinski sign and Kernig sign
Define acute encephalopathy
Acute onset of mental changes +/- hypnoid disturbance of conciousness (bw. wake state/confusion/deep coma)
Etiology of encephalopathy
Trauma, neurology infection, vascular/hemotological disorders, ischemic lesions, tumor, intoxications, fluid electrolyte imbalance, acid-base disturbance, endocrine disorders, renal- and hepatic insufficiency, Reye disease, cong. metabolic disorder, chronic neurological diseases with sudden onset.
What is lumbar puncture used for?
Used to obtain sample of CSF for microbiological, biochemical or metabolic analysis.
Contraindications of lumbar puncture
Thrombocytopenia or coagulation defect
Raised ICP
Significant cardiorespiratory compromise
Where is the lumbar puncture done?
L3-L4 intervertebral space
Name some inflammatory diseases of the nervous system
Meningitis, encephalitis
Etiology of meningitis
Septic (bacterial)
Aseptic (non-bacterial)
Granulomatous
Laboratory characteristics of septic, aseptic and granulomatous meningitis
Septic: CSF > 1000, very high proteins, low glc
Aseptic: CSF < 1000, high proteins, norm glc
Granulomatous: CSF < 1000, very high proteins, low glc
Pathogens causing bacterial meningitis
< 3 mo - 10 y: GBS, S. pneumonia, N. meningitis,
In > 10y: mainly N. meningitis only
Define meningitis
Inflammation of the meningitis. Inflammation is in the subarachnoid space, causing swollen tissue and CSF changes.
Symptoms of meningitis based on age
Infants: fever/hypothermia, vomit, irritable, bulging fontanelle
Older children: fever, loss of appetite, joint and muscles pain, altered mental state, increased ICP, positive meningeal signs
All ages: petechiae, seizures, photophobia, fever
Assessment/treatment of meningitis
- ABCDE assessment
- OMV (IV or OM access)
- Fluid resuscitation
- Vasopressors
- Take lab tests: WBC, CRP, PCT, liver, kidney, glc, coagulation, b.gas, microbiology
- Antibiotics: <3mo: cefotaxime + ampicillin, >3mo: cefriaxone
- Steroids: dexamethasone or hydrocortisone
Prophylaxis against meningitis
Meningococcus A/C/W/Y + B. vaccination
HiB vaccination
Pneumococcus vaccination
Define encephalitis
Inflammation of brain tissue. Usually involves meninges as well. Caused by direct injury or viral infection.
Prophylaxis given to people close contact with meningitis patients
Ciprofloxacin
Types of encephalitis
Viral
Immune-mediated
Autoimmune
Etiology of viral encephalitis
Enterovirus, arbovirus, herpes, adenovirus, TBE
Mechanism of immune mediated encephalitis
ADEM: acute dissaminated encephalomyelitis (demyelination disease in kids)
Mechanism of autoimmune encephalitis
NMDAe: antibodies against NMDA receptors cause the inflammation
Signs and symptoms of encephalitis
Fever, headache, light sensitivity, vomiting, change in consciousness, hallucination, delirium, seizures
Diagnosis of encephalitis
CSF: detect virus, autoantibodies
MRI
EEG
Treatment of encephalitis
– HSV: acyclovir
– ADEM, NMDAe: high dose methylprednisolone, IVIG, plasmapheresis
– Supportive treatment: pain management, electrolytes
Complications of encephalitis
Cognitive impairment, epilepsy
Difference in lesions of central- and peripheral facial nerve palsy
Central facial palsy: supranuclear and nuclear lesion
Peripheral facial palsy: infranuclear lesion
Etiology of central nerve palsy
MS, poliomyelitis, cerebral tumors, lacunar infarction, stroke, TIA
Etiology of peripheral nerve palsy
Infections: herpes zoster oticus, HSV, EBV, Lyme
Trauma
Bells palsy (idiopathic)
Inflammation
Tumor
Clinical signs of central nerve palsy
– Paralysis of inferior 1/4 of the face contralat. to the lesion
– Loss of nasolabial folds and drooping of lower lip
– Preservation of forehead and brow movements
Clinical signs of peripheral nerve palsy
– Paralysis of lateral half of the face ipsilateral to the lesion
– Loss of forehead and brow movements
– Inability to close eyes and drooping of eyelids
– Loss of nasolabial folds and drooping of lower lip
Diagnosis of facial nerve palsy
– History
– Lab tests
– Imaging
– Inspection
Diagnosis of facial nerve palsy
– History
– Lab tests
– Imaging
– Inspection
Testing motor function of facial nerve
Frontal branch: Wrinkling of forehead
Ophthalmic branch: Rapid blinking, lip closure
Oral branch: Baring of teeth, whistling, inflating cheeks
Testing of parasympathetic function of facial nerve
Schirmer’s test:
Gaustometry: evaluation of taste anterior 2/3
Testing of sensory function of facial nerve
Skin around the ear de
Phenotypes of seizures in childhood
Generalized, focal, myovlonic, non-compulsive
Etiology of seizures
- Febrile convulsions (2/3 causes under 3y)
- Epilepsy
- CNS pathology
- Metabolic problems, electrolyte disorders, toxins
- Idiopathic (10-20% in all ages)
Define seizures
A seizure is a clinical event in which there is a sudden
disturbance of neurological function caused by an
abnormal or excessive neuronal discharge. Seizures
may be epileptic or non-epileptic.
Causes of seizures
Epilepsy
* Idiopathic (70–80%) – cause unknown but
presumed genetic
* Secondary
– Cerebral dysgenesis/malformation
– Cerebral vascular occlusion
– Cerebral damage, e.g. congenital infection,
hypoxic-ischaemic encephalopathy,
intraventricular haemorrhage/ischaemia
* Cerebral tumour
* Neurodegenerative disorders
* Neurocutaneous syndromes
Non-epileptic
* Febrile seizures
* Metabolic
– Hypoglycaemia
– Hypocalcaemia/hypomagnesaemia
– Hypo/hypernatraemia
* Head trauma
* Meningitis/encephalitis
* Poisons/toxins.
Define febrile seizures
seizure accompanied by a fever in
the absence of intracranial infection due to bacterial
meningitis or viral encephalitis
Management of seizure first 5 min
Provide safe environment and assess pt. with ABCDE. Keep airway open, start O2 and exclude hypoglycemia. Most of the seizure resolve within 5 min
Management of seizures 5-10 min
Now it’s status epilepticus (>5min). Give benzodiazepines. Give 2 doses with 2-3 min in bw.
Management of seizures 10-20 min
If benzo was ineffective, run ABG (to exclude electrolyte imbalance), regularly assess ABCDE.
drugs: levetirecetam, valproic acid
Managament of seizure after 15 min
Admit to ICU/emergency dep., intubate and sedate.
Drugs: potent antiepileptics (propofol, ketamine) and muscle paralytics. Consider rare etiologies (NORSE).
Complications of seizures
Hypoventilation –> hypoxia, hypercapnia
Rhabdomyolysis –> kidney failure
Incr. lactic acid –> met. acidosis
If >24h –> brain edema, CNS injury, high mortality
Pathomechanism of febrile seizures
Increased body temperature leads to cytokine release and neuronal hyperexcitability
Complication of febrile seizure
High risk of developing epilepsy with recurrent episodes of febrile seizures
Define DM1
Chronic hyperglycemia due to destruction of B-cells in the pancreas, so they are unable to produce insulin. This is an autoimmune process.
Symptoms of hyperglycemia in infants and children
Infants: vomiting, dehydration, coma
Children: Polyuria, enuresis, polydypsia, weight loss, blurred vision
Diagnosis of DM1 in children
– Investigate b.glc and ketones and/or urinary glc and ketones
– Fasting glc > 7mmol/L + random b.glc > 11 mmol/L twice
– Clinical signs
Frequent differential diagnosis/misdiagnosis of DM1 in children
Misdiagnosis done bc. of the symptoms:
– Kussmaul breathing –> lung/heart disease
– Polyuria –> UTI
– Unconsciousness –> meningitis, encephalitis
Causes of DKA
Infections (50%)
Not taking insulin
Puberty
Clinical signs of DKA
Metabaolic acidosis
Hyperglycemia
Ketones in blood/urine
Symptoms of DKA
– Fq. urination
– Incr. thirs
– Dry mouth
– Blurry vision
– Sweet breath (bc. of ketones)
– Nausea, vomiting
– Abd. pain
Treatment of DKA
- ABCDE assessment
- Fluids (balanced crystalloids)
Treatment of DKA
- ABCDE assessment
- Fluids (balanced crystalloids)
- Insulin
- Insulin + glc
- Electrolyte resuscitation (K+)
Fluid therapy in children
- fluid bolus = 10ml/kg
1st. 10kg = 150ml/kg
2nd. 10kg = 50ml/kg
3rd. 10kg = 20ml/kg
Define congenital adrenal hyperplasia
group of autosomal recessive defects in the enzymes that are responsible for cortisol/aldosterone/androgen synthesi
Characteristic of all CAH (cong. adrenal hyperplasia) subtypes
- Low levels of cortisol
– High levels of ACTH
– Adrenal hyperplasia
