W07 - PAEDS: Cardiology; Infectious Diseases; Derm Flashcards
Ventricular Septal Defect Types & general mgmt
SUBAORTIC
PERIMEMBRANOUS
MUSCULAR
L->R Shunt
> Loop diuretics + amiloride/spironolactone/ACEi
> amplatzer; other occlusion device
patch closure, open heart sx
Presentation of septal defects
Pansystolic murmur lower left sternal edge, + thrill
very small VSDs, early systolic murmur
very large VSDs diastolic rumble due to relative mitral stenosis
Signs of cardiac failure in large VSDs, leading to biventricular hypertrophy and pulmonary hypertension
Eisenmenger Syndrome
irregular blood flow in the heart and lungs.
= blood vessels in the lungs to become stiff and narrow.
pulmonary arterial hypertension
Eisenmenger syndrome permanently damages the blood vessels in the lungs.
Patent ductur Arteriosus
common in premies
> fluid restriction
> diuretics
> prostaglandin inhibitors
> indomethacin
> surgical ligation
- spontaneous closure
Atrial Septal Defects
Few clinical signs, spontaneous closure chance, ACYANOTIC
- detected with AF in adults, HD, or Pulm HT
- recurrent chest infections/wheeze
wide dixed splitting of 2nd heart sound pulmonary flow murmur
-trisomy21 association
1) Secundum ASD - PATENT FORAMEN OVALE
2) PARTIAL AVSD: minority
> Cardiac catheresiation = closure
Sx
Coarctation of Ao
*narrowing of ao.; often descending arch / also commonly where ductus enters the ao.
- associated with turner’s, and M>F
*weak/absent femoral pulse
*radio-femoral delay (chronic co-arctation)
*systolic murmur - loudest on back
*sudden deterioration and collapse
- delayed duct closure = aortic blood flow flow through ductus art. into pulmonary trunk = reduced workload on LHS
- suprasternal ECHO
- MRI
Mgmt of Coarctation of Ao
> re-open ductus arteriosus via prostaglandin E1 or E2
=> transfer to centre
sick neonate:
> frusemide, correct HT: BB
> resection w/ end to end anastomosis
subclavian patch repair
balloon aortoplasty (via femoral art.)
Cyanotic Heart Defects
not as prevalent in incidence
* central cyanosis; significant cause dt RtoL shunt
* delayed if ductus arteriosus is delayed
dt transposition of great arteries
or
Fallot’s Tetralogy
transposition of great arteries
Ao comes out of the RV, pulm art exits LV, nil shunt = separate blood flows of oxygenated and systemic.
= ID’d antenatally
surviival depends on:
* open ductus arteriosus
* large ASD or VSD
> IV prostaglandins, umbillical catheter = ensure duct open and stabilisation
Rashkind procedure via femoral vein into RA = closure of foreamen ovale
> SWITCH PROCEDURE = swapping over vessels under cardiopulm bypass.
- avoid dmg to vessels = MI under reperfusion
thus surrounding tissue = stump transposed too.
Fallot’s Tetralogy
- narrowing of right ventircular outflow: pulmonary valve stenosis
- right ventricular hypertrophy
= RtL shunt - ventricular septal defect
- aorta = overriding aoirta
- good prognosis usually, mgmt at ~6mos
- boot shaped heart but rarely seen with early correction methods
> BB
Sx correction at 5kg body weught
Life long f-up dt recurring RV outflow obstruction
for critical pulmonary valve stenosis = subclavian artery shunt with pulm art.
- tendency to block and worsen
Common causes of death for children
INFECTIOUS DISEASES: pneumoniaa, diaarrheala diseases, measles etc.
Preterm birth
Neonatal asphyxia and traumaa
neonatal sepsis
Pneumonia
a
Meningitis
a
Pneumonia
a
Gastroenteritis
a
Staph and Strep Infection
a
Sepsis
Sepsis = SIRS + infection
Severe Sepsis = Sepsis + Organa dysfunction
Septic Shock = Sepsis + CVS Dysfunction
Flags for Children Sepsis
<3yo
- immsuppr., LT steroids
-recent sx
-indwelling
- complex neruodisability = PEWS may not pick up
- sig. parentaal concern
- group B strep.
- maternal group b strep. / UTI
> O2, Abx, Fluids, ADRENALINE
- CEPHALOSPORIN (Cefotaxime, Ceftriaxone)
+ IV amox if <1m y/o
Blood cultures, blood glc, blood lactate
+ fluid resus.
ORganisms for Sepsis in Children
Neonates:
- Group B Strep
- E coli
- Listeria monocytogenes
Older infaants & Children:
- Strep pneumon.
- Nisseria mingitidis
- Group A Strep
- S. aureus
Pathogenesis of Sepsis
LPS & bacterial component triggering inflamm response of neutrophils, monocytes, endothelium, cytokines and complement
* microvascular occlusion & vascular instability
* widespread coag., fever, vasodilation, capillary leak
* sepsis and multiple organ failure
Triad of mengism
FEVER
HEADACHE
NECK STIFFNESS
*focal deficit = raised ICP
* babies = apnoea. (resp distress), buldging fonatenelle (ICP)
Clinical Signs of Meningitis
NUCHAL RIGIDITIY
BRUDZINSKI’S SIGN = hips and knee flex on passive flexion of knee
KERNIG’S SIGN = pain on passive extension of the knee
Causes of Childhood Meningitis
1) mainly enterovirus
- bacterial
- Group B strep, E colo, Listeria
- Strep pneumonia, N meningitidis, Haemo. influenz. type B (low now dt vax)
- fungal
- unknown/ aseptic
H influenz.
small non-motile gram neg. coccobacillus
- nasopharyngeal carriage
- bacteraemia, meningitis, epiglottitis, pneumonia
Nisseria meningitidis
gram neg, diplococcus
- human natural hosts
- nasopharyngeal
- follows viral URTI
- endotoxin
RF for Nisseria meningitidis
*unimmunised
* crowded living conditions
- household or kissing contact
- cigarette smoking
- recent viral infection
Meningitis Vs Septicaemia
- petechial rash common in both
meningitis: headache, fever, vom, neck, fonatenelle, seizures
septicemia: fever, headache, myalgia, vom, abdo pain, limb pain, shock
Pneumococcus
LANCETshapred, diplococcus, gram+
- colonises nasopharynx
Mgmt of Meningitis
ABCD
> fluid bolus
> abx
CEPHALOSPORIN: ceftriaxone/cefotaxime
+ amox if <1m. yo
*glucose! hypos.
Treatment Duration Depending on Causative Agent in Bact. Meningitis
Neisseria meningitidis
7 days
Haemophilus influenzae
10 days
Streptococcus pneumoniae
14 days
Group B Streptococcus
≥14 days
Listeria monocytogenes
21 days
Interpretation of Lumbar Puncture
Bacterial meningitis has HIGH OPENING PRESSURE, LOWER GLUCOSE and LOWER WBC than VIRAL meningitis
viral meningitis = clearer
Commonest Dermatological Pres in Children
*ATOPIC ECZEMA
- eczema, asthma, hayfever
- typically spreads from face, neck, cheeks
- older: flexural pattern, hands, ankles
Eczema Variants
DISCOID: scattered circular patches, itchy
POMPHYLX ECZEMA : hand and foot, vesicular, itchy+++
EXOGENOUS: allergic type IV hypersens, irritant eczema
Eczema mgmt
Emollients
Topical steroids
- DERMOVATE
- BETNOVATE
- EUMOVATE
- HYDROCORTISONE
once daily, 1-2w progress to alternate days to few, FTU
Calcineurin inhibitors (e.g protopic – steroid sparing topical agents)
UVB light therapy
Immunosuppressive medication
Impetigo
Common bact.
Pustules, honey-coloured crusted erosions
STAPH AUREUS
> topical abx = fucidin
oral abx = fluclox.
Molluscum contagiosum
common benign, self-limiting
molluscipox virus
close contact transmission
*pearly papules, umbilicated centre
> reassure
Viral Warts
non cancerous growths w/ HPV
* sole foot = verruca
> salicylic acid + cryotherapy = stimulate imm system
Viral exanthems
Associated viral illnesses = response to organism toxin
Common
Fever, malaise, headache
Chickenpox - VARICELLA ZOSTER
varicella zoster virus
*red papule progressing to vesicles, common start at trunk, itchy, viral symptoms
> self-limiting
infection control = nursery
Parvovirus
Slapped Cheek; Fifth Disease; ERYTHEMA INFECTIOSUM
* erythemous rash cheek initally then develop to lace rash on trunk and limbs
self-limiting, viral symptoms.
!hemolytic crisis in disorders
! risk to pregnany women = abortion, intrauterine death, hydrops fetalis
Hand Foot and Mouth
ENTEROVIRUS
Usually Coxsackie virus A16
Blisters on hand, feet, and moouth, + viral symptoms
late summer or autumn months
self limiting
> supportive
+eczema variant; eczema herpeticum: monomorphic punched out lesions
> aciclovir, withold steroids
SYSTEMIC. DERMATOLOGICAL PRESENTATIONS
- OROFACIAL GRANULOMATOSIS
cobblestone appearance
+crohns
+ fecal caprotectin if GI symptoms
- ERYTHEMA NODODSUM
painful erythematous subcutaneous nodules, shins
slow resolution
strep, URTI, IBD, sarcoid, drugs, myco. - DERMATITIS HERPETIFORMIS
coeliac disease, rare. itchy blisters appearing in clusters, symmetrical, trunk + shoulders butt, flexural - URTICARIA
wheals hives, angioedema
6w+ = chronic otherwise acute
* multiple associations
> antihistamines: deskiratadube
S. aureus Vs S pyogenes
s. aureus
- gram +
- coagulase +
exotoxin superantigens
- skin and mucosaa
- MRSA!
strep pyogenes
- gram + , Bhemolytic
- oro-pharyngeal
- sensitive to penicillin
predominant cause of. skin and soft tissue infection in children
Staph. Scalded Skin Syndrome
<5yo, toxin mediated, starts w/ bullous lesion => widespread
nikolsky sign +, pyrexic, purulen conjuctivities
> IV Fluclox
IV Fluids
Nikolsky Sign
Nikolsky sign is a skin finding in which the top layers of the skin slip away from the lower layers when rubbed. Nikolsky sign is a condition caused by a staphylococcal infection in which the superficial layers of skin slip free from the lower layers with a slight rubbing pressure.
Scarlet Fever
Group A Strep.
fever sore throat; STRAWBERRY TONGUE => skin peeling (desquamation)
spares palms and soles
- notifiable disease
> 10d penicillin V
!rheumatic fever
! abscess
! post-strept glomerulonephritis
Toxic Shock Syndrome
Acute febrile illness caused by Gram +ve bacteria (S. aureus & GAS)
multiorgan failure dt superantigen = intense t response and cytokinestorm
Fever
Diffuse, maculopapular, ‘sunburn’ rash
Mucosal changes
+diarrhoea (s. aureus)
+ progression to shock
> ABC
Fluids
Cultures
IV Fluclox + Clindamycin
> IV Ig
Sx debridement
!avoidNSAIDs
Pres. of Infant with Congestive HF and subsequent mgmt
Tachyopnea on exertion - feeding, sweating /panting with feeds
Tachycardia
Hepatomegaly
No peripheral oedema
Cardiomegaly, faltering growth
?murmurs
? femorals palpable
> furosemide
spironolactone
fluid restrict., high nutr. and cal.feed.
Tetralogy of Fallot; Presentation
Large VSD
Right ventricular outflow obstruction
Overriding of the aorta
Right ventricular hypertrophy
common cause of CYANOTIC BABY
* Dyspnoea on feeding / crying / exertion
* murmur
* failure to thrive
- improved by squatting
! TET SPELLS = EMERGENCY
Sudden onset dyspnoea / cyanosis
Typically triggered by an event that slightly reduces O2 concentration, e.g. crying, defecating, feeding, distress
> corrective sx.
TGA pres and mgmt
neonatal period = cyanotic baby = high suspicion
> prostaglandin
Innocent Murmurs
*asymptomatic child
1) STILL’S MURMUR: commonest, school age children
- left of sternum
- systolic; vibratory
- decreased in standing, sitting, valsalva (POSTURAL)
2) PULM. FLOW MURMUR: common in older children and teenagers, thin chest walls
3) VENOUS HUM: continuous soft blowing
- above aortic valve site
- disappears lying down
4) CAROTID BRUIT: children and young adults
- supraclavic, carotids
- decreases with hypertextension of shoulder
5) PHYSIOLOGICAL PULM FLOW MURMUR OF NEONATE
6) Physiological pulmonary stenosis: common in newborns
- pulm. valve => radiate to the back
