Week 3--notes Flashcards
1
Q
what should you counsel parents about:
sun safety
A
if possible, no sunscreen before 6 months old
counsel on hydration, avoiding sun between 10 and 2, reapplying sunscreen, application to face, ears, backs of legs
use SPF 30 or higher
2
Q
what should you counsel parents about:
insect repellent
A
NO DEET for lesst han 6 months old
6m-2 years–> 10% DEET, applied once daily
over 2 years–> 10% DEET, applied 3x daily
adults–> 30% DEET
minimal amount of repellent possible, not under clothes
wash it off after
3
Q
contraindications to breastfeeding
A
HIV
chemo
herpes
TB
metabolic disease
4
Q
breastfeeding benefits to child
A
increased IQ at 7 or 8 years
decreased risk of obesity, DM, celiac disease
5
Q
breastfeeding benefits to mom
A
weight loss
uterus involution
protective against breast ca, ovarian ca, osteoporosis
6
Q
social benefits to breastfeeding
A
cheap
portable
7
Q
how much should you supplement vit D in babies
A
400 IU daily starting at birth until baby’s foods include 400 IU daily
8
Q
what should you counsel parents about:
dental care
A
wipe gums with soft warm cloth until teeth erupt
brush once teeth erupt–> under 3 years, smear of toothpaste, over 3 years, pea sized amount of toothpaste
visit dentist once kids have teeth
do not put kids to bed with juice or milk
9
Q
what should you counsel parents about:
sleeping
A
no blankets or pillows initially
do not recommend bed sharing or co sleeping
can recommend rooming in for 6m to 1y
increased risk of SIDS if child prone or smoking occurs in home
10
Q
what should you counsel parents about:
car seats
A
rear facing until 1 year
infant seat until 10 kg or 22 ibs, must always be used rear facing
use a convertible seat in the rear facing position if baby outgrown infant seat
buckle should be at armpit level, harness at or below shoulders
child seat until 18 kg
booster seat until 8y, 30 kg or 145 cm
front seat after 12 years old
11
Q
what should you counsel parents about:
bathing
A
keep everything within arms reach
children can drown in 2 inches of water
dont need soaps on body
water not hotter than 49 degrees
keep child away from faucet
12
Q
when should the baby be back to birth weight
A
by 10 days to 2 weeks
13
Q
risk factors for developmental dysplasia of the hip
A
female, breech, family history, swaddling
NOT prematurity
14
Q
what confers a good prognosis for developmental dysplasia of the hip
A
if detected before 6 months
15
Q
how can you detect developmental dysplasia of the hip
A
ortolani and barlow maneuvers useful up to 8-12 weeks
positive if clunks
ortolani==>”out”, flex hips and knees, adduct to anterior pressure
barlow–> “dislocatable”, abducts with posterior pressure
16
Q
if child positive for developmental dysplasia of the hip, what do you do
A
refer to pediatric ortho
if equivocal, refer or ultrasound (best under 4 mo, xray of over 4 months
17
Q
what are the results of developmental dysplasia of the hip
A
after 3 months you get limited abduction, shortened leg, asymmetric creases
18
Q
what should you counsel parents about:
vitamin K injection
A
1 mg within 6 hours of borth
helps prevent HEMORRHAGIC DISEASE OF NEWBORN
alternative is oral vitamin K at birth and twice more over 4-8 weeks
19
Q
what should you counsel parents about:
erythromycin eye ointment
A
can be delayed for about 1 hour after birth
primary purpose is to prevent disease from gonorrhea
provides benefit towards chlamydia trachomatis
20
Q
what should you counsel parents about:
newborn screen
A
wait at least 24 hours as baby needs to have seen a protein load in order to detect high levels of phenylalanine (seen in PKU)
ideally performed within 48-72 hours can be up to 7d-14d
tests PKU, galactosemia, congenital hypothyroidism, MCAD and 14 others
21
Q
what should you counsel parents about:
fever above 38 degrees
A
MEDICAL EMERGENCY if less than 3 months
risk of serious bacterial infection
rectal temp is gold standard (tympanic controversial if less than 2 years old)
less than 28 days–> full septic workup and antibiotics
less than 90 days–> full septic workup and antibiotics if sending home (partial workup if staying in hospital)
22
Q
what should you counsel parents about:
tylenol dosing
A
15 mg/kg/dose max 75 mg/kg/day
23
Q
what should you counsel parents about:
advil dosing
A
10 mg/kg/dose (first choice if under 6 months)
24
Q
what causes the most risk for febrile seizures
A
rate of rise of T not peak T
25
when can you start giving OTC cough meds
OLDER THAN 6 YEARS
26
what should you counsel parents about:
| rickets
due to vitamin D deficiency
signs--bowing of long bones, widened joint space, ricketsial rosary
labs--calcium, phosphate, BUN, Cr
27
what should you counsel parents about:
| red reflex
screens for abnormalities of the back of eye and opacities in visual axis
28
what should you counsel parents about:
| lead screening
not routine
recommend if house is from before 1950, family history of lead poisoning, eating paint chips
can slow development, and be asymptomatic or non specific signs
treat with chelation (EDTA)
29
what should you counsel parents about:
| feeding
WHO/CPS recommends exclusive breastfeeding up to 6 months with continued breastfeeding along with appropriate complementary foods up to two years of age
in high risk atopic babies, helps to exclusively breast feed until 4 months
no egg whites, nuts or honey until 12 months
yogurt and other dairy from 6 months
breast milk ot formular until 1 year--homomilk from 1-2 years, 2% when above 2
30
risk factors for adolescent drug/alcohol use
family--> family history, anti social, criminality, drug use norms, absent parenting
youth--> low connection to adults, schools, mental illness, low achievement/hope
peer norms
early drug use
31
how do you identify adolescent drug/alcohol use
HEADSS assessment--> home, education, activities, drugs, sex, suicidality, safety
32
how do you assess extent of adolescent drug/alcohol use
CRAFT--> do you use drugs in your car? to relax? alone? to forget? are you in trouble?
are family and friends telling you to cut down?
no evidence for utility of urine drug screening
assess how much, how often, use more than intended? trouble? inject? impact at home or school?
33
how to use motivational interviewing with adolescent drug/alcohol use
aim for patient to describe only their next stage of motivation
precontempative--> contempative--> preparation--> action--> maintenance
34
how to treat adolescent drug/alcohol use
treat other mental health problems
consider methadone
ADHD treatment does NOT increase drug use
harm reduction--> eat, sleep, use regularly (vs binging), oral> snort> smoke> inject related to time of onset, choose safer drugs, places and people
35
what is a good way to rmember withdrawal syndromes
are usually the opposite of intoxication
36
how to detect drug of abuse toxidromes
examine mental status
vital signs
breathing pattern
unusual odors
pupil size and reactivity
skin colour
skin moisture
presence of bowel sounds
presence of urinary retention
37
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
skin abnormally dry
```
anticholinergics
38
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
diaphoretic
```
sympathomimetics or cholinergics
39
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
decreased bowel sounds
```
anticholinergics
40
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
increased bowel sounds
```
cholinergics
41
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
urinary retention
```
anticholinergics
42
```
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
excessive urination
```
cholinergics
43
what is the mechanism of the alcohol intoxication toxidrome
GABA-ergic
44
what are the symptoms of the alcohol intoxication toxidrome
ataxia
slurred speech
lack of coordination
depressed LOC
45
what are the serious possible consequences of the alcohol intoxication toxidrome
coma
hypotension
respiratory arrest common when taken with other sedatives
46
what should you also assess for when you suspect the alcohol intoxication toxidrome
head trauma
CNS infection
co ingestants
47
what is the GHB toxidrome
think alcohol
48
what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal at 5-10 hours
delerium
tachy
hypertension
hyperthermia
tremor
49
what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal
at 6-48 hours
generalized seizures, typically isolated or occurring in brief flurries
50
what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal after 48 hours
delirium tremens --> confusion, hallucinations, extreme agitation, hyperthermia, tachycardia, tachypnea, unstable BP
51
how do you treat alcohol withdrawal
benzodiazepines
52
what are the symptoms of the anticholinergic toxidrome
mad as a hatter, dry as a bone, red as a beet, blind as a bat, hot as hades
patient is dry--> altered mental status, decreased bowel sounds and urinary retention, dry, flushed skin, large pupils, tachycardia
53
common causes of the anticholinergic toxidrome
antihistamines
anticholinergic plants
54
what are the symptoms of the cholinergic toxidrome
```
SLUDGE
salivation
lacrimation
urination
defectation
GI upset
emesis
```
patient is wet--> excessive respiratory secretions, tearing, diaphoresis, increased bowel sounds, vomiting, diarrhea, urinary incontinence, bradycardia (may be tachy early after exposure)
55
what causes death with a cholinergic toxidrome
hypoxia and respiratory arrest
56
common causes of cholinergic toxidromes
organophosphates and carbamate insectisides
57
mechanism of the opiate toxidrome
depression of SNS
58
symptoms of the opiate toxidrome
respiratory depression
depressed mental status
pinpoint pupils
59
how do you diagnose the opiate toxidrome
prompt response to naloxone/narcan
60
common causes of the opiate toxidrome
heroin
dextromethorphan
codeine
oxycodone
61
symptoms of opiate withdrawal
nausea
vomiting
abdo cramps
diarrhea
piloerection
yawning
rhinorrhea
62
what are the symptoms of the sympathomimetic toxidrome
CNS and systemic signs of agitation--> agitation, mydriasis, tachycarida, hypertension, diaphoresis, hyperthermia
63
treatment of the sympathomimetic toxidrome
supportive with benzodiazepines (maybe antipsychotics) for sedation
hyperthermia may require cooling measures and paralysis
IV fluids for dehydration and rhabdomyolysis
64
MOA of cocaine
blocks reuptake of dopamine and upregulates presynatptic alpha2 receptor--> depression after chronic use so much watch out for suicide
downregulates presynaptic dopamine ("chasing the high")
65
what does methamphetamine do
potent NA and DA release, AP dependent
66
what is the most efficient methamphetamine delivery route
when smoked
67
which is longer with meth--psychogenic effects of pharmacologic half life
psychogenic effects
68
why is MDMA less addictive
because taken orally
also has NA, DA, 5HT release
69
how do hallucinogens work
inhibit inhibitory systems
cause subjective auditory, visual, tactile or olfactory perceptions that occur without external stimulus
i.e LSD (sympathomimetic), mushrooms, nutmeg, peyote cactus
70
how does a patient appear who has used a oure hallucinogen
patient is alert and oriented but with altered perceptions, which can induce feelings of anxiety or euphoria
most drug hallucinations are visual, synesthesias are common with LSD
GI upset common following ingestion of mushrooms, peyote, nutmeg
71
treatment of hallucinogen ingestion
supportive with reassurance and benzos for anxiety PRN
72
what are the most common sedative hypnotics
benzodiazepines and non-benzo hypnotics (i.e zopiclone)
73
what does overdose with sedative hypnotics look like
characterized by sedation or coma with relatively normal vitals
respiratory depression uncommon unless mixed with EtOH
supportive management
74
what is the half life of THC/cannabis
32 hours
very lipid soluble
75
effects of THC/Cannabis
impairs coordination and judgement, time and depth perception, glare recovery
more carcinogenic than tobacco
76
what does a patient on THC look like
red eyes
hungry
smells like smoke
poor coordination
77
list the dissociative anesthetics
ketamine
PCP
78
who does the infants act apply to
anyone under 19 years old
79
what infant can give consent
if the infant meets the standard to give informed consent then they can do so
if not capable, parents can refuse or consent on their behalf
government can intercede if determined by 2 physicians that child's safety and health is compromised
80
when can children be involved in medical research
only if determined to be in their best interest
81
how do you make treatment decisions for children and adolescents
must always act in the childs best interest
never sacrifice for interest of family or class of patients
no one has absolute authority to be decision maker
82
when can you withdraw life sustaining treatment from a child
US--> certain treatment is futile or harmless as determined by physician
CPS--> highly probable that treatment futile or harmful
GB--> on balance probable that treatment futile or harmful (most power to parents)
83
how do you manage an infant with a fever without a source
neonates have high risk of bacterial infection --> 12% of all ER visits for fever have positive blood cx
do full workup for neonates and admit for abx if less than 28 days old --> CBC and diff. blood bx, catheter urine for cx, UA, R+M, and do an LP for cell count, glucose, protein, cx, HSV PCR
84
what are the most likely pathogens causing fever in a neonate
e coli
GBS
listeria
HSV
85
how should you treat a neonate with fever--what are the agents and what are you covering for
ampicillin--> covers listeria
gentamycin--> broad coverage
3rd gen cephalosporin is an option (not ceftriaxone)
acyclovir to cover HSV in higher risk infants
86
what abx should you avoid in a neonate and why
ceftriaxone--causes increased bilirubin
87
how should you manage a WELL LOOKING young child with a sore throat
clinical exam is very poor at identifying bacterial vs viral etiologies
can do a throat swab
no rx initially, should wait for swab
rx if swab positive for GAS--> treat with penicillin V--> aim is to prevent rheumatic fever
rx does not prevent PSGN renal failure
88
how do you manage a teen girl with dysuria
remember to do HEADSS assessment
UTI may suggest sexual activity
urine for r+m, cx, sensitivity
tx with septra 2 tab BID for 3 days
could also use nitrofurantoin
89
how many people aged 25-34 in Ontario die due to opioid use issues
1 in every 8
90
what % of mental health issues have onset during childhood or adolescence
70%
people aged 15-24 are more likely to experience mental illness and/or substance use disorders than any other age group
91
how much more likely are people with a mental illness to have a substance use disorder
twice as likely
at least 20% of people with a mental illness have a co occurring substance use problem (as high as 50% if have schizophrenia)
92
what % of youth report drinking alcohol in last year
60% (ages 15-19)
93
what % of ages 15-19 smoke
11% (normal cigarettes)
| 20% smoke e cigarettes
94
what % of 15-19 year olds have used cannabis
22%
95
what do you need to include when writing a pediatric rx that you dont usually on adult ones
the patients weight (try and also include the indication for treatment)
96
how does body composition change throughout childhood
extracellular fluid decreases
| fat increases
97
how does renal function change throughout childhood
*we care because it influences drug clearance
GFR is low at birth, doubles by 1 week, then adult values are reached by 6-12 months of age
at birth, GFR is proportional to adult renal failure levels
98
how does hepatic function change over childhood
*causes altered drug metabolism in kids
phase I metabolic enzymes that are involved in redox reactions and hydrolysis are low at birth, then mature at variable rates
activity in young kids may exceed adult levels but unpredictable
99
what % of rx drugs in kids are off label
75%
*unapproved does not mean improper
100
what are important things you must do to ensure safe prescribing for children
print clearly
include AGE, WEIGHT, MG/KG/DAY
write full word for milligrams, micrograms etc
write out frequency (i.e once daily)
101
name 4 drugs that have a particularly bad taste
flagyl
cloxacillin
steroids
augmentin
102
name 3 drugs that are decent tasting
cezprozil
amoxicillin
zithromax
103
what % of pregnancies are unplanned
49%
104
tylenol dosing for fever and pain control in kids
15mg/kg/dose every 4 hours
max 5 doses in 24 hours
*beware of chronic overdose if giving around the clock
105
advil dosing for fever and pain control in kids
10 mg/kg/dose every 6 hours
106
why should you avoid codeine in kids
effect is dependent on rate of metabolism into morphine
slow metabolizers will get no pain relief
fast metabolizers may get toxic levels
107
dose of morphine oral solution in kids
over 1 year old
0.15-0.6 mg/kg/dose every 3-4 hours as needed (begin with lower dose and go up as needed)
108
what are important considerations when dosing anti epileptics in kids
DO NOT UNDER-DOSE when the patient is seizing--> stacking lower doses often will not stop the seizure and will cause increased respiratory depression
109
dosing of lorazepam for kids
0.1 mg/kg/dose SL or IV q10 min PRN
110
which type of delivery should you use for asthma meds for kids
puffers and spacers more effective than nebs
MUST use spacer
111
what should you do when you are diagnosing a kid with asthma for the first time
must do CXR at diagnosis to rule out other pathology (ie mediastinal mass)
112
dosing of ventolin for kids
100mcg/puff, 1-2 puffs via spacer every 4 hours PRN
113
dosing of flovent for kids
50-100 mcg BID
114
what meds should you use for kids with atopic dermatitis
1% hydrocortisone ointment (NOT CREAM)
apply to rash BID until it clears
can use 0.1% bethamethasone if not responding
moisturize with glaxal base, aquefor, vaseline etc for maintenance
warn parents this will be a chronic disease
115
how to discuss vaccine safety with parents
no vaccine 100% safe
surveillance is rigorous
evidence is clear that the benefits outweigh the risk
no proven evidence that links vaccines with autism
*parents have the right to accept/refuse the advise given
116
how to discuss the fear of "antigen load" with parents
has been decreasing
no evidence of increased side effects with the increased number of vaccines given at one time
staggering schedules can easily lead to under vaccination
117
what is the 4th-6th leading cause of death in the USA
adverse drug reactions
causes 7% of all hospital admissions
fatal reactions in over 100 000 hospitalized patients each year
118
what is the GATC project
hypothesis that genetic polymorphisms can be associated with adverse drug reactions
119
prior to widespread vaccine coverage, how many kids were usually infected by measles before age 15
90%
120
measles incubation period
7-21 days
121
how infective is measles
90% of those who are susceptible and in contact with carrier will get it
122
what are the 4 Cs of measles infection
cough
coryza
conjunctivitis
Koplik spots
123
how many people still die of measles worldwide
118 000-240 000 annually
pre vaccination--> in north american, 500 000 cases annually with 500 deaths--> 25% of kids hospitalized
124
side effects of measles
pneumonia
encephalitis--> post infectious--> deafness, motor deficits, intellectual disabilities, death
death
subacute sclerosing panencephalitis --> rare but nearly always fatal
125
what % must vaccinate to get herd immunity
95%
126
what is canada's overall vaccination rate
84%
fraser valley east--60-70%
127
what are three things that contribute to vaccine hesitancy
confidence
complacency
convenience
128
how many people's lives are estimated to be saved each year from vaccines
approx 3 million a year
*investing in vaccines saves more money than it costs
129
what are blasts
immature leukocytes
with rare exceptions, should NEVER be seen in peripheral blood
less than 5% blasts is normal
130
what should you think if a lab result indicates blasts and pancytopenia
acute leukemia
leukemia has more than 25% blasts
131
what are critical values?
lab findings which imply an IMMEDIATE or SERIOUS risk of morbidity or mortality
must be communicated by the lab to the responsible physician immediately
132
how long is the turnaround time for a malignant diagnosis
depends on degree of certainty and amount of details
acute leukemia--> hours
solid tumours--> 1-2 days
cytogenetics--> 1-3 days
133
what are salter harris factures
fractures through a growth plate (thus unique to pediatric populations)
categorized according to involvement of the physis, metaphysis, and epiphysis
classification important because affects treatment and provides clues to possible long term complications
134
define salter harris type I fracture
TRANSVERSE fracture through the hypertrophic zone of the physis
the wide of the physis is increased
growing zone is usually not injured and growth disturbance is uncommon
135
define salter harris type II fracture
most common type of salter harris fracture
occurs through the physis and metaphysis
epiphysis not involved
may cause minimal shortening but rarely result in functional limitations
136
define salter harris type III fracture
fracture through the physis and epiphysis
passes through the hypertrophic layer of the physis and extends to split the epiphysis
inevitably damages the reproductive later of the physis
this type is prone to chronic disability because extends to articular surface of the bone, but rarely result in significant deformity and thus have relatively favorable prognosis
a TILLAUX fracture is a type III fracture that is prone to disability--> 15% of juvenile long bone injuries involve the epiphyseal growth plate, with 2.9% of these being tillaux fractures, in which the avulsed fragment is quadrangular (in adults is triangular)
*type III fractures often treated surgically
137
define salter harris type IV fracture
involved all 3 elements of the bone
like type III, in an intra-articular fracture and can thus result in chronic instability
138
define salter harris type V fracture
compression or crush injury of the epiphyseal plate with no associated epiphyseal or metaphyseal fracture
associated with growth disturbances at the physis
typical history if that of an axial load injury
have very poor functional prognosis
139
what is the standard trauma imaging screen
cervical XR
CXR
pelvic XR
140
what is the lifetime additional risk of mortality from CT in kids
1/1000
kids are more radiosensitive than adults
141
why are fractures sometimes harder to diagnose radiologically in kids
sometimes you cant see the fracture because it is in a section of cartilage that hasnt formed bone yet and thus it can look like a dislocation when it is actually a fracture
**look out for fractures when xrays look like dislocations in young kids with trauma histories
142
what types of things can be detected antenatally by radiography that can then be dealt with
hydronephrosis
| cardiac anomalies
143
what types of things can be detected related to birth by radiography that can then be dealt with
hypoxic ischemic encephalopathy (HIE)
fractures
cephalohematoma
144
when should you suspect hypertrophic pyloric stenosis clinically
NONbilious projectile vomiting
may be mass in abdomen
145
in what age group do you see hypertrophic pyloric stenosis
only really ages of 3 weeks to 3 months
146
what imaging modality do you use to diagnose hypertrophic pyloric stenosis
U/S
147
what do you see on U/S in hypertrophic pyloric stenosis
pyloric muscle thickens to greater than 3 mm and the length of the pyloric canal is above 14 mm
148
what imaging modality should you use to dx appendicitis in kids
U/S
sensitivity and specificity of 70-80% (higher in kids than adults)
--> about 90% for CT but reserve it for problem cases due to radiation exposure
149
when should you suspect malrotation and volvulus in kids?
bilious vomiting
150
what imaging is preferred in malrotation or volvulus
upper GI series with contrast
but U/S also has a role
151
what are the most common type of intususseptions in kids
small into large bowel (typically ileum into cecum)
152
in what age range is intususseption most common
3 months to 3 years old (if outside of this range, consider a pathological lead point)
153
how do you treat intususseptions
air enema for reduction--done by rads, if successful can avoid surgery
154
what % of intususseptions recurr within 24 hours
10%
155
how do you diagnose hip dysplasia in infants/kids
dynamic hip U/S for developmental hip dysplasia--> imaged at 4-6 weeks old
want a normal angle which is under 60 degrees
156
who should you scan for hip dysplasia
kids with weird births/breech
family history of hip dysplasia
positive ortolani or barlow maneuvers after birth
157
how do you evaluate swallowing issues (either post traumatic or congenital) in kids
video-fluoroscopic swallowing studies (VFSS)
158
what % of all new cancers in kids are leukemias
33%
159
what are the cure rates for:
| standard risk ALL
90%
160
what are the cure rates for:
| high risk ALL
above 75%
161
what are the cure rates for:
| AML
50-60% five year EFS
162
who should you call when you suspect a diagnosis of pediatric leukemia
pediatric oncology at BCCH (phone line 24h/day)
163
what further blood work is required when you suspect leukemia
blood cx if febrile
```
lytes
BUN
Cr
Ca
phosphate
uric acid
LDH
PTT
INR
d-dimer
fibrinogen
```
CXR-->mediastinal mass?
164
what is the immediate management of a suspected pediatric leukemia
infant transport team--> specialized paramedic team that runs through the BC ambulance service and NICU/PICU at BCCH
arrange via PICU
can help with seriously ill kids anywhere, not just those coming to BCCH
concerned about TUMOUR LYSIS SYNDROME
165
what is tumour lysis syndrome
describes metabolic consequences of spontaneous or treatment-related tumour necrosis
can lead to:
1. acute renal failure--> due to deposits of uric acid and Ca-P in microvasculature and renal tubules (increased risk in setting of renal tumour/infiltration or ureteric/renal vessel obstruction)
2. cardiac arrhythmias
166
what should you follow when monitoring for tumour lysis syndrome
INCREASING uric acid, K+ and phosphate, with DECREASING calcium
167
when does tumour lysis syndrome usually occur
within 1-5 days of starting treatment in tumours with rapid growth
i.e in burkitt's lymphoma, t-cell lymphoblastic leukemia/lymphoma, ALL with lots of blasts
168
what are the signs and symptoms of tumour lysis syndrome
abdominal pain
back pain
decreased urine output
increased potassium--> GI sx, weakness, ECG changes (wider QRS, peaked T waves), ventricular arrhythmias, death
decreased calcium--> anorexia, vomiting, cramps, caropedal spasm, tetany, seizures
169
how do you manage tumour lysis syndrome
1. fluids--> 2-3x maintenance
2. alkalinization--> sodium bicarb 50-100 mEq/L to maintain urine pH 6.5-7.5
3. allopurinol--> inhibits xanthine oxidase, resulting in decreased uric acid production
4. urate oxidase--> converts uric acid to allantoin (which is water soluble)
5. manage hyperkalemia with calcium gluconate, insulin and glucose, ventolin, key-exalate, dialysis PRN
170
what are indications for dialysis in kids
1. rapid rise in BUN or Cr
2. K+ above 7
3. severe metabolic acidosis
4. hypertension secondary to fluid overload
5. CCF or pulmonary edema
6. uncontrolled tumour lysis syndrome
171
why do we care about hyperleukocytosis
can cause hyperviscosity--> which leads to respiratory dysfunction, CNS bleeds or strokes
highest risk in AML with WBC count above 200, ALL with WBC count above 300
172
what is DIC
uncontrolled activation of coagulation and fibrinolysis
consumption of clotting factors AND platelets
results in bruising, bleeding, shock, intracranial bleeding and possibly death
occurs in patients with severe illness/septic shock, as well as patients with AML
173
what are the lab results indicative of DIC
increased PT, PTT and d dimer
decreased platelets, fibrinogen, clotting factors
174
how do you manage DIC
TREAT UNDERLYING CAUSE
treat the numbers second--> FFP, cryoprecipitate/platelets, pRBCs
heparin use is controversial--> only recommended when aggressive replacement therapy fails to correct a dangerous coagulopathy
175
why do we get concerned about mediastinal masses
SVC syndrome
assess with CXR, DO NOT INTUBATE, let kids find their most comfortable position
176
how should you manage febrile neutropenia in a child
MEDICAL EMERGENCY
fever above 38.5 (oral) or 38 for 2 readings
neutropenia (ANC less than 1)--> increased risk for bacterial and fungal infections
increased risk for serious infection is ANC less than 0.5
crazy high risk if ANC less than 0.1
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what bacterial infections do we worry about in febrile neutropenia
gram - enteric bacilli
meningococcus
pneumococcus
S. aureus
GAS
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what fungal infections do we worry about in febrile neutropenia
candida
cryptococcus
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what are the signs and symptoms of febrile neutropenia
septic shock may occur very quickly in neutropenic patients
fever or hypothermia
hypotension, tachy
decreased perfusion
respiratory distress--"grunting"
edema
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how to assess and monitor febrile neutropenia
must move quickly
frequent vitals (ABCs)
full physical to look for source
always take off diaper and central venous catheter dressing
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how do you manage febrile neutropenia in a child
draw cultures--> blood, CSF, urine (catheter preferred), other (i.e abscess)
empiric broad spectrum abx ASAP--> VANCO and CEFOTAXIME is good initial coverage for non-oncology patients
fluid bolus of 20 ml/kg of normal saline, repeat as needed (push with big syringe if needed)
get central access of possible
inotropes and help with giving 3rd bolus
CXR
oxygen
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are pediatric codes usually cardiac?
no--almost all are airway and breathing
most important thing in pediatric codes is airway management
*need to know how to bag mask ventilate
do not need intubation--> if mediastinal mass, intubation is dangerous
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when should you transfuse the anemic pediatric patient
children can tolerate anemia much better than adults
transfuse for chronic anemia if: CV compromise present, known mechanism that will not allow rapid reversal or if logistics necessitate it
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when should you transfuse a pediatric patient with thrombocytopenia
depends on age and clinical situation
always transfuse if platelets less than 10, or if significant bleeding
if planning surgery or LP, keep plts above 50
if neurosurgery planned, keep above 80-100
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how to treat pediatric anaphylaxis
give epinephrine 0.01 mL/kg/dose of 1:1000 strength SQ (up to 0.5 mL)
give benadryl and hydrocortisone
admit and close observation
(inform blood bank if after transfusion)
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how is childhood leukemia managed in BC?
all come to bcch for dx and initiation of tx
diagnostic bone marrow and LP
central line placed by peds general surgeon
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what people are on the healthcare team involved in the management of childhood leukemia
oncologist
nurse
pediatric oncology fellows
social worker
physio
patient advocate
if needed: first nations advocate, spiritual care, nutritionist, psychologist
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once diagnosis is made at BCCH, how is AML managed
inpatient therapy given exclusively at BCCH
usually 6-8 months of intensive therapy
strict isolation for 28-60 days at a time
ICU admissions common
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once diagnosis is made at BCCH, how is ALL managed
admitted for 7-14 days initially
mostly outpatient therapy
initial 7-9 months are intensive
next 18-30 months is easier--?daily oral meds, once monthly IV meds, intrathecal chemo every 3 months
chemo is done through oncology clinic at BCCH or given in home community by pediatricians or family doctors with guidance from oncology
admit for fever/neutropenia or other complications
