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PMP > Week 3--notes > Flashcards

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

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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

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3
Q

contraindications to breastfeeding

A

HIV

chemo

herpes

TB

metabolic disease

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4
Q

breastfeeding benefits to child

A

increased IQ at 7 or 8 years

decreased risk of obesity, DM, celiac disease

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5
Q

breastfeeding benefits to mom

A

weight loss

uterus involution

protective against breast ca, ovarian ca, osteoporosis

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6
Q

social benefits to breastfeeding

A

cheap

portable

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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

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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

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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

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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

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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

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12
Q

when should the baby be back to birth weight

A

by 10 days to 2 weeks

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13
Q

risk factors for developmental dysplasia of the hip

A

female, breech, family history, swaddling

NOT prematurity

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14
Q

what confers a good prognosis for developmental dysplasia of the hip

A

if detected before 6 months

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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

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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

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17
Q

what are the results of developmental dysplasia of the hip

A

after 3 months you get limited abduction, shortened leg, asymmetric creases

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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

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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

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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

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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)

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22
Q

what should you counsel parents about:

tylenol dosing

A

15 mg/kg/dose max 75 mg/kg/day

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23
Q

what should you counsel parents about:

advil dosing

A

10 mg/kg/dose (first choice if under 6 months)

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24
Q

what causes the most risk for febrile seizures

A

rate of rise of T not peak T

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25
Q

when can you start giving OTC cough meds

A

OLDER THAN 6 YEARS

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26
Q

what should you counsel parents about:

rickets

A

due to vitamin D deficiency

signs–bowing of long bones, widened joint space, ricketsial rosary

labs–calcium, phosphate, BUN, Cr

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27
Q

what should you counsel parents about:

red reflex

A

screens for abnormalities of the back of eye and opacities in visual axis

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28
Q

what should you counsel parents about:

lead screening

A

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)

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29
Q

what should you counsel parents about:

feeding

A

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

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30
Q

risk factors for adolescent drug/alcohol use

A

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

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31
Q

how do you identify adolescent drug/alcohol use

A

HEADSS assessment–> home, education, activities, drugs, sex, suicidality, safety

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32
Q

how do you assess extent of adolescent drug/alcohol use

A

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?

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33
Q

how to use motivational interviewing with adolescent drug/alcohol use

A

aim for patient to describe only their next stage of motivation

precontempative–> contempative–> preparation–> action–> maintenance

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34
Q

how to treat adolescent drug/alcohol use

A

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

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35
Q

what is a good way to rmember withdrawal syndromes

A

are usually the opposite of intoxication

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36
Q

how to detect drug of abuse toxidromes

A

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

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37
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
skin abnormally dry
A

anticholinergics

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38
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
diaphoretic
A

sympathomimetics or cholinergics

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39
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
decreased bowel sounds
A

anticholinergics

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40
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
increased bowel sounds
A

cholinergics

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41
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
urinary retention
A

anticholinergics

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42
Q 
what class of drugs cause toxidromes that cause (i.e what should you think when you see...):
excessive urination
A

cholinergics

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43
Q

what is the mechanism of the alcohol intoxication toxidrome

A

GABA-ergic

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44
Q

what are the symptoms of the alcohol intoxication toxidrome

A

ataxia

slurred speech

lack of coordination

depressed LOC

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45
Q

what are the serious possible consequences of the alcohol intoxication toxidrome

A

coma

hypotension

respiratory arrest common when taken with other sedatives

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46
Q

what should you also assess for when you suspect the alcohol intoxication toxidrome

A

head trauma

CNS infection

co ingestants

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47
Q

what is the GHB toxidrome

A

think alcohol

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48
Q

what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal at 5-10 hours

A

delerium

tachy

hypertension

hyperthermia

tremor

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49
Q

what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal
at 6-48 hours

A

generalized seizures, typically isolated or occurring in brief flurries

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50
Q

what are the symptoms to expect in alcohol (and other sedative hypnotic) withdrawal after 48 hours

A

delirium tremens –> confusion, hallucinations, extreme agitation, hyperthermia, tachycardia, tachypnea, unstable BP

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51
Q

how do you treat alcohol withdrawal

A

benzodiazepines

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52
Q

what are the symptoms of the anticholinergic toxidrome

A

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

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53
Q

common causes of the anticholinergic toxidrome

A

antihistamines

anticholinergic plants

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54
Q

what are the symptoms of the cholinergic toxidrome

A 
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)

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55
Q

what causes death with a cholinergic toxidrome

A

hypoxia and respiratory arrest

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56
Q

common causes of cholinergic toxidromes

A

organophosphates and carbamate insectisides

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57
Q

mechanism of the opiate toxidrome

A

depression of SNS

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58
Q

symptoms of the opiate toxidrome

A

respiratory depression

depressed mental status

pinpoint pupils

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59
Q

how do you diagnose the opiate toxidrome

A

prompt response to naloxone/narcan

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60
Q

common causes of the opiate toxidrome

A

heroin

dextromethorphan

codeine

oxycodone

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61
Q

symptoms of opiate withdrawal

A

nausea

vomiting

abdo cramps

diarrhea

piloerection

yawning

rhinorrhea

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62
Q

what are the symptoms of the sympathomimetic toxidrome

A

CNS and systemic signs of agitation–> agitation, mydriasis, tachycarida, hypertension, diaphoresis, hyperthermia

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63
Q

treatment of the sympathomimetic toxidrome

A

supportive with benzodiazepines (maybe antipsychotics) for sedation

hyperthermia may require cooling measures and paralysis

IV fluids for dehydration and rhabdomyolysis

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64
Q

MOA of cocaine

A

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”)

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65
Q

what does methamphetamine do

A

potent NA and DA release, AP dependent

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66
Q

what is the most efficient methamphetamine delivery route

A

when smoked

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67
Q

which is longer with meth–psychogenic effects of pharmacologic half life

A

psychogenic effects

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68
Q

why is MDMA less addictive

A

because taken orally

also has NA, DA, 5HT release

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69
Q

how do hallucinogens work

A

inhibit inhibitory systems

cause subjective auditory, visual, tactile or olfactory perceptions that occur without external stimulus

i.e LSD (sympathomimetic), mushrooms, nutmeg, peyote cactus

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70
Q

how does a patient appear who has used a oure hallucinogen

A

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

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71
Q

treatment of hallucinogen ingestion

A

supportive with reassurance and benzos for anxiety PRN

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72
Q

what are the most common sedative hypnotics

A

benzodiazepines and non-benzo hypnotics (i.e zopiclone)

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73
Q

what does overdose with sedative hypnotics look like

A

characterized by sedation or coma with relatively normal vitals

respiratory depression uncommon unless mixed with EtOH

supportive management

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74
Q

what is the half life of THC/cannabis

A

32 hours

very lipid soluble

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75
Q

effects of THC/Cannabis

A

impairs coordination and judgement, time and depth perception, glare recovery

more carcinogenic than tobacco

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76
Q

what does a patient on THC look like

A

red eyes

hungry

smells like smoke

poor coordination

77
Q

list the dissociative anesthetics

A

ketamine

PCP

78
Q

who does the infants act apply to

A

anyone under 19 years old

79
Q

what infant can give consent

A

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
Q

when can children be involved in medical research

A

only if determined to be in their best interest

81
Q

how do you make treatment decisions for children and adolescents

A

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
Q

when can you withdraw life sustaining treatment from a child

A

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
Q

how do you manage an infant with a fever without a source

A

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
Q

what are the most likely pathogens causing fever in a neonate

A

e coli

GBS

listeria

HSV

85
Q

how should you treat a neonate with fever–what are the agents and what are you covering for

A

ampicillin–> covers listeria

gentamycin–> broad coverage

3rd gen cephalosporin is an option (not ceftriaxone)

acyclovir to cover HSV in higher risk infants

86
Q

what abx should you avoid in a neonate and why

A

ceftriaxone–causes increased bilirubin

87
Q

how should you manage a WELL LOOKING young child with a sore throat

A

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
Q

how do you manage a teen girl with dysuria

A

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
Q

how many people aged 25-34 in Ontario die due to opioid use issues

A

1 in every 8

90
Q

what % of mental health issues have onset during childhood or adolescence

A

70%

people aged 15-24 are more likely to experience mental illness and/or substance use disorders than any other age group

91
Q

how much more likely are people with a mental illness to have a substance use disorder

A

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
Q

what % of youth report drinking alcohol in last year

A

60% (ages 15-19)

93
Q

what % of ages 15-19 smoke

A

11% (normal cigarettes)

20% smoke e cigarettes

94
Q

what % of 15-19 year olds have used cannabis

A

22%

95
Q

what do you need to include when writing a pediatric rx that you dont usually on adult ones

A

the patients weight (try and also include the indication for treatment)

96
Q

how does body composition change throughout childhood

A

extracellular fluid decreases

fat increases

97
Q

how does renal function change throughout childhood

A

*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
Q

how does hepatic function change over childhood

A

*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
Q

what % of rx drugs in kids are off label

A

75%

*unapproved does not mean improper

100
Q

what are important things you must do to ensure safe prescribing for children

A

print clearly

include AGE, WEIGHT, MG/KG/DAY

write full word for milligrams, micrograms etc

write out frequency (i.e once daily)

101
Q

name 4 drugs that have a particularly bad taste

A

flagyl
cloxacillin
steroids
augmentin

102
Q

name 3 drugs that are decent tasting

A

cezprozil
amoxicillin
zithromax

103
Q

what % of pregnancies are unplanned

A

49%

104
Q

tylenol dosing for fever and pain control in kids

A

15mg/kg/dose every 4 hours
max 5 doses in 24 hours

*beware of chronic overdose if giving around the clock

105
Q

advil dosing for fever and pain control in kids

A

10 mg/kg/dose every 6 hours

106
Q

why should you avoid codeine in kids

A

effect is dependent on rate of metabolism into morphine

slow metabolizers will get no pain relief

fast metabolizers may get toxic levels

107
Q

dose of morphine oral solution in kids

A

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
Q

what are important considerations when dosing anti epileptics in kids

A

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
Q

dosing of lorazepam for kids

A

0.1 mg/kg/dose SL or IV q10 min PRN

110
Q

which type of delivery should you use for asthma meds for kids

A

puffers and spacers more effective than nebs

MUST use spacer

111
Q

what should you do when you are diagnosing a kid with asthma for the first time

A

must do CXR at diagnosis to rule out other pathology (ie mediastinal mass)

112
Q

dosing of ventolin for kids

A

100mcg/puff, 1-2 puffs via spacer every 4 hours PRN

113
Q

dosing of flovent for kids

A

50-100 mcg BID

114
Q

what meds should you use for kids with atopic dermatitis

A

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
Q

how to discuss vaccine safety with parents

A

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
Q

how to discuss the fear of “antigen load” with parents

A

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
Q

what is the 4th-6th leading cause of death in the USA

A

adverse drug reactions

causes 7% of all hospital admissions

fatal reactions in over 100 000 hospitalized patients each year

118
Q

what is the GATC project

A

hypothesis that genetic polymorphisms can be associated with adverse drug reactions

119
Q

prior to widespread vaccine coverage, how many kids were usually infected by measles before age 15

A

90%

120
Q

measles incubation period

A

7-21 days

121
Q

how infective is measles

A

90% of those who are susceptible and in contact with carrier will get it

122
Q

what are the 4 Cs of measles infection

A

cough
coryza
conjunctivitis
Koplik spots

123
Q

how many people still die of measles worldwide

A

118 000-240 000 annually

pre vaccination–> in north american, 500 000 cases annually with 500 deaths–> 25% of kids hospitalized

124
Q

side effects of measles

A

pneumonia

encephalitis–> post infectious–> deafness, motor deficits, intellectual disabilities, death

death

subacute sclerosing panencephalitis –> rare but nearly always fatal

125
Q

what % must vaccinate to get herd immunity

A

95%

126
Q

what is canada’s overall vaccination rate

A

84%

fraser valley east–60-70%

127
Q

what are three things that contribute to vaccine hesitancy

A

confidence

complacency

convenience

128
Q

how many people’s lives are estimated to be saved each year from vaccines

A

approx 3 million a year

*investing in vaccines saves more money than it costs

129
Q

what are blasts

A

immature leukocytes

with rare exceptions, should NEVER be seen in peripheral blood

less than 5% blasts is normal

130
Q

what should you think if a lab result indicates blasts and pancytopenia

A

acute leukemia

leukemia has more than 25% blasts

131
Q

what are critical values?

A

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
Q

how long is the turnaround time for a malignant diagnosis

A

depends on degree of certainty and amount of details

acute leukemia–> hours

solid tumours–> 1-2 days

cytogenetics–> 1-3 days

133
Q

what are salter harris factures

A

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
Q

define salter harris type I fracture

A

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
Q

define salter harris type II fracture

A

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
Q

define salter harris type III fracture

A

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
Q

define salter harris type IV fracture

A

involved all 3 elements of the bone

like type III, in an intra-articular fracture and can thus result in chronic instability

138
Q

define salter harris type V fracture

A

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
Q

what is the standard trauma imaging screen

A

cervical XR
CXR
pelvic XR

140
Q

what is the lifetime additional risk of mortality from CT in kids

A

1/1000

kids are more radiosensitive than adults

141
Q

why are fractures sometimes harder to diagnose radiologically in kids

A

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
Q

what types of things can be detected antenatally by radiography that can then be dealt with

A

hydronephrosis

cardiac anomalies

143
Q

what types of things can be detected related to birth by radiography that can then be dealt with

A

hypoxic ischemic encephalopathy (HIE)

fractures

cephalohematoma

144
Q

when should you suspect hypertrophic pyloric stenosis clinically

A

NONbilious projectile vomiting

may be mass in abdomen

145
Q

in what age group do you see hypertrophic pyloric stenosis

A

only really ages of 3 weeks to 3 months

146
Q

what imaging modality do you use to diagnose hypertrophic pyloric stenosis

A

U/S

147
Q

what do you see on U/S in hypertrophic pyloric stenosis

A

pyloric muscle thickens to greater than 3 mm and the length of the pyloric canal is above 14 mm

148
Q

what imaging modality should you use to dx appendicitis in kids

A

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
Q

when should you suspect malrotation and volvulus in kids?

A

bilious vomiting

150
Q

what imaging is preferred in malrotation or volvulus

A

upper GI series with contrast

but U/S also has a role

151
Q

what are the most common type of intususseptions in kids

A

small into large bowel (typically ileum into cecum)

152
Q

in what age range is intususseption most common

A

3 months to 3 years old (if outside of this range, consider a pathological lead point)

153
Q

how do you treat intususseptions

A

air enema for reduction–done by rads, if successful can avoid surgery

154
Q

what % of intususseptions recurr within 24 hours

A

10%

155
Q

how do you diagnose hip dysplasia in infants/kids

A

dynamic hip U/S for developmental hip dysplasia–> imaged at 4-6 weeks old

want a normal angle which is under 60 degrees

156
Q

who should you scan for hip dysplasia

A

kids with weird births/breech

family history of hip dysplasia

positive ortolani or barlow maneuvers after birth

157
Q

how do you evaluate swallowing issues (either post traumatic or congenital) in kids

A

video-fluoroscopic swallowing studies (VFSS)

158
Q

what % of all new cancers in kids are leukemias

A

33%

159
Q

what are the cure rates for:

standard risk ALL

A

90%

160
Q

what are the cure rates for:

high risk ALL

A

above 75%

161
Q

what are the cure rates for:

AML

A

50-60% five year EFS

162
Q

who should you call when you suspect a diagnosis of pediatric leukemia

A

pediatric oncology at BCCH (phone line 24h/day)

163
Q

what further blood work is required when you suspect leukemia

A

blood cx if febrile

lytes
BUN
Cr
Ca
phosphate
uric acid
LDH
PTT
INR
d-dimer 
fibrinogen

CXR–>mediastinal mass?

164
Q

what is the immediate management of a suspected pediatric leukemia

A

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
Q

what is tumour lysis syndrome

A

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
Q

what should you follow when monitoring for tumour lysis syndrome

A

INCREASING uric acid, K+ and phosphate, with DECREASING calcium

167
Q

when does tumour lysis syndrome usually occur

A

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
Q

what are the signs and symptoms of tumour lysis syndrome

A

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
Q

how do you manage tumour lysis syndrome

A
  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
Q

what are indications for dialysis in kids

A
  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
Q

why do we care about hyperleukocytosis

A

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
Q

what is DIC

A

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
Q

what are the lab results indicative of DIC

A

increased PT, PTT and d dimer

decreased platelets, fibrinogen, clotting factors

174
Q

how do you manage DIC

A

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
Q

why do we get concerned about mediastinal masses

A

SVC syndrome

assess with CXR, DO NOT INTUBATE, let kids find their most comfortable position

176
Q

how should you manage febrile neutropenia in a child

A

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

177
Q

what bacterial infections do we worry about in febrile neutropenia

A

gram - enteric bacilli

meningococcus

pneumococcus

S. aureus

GAS

178
Q

what fungal infections do we worry about in febrile neutropenia

A

candida

cryptococcus

179
Q

what are the signs and symptoms of febrile neutropenia

A

septic shock may occur very quickly in neutropenic patients

fever or hypothermia

hypotension, tachy

decreased perfusion

respiratory distress–“grunting”

edema

180
Q

how to assess and monitor febrile neutropenia

A

must move quickly

frequent vitals (ABCs)

full physical to look for source

always take off diaper and central venous catheter dressing

181
Q

how do you manage febrile neutropenia in a child

A

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

182
Q

are pediatric codes usually cardiac?

A

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

183
Q

when should you transfuse the anemic pediatric patient

A

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

184
Q

when should you transfuse a pediatric patient with thrombocytopenia

A

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

185
Q

how to treat pediatric anaphylaxis

A

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)

186
Q

how is childhood leukemia managed in BC?

A

all come to bcch for dx and initiation of tx

diagnostic bone marrow and LP

central line placed by peds general surgeon

187
Q

what people are on the healthcare team involved in the management of childhood leukemia

A

oncologist

nurse

pediatric oncology fellows

social worker

physio

patient advocate

if needed: first nations advocate, spiritual care, nutritionist, psychologist

188
Q

once diagnosis is made at BCCH, how is AML managed

A

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

189
Q

once diagnosis is made at BCCH, how is ALL managed

A

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

PMP (9 decks)

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