You can do this! Flashcards
Most common organisms associated with viral gastroenteritis
Rotavirus Adenovirus Astrovirus Calicivirus Coronavirus Sapovirus Parvovirus
Top 3-4 are going to be Rotavirus Adenovirus Noravirus Coronavirus
Organisms associated with bacterial gastroenteritis
Staphylococcus E.Coli Campyobacter Salmonella Shigella Yersinia Vibrio Parahaemolyticus Aeromonas Bacillus Cereus Clostridium Perfringens C.Difficile
Protozoa and parasites associated with gastroenteritis that cause infection resulting in fluid loss and malabsorption
Cryptosporidium
Isospora
Cyclospora
Protozoa and parasites associated with gastroenteritis that directly infect the small bowel leading to malabsorption
Giardia
Enteromonas hominis
most common 3 symptoms for gastroenteritis
fever
vomiting
diarrhea
not all 3 are required to be present
diarrhea definitions
1) a normal BM that has increased in frequency and large water content
2) Stool output greater than 3 times per day (24 hours)
days to be acute diarrhea
<= 14 days
days to be persistent diarrhea
15-29 days
days to be chronic diarrhea
> =30 days
bloody diarrhea, vomiting, and periorbital edema or edema of extremities
should make you think about
HUS (Hemolytic Uremic syndrome)
Can ear infections be a reason for vomiting and/or diarrhea
yes
diarrhea, vomiting and oral lesions may be a sign of
IBD
certain viral illnesses
diarrhea, vomiting, fever, and erythema in the oropharynx or malodorous breath may be evidence of
sinusitis or pharyngitis
Pain in the RLQ should make you think
appendicitis
Pain in the LUQ may be associated with what organs
pancreas
Spleen
Pain at the costovertebral angle may indicate
kidney infection
Pain at the flank may be related to
pylonephritis
localized pain is a red flag that says what about gastroenteritis
that there is another cause for the pain other than gastroenteritis
maintenance ORS guidelines
Use for maintenance fluids
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea
plus regular diet
ORS for mild to moderate dehydration
severe requires IV fluid
first replace fluid deficits then maintain
50-100mL/kg over 2-4 hours
An additional
<10kg- 60mL-120mL for each episode of vomiting or diarrhea
>10kg - 120-240mL for each episode of vomiting or diarrhea
start small (5-10 mL) every 5-10 min and increase as tolerated
after replace losses and vomiting stops, resume diet and continue maintenance ORS
Probiotic use in gastroentritis
may shorten by 1 day
Lactobacillus rhamnosus GG (LGG) was most effective
Zinc in gastroenteritis
Not formally recommended by CDC but research shows potential reduction in diarrhea with improved outcomes
which organisms cultured from stool would a pt need to demonstrate several negative stool cultures before returning to school or daycare
Salmonella serotype Typhi
Shiga toxin-producing E.Coli (STEC)
E.Coli 0157:H7
Shigella
In general, other than Salmonella serotype Typhi Shiga toxin-producing E.Coli (STEC) E.Coli 0157:H7 Shigella
afebrile pts with gastroenteritis may return to school when?
when they have less than 3 episodes of loose stool a day
Which organism does the book point out as the cause for nearly 600,000 visits to HCPs , upwards of 70,000 hospitalizations and 20-70 deaths exceeding 1 billion in care costs
Rotavirus
Type of transmission for Gastroenteritis
Fecal-oral transmission
person to person…direct…fomites, ect
a right lower quadrant pain elicited by pressure applied on the left lower quadrant
Rovsing’s sign
appendicitis
Rovsing’s sign
a right lower quadrant pain elicited by pressure applied on the left lower quadrant
appendicitis
the point on the lower right quadrant of the abdomen at which tenderness is maximal
McBurney’s point
appendicitis
McBurney’s point
the point on the lower right quadrant of the abdomen at which tenderness is maximal
appendicitis
Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward
Psoas sign
appendicitis
Psoas sign
Pain is elicited by having the patient lie on his or her left side while the right thigh is flexed backward
appendicitis
discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward
Obturator sign
appendicitis
Obturator sign
discomfort felt by the subject/patient on the slow internal movement of the hip joint, while the right knee is flexed with lateral movement of flexed knee outward
appendicitis
What sign?
pain with coughing
Dunphy
appendicitis
Dunphy sign
pain with coughing
appendicitis
What sign
pain with heel drop
Markle sign
appendicitis
Markle sign
pain with heel drop
appendicitis
stool that has the appearance and consistency of liquid tar, is black in color and offensive in odor
Melena
The vast majority of patients with UGI bleeding have ________ or _____ secondary to _____
lesions of the GI mucosa
esophageal varices
liver disease
The vast majority of patients with UGI bleeding have lesions of the GI mucosa or esophageal varices secondary to liver disease
most common cause of colonic bleeding worldwide
Infectious colitis
an infant with GI bleeding who is fed cows milk or soy based formula may have
allergic collitis
A history of dry heaves followed by hematemesis or melena may suggest
Mallory Weiss tear
Recent illness with GI bleeding may lead you to what
HUS
Ingestion of ______ can lead to gastritis, duodenitis, or ileal and right colonic lesions
NSAIDS
Liver disease may be related to what inherited deficiency
Alpha 1 antitrypsin
what disease can be transmitted at birth and affect the liver
Hepatitis B
BRUE symptom with GI bleed…think…
UGI bleed such as esophagitis, gastritis or ulcer
Urgency to defecate or Tenesmus ( the feeling that you need to pass stools, even though your bowels are already empty) suggests
colitis
Delayed passage of meconium or constipation in infancy can be a sign of
Hirschsprung disease
Cystic Fibrosis
The presence of spider angiomata, palmar erythema, fetor hepaticus or splenomegaly suggests chronic ______ disease and _____ _____
Chronic liver disease
Portal Hypertension
If a pt is on antibiotics and getting no enteral nutrition, what should you be concerned with?
Killing the intestinal track’s vitamin K producing bacteria which will cause the patient’s prothrombin time (PT) to rise, resulting in a coagulopathy. Add NG suction to this perfect storm and you have an UGI bleed from the NG tube suction induced mucosal injury
GI bleed patient that you find a palpable moveable rectal mass on might identify _____ as a possible etiology
Polyps
what are some things that patients may ingest that can give the appearance of blood in stool
commercial dyes (#2 and #3)
Blueberries
Beets
Bismuth
what diagnostic exam is used if you suspect upper GI bleeding
upper endoscopy
what diagnostic exam is used if you suspect bright red lower GI bleeding
Colonoscopy
what organism is associated with bleeding duodenal or gastric ulcer
Helicobacter Pylori
What should occur with bleeding esophageal varices or varices that have recently bled
Should be sclerosed or banded to decrease risk of re-bleeding
what medication is used to decrease central venous pressure for management of bleeding esophageal varices before endoscopic intervention
Octreotide
In the case of variceal bleeding that is not controlled by endoscopic and/or tamponade intervention, what procedure is warranted
emergency transjugular intrahepatic portosystemic shunting (TIPS) or surgical shunting to decrease portal hypertension may be warranted
In patients with significant GI bleeding who the source was not detected by upper endoscopy and colonoscopy, what is next step
a nuclear medicine tagged RBC bleeding study to help find source of blood loss
(bleeding will have to be brisk enough to detect with this scan)
If actively bleeding, an angiogram with selective vessel embolization may be required
A single or double balloon enteroscopy may help identify a radiographically silent lesion or one beyond the reach of the conventional upper or lower endoscope
does a negative gastric lavage test with NGT rule out UGI bleed
No, bleeding may have stopped or pylorospasm could be preventing blood from a duodenal source from entering the stomach
Not routinely performed for a stable patient with formed brown guiac positive stools
why is continuous suction via NGT controversial in GI bleeds
can exacerbate bleeding
Polyps are removed with what during a colonoscopy
Electrocautery
When does GI bleeding resolve in Henoch-Schonlein Purpura (HSP) and HUS
with resolution of the disorders
UGI bleeds - when can the patient resume their diet
within 24 hours
Upper GI bleed discharge meds
PPI for gastritis
Beta blocker (propanolol) for esophageal varices
follow up with GI
lower GI bleeds will depend on the etiology of the bleed
upper GI bleeding differentials
infant vs young child vs older child/adolescent
Bolick chart pg 441
All ages
- Hemorrhagic gastritis/gastritis
- Stress ulcer
- Reflux esophagitis
Infant only
-Vascular malformation
Young child to adolescent
- gastric/duodenal ulcer
- Esophageal varices
- Epistaxis
- Mallory-Weiss tear
Young Child
- Foreign Body
- Toxic Ingestion
Lower GI bleeding differentials
infant vs young child vs older child/adolescent
Bolick chart pg 441
All ages
- Infectious colitis
- Anal fissures
Infant only
- Necrotizing enterocolitis
- Milk Protein Allergy
- Hirschsprung disease
- Lymphonodular hyperplasia
Infant and young child
- Midgut volvulus
- Intussusception
young child only
- Pseudomembranous colitis
- Ischemic colitis
young child through adolescence
- Hemorrhoid
- Ulcers
- Polyps
- Juvenile Polyps
- Hemolytic-uremic syndrome (HUS)
- Inflammatory bowel disease
- Henoch-Schonlein purpura (HSP)
- Meckel Diverticulum
- Angiodysplasia
- Graft-vs-host disease
older child through adolescence
-Bacterial enteritis
Pediatric end-stage liver disease scoring formula
PELD score = 1 x (0.48 x (bilirubin)) + (1.857 x (INR)) - (0.687 x (albumin)) + listing age factor + growth
Upper GI bleed vs Lower GI bleed is differentiated by the
Ligament of Treitz (located between jejunum and duodenum)
hematemesis is associated with upper or lower GI bleeding
upper
Hematochezia is associated with upper or lower GI bleeding
Lower
Most common intra- abdominal tumors in children
neuroblastoma and Wilms tumor
an ischemic and inflammatory disorder of the bowel most prominently seen in the jejunum, ileum, and colon primarily affecting premature infants after then initiation of enteral feeding.
Necrotizing enterocolitis (NEC)
What happens in NEC
intestinal injury then activates the gut’s inflammatory cascade, causing mucosal damage and allowing invasion of the bowel wall by bacteria
who is at highest risk for NEC
preterm infants in the first 6 weeks of life
more than 90% of cases occur in preterm infants born less than 32 weeks PCA and birth weights less than 1500gms
10% of NEC cases occur in term infants with underlying pre-existing illnesses such as congenital heart disease
Maternal risk factors associated with NEC
placental insufficiency
gestational hypertension with superimposed pre-eclampsia
maternal smoking
maternal infection/inflammatory conditions
shiga-toxin producing organism strain that causes gastroenteritis
E. coli O157:H7
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1222). Wolters Kluwer Health. Kindle Edition.
what organism for bacterial gastroenteritis is antibiotics contraindicated in treating
E. coli O157:H7
antidiarrheal medications for gastroenteritis for kids
Antidiarrheal medications often contain aspirin, which contributes to Reye syndrome and should be avoided.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1223). Wolters Kluwer Health. Kindle Edition.
causes of inflammatory bowel disease
Crohn disease
ulcerative colitis.
Meckel diverticulum (ectopic gastric mucosa) is most common in what age
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1224). Wolters Kluwer Health. Kindle Edition.
school aged children
coffee ground emesis….are you thinking upper or lower GI bleed
upper
Management of GI bleed, unstable
- Obtain IV access and administer fluid volume.
- Initial fluids: normal saline, lactated Ringer solution, and/or packed RBCs (PRBCs).
- NPO.
- Proton pump inhibitor; intravenously.
- Consider octreotide for bleeding esophageal varices; may also require banding via upper endoscopy.
- Consider vitamin K administration if coagulopathy noted.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1225-1226). Wolters Kluwer Health. Kindle Edition.
infant risk factors for NEC
gestational age birth weight less than 1500 gms nonhuman milk enteral feeding circulatory instability with associated GI ischemia Anemia with blood transfusion
clinical presentation of NEC
mild to gaseous abd distention feeding residuals - can be bilious or bloody vomiting bloody stools signs of shock
also can have lethargy episodes of apnea resp distress bradycardia desaturations temp instability
diagnostic for NEC
AP or Lat decub of abdomen may show ileus, dilated loops of bowel, pneumatosis intestinalis, ascites, intrahepatic portal venous air, persistent fixed loops of bowel and free air indicative of perforation
lab findings commonly found in NEC
metabolic acidosis thrombocytopenia neutropenia coagulopathies electrolyte disturbances
Management of NEC
decompression of bowel broad spectrum abx coverage for sepsis supportive care NPO collect blood cultures, urine, CSF
pneumatosis intestinalis on x ray
NEC
The infant with medical NEC will typically recover after
prolonged period of bowel rest (parenteral nutrition support)
empiric treatment for infection (7-10 days)
if they perforate they will need peritoneal drain or laparotomy of diseased segments of bowel
abd mass with weight loss, anorexia, fever, night sweats, and often easy bleeding or bruising
think neoplasm
abd mass with hx of bilious emesis or encopresis (fecal incontinence)
bowel obstruction
cola- colored urine and acholic stools
Urinary excretion of bile salts
associated with renal pathology of abd mass
RUQ masses most often involve
liver
gallbladder
biliary tree
Epigastric masses can include both
epigastric hernias
Diastasis recti
LUQ masses think
spleen
stomach
adrenal gland
kidney
R and LLQ masses may be from
ovarian and fallopian processes
or intestines in orgin
suprapubic masses are most commonly ____ in nature
genitourinary
mobility or immobility of abd mass suggest
degree of attachment or invasion of the retroperitoneum
immobile abd mass
invasive tumors or
masses that arise from the retroperitoneal organs
Tenderness to abd mass generally suggests
a recent change such as bleeding
Firmness, hardness and irregularity of an abd mass suggest either
tumor or
desmoplasia (scar)
smoothness of an abd mass suggests
encapsulated mass
Tympany indicates
gas such as in a hollow viscus
dullness indicates
fluid or solid mass
diagnostic imaging for Hepatobiliary and pancreatic masses
Neither US nor CT is effective at imagining the biliary and pancreatic ductal system HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
milk allergy typically presents how long after introduction of dairy into diet
within a week
types of benign cystic lesions (uncommon in children)- abd masses
choledochal cyst
polycystic kidney disease
duplication cyst
cystic teratoma
most common age of presentation of a neuroblastoma
18 months with the prevalence greatest in children <4 yrs
Most common renal tumor and 5th most common pediatric malignancy
Wilms tumor
Most common age of presentation of Wilms tumor
1-5 yrs
most common malignant liver tumor
Hepatoblastoma
mean age at diagnosis for hepatoblastoma
1 year old
What is hepatoblastoma associated with (increased risk factors)
extreme prematurity very low birth weight Beckwith-Wiedemann syndrome Gardner syndrome Familial Adenomatous Polyposis Disease
what is the preferred diagnostic test for neuroblastoma
CT
what race and gender is at highest risk for NEC
Black males
prevention for NEC
Breastfeeding
preliminary evidence shows probiotics
type of small bowel obstruction….
history of surgery
adhesive SBO
type of small bowel obstruction….
with bilious or feculent vomiting and no gas or stool
Complete obstruction
type of small bowel obstruction….
decreased stool and almost no gas
partial SBO
Bilious vomiting should always suspicious for
malrotation with volvulus
why? In pyloric stenosis, their vomitus never contains bile
because gastric outlet obstructed proximal to duodenum
Gastric peristaltic waves are often visible in LUQ in
pyloric stenosis
“olive” may be palpated
pyloric stenosis
Hypertrophied pylorus “olive” may be palpated
lab expectations in pyloric stenosis
Hyperchloremic, hypokalemic metabolic alkalosis, elevated BUN secondary to dehydration
xray in pyloric stenosis
xray- show huge stomach and diminished or absent gas in intestine
string sign
pyloric stenosis
treatment for pyloric stenosis
Hydration
electrolyte correction
Surgery - Pyloromyotomy (Ramstedt’s procedure)
Before surgery correct dehydration and hyperchloremic alkalosis
NS bolus followed by infusion of ½ NS containing 5% dextrose and KCl when urine output is observed
classic presentation age for pyloric stenosis
3-6 weeks old
Alvardado/MANTRELS rule
Appendicitis 1 point for each the following- -Migration of pain to RLQ -Anorexia -N/V -Rebound pain -Temp of at least 37.3 -WBC great then 75% neutrophils 2 points for each of -tenderness in RLQ and -leukocytosis greater than 10,000
Children with score of 4 or less- unlikely appy
Score of 7 or greater- increased likelihood
thick-walled appendix with surrounding fluid
Diameter over ___mm considered dx
6
most common reason for abd surgery in kids in the US
appendicitis
most common age and gender for appendicitis
Although it can occur at any age, it is most commonly diagnosed between 10 and 12 years of age and occurs more often in males than females.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.
a finger-like structure projecting from the cecum,
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1200). Wolters Kluwer Health. Kindle Edition.
Appendix
perforated appendicitis treatment
• Antibiotic therapy is generally prescribed for 5 to 7 days depending on patient response. Ceftriaxone and Flagyl for perforated appendix have proven to be adequate.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1204). Wolters Kluwer Health. Kindle Edition.
Characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, renal injury
HUS
Most common type of HUS
prodromal diarrheal illness (D+HUS)
Contaminated meat, fruit, veggie, or water with verotoxin producing E.coli (O157:H7) or Shigella → will have hemorrhagic enterocolitis and progress to HUS
what am I? presents without prodrome of diarrhea Can occur at any age More severe Can be secondary to infection (strep pneumo, HIV), genetic, medication, malignancy, SLE, pregnancy
Atypical HUS
Entercolitis with bloody stools, followed in 7-10days by weakness, lethargy, anuria/oliguria
Irritable, pallow, petechiae
Dehydration, however some children have volume overload (hypertension may occur)
CNS seizures in 25%, pancreatitis, cardiac dysfunction, colonic perforation
D+ HUS
Lab smear: microangiopathic hemolysis
Anemia, thrombocytopenia, schistocytes/helmet/burr cells on smear, incr LDH, incr indirect bili, incr AST, incr reticulocyte
Coombs test is NEGATIVE
Renal injury: elevated Cr, hematuria, proteinuria, pyuria, casts on UA
Leukocytosis, E coli stool culture, shiga toxin, elevated amylase/lipase
HUS
Treatment of HUS
Volume repletion
Hypertension control
Managing renal insufficiency – dialysis
RBC transfusions
DO NOT GIVE PLATELETS – may add to thrombotic microangiopathy
Only give if active hemorrhage or procedural
NO ABX OR ANTIDIARRHEAL – will make HUS worse
double bubble sign on x ray
volvulus
coffee bean sign on x ray
volvulus
swirl sign on CT
volvulus - diagnostic
an infant with acidosis and abdominal distension is most suspicious for
bowel obstruction
infant with aganglionic section of bowel
Hirschsprung’s disease
absence or obstruction (due to fibrosis) of the biliary tree, (extrahepatic) leading to intrahepatic bile duct obstruction and proliferation.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.
Biliary atresia
types of Biliary atresia
(1) syndromic BA and associated malformations (i.e., BA splenic malformation syndrome, cat-eye) and random malformations (e.g., esophageal atresia (EA), jejunal atresia, malrotation)
(2) cystic BA—cystic change in an obliterated biliary tract
(3) cytomegalovirus-associated BA, in which the infants have positive serology
(4) isolated BA (largest group of infants).
•Proposed nongenetic etiologies: infection, intrauterine infection, toxin exposure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1207). Wolters Kluwer Health. Kindle Edition.
physical exam findings in biliary atresia
jaundice
acholic stools
dark urine
labs
hyperbili
elevated LFT
infectious causes of biliary atresia
viral hepatitis TORCH Toxoplasmosis other agents Rubella Cytomegalovirus Herpes simplex
diagnostics for biliary atresia
• Radiologic evaluation. • Abdominal ultrasound: gallbladder noted to be absent or small. • Hepatobiliary scintigraphy, in which there is no excretion of the isotope detected in the intestine. • Confirmatory cholangiogram is done at the time of laparotomy/laparoscopy for surgical intervention.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.
surgical management for biliary atresia
• Kasai procedure or portoenterostomy. • Best results in children <2 months of age in experienced hands. •Excision of the extrahepatic biliary tract and anastomosis of a Roux-en-Y limb to the jejunal limb at the porta hepatis. •The goal of the procedure is to reestablish bile flow as evident by pigmented stool in the immediate postoperative period. •Deemed a successful operation if conjugated bilirubin level is <2 mg/dL at 3 months postop; long-term outcome is variable with a small percentage of children achieving lasting drainage that is effective. • Complications: bacterial cholangitis.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1208). Wolters Kluwer Health. Kindle Edition.
mutation in CFC1 gene
biliary atresia
most common indication for liver transplant
biliary atresia
biliary atresia nutritional requirements
- Nutrition. • Require 130% to 150% of the recommended daily allowance, and many require 150 kcal/kg/day to achieve appropriate growth. • May require formulas with increased medium chain triglycerides as they do not require bile acids for digestion (e.g., breastmilk, Pregestimil, or Portagen). • Supplement with fat-soluble vitamins (A, D, E, and K).
- Supplemental nocturnal feeds with a nasogastric (NG) tube may be necessary for growth failure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1208-1209). Wolters Kluwer Health. Kindle Edition.
Acute cholecystitis is often attributed to the presence of
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1210). Wolters Kluwer Health. Kindle Edition.
Gallstones
Hypoalbuminemia and abdominal mass may suggest
nonspecific but indicates significant illness
Uric acid and LDH plus abdominal mass may indicate
Solid tumors
Abdominal mass plus BUN and Creatinine may indicate
Renal dx
Abdominal mass plus elevated amylase and lipase levels may indicate
pancreatic dx
Abdominal mass plus elevated LFTs think
Liver dx
2 view abd x ray with abdominal mass will show things such as
Intestinal obstruction
fecal impaction
calcifications associated with tumor
US in the setting of abdominal mass may be used to
identify origin of the mass
solid vs cystic
can help further lab testing and imaging
CT scan with IV contrast in the setting of abdominal mass may be used to
- evaluate solid abd mass
- vascular abnormalities
- associated lymph nodes
- stage many types of cancers
- helps with cystic mass to see if there is continuity with bowel or bladder
- Not helpful if mass of primary bowel or bladder -> Fluoroscopic studies such as UGI series, BE and voiding cystourethrogram
- Oral contrast will cause artifact to the bowel and bladder
best diagnostic exam for abdominal mass of primary bowel or bladder
Fluoroscopic studies such as UGI series, BE and voiding
what diagnostic is used for hepatobiliary and pancreatic masses?
- Neither US nor CT is effective at imagining the biliary and pancreatic ductal system
- HIDA scan (Hepatobiliary iminodiacetic acid)- traditionally used first now have MRCP (magnetic resonance cholangiopancreatography is now used for hepatobiliary and pancreatic disease
radiograph after standing for 2 minutes has maximum sensitivity for free gas suggesting perforation. (Bowel perforation)
Abdominal X-ray- upright chest radiograph
radiograph that has better sensitivity than other radiograph views because gas collects around the liver. Looking for bowel perforation
Left lateral decubitus
Radiograph useful for proximal bowel obstruction
Upper GI contrast series
imaging Usually appropriate if the abdominal radiograph or physical examination suggests distal bowel obstruction (as might be seen in Hirschsprung disease).
contrast enema
imaging used to determine bowel obstruction site
CT with IV contrast. Do not use contrast if suspect perforation
on imaging you see numerous air fluid levels, distended bowel normally more central
what does this sound like
small bowel obstruction
on imaging you see few to no air fluid levels. Distended bowel normally more peripheral
Large bowel obstruction
what type of obstruction?
a small bowel obstruction in a patient who has had surgery or a severe infection of the abdominal cavity
Adhesive bowel obstruction
what type of bowel obstruction?
there will be bilious and feculent vomiting with no gas or stool passage per anus
Complete bowel obstruction
what type of bowel obstruction??
decreased stool passage and almost no gas passage
Partial bowel obstruction
causes of functional bowel obstruction
Abd surgery Peritonitis Sepsis Trauma Medications (opioids, anxiolytics) Metabolic imbalances (hypokalemia, hyponatremia, hypomagnesemia, acidosis)
causes of mechanical bowel obstruction
Postoperative adhesions Hematoma Intussusception Distal intestinal obstruction syndrome Malrotation with volvulus Tumors Bezoar Congenital abnormalities: -Duodenal atresia -Duodenal web -Annular pancreas -Jejunoileal atresia
an obstruction caused by a loop in the intestines that twists around itself and surrounding mesentery
Volvulus
volvulus that happens in the last part of the large intestines leading to the rectum
Sigmoid volvulus
volvulus that happens in the beginning part of the large intestines
cecal volvulus
volvulus that happens in the small intestines
midgut volvulus
which type of volvulus is the most common type?
sigmoid volvulus
occurs when small bowel twists around the superior mesenteric artery, resulting in vascular compromise to large portions of the midgut.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
Volvulus
______volvulus may lead to widespread intestinal ischemia and progress rapidly to necrosis of the bowel, perforation, shock respiratory failure, and death.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
Midgut
At approximately the _____week of embryonic life, the gut begins to change from a straight-line structure to an elongated tube herniating into the umbilical cord.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1242). Wolters Kluwer Health. Kindle Edition.
4th
Abdominal rotation and attachments are complete by __ months’ gestation.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
3
______ occurs when the bowel fails to rotate after it returns to the abdominal cavity.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
Malrotation
Presentation of malrotation is usually when and how does it appear?
Presentation of infants older infants children adolescents
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
in the first year of life with symptoms of acute or chronic bowel obstruction.
Infants present within the first week of life with bilious emesis and acute bowel obstruction.
Older infants present with episodes of recurrent colicky abdominal pain.
Children may present with recurrent episodes of vomiting, abdominal pain, or both.
•Occasionally, patients may present with malabsorption or protein-losing enteropathy associated with bacterial overgrowth. Symptoms are caused by intermittent volvulus or duodenal compression by Ladd bands or other adhesive bands affecting the small and large bowel.
25-50% of adolescents with malrotation are asymptomatic
Symptomatic adolescents present with acute intestinal obstruction of history of recurrent episodes of abdominal pain with less frequent vomiting and diarrhea.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1243). Wolters Kluwer Health. Kindle Edition.
If you suspect malrotation what labs are you ordering?
what is diagnostic?
CBC
type and screen
electrolytes (imbalances secondary to vomiting and 3rd spacing fluid into the bowel and abd cavity)
anemia can be caused by pooling of blood intestines
-Flat and upright or lat decub abd x rays - evaluates for intestinal obstruction but cannot diagnose malrotation
Upper GI Series is the preferred study to evaluate the position of the ligament of Trietz
•If malrotation exists, UGI will show abnormal position of the ligament of Trietz, partial obstruction of the duodenum, with a spiral or corkscrew appearance, and proximal jejunum in the right abdomen.
•When volvulus is present, the barium column is noted to end in a peculiar beaking effect and pathognomonic for a volvulus.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1244). Wolters Kluwer Health. Kindle Edition.
management of Malrotation with volvulus
emergent LADD procedure
Preop management for Malrotation with volvulus
cardiopulmonary and circulatory resuscitation. A gastric decompression tube should be placed, along with the administration of broad-spectrum antibiotics, to cover gut flora.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1244-1245). Wolters Kluwer Health. Kindle Edition.
bilious vomiting in a neonate is highly suspicious for
malrotation with volvulus until proven otherwise
cecal volvulus usually occurs in what age group
young adults
______ volvulus is most commonly seen in babies and small children
midgut volvulus
coffee bean sign on x ray
volvulus
birds beak shape on barium enema
volvulus
sigmoid volvulus is usually treated with
sigmoidoscopy
A _______ may be used to resolve a cecal volvulus
Colonoscopy
A colonoscopy cannot be used to treat a _____ volvulus
midgut
The most common presenting symptom in Chrohn’s disease
is abdominal pain. Pain is commonly crampy, epigastric or periumbilical, and intermittent
increases the risk of IBD
smoking
oral contraception
infectious colitis
infectious agents
treatment of Chrohn’s disease
Aminosalicylates; oral or IV steroids are more important in reducing remission.
is an umbrella term for Crohn disease and ulcerative colitis, which are inflammatory processes of the GI tract with very similar presentations.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Inflammatory Bowel Disease
•The difference between Crohn disease and Ulcerative Colitis is
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
based on the location and characteristics of the inflammation.
inflammatory process that can affect any portion of the GI tract. Most commonly affects the terminal ileum. The inflammation is in the entire lumen of the intestines.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
•Crohn Disease:
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
inflammatory process that affects the colon and rectum. The inflammation is in the mucosal layer of the intestinal wall.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis:
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1235). Wolters Kluwer Health. Kindle Edition.
Inflammatory bowel disease is most commonly diagnosed between ____ and ____ age with a second peak between 50-80 yrs of age
15 and 30
genetic predisposition that is turned on by environmental factors that causes an excessive immune response that results in chronic intestinal inflammation.
pain, diarrhea, weight loss, perirectal inflammation with fistula.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.
Crohn disease
bloody, watery diarrhea, weight loss, tenesmus, and urgency.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1236). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis
gold standard diagnosis of IBD
Endoscopy of the intestinal tract with biopsy and histology
Labs in IBD workup
CBC ESR CRP LFT GGT IBD serology Stool studies looking for infectious etiology of diarrhea
induction of remission in IBD
- Corticosteroids are used as first-line therapy for induction and remission after an IBD flare-up. During induction of remission, all maintenance medications are continued because they have the ability to induce remission or help the action of the corticosteroids.
- Exclusive PN for 8 weeks with bowel rest. This therapy has a similar remission rate as corticosteroids with less side effects.
- Biologic agents (e.g., Infliximab) are used for severe inflammation or refractory to other treatments to help induce remission.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1236-1237). Wolters Kluwer Health. Kindle Edition.
Maintenance of remission in IBD
• Immunosuppressive medications are used to maintain remission because of slow onset of action. • Aminosalicylates (5-ASA) reduce inflammation to maintain remission in mild UC and Crohn disease. • Immunosuppressive therapy should be started while still on steroid treatments; steroids are then tapered. • Supplementary nutrition with any treatment. Probiotics are useful as adjunct therapy. • Antibiotics have a role in treating perirectal fistula or abscess in Crohn disease. •Surgical intervention is appropriate for patients with refractory disease, uncontrolled GI bleeding, bowel perforation, or stricture causing an obstruction, with bowel resection being the last option. •Total colectomy in UC with J-pouch is the surgical treatment of refractory disease, toxic megacolon, perforation, or severe colitis. In UC, a total colectomy can be curative. •Resection of a stricture or area of colitis in Crohn disease is the surgical treatment. In severe cases when the intestines become perforated, an ostomy is required.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1237). Wolters Kluwer Health. Kindle Edition.
Ulcerative colitis is most commonly seen in what age group
20-30 yrs old
Ulcerative colitis symptoms
Systemic:
- Fatigue
- Fever
- Weight Loss
- Dyspnea
- Palpitations (iron def anemia secondary to blood loss)
GI
- Bloody Diarrhea
- Colicky Abd pain
- Tenesmus
Extraintestinal
- Arthritis
- Uveitis
- Episcleritis
- Skin Lesions (pyoderma gangrenosum & erythema nodosum)
- Primary sclerosing cholangitis
- Venous/Arterial Thromboemboli
Acute complications of UC
Severe GI bleeding Fulminant colitis (bleeding with more than 10 stools per day) Toxic megacolon (nerves and muscles damaged with the colon atonic and dilated) -> can lead to perforation with peritonitis (fevers and severe abd pain)
Long term complications of UC
- increased risk for colorectal cancer
- strictures ->rectosigmoid colon which can lead to bowel obstruction
Chrohns disease symptoms
Systemic
- Fatigue
- Fever
- Weight loss
Gastrointestinal
- Crampy abd pain
- Watery diarrhea
- Malabsorption symptoms (Steatorrhea)
- Fistulas (Communication between 2 epithelial organs)
- Phlegmon -> abscess
- oral (ulcers, gingivitis)
- Gallstones (biliary colic
Extraintestinal
- Arthritis
- Uveitis
- Episcleritis
- Skin Lesions (pyoderma gangrenosum & erythema nodosum)
- Primary sclerosing cholangitis
- Venous/Arterial Thromboemboli
- Kidney stones
string sign
strictures
can be seen in Crohns disease
skip lesions
Chrohns disease
not seen in UC
IBD with ileal involvement
common in Crohns disease
not seen in UC
IBD with fistulas
Common in Chrohns disease
very rare in UC
smoking decreases risk of
UC
increases risk of CD
an ilieus is a
non-mechanical obstruction of the intestines (caused by a disruption of peristalsis that can be partial or complete resulting in dilation of proximal intestines
Most common cause of an ileus is form
manipulation of intestines during surgery
clinical presentation of ilieus
Abd distention
absent/hypoactive bowel sounds
pain
vomiting
diagnostic for ileus
abd x ray
management of ileus
Bowel rest
decompression with NG
Adequate postop pain management w/non-narcotic meds
Routine postop care to include ambulation and time
if an infant doesnt pass meconium within first 48 hrs abd distension refuses to feed bilious vomiting what should be on your differential
Imperforate anus
Meconium ileus
Hirschsprung’s disease
VACTERL Syndrome
Vertebral defects Anal atresia Cardiac anomalies Tracheoesophageal fistula Esophageal atresia renal anomalies limb anomalies
meconium ileus is seen with what disease process
Cystic fibrosis
what test is for cystic fibrosis if newborn screening test isnt back yet
Abnormal sweat chloride test
>60mmol/L
on exam the newborn has a empty rectum with no meconium and with normal sphincter tone
Meconium ileus which is a surgical emergency
Abd x ray
Dilated bowel loops
“Soap Bubble”/”Ground Glass” appearance
Meconium ileus
Squirt sign or blast sign
explosive of gas or liquid stool after digital rectal exam (relieves obstruction temporality) in Hirschsprung’s
anorectal maonometry will show failure of anal sphincter to relax
Hirschsprung’s
Disease is due to injury to the mucosa of the small intestine caused by ingestion of gluten (protein component) from wheat, barley, rye, and related gains (causes flattening of the finger-like villi in the small intestine that are used for absorption)
Celiac disease
celiac disease is associated with what other diseases and syndromes
Type I DM
Thyroiditis
Turner’s syndrome
Trisomy 21
Diagnostic for Celiac
Biopsy diagnostics: villus atrophy; screening with IgA antitissue transglutaminase and antigliadin; resolution of symptoms with gluten elimination and relapse on oral challenge
clinical manifestations of celiac disease
Chronic diarrhea, irritability, decreased appetite, malabsorption, abdominal distension, flatulence, FTT, weight loss, ascites caused by hypoproteinemia
Other symptoms can include osteopenia, arthritis or arthralgias, ataxia, dental enamel defects, elevated liver enzymes, dermatitis herpetiformis, and erythema nodosum
what should be considered in Should be considered in any child with chronic abdominal complaints, short stature, poor weight gain, or delayed puberty
Celiac
Serological markers for celiac
IgA antiendomysial antibody
IgA tissue transglutaminase antibody (ANTI -tTG)
IgA deficient - Use IgG screening test
Biopsy for celiac
Small bowel biopsy essential to confirm the diagnosis and should be performed while patient still ingesting gluten
Biopsy shows various degrees or villous atrophy (short or absent villi), mucosal inflammation, crypt hyperplasia, and increased numbers of intraepithelial lymphocytes
treatment for celiac
Elimination of gluten from diet
what skin rash can be seen in celiac
Dermatitis herpetiformis
Celiac disease increases risk of
small bowel cancer
T-cell lymphoma
due to chronic inflammation and immune system activation
infection responsible for most ulcers in stomach and duodenum in adults; plays a lesser role in childhood ulcer disease
H.Pylori
What drugs put you at higher risk for Peptic ulcer disease
NSAIDS
Tobacco
Bisphosphonates
Potassium supplements
other than meds, what other risk factors for PUD
Family history sepsis head trauma burn injury hypotension
symptoms of peptic ulcer disease
- “Alarm” symptoms (GI bleeding, weight loss, early satiety, dysphagia or odynophagia, family history of upper GI malignancy, iron deficiency anemia or new upper GI symptoms in patients older than 55)
- Weight loss, hematemesis, melena (heme-positive stools), chronic vomiting, microcytic anemia, nocturnal pain
what type of ulcers?
pain occurs several hours after meals and often awakes patient at night; eating tends to relieve the pain
Duodenal ulcers
Gastric and duodenal ulcers heal in 4-8 weeks in 80% patients
what type of ulcers?
pain aggravated by eating, resulting in weight loss, GI bleeding can occur; symptom relief with antacids or acid blockers
Gastric ulcers
Gastric and duodenal ulcers heal in 4-8 weeks in 80% patients
diagnostics for Peptic ulcer disease
Endoscopy mandatory with alarm symptoms
Test for H. Pylori
CBC, ESR, amylase, lipase, abd US
-“Alarm” symptoms (GI bleeding, weight loss, early satiety, dysphagia or odynophagia, family history of upper GI malignancy, iron deficiency anemia or new upper GI symptoms in patients older than 55)
H-Pylori treatment with ulcers. regimen is twice daily for 1-2 weeks
- Omeprazole (Prilosec)-clarithromycin-metronidazole (flagyl)
- Omeprazole- amoxicillin- clarithromycin
- Omeprazole-amoxicillin-metronidazole
- Other Proton pump inhibitors (PPI) may be substituted when necessary and bismuth compounds may also be considered
- Tetracycline useful in adults but should be avoided in children less than 8 yo
Treatment for PUD with no H. Pylori
PPI
syndrome that causes a tumor leading to duodenal ulcers
Zollinger-Ellison syndrome
Risk factors for GERD
neurologic impairment, obesity, repaired EA or other congenital esophageal disease, cystic fibrosis, hiatal hernia, repaired achalasia, family history of gastroesophageal reflux disease (GERD).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.
the symptoms or complications of gastroesophageal reflux.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.
GERD
Gastroesophageal reflux: the movement of gastric contents into the esophagus.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.
irritants of peptic ulcers
NSAIDS
Alcohol
Tobacco
Caffeine
Primary cause is transient relaxation of the lower esophageal sphincter, which allows gastric contents to move into the esophagus.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1218). Wolters Kluwer Health. Kindle Edition.
Gastroesophageal reflux
GERD
clinical presentation of GERD
• Poor weight gain, feeding aversion. • Unexplained crying, choking, or coughing. • Sleep disturbances. • Gagging. • Regurgitating. Dental erosion (older child). -Dystonic head positioning (Sandifer syndrome) -Abdominal or chest pain (older child)
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1219). Wolters Kluwer Health. Kindle Edition.
GERD infant managment (non-pharmacologic)
• Elevate head of crib 30°; can use reflux wedge, avoidance of overfeeding, upright position for 30 minutes after feeding. • Consider a 1-to-2 week trial of hypoallergenic formula. • Increase caloric density of formula, or consider tube feeding if poor weight gain.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1219-1220). Wolters Kluwer Health. Kindle Edition.
GERD child or adolescent non pharmacologic managemment
- Elevated head of bed, left-sided positioning, avoidance of caffeine, chocolate, fatty or spicy foods, carbonated beverages.
- Small frequent meals, avoid eating 2 to 3 hours before bedtime. • Lose weight if overweight.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.
medication management for GERD
• H2 blockers are generally first-line choice, especially for infants. • Proton pump inhibitors; not indicated for infants <1 year of age. • Prokinetic agents can be used to promote stomach emptying.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.
surgical management for GERD
•Nissen fundoplication—the fundus of the stomach is wrapped around the lower esophagus to improve function of the lower esophageal sphincter. • Complication rates are higher in neurologically impaired children. •Due to the risk of complications, usually reserved for those children with multiple pneumonia episodes felt to be related to aspiration and those with intractable reflux unresponsive to medical therapy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1220). Wolters Kluwer Health. Kindle Edition.
one of the most common causes of vomiting in infant
pyloric stenosis
Vomiting secondary to gastric outlet obstruction from hypertrophied pyloric muscle and subsequent gastric outlet obstruction.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1252). Wolters Kluwer Health. Kindle Edition.
Pyloric stenosis
onset of symptoms age for pyloric stenosis
2-8 weeks of age with peak at 3-5 weeks
common findings on chemistry in pyloric stenosis
Hypochloremia
hypokalemia
hyperbilirubinemia
•Peristaltic waves may be visualized across the abdomen. •Olive-sized mass may be palpated in right upper quadrant.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1253). Wolters Kluwer Health. Kindle Edition.
Pyloric stenosis
diagnostic confirmed for Pyloric stenosis with
abdominal US
How do we fix pyloric stenosis
Pyloromyotomy either open or laparoscopically - splits the pyloric muscle to increase diameter and gastric emptying
After a pyloromyotomy, when can feedings restart
once gastric contents are able to empty into duodenum, usually 6 hours postop
Telescoping of segment of proximal bowel into downstool bowel, usually occur between 1-2 yrs old
Intussusception
symptoms of Intussusception
Sudden onset of crampy abdominal pain- infants knees draw up and infant cries out and exhibits pallor with colicky pattern occurring every 15-20 minutes
Feedings are refused
As it progresses and becomes prolonged- bilious vomiting and dilated fatigued intestine generate less pressure and less pain
Currant jelly stools
Lethargy – glassy eyes and groggy infant
Sausage shaped mass palpable in RUQ or epigastrium
imaging for Intussusception
Abdominal US
Pneumatic or contrast enema under fluoroscopy – can be used to identify and treat intussusception
Air and barium
most common cause of intestinal obstruction in infants and children. It can lead to intestinal death and high morbidity if untreated.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1237). Wolters Kluwer Health. Kindle Edition.
Intussusception
who is Intussusception most commonly seen in
slight increase among white males
idiopathic Intussusception is most common in what age group
infants and young children
idiopathic Intussusception - association with what?
recent URI or gastroenteritis
Lead point intussusception is most common in what age
5-14 years
Lead point intussusception - increased risk with what
Meckel diverticulum Polyps cyst carcinoid tumors foreign bodies hemangioma Non-hodgkins lymphoma Intestinal hematomas Henoch-schonlein purpura
Postsurgical intussusception is typically seen after
abd or chest surgery from decreased motility after anesthesia
in babies what is the leading edge most often from that causes intussusception
Lymphoid hyperplasia (enlargement of lymph tissue such as peyers patches)
sausage like mass in abdomen
intussusception
intussusception can lead to what complication
obstruction and even volvulus
Bull’s eye sign
intussusception
a congenital defect in which there is interruption of the continuity of the esophagus; the esophagus ends in a blind pouch;
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1213). Wolters Kluwer Health. Kindle Edition.
Esophageal atresia
Esophageal atresia
Type A is
EA without fistula
Esophageal atresia
Type B is
EA with proximal fistula
Esophageal atresia
Type C is
EA with distal fistula; most common type
Esophageal atresia
Type D is
EA with proximal and distal fistulas
Esophageal atresia
Type E is
Tracheoesophageal fistula without atresia
•Newborn with excessive oral secretions, drooling, accompanied by coughing, choking, or sneezing. • Feeding can cause cyanosis, choking, and emesis.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1214). Wolters Kluwer Health. Kindle Edition.
Esophageal atresia
diagnostic for Esophageal atresia
•Failure to pass NG or orogastric tube into the stomach. •Chest radiograph—anteroposterior and lateral, which demonstrates NG tube coiled in upper esophagus. •Assess for VACTERAL (Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, and Limb anomalies) association.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1214). Wolters Kluwer Health. Kindle Edition.
Most pt with an esophageal atresia have a
Tracheoesophageal fistula
In Esophageal atresia The end of the oral gastric tube is typically observed at the ___ to ____ level
T2 to T4
when air is seen in the stomach and bowel with a esophageal atresia, the presence of what is confirmed
distal fistula
However a gasless abdomen on CXR does not negate the presence of a fistula. The TEF can be proximal
Holiday-Segar Method:
1-10 kg= 100 mL/kg/day
10-20 kg= add 1,000 mL + 50 mL/kg/day for every kg greater than 10
> 20 kg= 1,500 mL + 20 mL/kg/day for every kg greater than 20
421 method
4 mL/kg/hr for 1st 10 kg
Example: a 10kg pt would receive 40 mL/hr
2 mL/kg/hr for next 10 kg
Example: a 20kg pt would receive 60 mL/hr
1 mL/kg/hr thereafter
Example: a 30kg pt would receive 70 mL/hr
BSA method
Used for pts who are 10 kg or over
1600 mL/m2/day
which maintenance fluid calculation method is the most accurate
BSA
standard formula or breastmilk has how many kcal/oz
20 kcal/oz
Fortified formula/EBM has how many kcal/oz
22-30 kcal/oz
Pediasure has how many kcal/oz
30kcal/oz
If you have 20kcal in 1 oz
how many kcal in 1 mL
20 divided by 30
= 0.66Kcal/mL
most common type of dehydration, often related to gastroenteritis where losses of water and salt in stool are typically balanced
isonatremic
type of dehydration?
If patient also has vomiting and more loss of water than salt occurs (most dangerous d/t neurologic damage)
Hypernatremic
type of dehydration?
Results from loss of fluid, especially salt, in stool or sweat
Hyponatremic
tachycardia is present in what degree of dehydration
moderate and severe
Palpable pulses are decreased in what degree of dehydration
severe
weak pulses in moderate
Orthostatic hypotension is seen in what degree of dehydration
moderate
Hypotension is seen in what degree of dehydration
severe
absent tears are seen in what degree of dehydration
severe
in Hyperchloremic dehydration what is the preferred fluid replacement
LR
advantage of LR over NS
NS will make you more acidotic. pH of NS is 5.7, pH of LR is 6.75
what increases insensible losses
Fever (12.5% per degree >38 C) heat sweating tachypnea/hyperventilation vomiting/diarrhea Hyperosmolar states (dehydration and DKA)
what decreases insensible losses
Renal failure
Humidity
Hypothermia
Hypometabolic states
Standard of care of care for diagnosis of pyloric stenosis and intussusception
US
Reserved for either treatment or diagnostic uncertainty when US cannot diagnose pyloric stenosis or intussusception
Fluoroscopy
Excellent for imaging the biliary tree, gallstone dx
MRI
Diagnosing appendicitis
CT
diagnosing pancreatitis
Acute is a result of inflammation from injury/insult. Diagnosed by having at least 2 of the 3 symptoms=
Abdominal pain (or surrogate symptoms such as irritability or listlessness)
Elevation of serum pancreatic enzymes
Radiological findings
what diagnostic test?
•Used to assess colon for etiology of obstruction, some problems include intestinal atresia and Hirschsprung disease.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1255). Wolters Kluwer Health. Kindle Edition.
Air or barium enema
a plain frontal supine radiograph of the abdomen that visualizes from the diaphragm to the bladder. A KUB will aid in observation of calcifications, gas patterns, feces, or free peritoneal air.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1257). Wolters Kluwer Health. Kindle Edition.
KUB
•Useful study in detecting GI conditions as well as assessment of indwelling devices (e.g., NG tubes, jejunal tubes).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1257-1258). Wolters Kluwer Health. Kindle Edition.
KUB
where is olive shaped mass found in pyloric stenosis
epigastric
Amylase levels are ____ for first 2 months of life
low
Children up to age ___ have virtually no pancreatic amylase
2
Adult amylase levels may not be reached until
later school-age or adolescent years
Kidney insufficiency may lead to hyper/hypo amylasemia
hyperamylasemia
what labs are elevated in pancreatitis
amylase
lipase
other labs affected:
hypocalcemia, transient hypoglycemia, hyperbilirubinemia (d/t possible obstruction of pancreatic duct), increased LFTs, and hypoalbuminemia may be found in conjunction with pancreatitis.
imaging of choice for pancreatitis
US
imaging for chronic pancreatitis
ERCP- invasive; sedation is required
Used for chronic pancreatitis to visualize anatomy, perform manometry of sphincter of Oddi, perform therapeutic maneuvers when indicated
Should be avoided during an acute attack of pancreatitis
Na level
135-145
sodium is key in what body functions
key to skeletal muscle function, nerve, and myocardial action potentials
causes of hyponatremia
Hypervolemia -> renal failure, nephrotic syndrome, CHF, and water intox
Hypovolemic - renal losses, diuretic use, diarrhea, vomiting, burns
Normovolemic -> CNS diseases like cerebral salt wasting or meningitis
Presentation of hyponatremia
nausea, lethargy, seizures, coma
Treatment goals for raising sodium in hyponatremia
Raise 2-4 mEq/L every 4 hours (10-20 in 24 hours)
If comes in seizing - get to 125 quickly with HTS (3%)
Formula - 0.6x (wt in kg) x (target Na - measured Na)
causes of hypernatremia
- Excessive Na intake
- Inappropriately concentrated formula
- Excessive free H2O loss→ -breastfeeding failure,
- –diarrhea,
- DI
presentation of hypernatremia
weakness, lethargy, decreased DTR’s, irritability, muscle cramps, renal failure, AMS, seizures
diagnostic for hyper/hyponatremia
serum Na and osmols
treating hypernatremia
Avoid decreasing more than 12-15 mEq/L in 24 hours→ risk for cerebral edema
If hypovolemic, calculate free water deficit= 0.6 X kg X (current Na/desired Na) - (0.6 X wt kg)
-This is how much water they’ll need in the next 24 hours. Can give free water PO or via NGT. Be careful if decreasing with IV because D5W will bring level down fast→ check lytes every 2-4 hours. Will typically continue with maintenance of ½ NS or ¼ NS with D5W Y’ed in so that Na level is brought down slower.
beta blocker ingestion…looking for
bradycardia
hypotension
treatment in beta blocker ingestion
- Glucagon IV dosed at 0.05-0.1mg/kg bolus with a maximum of 5mg; may be followed by an ongoing IV infusion or response dose over 1 hour.
- Improves bradycardia and hypotension via noradrenergic pathway & may cause vomiting & hypokalemia.
- Nelson says initial bolus is 0.15 mg/kg IV, followed by infusion of 0.05-0.15 mg/kg/hr
Calcium channel blocker ingestion
watch for
bradycardia
hypotension
treatment for CCB ingestion
- Glucagon IV dosed at 0.05-0.1mg/kg bolus with a maximum of 5mg; may be followed by an ongoing IV infusion or response dose over 1 hour.
- Improves bradycardia and hypotension via noradrenergic pathway & may cause vomiting & hypokalemia.
- According to Nelson, can also use calcium chloride 10% IV/IO: 20 mg/kg; maximum single dose 2 g; administer slowly
Salicylate ingestion….what meds are these?
Encompasses a variety of prescription & non-prescription agents with aspirin, also known as salicylic acid (ASA). Other examples include methyl salicylate (oil of wintergreen), trolamine salicylate (muscle rubs), bismuth subsalicylate (GI preparations), salicylic acid (acne preparations, corn & wart removers), and magnesium salicylate (backache and pain relief medication).
toxic dose for salicylate ingestion
refer to ED for greater than 150mg/kg or 6.5g of ASA equivalent
ingestions of 300-500mg/kg are associated with serious tox
Chronic dose of > 100mg/kg/day for 2 days also will produce tox
metabolic derangement seen in salicylate tox
wide anion gap metabolic acidosis
resp alkalosis may occur due to direct stim of resp center
exposure to _____ can increase risk of pyloric stenosis
Erythromycin
what medication in maternal while pregnant is associated with pyloric stenosis for neonates
fluoroquinolones
-floxacin
electrolyte concerns in salicylate toxicity
hypoglycemia
hypokalemia (increased renal excretion)
symptoms of salicylate tox
n/v hematemesis gastric pain tinnitus impaired hearing tachypnea tachycardia dehydration diaphoresis fever
serious tox
- delirium
- seizures
- coma
- metabolic acidosis
- rhabdomyolysis
- noncardiogenic pulmonary edema
- arrhythmias
- asystole
what syndrome can mimic salicylate tox
Reye syndrome
- vomiting
- hypoglycemia
- hepatic dysfunction
- encephalopathy
salicylate tox. How often do you check levels
Q2 hours until a peak is determined and Q4 hours thereafter
treatment for salicylate tox
follow salicylate levels Q2 until peaks then Q4 hours
IV fluids
Wide anion gap metabolic acidosis - correct with IV sodium bicarb at 1-2 meq/kg
correct hypoglycemia with IV dextrose
manage seizures with IV benzos
get x ray and monitor for non-cardiac pulmonary edema - if intubated - important to hyperventilate to maintain a high arterial pH - to prevent salicylates from crossing BBB
Because salicylates become more ionized as the urine pH rises, enhanced urinary excretion of salicylates may be achieved via administration of IV sodium bicarb with potassium chloride, with a goal of alkalinization of the urine to target pH of 7.5-8à known as ion trapping
Obtain arterial blood gases, electrolytes, and urine pH frequently (Q4-6H) to guide therapy.
Urine alkalinization can be terminated when salicylate levels fall below 30mg/dL
Emergent hemodialysis can be necessary to enhance elimination of high salicylate blood levels and correct fluid electrolyte & acid-base abnormalities
Indications of HD include: salicylate levels approaching 100mg/dL in acute ingestions OR 40-60mg/dL in chronic supratherapeutic ingestions, pulmonary edema, CV instability, seizures, AMS, or intractable acidosis or electrolyte abnormalities.
what med class?
amitriptyline, clomipramine, desipramine, doxepin, imipramine, and nortriptyline
Tricyclics
toxic dose of tricyclics
- All TCAs except for desipramine, nortriptyline, trimipramine, and protriptyline were > 5mg/kg.
- Desipramine, nortriptyline, trimipramine > 2.5mg/kg
- Protriptyline > 1mg/kg
- Ingestions of 10-20mg/kg in pediatric patients constitute a serious risk of toxicity.
- Admission to PICU is advised for any patient demonstrating AMS or CV toxicity until symptoms have resolved.
symptoms of TCA tox
These are potent CNS and resp depressants and anticholinergic activity with alpha adrenergic blockade
- Rapid coma and resp failure
- dry mucous membranes
- mydriasis
- Tachycardia
- agitation
- delirium
- hyperthermia
- decreased GI activity
- Hypotensive (alpha adrergic)
Sodium blockage in the myocardium -> Wide QRS complex Prolonged QT V-Tach V-Fib Cardiac arrest
Seizures
Treatment for TCA tox
- Consists of appropriate GI decontamination and supportive measures.
- Patients with rapid obtundation, loss of protective airway reflexes or coma require rapid ETT & ventilatory support.
- Seizures are managed with benzos and barbiturates for refractory seizures.
- Cardiac conduction defects noted by a widened QRS complex greater than 110-120 ms may respond to sodium bicarb & serum alkalization (throwing it back to the beginning of the semester)
- IV sodium bicarb at 1-2meq/kg and hyperventilation in intubated patients with a goal of an arterial pH of 7.45-7.55 can correct many of the wide complex tachydysrhythmias associated with TCA OD.
- Continuous sodium bicarb is not routinely recommended.
-Hypotension can be managed with IV bolus of sodium bicarb, crystalloid fluids, and administration of pressor agents. Intralipid emulsion (ILE) can be an alternative treatment for TCA OD with serious effects unresponsive to standard resuscitation measures, but not first line.
-Bolus of 20% of ILE at 1.5ml/kg administered over 2-3 minutes, followed by a repeat bolus or an infusion.
Consultation with a medical toxicologist is advised.
Contraindications:
-physostigmine salicylate is used in the management of anticholinergic poisonings, however in TCA OD, it has been associated with seizures, asystole, and death.
- Class 1-A & 1-C antidysrythmics such as quinidine, procainamide, disopyramide, flecainide, can WORSEN cardiac conduction & should be avoided.
- Beta blockers can correct tachycardia but has been linked to severe hypotension and cardiac arrest & should also be avoided.
Tylenol OD amount
patients should be referred to the ED if the ingested amount is greater than or equal to 200mg/kg in patients <6yrs or 200mg/kg or 10gm (whichever is less) in adults.
For chronic or supratherapeutic ingestions, patients should be referred for emergent eval of pediatric patients younger than 6 years of age ingest–
> 200mg/kg in a 24 hour period
> 150mg/kg per 24-hour period for the preceding 48 hours, OR
> 100mg/kg per 24 hour period for 72 hours or longer
Adults should be referred to ED if a chronic or supratherapeutic ingestion of >10gm or 200mg/kg (whichever is less) per 24 hours, or greater than 6gm or 150mg/kg (whichever is less) per 24 hour period for 48 hours or longer occurs.
symptoms tylenol OD
Initial symptoms may be nonspecific and include N/V, malaise, and sweating.
Within 24-36 hours following ingestion, elevations of the hepatic enzymes, AST & ALT, begin to occur.
Peak hepatotoxicity occurs at 72-96 hours post ingestion, with possible signs of fulminant hepatic failure, renal failure, coma, encephalitis, and coagulopathy.
At this point patients may begin to recover, require a liver transplant or die.
If recovery occurs, it usually occurs within the first 5-7 days following ingestion.
treatment in Tylenol OD
Antidote is N-acetylcysteine (NAC)
In the US, an IV preparation, Acetadote, and an oral preparation, Mucomyst, are also available.
-Most effective when initiated within 8 hours post-ingestion but is still effective at any time after a significant OD. Treatment should not be delayed in the absence of rapid blood APAP quantification.
NAC should be initiated in any patient demonstrating abnormal liver function tests thought to be caused by APAP toxicity even if APAP blood level is undetectable.
It possesses hepatoprotective properties by acting as an antioxidant and free radical scavenger & improving blood microcirculation.
2 indications for use of NAC: Patient presenting with a known or suspected toxic blood level of APAP and/or evidence of hepatotoxicity.
2 NAC treatment regimens
72-hour oral course
Considered safe with only minor GI disturbances such as vomiting or diarrhea.
Has an unpleasant sulfur or “rotten egg” taste and odor. Best administered when diluted to a concentration of 5%, mixing it with any soft drink or juice that the patient prefers and served with ice in a covered container.
Any oral dose vomited within an hour of administration should be repeated.
21- hour IV course
Preferred in situations where the patient is unable or is unwilling to take NAC orally in cases where GI bleeding or obstruction is suspected.
Carries greater risk of hypersensitivity reactions such as pruritus and urticaria
Criteria for Liver transplantation in Tylenol OD setting
- Acidosis defined as arterial pH <7.3 after adequate fluid resuscitation
- Coagulopathy, defined as PT > 40 secs at 40 hours OR PT > 100 secs at any time OR rapidly rising PT OR INR greater than 6.5
- Creatinine greater than 3.3mg/dL
- Grade III or IV encephalopathy
- In these patients, NAC is infused continuously at the rate of 100mg/kg/16 hours until the patient improves or undergoes transplant surgery or fails to survive.
Digoxin tox symptom
bradycardia
Treatment for Digoxin OD
Digoxin immune fab is the antidote # vials = digoxin level (ng/mL) x weight (kg) divided by 100
- This may cause hypokalemia
iron tox is due to the effects of _____ iron
elemental
ferrous sulfate is ___% elemental iron
20%
ferrous fumarate is ___% elemental iron
33%
toxic iron dose
- Referral to the ED is recommended in patients with ingestions > 40 mg/kg of elemental iron in the form of adult ferrous salt formulations.
- Toxicity is likely at > 60mg/kg dose.
- Ingestion of any quantity of children’s chewable MV with iron, carbonyl iron formulations or polysaccharide iron complexes can be observed at home regardless of the amount ingested.
iron tox symptoms
Early s&s of iron toxicity within the first 6 hours include N/V, and diarrhea, which can be bloody.
This can be followed by a period of apparent improvement or stability; however some patients may progress to more serious complications, including metabolic acidosis, coma, hypotension, shock, hepatic failure, coagulopathies, seizures, and death.
Late complications can include bowel obstruction or stricture.
Iron tox tx
Orogastric lavage may be considered in life threatening iron ingestions if It can be performed within an hour however, iron-containing tablets can be large and form concretions, making passage through the lavage tube difficult, especially in young children. Activated charcoal does not absorb iron and should not be administered. Iron tablets are radiopaque and can be visualized with abd radiography. If tablets are seen, whole bowel irrigation can be considered. Supportive measures include: crystalloid fluids & vasopressors for hypotension, IV sodium bicarb for metabolic acidosis, and benzos for seizures. Deferoxamine methylate (DFO) is a specific antidote for iron poisoning. DFO acts as a chelating agent that binds to free iron and forms ferrioxamine, a water soluble complex, excreted by the kidneys (can cause “vin rose” or reddish brown urine). DFO is indicated for patients with severe iron intoxication, presenting with shock, severe acidosis, or serum iron levels greater than 500mg/dL. End point of therapy is resolution of symptoms.
glucagon is tx of choice for what ingestions?
Dosing?
B blocker
CCB
This helps bradycardia and hypotension via the noradrenergic pathway
Bolus: 0.05-0.1 mg/kg, max dose 5 mg
Infusion: 0.05-0.15 mg/kg/hr that follows bolus, can also use second dose
side effect of glucagon
vomiting
hypokalemia
hydrocarbon/kerosene abuse includes
glue, paint thinners, cleaning products, or spot removers.
Most commonly abused is compressed air computer dusters, typically containing fluorinated hydrocarbons such as difluoroethane.
presentation of hydrocarbon/kerosene abuse
Generally affects 3 organ systems: CNS, pulmonary, and cardiac.
Upon inhalation, blood levels of most inhalants peak within mins and are rapidly taken up into fat stores.
Patients may present with initial CNS excitation, including euphoria with rapid progression to AMS & CNS depression.
Respiratory tract irritation leading to tachypnea, bronchospasm, hypoxemia, cyanosis, and respiratory distress can occur, especially in patients with asthma or COPD.
Cardiac toxicity is due to myocardial sensitization to endogenous catecholamines and can result in A-fib, v-tach, v-fib, and cardiac arrest.
Cardiac mechanism is unclear but may be due to alterations in potassium channels and delayed calcium release.
Frostbite injury may occur if the product source is compressed gas.
tx for hydrocarbon/kerosene abuse
Primarily supportive with emphasis on respiratory & circulation.
All symptomatic patients should be placed on cardiac monitors and EKG should be obtained.
Monitor VS & oxygen frequently.
CXR, ABG, and metabolic panel should be obtained.
Avoid catecholamines such as dopamine, epi and norepi unless absolutely necessary for cardiac resuscitation because symptoms may worsen with these agents due to increased cardiac sensitivity.
Phenylephrine is the preferred DOC for hypotension in this patient
Esmolol is preferred for arrhythmias;
Lidocaine can be considered for arrhythmias.
Albuterol sulfate & systemic corticosteroids can be used for respiratory symptoms.
ethanol tox presentation
Initial stimulation and loss of inhibitions, followed by lethargy, slurred speech, ataxia, stupor, and coma.
Pediatric patients experience facial flushing, vomiting, diaphoresis, respiratory depression, seizures, hypotension, hypothermia, and hypoglycemia.
Ethanol is metabolized in the liver, pediatric patients are at risk of profound hypoglycemia due to impaired hepatic gluconeogenesis. Hypoglycemia may be delayed up to 6 hours after ingestion.
ethanol tox tx
Can be managed with at home observation and telephone follow-up for exposures of “mouthful” or “taste” ingestions of alcohol.
With more serious ethanol ingestion, no GI decontamination is warranted unless co-ingestants are suspected.
Respiratory, cardiac, blood sugar and electrolytes should all be closely monitored.
Correct hypoglycemia with IV dextrose with the addition of oral caloric intake in an awake and alert patient.
Hemodialysis is indicated in patients with very high blood alcohol levels who do not respond to standard supportive measures.
Hospital admission is advised for any patient demonstrating significant toxicity with signs of marked CNS depression, hypoglycemia, seizures or fluid electrolyte abnormalities.
gold standard for ovarian torsion dx
color flow doppler US
CT/MRI reserved for pts who have nondefinitive findings or if symptoms are intermittent
in ovarian torsion salvage may be possible up to ___ hrs
24
Twisting of adnexal structures compromising blood flow to the ovary. • Usually associated with a cyst or mass.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1307). Wolters Kluwer Health. Kindle Edition.
Ovarian (Adnexal) Torsion
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1307). Wolters Kluwer Health. Kindle Edition.
clinical presentation ovarian torsion
• Peaks in adolescence.
•Acute onset of abdominal pain caused by ischemia.
• More common on right side.
-N/V
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1307). Wolters Kluwer Health. Kindle Edition.
•Twisting of the spermatic cord causing compromised blood flow to testicle.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1305). Wolters Kluwer Health. Kindle Edition.
testicular torsion
predisposing factors for testicular torsion
- Trauma.
- Testicular tumor.
- Testicles lying in horizontal plane.
- History of cryptorchidism and increasing testicular volume.
- Occurs in children <3 years of age and after puberty most commonly.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1306). Wolters Kluwer Health. Kindle Edition.
clinical symptoms testicular torsion
- Sudden onset of pain involving the testis; usually unrelenting.
- Testis is enlarged and tender.
- Absence of cremasteric reflex.
- Affected testicle higher in the scrotum.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1306). Wolters Kluwer Health. Kindle Edition.
procedure to fix testicular torsion is called
• Affix testis to scrotal wall to prevent recurrence (orchiopexy).
-Manual detorsion to decrease degree of ischemia prior to surgery → rotate testicle in a medial to lateral direction for 1 or 2 full 360 degree turns
You have 4-8 hours generally before you loose testicle
• If testicle cannot be salvaged, it is removed (orchiectomy).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1306). Wolters Kluwer Health. Kindle Edition.
Characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, renal injury
HUS
types of HUS
D+ HUS
Atypical HUS
which type of HUS is associated with contaminated meat, fruit, veggie or water with verotoxin producing E.Coli (0157:H7) or shigella
D+ HUS
Atypical HUS can be secondary to what infections?
Strep pneumo
HIV
Can also be genetic medication malignancy SLE pregnancy
HUS typically occurs in children < __ yrs
5
which type HUS is more severe
Atypical HUS
Presentation of D+ HUS
•Gastroenteritis with fever, vomiting, diarrhea, abdominal pain, and diarrhea that begins as watery but then becomes bloody.
Entercolitis with bloody stools, followed in 7-10days by weakness, lethargy, anuria/oliguria
Irritable, pallow, petechiae
Dehydration, however some children have volume overload (hypertension may occur)
CNS seizures in 25%, pancreatitis, cardiac dysfunction, colonic perforation
•Physical examination: dehydration, edema, petechiae, hepatosplenomegaly, and marked irritability.
HUS Triad
Triad
1) Microangiopathic Hemolytic anemia (MAHA) -> weakness, fatigue, lethargy, jaundice
2) Thrombocytopenia (easy bruising and purpura) blood clots in brain can cause visual problems, AMS, seizures, stroke, fever
3) Acute renal failure (uremia)
D+HUS treatment
supportive
Aggressive fluid management with electrolytes and nutrition
shiga like toxin clears in days to weeks
No antibiotics -> dead bacteria release more toxin
For TTP HUS - Plasmapheresis
Volume repletion
Hypertension control
Managing renal insufficiency – dialysis
RBC transfusions
DO NOT GIVE PLATELETS – may add to thrombotic microangiopathy
Only give if active hemorrhage or procedural
NO ABX OR ANTIDIARRHEAL – will make HUS worse
Atypical HUS treatment
address underlying cause
diagnostics for HUS
Lab smear: microangiopathic hemolysis
-Anemia (Hgb commonly 5-9), thrombocytopenia, schistocytes/helmet/burr cells and fragmented rbcs on smear, incr LDH, incr indirect bili, incr AST, incr reticulocyte
Coombs test is NEGATIVE
Renal injury: elevated Cr, hematuria, proteinuria, pyuria, casts on UA
Leukocytosis (>300,000)
, E coli stool culture, shiga toxin, elevated amylase/lipase
the most common cause of acute renal failure (ARF) in children <4 years of age.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1296). Wolters Kluwer Health. Kindle Edition.
HUS
•Characterized by the simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and uremia.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1296). Wolters Kluwer Health. Kindle Edition.
HUS
pyelonephritis risk factors
Female sex sexual intercourse indwelling catheter DM urinary tract obstruction Vesicoureteral reflux (VUR)
what organism is the most common cause of UTI in children
E. Coli
upper UTI
pyelonephritis
for UTI who has the highest incidence in the first 3 months of life
uncircumsized males
UTI are commonly associated with what organisms
gram neg
- E.Coli
- Klebsiella species
- Pseudomonas aeruginosa
gram pos
- Enterococcus
- Staph Aureus
- Group B strep
Also
Candida
Adenovirus
HSV
More than ____ colony-forming units/mL of a single organism and pyuria represent UTI in appropriately obtained specimens.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1287). Wolters Kluwer Health. Kindle Edition.
50,000
when is US indicated for UTI
2 mos - 2 yrs of age
Ultrasound: evaluates anatomy, kidney size/shape, and for evidence of hydronephrosis. Can also be used to evaluate for areas of inflammation and signs of pyelonephritis.
If renal and bladder US show hydronephrosis, scarring or other evidence of high grade VUR or obstructive uropathy …..what should you order?
voiding cystourethrography
UTI antibiotics
• Trimethoprim–sulfamethoxazole
amoxicillin–clavulanate,
cefixime are acceptable selections for initial oral therapy.
• Ceftriaxone, cefotaxime, gentamicin are acceptable selections for initial parenteral therapy. • In general, oral antibiotics are equally effective as parenteral therapy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1288). Wolters Kluwer Health. Kindle Edition.
education on preventing UTI
signs of UTI, hygiene, limiting bubble baths, constipation prevention, urination after intercourse if sexually active.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1288). Wolters Kluwer Health. Kindle Edition.
•Bacterial infection of the upper urinary tract caused by an ascending infection originated in the lower urinary tract.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1288). Wolters Kluwer Health. Kindle Edition.
Pyelonephritis
Most common organisms for pyelonephritis
• Gram-positive bacteria: Enterococcus spp. and Staph. aureus. •
Gram-negative bacteria: E. coli, Klebsiella spp., Proteus spp.,
• P. aeruginosa, Serratia spp., and Enterobacter aerogenes.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1289). Wolters Kluwer Health. Kindle Edition.
symptoms of pyelonephritis
• Fever, lethargy. • Tachycardia, tachypnea, dehydration. • Pain (abdominal, suprapubic, flank, and/or costovertebral). • Odorous urine.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1289). Wolters Kluwer Health. Kindle Edition.
diagnostic pyelonephritis
Urinalysis: detection of leukocyte esterase and nitrites
• Basic metabolic panel: evaluation of kidney function. •CBC with differential: evaluation of WBC count and differential. • Blood culture: Positive culture indicates bacteremia. • C-reactive protein: elevated, indicating an inflammatory process. •Erythrocyte sedimentation rate: elevated, indicating an inflammatory process. •Renal ultrasound for children 2 to 24 months of age.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1289). Wolters Kluwer Health. Kindle Edition.
when is VCUG typically done
children with recurrent febrile UTIs who have evidence of abnormalities on US
Inflammation within the kidney.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1290). Wolters Kluwer Health. Kindle Edition.
Nephritis
symptoms/clinical presentation of Nephritis
Hypertension, gross hematuria, edema = classic triad
- History of recent throat infection, decreased urine output, dark urine, fatigue, headache.
- Rash on buttocks and posterior legs, arthralgia, and weight loss (symptoms of secondary GN).
- Elevated blood pressure.
- Edema.
- Other signs of fluid overload/congestive heart failure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1290). Wolters Kluwer Health. Kindle Edition.
diagnostic eval for Nephritis
- Electrolyte panel, creatinine, BUN, CBC with differential, urinalysis with urine culture and sensitivities, and throat culture. •If acute poststreptococcal GN is suspected, a serum antistreptolysin-O (ASO) titer should be checked.
- To assess for systemic disease, autoimmune panels such as serum complement levels (C3, C4), lupus serologies, anti-DNase B, perinuclear antineutrophil antibody (P-ANCA), cellular antineutrophil cytoplasmic antibody (C-ANCA), and IgA are useful.
- Low serum C3 levels are indicative of secondary GN.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1290-1291). Wolters Kluwer Health. Kindle Edition.
Treatment of nephritis
- Antibiotic: penicillin, first line. - 10 day course (use ceph or macrolide if allergy)
- Treatment of hypertension or acute renal insufficiency.
- Judicious fluid management.
- Sodium-restricted diet.
- Diuretics.
- Calcium channel antagonists, vasodilators, or ACE inhibitors.
- For secondary forms of GN.
- Corticosteroids and cyclophosphamide to counteract the inflammatory process.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1291). Wolters Kluwer Health. Kindle Edition.
pyelonephritis caused by Klebsiella is more common in what gender
boys
pyelonephritis caused by Enterobacter aerogenes is more common in what gender
girls
- Caused by a prior infection with specific nephritogenic strains of a beta-hemolytic streptococcus of the throat or skin.
- Most common glomerular cause of hematuria.
Commonly follows group A streptococcal pharyngitis during the cold weather months and streptococcal skin infections or pyoderma during warm weather months.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1291). Wolters Kluwer Health. Kindle Edition.
Acute poststreptococcal glomerulonephritis
clinical symptoms of Acute poststreptococcal glomerulonephritis
•Sudden onset of gross hematuria, edema, hypertension, and renal insufficiency.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1292). Wolters Kluwer Health. Kindle Edition.
Diagnostics Acute poststreptococcal glomerulonephritis
•Urinalysis: red blood cells—often associated with red blood cell casts, proteinuria, and polymorphonuclear leukocytes.
Elevated ASO titer.
•Complement level: C3 level initially decreased; returns to normal 6 to 8 weeks after presentation (sometimes sooner). •Throat culture positive for group A streptococcus can confirm diagnosis.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1292). Wolters Kluwer Health. Kindle Edition.
mgmt of Acute poststreptococcal glomerulonephritis
- Penicillin: a 10-day course. •Cephalosporins or macrolide antibiotics can be used in patients with penicillin allergy.
- Acute renal insufficiency: furosemide.
- Hypertension: antihypertensive agents and sodium restriction.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1292). Wolters Kluwer Health. Kindle Edition.
Pyelonephritis complication
tubulointerstitial nephritis (TIN): inflammation that affects the interstitium and renal tubules of kidney
Major dysfunction of collecting tubules -> inability to concentrate urine, salt wasting, metabolic acidosis
ONLY DIAGNOSED WITH RENAL BIOPSY – often goes undiagnosed
maculopapular rash, joint pain with flexion and extension, uveitis
kidney function is indicated by what
GFR
•The kidneys of children reach adult GFR at approximately what age
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1281). Wolters Kluwer Health. Kindle Edition.
1 year
GFR equation
•GFR can be estimated (eGFR) with the patient height, serum creatinine, and a constant (Schwartz equation).
eGFR mL/minute/1.73 m2 = (k)(height)/serum creatinine • k = constant of 0.413 for all ages/genders.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1281). Wolters Kluwer Health. Kindle Edition.
• Equation used to determine whether kidney dysfunction is only a result of hypoperfusion to kidney.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1281). Wolters Kluwer Health. Kindle Edition.
Fractional excretion of sodium
normal BUN to creatinine ratio
10:1 to 20:1
Elevated BUN to creatinine ratios are associated with
shock or dehydration with acute kidney failure. Also may result from nephrolithiasis or gastrointestinal or pulmonary hemorrhage.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1282). Wolters Kluwer Health. Kindle Edition.
low BUN to creatinine ratios are associated with
rhabdomyolysis, syndrome of inappropriate antidiuretic hormone secretion, lung disease, malignancy, low dietary protein intake, or certain medications.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1282). Wolters Kluwer Health. Kindle Edition.
Prerenal causes
hypovolemia
Distributive volume issues
sepsis
congestive heart failure
Intrinsic causes
acute tubular necrosis Glomerulonephritis Medication induced Infection (HUS, poststreptococcal GN) Interstitial nephritis renal artery or vein thrombosis vascular lesions endogenous toxins (Myoglobin) Exogenous toxins (methanol, ethylene glycol) Idiopathic
postrenal causes
obstruction
urolithiasis
An abrupt cessation or significant decline in the kidney’s ability to eliminate waste products, regulate acid–base balance, and regulate electrolyte balance.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1282). Wolters Kluwer Health. Kindle Edition.
Acute renal failure
what type of renal failure is most common
Prerenal
Genetic conditions associated with acute renal failure
Polycystic kidney disease Alport syndrome Nephrotic syndrome Systemic Lupus erythematosus (SLE) Diabetes
Presenting signs and symptoms of acute renal failure
oliguria/anuria edema electrolyte abnormalities decreased appetite nausea fatigue shortness of breath hypertension confusion
Management of acute renal failure
Fluid management: judicious (e.g., restore intravascular volume or diuresis depending on clinical status). Aggressive hydration may result in fluid overload, pulmonary edema, and respiratory compromise.
- Calculation of fractional excretion of sodium may help guide fluid management.
- Fluid management with urine output replacement and calculated insensible losses may be warranted.
- Hyponatremia is common. Risk for seizure activity if serum sodium <125 mEq/L. Treat with hypertonic saline solution (e.g., 3% saline administration).
- Hyperkalemia may be life-threatening (e.g., ventricular tachycardia, ventricular fibrillation).
- EKG findings in hyperkalemia may include peaked T waves, prolongation of PR interval, widening of QRS complex, flattening of P waves.
- Imperative to reduce extracellular potassium level and stabilize the cardiac cell membrane to avoid ventricular tachycardia/fibrillation. Glucose, sodium bicarbonate, insulin, and albuterol shift potassium into the cells.
- Calcium chloride can stabilize the cardiac cell membrane.
- Sodium polystyrene can exchange potassium and sodium in the colon. • Emergent dialysis is often indicated for serum potassium levels >7 mEq/L.
- Hypertension therapy: avoid angiotensin-converting enzyme (ACE) inhibitors. Goal is normal blood pressure for gender and height.
- Adjust medications that are renally excreted; consult a pharmacist.
- Renal supportive therapies may be indicated. See more information on renal supportive therapies later in this section.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1283). Wolters Kluwer Health. Kindle Edition.
clinical presentation of Renal artery or vein thrombosis
• Abrupt onset of hematuria. • Flank mass, unilateral or bilateral. • Flank pain. • Oliguria. • Hypertension.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1293). Wolters Kluwer Health. Kindle Edition.
diagnostic for Renal artery or vein thrombosis
Doppler US
- Monitor and maintain fluid and electrolyte balance.
- Blood pressure monitoring; antihypertensive agents.
- If refractory to pharmacologic therapy, may require nephrectomy.
- Treatment with anticoagulants (e.g., heparin) or thrombolytics (e.g., streptokinase, recombinant tissue plasminogen activator) is common, but controversial.
- Inferior vena cava thrombus may require thrombectomy.
- Treat underlying disease (e.g., nephrotic syndrome), if indicated.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1294). Wolters Kluwer Health. Kindle Edition.
•Result of an inherited or acquired defect that affects the kidneys’ ability to filter bicarbonate or excrete ammonia.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1294). Wolters Kluwer Health. Kindle Edition.
Renal tubular acidosis
what can be a genetic cause of renal tubular acidosis
Sickle cell anemia
renal tubular acidosis is often associated with the presence of a
UTI
A relatively uncommon clinical syndrome characterized by defects in the renal tubules as a result of failure to maintain a normal serum bicarbonate level despite the consumption of a regular diet and normal metabolism and acid production.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1294). Wolters Kluwer Health. Kindle Edition.
Renal tubular acidosis
symptoms of renal tubular acidosis
- Polyuria.
- Polydipsia.
- Preference of savory foods.
- Hypokalemia.
- Refractory rickets.
- Metabolic acidosis.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1295). Wolters Kluwer Health. Kindle Edition.
what type of RTA?
linked to multiple genetic disorders (sensorineural hearing loss and nephrocalcinosis); failure to thrive or short stature, anorexia, vomiting, and dehydration.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1295). Wolters Kluwer Health. Kindle Edition.
Type I RTA
what type RTA
failure to thrive, hyperchloremic acidosis with hypokalemia, and rarely nephrocalcinosis; rickets or osteomalacia may indicate Fanconi syndrome.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1295). Wolters Kluwer Health. Kindle Edition.
Type II
what type RTA
no longer used as a classification; now thought to be a combination of types I and II.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1295). Wolters Kluwer Health. Kindle Edition.
Type III
What type RTA
Hypertension common if child has underlying Gordon syndrome, renal parenchymal disease, or mineralocorticoid dysfunction.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1295). Wolters Kluwer Health. Kindle Edition.
Type IV
diagnostic eval for RTA
- Serum and urine electrolytes.
- Fractional excretion of bicarbonate and urine pH.
- Urine glucose and protein, calcium-to-creatinine ratio.
- 24-hour urine sample (i.e., citrate, calcium, potassium, and oxalate). •Radiographies of long bone or wrists for evaluation of rickets.
- Abdominal ultrasound (kidneys).
- Genetic or chromosomal evaluation.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1295-1296). Wolters Kluwer Health. Kindle Edition.
Management of RTA
- Emergency or impatient management for children with hyperchloremic, non–anion gap acidosis requiring bicarbonate replacement intravenously.
- Slow rehydration and electrolyte replacement, sodium bicarbonate or citrate, diuretic, phosphate replacements in children with rickets.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1296). Wolters Kluwer Health. Kindle Edition.
chronic acidity in the blood results in
in growth retardation, nephrolithiasis, bone disease, and chronic renal failure.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1296). Wolters Kluwer Health. Kindle Edition.
Normal BP
Children 1-13 <90%ile
<120/<80 for children >= 13
stage 1 HTN
old guidelines: 140-159/90-99
new
1-13: >=95%ile to <95%ile + 12 mmHg or 130/80 to 139/89
> = 13 yrs: 130/80 to 139/89
Stage 2 HTN
old guidelines:
160+/100+
New:
1-13: >=95%ile + 12mmHg or >=140/90mmHg
> = 13 yrs >=140/90
key difference from Stage 1 HTN and Stage 2 HTN in approach
confirmed stage 1 allows for time for evaluation prior to intervention while stage 2 requires swift eval within 1 week or sooner if symptomatic and intervention.
if symptomatic stage 2. Immediate intervention required with referral to specialist promptly
stage 1 is reevaluated on repeat visits. 3 separate measurements within 1 mth
Secondary HTN is more common in ___ than in ____
children
adults
most common cause of secondary HTN. What are some other causes?
Kidney disease
adrenal gland medications obstructive sleep apnea stress anxiety coarctation of the aorta endocrine pregnancy metabolic syndrome
physical exam clues to HTN
- Tonsillar hypertrophy (sleep-disordered breathing)
- Papilledema (Intracranial HTN)
- Acanthosis Nigricans (type 2 DM)
- Murmur (coarctation of aorta)
- Abd mass (kidney tumor, hydronephrosis, polycystic kidney disease)
- Disparate pulses; upper pulses >lower pulses (coarctation of aorta)
- Elfin or Moon facies (Williams syndrome, cushing syndrome)
Thyroid enlargement (hyperthyroidism)
Muscle weakness (hyperaldosteronism)
Diminished pain response (Familial dysautonomia)
Ambiguous genitalia (Adrenal hyperplasia)
Advanced puberty (intracranial tumor/pathology)
labs to order on anyone with stage 1 HTN or higher
CBC: Anemia is a classic sign or chronic kidney disease
Renal function panel: looking at BUN/Creatinine and electrolytes. Hyperphosphotemia and hypocalcemia are commonly noted in kidney disease
Urinalysis
Consider Urine protein/creatinine ratio
Lipid panel
Fasting lipid panel and fasting blood glucose measurement on obese patients
Other diagnostic studies in HTN
Echocardiogram: eval for LV hypertrophy
Renal US: looking for kidney scarring, congenital abnormalities, unequal kidney size
Retinal exam: Eval for retinal vascular changes
Nonpharmacy therapy (First line plan in stage 1 HTN)
Lifestyle changes:
- Weight loss
- exercise
- dietary mods
- Reduce salt intake: 2.4g sodium restriction/day
- Increase fresh fruit and vegetables
- Increase low-fat dairy products
- Avoid smoking and alcohol intake
No added salt with preparation
Foods with >200mg Na per serving should be avoided
Limit processed foods, fast foods and fried foods
-consider school meal choices
-no gatorade
-ramen noodles
-Seasonings -Tajin
limit caffeine
- coffee/tea
- energy drinks
- soda
Pharm therapy in Stage 2 HTN
Pharm treatment is indicated in children with symptomatic HTN, stage 2 without an identified modifiable factor, comorbidities such as DM or CKD or who remain Hypertensive after a tiral of lifestyle mods.
Treatment should be initiated with a single agent at a low dos, with dose adjustments every 2-4 weeks. If BP is not adequately controlled, additional agent(s) can be added. Start with either ACE, ARB, long acting CCB or thiazide diuretic. B blockers are not recommended as initial treatment in children
1) ACE inhibitors (-prils)
or
ARB (-sartan)
or
CCB
Diuretic to decrease blood volume and excrete sodium
-Thiazide-like:
- Loop
- Potassium sparing
Vasodilators (hydralazine, minoxidil) -> reserved for patients failing other therapies due to unfavorable side-effect profile.
• Peripheral α1-antagonists and centrally acting α2-agonists.
-B Blockers
what does ACE inhibitors do
• ACE (angiotensin-converting enzyme) inhibitors (“-prils”): Dilate blood vessels to decrease resistance.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 421). Wolters Kluwer Health. Kindle Edition.
common side effects ACE Inhibitors
- Cough.
- Skin rash (red, itchy).
- Dizziness/lightheadedness, orthostatic hypotension.
- Taste impairment (salty or metallic).
- Edema (lower extremities).
- Hyperkalemia.
- Decrease in glomerular filtration rate (GFR).
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 421). Wolters Kluwer Health. Kindle Edition.
Precautions for ACE inhibitors
- Not to be used in volume-depleted patients.
- Not to be used in patients with bilateral renovascular hypertension.
- Avoid salt substitutions as they contain potassium.
- Avoid nonsteroidal anti-inflammatory (NSAID) medications.
- Check BP and kidney function regularly.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 421). Wolters Kluwer Health. Kindle Edition.
what do ARBS do
•ARB (angiotensin II receptor blockers) (“-sartan”): angiotensin II receptor blockers decrease chemicals that cause vasoconstriction; decrease intraglomerular pressure through decreasing efferent arteriolar tone.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 421). Wolters Kluwer Health. Kindle Edition.
what med class?
decrease chemicals that cause vasoconstriction; decrease intraglomerular pressure through decreasing efferent arteriolar tone.
ARB (angiotensin II receptor blockers) (“-sartan”):
what med class?
Dilate blood vessels to decrease resistance.
ACE (angiotensin-converting enzyme) inhibitors (“-prils”):
side effects for ARBS (-sartan)
• Dizziness, orthostatic hypotension (worse with first dose, need to take for a week+ before full effect), muscle cramping, diarrhea.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
Precaution for ARBS (-sartan)
Monitor BP and kidney function
what do CCBs do?
Calcium channel blockers (“-pine”): dilate blood vessels, decreasing cardiovascular resistance. These agents slow the movement of calcium into cells of the heart and blood vessels. May be the desired class in patients with asthma.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
preferred antihypertensive in asthma pts
CCB
what med class?
dilate blood vessels, decreasing cardiovascular resistance. These agents slow the movement of calcium into cells of the heart and blood vessels. May be the desired class in patients with asthma.
Calcium channel blockers (“-pine”):
side effects for CCBs
effects: edema, arrhythmias, fatigue, dizziness.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
Precautions for CCBS
monitor heart rate, avoid grapefruit, avoid alcohol, contraindicated in patients with sick sinus syndrome.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
How does Thiazide-like diuretics work in anti hypertension treatment
decrease blood volume and excrete sodium.
- Thiazide-like: most effective in lowering BP (metolazone, hydrochlorothiazide).
- Can be used as primary therapy.
- Can enhance the effects of other antihypertensive agents.
- Requires salt restriction as concurrent therapy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
what med class am I?
Metolazone
Hydrochlorothiazide
Thiazide like diuretic
for this ch - used in treating HTN
Thiazide like diuretics (metolazone, hydrochlorothiazide) precautions
- Requires salt restriction as concurrent therapy.
- Can infrequently cause hypokalemia, glucose intolerance, adverse lipid effects.
- Periodic blood chemistries needed. •
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
What diuretic can be helpful in Hypertensive emergencies
Loop diuretic (lasix)
What med class am I?
furosemide
bumetanide
torsemide
Loop diuretic
which is the more powerful class of diuretics used in treatment for HTN
Loop
which diuretic can be helpful with CHF
potassium sparing
which diuretic class is usually used as an adjunct
Potassium sparing
what med class am I
spironolactone
Potassium sparing diuretic
side effects of diuretics
frequent urination, electrolyte imbalance, fatigue or weakness, muscle cramping, dizziness, dehydration, anorexia.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 422). Wolters Kluwer Health. Kindle Edition.
what med class am I?
Hydralazine, minoxidil
Vasodilators
what med class am I?
Doxazosin
Prazosin
Terazosin
Alpha 1 antagonists
what med class am I?
Clonidine
Guanfacine
tizanidine
A2 agonists
what med class?
block the effects of sympathetic nervous system (adrenaline) in the heart.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 423). Wolters Kluwer Health. Kindle Edition.
B Blockers (-lol)
reduces HR in a reduction of cardiac output
Who are BBlockers contraindicated in
children with heart block, asthma, or pregnancy. May reduce the ability of a diabetic patient to identify a hypoglycemic event; use with extreme caution in diabetic patients.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 423). Wolters Kluwer Health. Kindle Edition.
Hypertensive crisis managment
- Intravenous (IV) form of antihypertensive medications (e.g., esmolol, labetolol, nicardipine, hydralazine).
- Fluid management and restriction.
- Goal is NOT to decrease BP to a normal level, but rather to return BP to a safe level.
- Overcorrection of hypertension may result in hypoperfusion to end-organ and cerebral ischemia.
- First 6 to 12 hours, reduce BP no more than 25% to 33% of overall goal reduction. Rest of the correction to occur over subsequent 48 to 72 hours.
- Monitor for hypertensive encephalopathy; can be further exacerbated by antihypertensive pharmacologic therapy.
- Treat underlying cause (e.g., intracranial hypertension, pheochromocytoma, collagen vascular disease, glomerulonephritis).
- Evaluate for end-organ damage.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 423). Wolters Kluwer Health. Kindle Edition.
complications of HTN
- Kidney disease.
- Left ventricular hypertrophy (LVH)/CHF.
- Seizures.
- Hypertensive encephalopathy.
- Obstructive sleep apnea.
- Cerebrovascular accident.
- Ongoing hypertension into adulthood; increased risk of cerebrovascular accident, myocardial infarction.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 423-424). Wolters Kluwer Health. Kindle Edition.
Elevated BP which is the new term for prehypertension
> =90%ile to <95%ile or 120/80 to <95%ile
> =13: 120/<80 to 129/<80
bladder length of the cuff should be ___ to ____% around arm
80-100%
preferred medications for antihypertension in the setting of DM, CKD or proteinuria
ACE/ARB
You should consider a higher inital dosing of ACE or alternative therapies in what race
African Americans
In HTN treatment….
When do you try other agents other than CCB, ACE, ARB or thiazides
reserved for children who do not respond to 2 or more of the preferred agents
Antihypertensive pharm treatment goal
General population
<=90%ile or 130/80
CKD with HTN
<=50ile 24 hour MAP on ABPM
How often do you f/u with HTN patients
on pharm treatment
-every 4-6 weeks while titrating meds then every 3-4 months after control is achieved
Lifestyle modifications
-every 3-6 months
In a diabetic pt you should treat at what point
if BP >= 95%ile or >130/80
Hypertension and sports
Restricted from competitive sports if
- LVH beyond what is seen with athletes heart until BP controlled
- Stage 2 HTN until controlled - particularly high static sports such as weights, boxing, wrestling)
CKD classifications
1- Kidney damage with a normal or increased GFR (>90)
2 - Mild reduction in GFR
60-89
3-Moderate reduction in GFR
30-59
4- Severe reduction in GFR
15-29
5- Kidney failure
GFR <15 or dialysis
GFR equation
Modified Schwartz:
eGFR = K (height in cm/serum creatinine)
K=0.413
what does this stand for
CAPD
Continuous ambulatory peritoneal dialysis
what does this stand for
CCPD
Continuous cycling peritoneal dialysis
considerations for initiating dialysis
CKD stage 5 with GFR <15
uremic symptoms
malnutrition/growth
Uncontrolled hypertension
volume overload
metabolic acidosis
How does peritoneal dialysis work
sterile dialysate introduced into peritoneum through a catheter
Dialysate exchanged at intervals after a prescribed indwelling period.
Particle removal by diffusion
Fluid removed by ultrafiltration (osmotic gradient using dextrose)
Peritoneal dialysis fluid is removed by _______
ultrafiltration (osmotic gradient using dextrose)
differences between hemodialysis and peritoneal dialysis
Hemodialysis uses artificial membrane whereas PD uses natural membrane
HD uses continuous dialysate flow so never reaches equilibrium whereas PD stagnate dialysate eventually reaching equilibrium
HD occurs in a center where PD is at home
HD has higher blood flow and PD has higher capillary blood flow
typical Peritoneal dialysis prescription
Fill 10 minutes, dwell 45 min, drain 5 min = 1 hr exchanges
8-10 hrs each night while sleeping by cycler machine
Caregivers are trained and have RN available for questions. These kids are able to attend school
PD catheter exit site instructions
- Away from vesicostomies, G-buttons, ureterostomies
- Either in lateral of downward facing orientation
- Prophylactic antibiotic administration at time of placement
- prevent constipation to prevent catheter malfunction and malposition
- catheter use delayed for at least 2 weeks for healing
contraindications for PD
Absolute
- Omphalocoele or gastrochisis
- Bladder extrophy
- Diaphragmatic hernia
- Peritoneal membrane failure
- Lack of appropriate caregiver
Relative
- impending abd surgery
- impending living related transplant
- VP shunt
- Peritoneal leaks
- Ischemic bowel disease
complications of PD
exit site infection
tunnel infection
peritonitis
Catheter malfunction
Peritonitis symptoms
abd pain fever cloudy fluid (newspaper test) nausea vomiting
Diagnostic cell count for peritonitis
> 100/mm3 white blood cells
-at least 50% being polymorphonuclear leukocytes (neutrophils)
treatment of peritonitis
intraperitoneal infusion of antibiotics
-gram positive and gram neg antibiotics given while awaiting culture results
narrow spectrum of antibiotics once results are available
co-morbit conditions associated with ESRD
Anemia
Cardiovascular complications
growth failure
renal osteodystrophy
Patho of anemia secondary to ESRD
diminished production of erythropoietin by interstitial cells of the renal cortex
shortened erythrocyte life span in CKD
iron deficiency through diet, GI losses, menses
chronic inflammation - systemic and complement activation from dialysis
Bone marrow suppression- inhibitory factors, hyperparathyroidism, medications
increased red cell turnover - Carnitine deficiency, primary renal disease (HUS)
malnutrition - b12 or folate deficiency
Anemia management in ESRD
minimize blood draws
Erythropoietin stimulating agent (ESA)
Iron supplements (IV vs PO)
_______ disease accounts for most deaths in patients with pediatric onset CKD
cardiovascular (almost 1000 times higher than age matched peers)
most common: arrythmias, valvular heart disease, cardiomyopathy, acute cardiac death
Cardiovascular disease mgmt in ESRD
control risk factors
- anemia
- HTN (Left ventricular hypertrophy, volume overload)
- Hyperlipidemia
What is metabolic bone disease
comorbidity of CKD
inability of kidneys to excrete phosphorous and synthesize Vit D 1, 25
Metabolic bone disease diet restrictions
Low phosphorous foods
Foods high in phosphorous content: processed foods, dairy (milk, cheese), dark sodas, beans
medications for metabolic bone disease treatment
Phosphorous binders (Renvela, PhosLo)
Calcium supplements (Tums, Calcium Carbonate)
Vit D analog (Calcitrol)
average height for CKD pt
1.5 SD below the mean bc of the protein –calorie malnutrition and growth hormone deficiency
co-morbidities of CKD
quality of life
neurocognitive
- impaired memory and executive functioning
- sleep disturbances
Growth hormone deficiency
Nutrition
- taste disturbances
- n/v
- impaired gastric emptying
- low nutrition intake
- limited dietary options
metabolic bone disease
Anemia
Cardiovascular disease
Hyperosmolar dialysate solution is infused into the peritoneal cavity to facilitate the removal of electrolytes, toxins, and free water.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1315). Wolters Kluwer Health. Kindle Edition.
Peritoneal dialysis
Tenckhoff catheter used in
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1315). Wolters Kluwer Health. Kindle Edition.
Peritoneal dialysis
what type of peritoneal dialysis is used to maximize fluid and toxin removal
CAPD - Continuous ambulatory peritoneal dialysis
what is kidney biopsy used for
- Diagnostic evaluation of kidney disease.
- Evaluation of rejection after kidney transplant; guides immunosuppression therapy.
- Detection of primary or metastatic kidney malignancy.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1317). Wolters Kluwer Health. Kindle Edition.
most common etiologies for kidney transplant
congenital
urologic
inherited disorders
when does kidney transplant eval begin
When estimated creatinine clearance is <60
transplant prior to dialysis requirement is ideal to avoid associated morbidities
what does this look for?
•Anti-human leukocyte antigen antibodies and panel-reactive antibodies:
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1318). Wolters Kluwer Health. Kindle Edition.
sensitization to determine which donor antigens should be avoided to prevent rejection
Posttransplant care
• Maintenance immunosuppression. •Calcineurin inhibitor, usually in conjunction with a second agent such as an antiproliferative agent (e.g., mycophenolate mofetil) or mTOR inhibitor (e.g., rapamune). • Calcineurin inhibitors are nephrotoxic; levels require monitoring.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1319). Wolters Kluwer Health. Kindle Edition.
signs of renal transplant rejection
hypertension, fever, proteinuria, oliguria, or graft nonfunction.
• Hyperacute: minutes to hours after transplant. • Acute: 3 to 90 days after transplant. • Chronic: >60 days after transplant.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1320). Wolters Kluwer Health. Kindle Edition.
Posttransplant education
avoid aminoglycosides/nephrotoxic drugs
no live immunizations
tumor lysis syndrome lab levels
elevated -potassium -uric acid -bun -creatinine -phosphorous decreased calcium
pancreatitis, celiac, short gut and inflammatory bowel disease affects magnesium in what way
hypomagnesemia
expected
PT/PTT in D+HUS
normal
Labs for HUS D+
Uremia
anemia
thrombocytopenia
reticulocytes
clinical presentation of Tylenol overdose
- Initial symptoms, mild.
- Vomiting.
- Malaise.
- > 24 hours, symptoms progress.
- Increased alanine transaminase (ALT) and aspartate transaminase (AST).
- > 72 hours, peak toxicity.
- Coagulopathy.
- Encephalopathy.
- Liver failure.
- Cerebral edema (some cases).
- Possibly, death.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (pp. 1098-1099). Wolters Kluwer Health. Kindle Edition.
Refer to ER for tylenol ingestion levels of
Children <6 years of age.
• >200 mg/kg in children <6 years of age in a 24-hour period.
- > 150 mg/kg per 24-hour period for the preceding 48 hours.
- > 100 mg/kg per 24-hour
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1099). Wolters Kluwer Health. Kindle Edition.
Tylenol overdose antidote should be started within ___ hours of ingestion for best efficacy
8
- The alcohol most commonly recognized; produced by the fermentation of grains, “grain alcohol.”
- Alcoholic beverages and distilled spirits. • Found in accessible household products—hand sanitizer, mouthwash, colognes, and others.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1103). Wolters Kluwer Health. Kindle Edition.
Ethyl alcohol (ethanol)
- Produced from the distillation of wood, “wood alcohol.”
- Found in industrial solvents, gasoline blends, plastic products, windshield wiper fluid, paint strippers, glass cleaners, hobby and craft adhesives, food warming cans used under chafing dishes (e.g., Sterno), and others.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1103). Wolters Kluwer Health. Kindle Edition.
methyl alcohol (methanol)
- Used in various solvents.
- Primary component of automobile antifreeze.
- Found in herbicides/pesticides, liquid detergents, paints and paint products, among others.
- May have a sweet taste and attractive color which can pose a particular danger to children.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1103). Wolters Kluwer Health. Kindle Edition.
Ethylene glycol
Painless rectal bleeding in preschool or young school age…think
Meckels diverticulitis
clinical presentation of ethanol ingestion
- Symptoms similar to other sedatives.
- Vomiting due to GI distress.
- Slurred speech, ataxia, lethargy, and coma.
- Respiratory depression.
- Hypotension.
- Bradycardia.
- Facial flushing.
- Profound hypoglycemia secondary to impaired gluconeogenesis can be problematic, and often is a delayed presentation.
- An odor to the breath can sometimes be detected.
Kline, Andrea M.; Haut, Catherine. Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner (p. 1104). Wolters Kluwer Health. Kindle Edition.
late toxic finding of ethanol ingestion
hypoglycemia
normal weight gain infant per day
20-30 g/day (about an ounce a day)
what electrolyte abnormality are you concerned in a jaundice baby receiving phototherapy due to insensible losses
hypernatremia
electrolyte abnormalities with Amphotericin B
Hypokalemia
Hypomagnesemia
what electrolyte abnormalities with Tumor lysis syndrome
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
High uric acid levels
treatment for steroid resistant nephrotic syndrome
administer steroids with goal of immunosuppression is recommended
treatment for meningococcal meningitis
symptoms?
ceftriaxone 100mg/kg/day for 5-7 days
symptoms rapid onset fever malaise vomiting diarrhea nuchal rigidity maculopapular rash
4 wk old infant with projectile vomiting an da palpable olive shaped mass on exam. What are the expected lab findings
Hypochloremia
Hypokalemia
Hyperbilirubinemia
Phos and Ca have what relationship
inverse
hallmark sign of necrotizing enterocolitis on x ray is
pneumatosis - intestinalis
what supplement is often needed with DiGeorge syndrome
Calcium
most often hypocalcemic
electrolyte derangement expected in massive transfusion
Hypocalcemic and hyperkalemic because the calcium citrate binds to the calcium in blood
older child with intussusception what are you worried about?
usually in younger than 2
older needs workup for oncology
what is expected caloric intake for a 3-4 month old or 12kg infant
110 calories/kg/day
substance ingestion with highest fatality if ingested by a young toddler
Calcium Channel Blocker
how much breastmilk for 1 month old per day
100ml/kg/day
how much Na is in NS
154
organophosphate poisoning
atropine for muscarinic symptoms
Pralidoxime
benzos for seizures
treatment for nephrotic syndrome
high dose steroids (2mg/kg/day) x 6 weeks until in remission which is defined as 3 consecutive days with no protein on urine dipstick
KCL dosing
0.5-1mEQ/kg over 90 min
Type II RTA is associated with what syndrome
Fanconi
what RTA
FTT
metabolic acidosis and
hypokalemia
Type II RTA
In RTA what does chloride, bicarb and urine bicarb look like. How to treat?
High chloride
low bicarb
high urine bicarb
treat with oral bicarbonate supplements
Calcium dosing
Ca Chloride - 10mg/kg CVC
or Ca Gluconate 100mg/kg PIV
Tests for SLE
ANA
Anti-double strand DNA
Anti smith Antibody
treat for poststreptococcal GN
Penicillin V
treat for IgA nephropathy
Antihypertensives
Treat for PKD
Antihypertensives
causes of hypermag
renal failure
excessive intake
tumor lysis syndrome
in DKA treatment what do you expect Mg to do
Low Mg
insulin stimulates cell uptake of Mg
Serum calcium levels is affected by
Albumin levels
Low phos causes
muscle weakness to include resp muscles
High phos causes
laryngospasm and tetany
Hypochloremia is associated with what syndrome
Bartter syndrome
Potassium phos is infused over ___ to __ hrs
4-6
to raise Na levels this should be done
2-4 mEQ in 4 hrs or 10-20 meQ in 24 hrs
