Clinical Practice Guidelines - PCAP Flashcards Preview

Nelson's Pediatrics > Clinical Practice Guidelines - PCAP > Flashcards

Flashcards in Clinical Practice Guidelines - PCAP Deck (135):
1

Predictors of PCAP:
3 mos. - 5 yrs.

tachypnea
chest indrawing

2

Predictors of PCAP:
5-12 yrs.

fever
tachypnea
crackles

3

Predictors of PCAP:
> 12 yrs.

fever (> 37.8°C)
tachypnea (> 20 bpm)
tachycardia (> 100 bpm)
at least 1 abnormal chest finding (rhonchi, crackles, wheezes, ↓BS)

4

_____ is still the best predictor of pneumonia.

Tachypnea

5

Tachypneic RR for 2-12 mos.

≥ 50 bpm

6

Tachypneic RR for 1-5 yrs.

≥ 40 bpm

7

Tachypneic RR for > 5 yrs.

≥ 30 bpm

8

Who will require admission?

mod.-high risk for pneumonia-related mortality

9

Patients with minimal-low risk can be managed on an _____.

outpatient basis

10

PCAP A (Minimal Risk):
Co-Morbidities

none

11

PCAP A (Minimal Risk):
Compliant Caregiver

yes

12

PCAP A (Minimal Risk):
Able to Follow-Up

yes

13

PCAP A (Minimal Risk):
Dehydration

none

14

PCAP A (Minimal Risk):
Able to Feed

yes

15

PCAP A (Minimal Risk):
Age

> 11 mos.

16

PCAP A (Minimal Risk):
Respiratory Rate

2-12 mos. - ≥ 50 bpm
1-5 yrs. - ≥ 40 bpm
> 5 yrs. - ≥ 30 bpm

17

PCAP A (Minimal Risk):
Signs of Respiratory Failure

none

18

PCAP A (Minimal Risk):
Sensorium

awake

19

PCAP A (Minimal Risk):
Complications

none

20

PCAP A (Minimal Risk):
Management

OPD
follow-up at the end of treatment

21

PCAP B (Low Risk):
Co-Morbidities

present

22

PCAP B (Low Risk):
Compliant Caregiver

yes

23

PCAP B (Low Risk):
Able to Follow-Up

yes

24

PCAP B (Low Risk):
Dehydration

mild

25

PCAP B (Low Risk):
Able to Feed

yes

26

PCAP B (Low Risk):
Age

> 11 mos.

27

PCAP B (Low Risk):
Respiratory Rate

2-12 mos. - ≥ 50 bpm
1-5 yrs. - ≥ 40 bpm
> 5 yrs. - ≥ 30 bpm

28

PCAP B (Low Risk):
Signs of Respiratory Failure

none

29

PCAP B (Low Risk):
Sensorium

awake

30

PCAP B (Low Risk):
Complications

none

31

PCAP B (Low Risk):
Management

OPD
follow-up after 3 days

32

PCAP C (Moderate Risk):
Co-Morbidities

present

33

PCAP C (Moderate Risk):
Compliant Caregiver

no

34

PCAP C (Moderate Risk):
Able to Follow-Up

no

35

PCAP C (Moderate Risk):
Dehydration

moderate

36

PCAP C (Moderate Risk):
Able to Feed

no

37

PCAP C (Moderate Risk):
Age

< 11 mos.

38

PCAP C (Moderate Risk):
Respiratory Rate

2-12 mos. - ≥ 60 bpm
1-5 yrs. - ≥ 50 bpm
> 5 yrs. - ≥ 35 bpm

39

PCAP C (Moderate Risk):
Signs of Respiratory Failure

intercostal retractions
subcostal retractions
head bobbing
cyanosis

40

PCAP C (Moderate Risk):
Sensorium

irritable

41

PCAP C (Moderate Risk):
Complications

present

42

PCAP C (Moderate Risk):
Management

ward

43

PCAP D (High Risk):
Co-Morbidities

present

44

PCAP D (High Risk):
Compliant Caregiver

no

45

PCAP D (High Risk):
Able to Follow-Up

no

46

PCAP D (High Risk):
Dehydration

severe

47

PCAP D (High Risk):
Able to Feed

no

48

PCAP D (High Risk):
Age

< 11 mos.

49

PCAP D (High Risk):
Respiratory Rate

2-12 mos. - ≥ 70 bpm
1-5 yrs. - ≥ 50 bpm
> 5 yrs. - ≥ 35 bpm

50

PCAP D (High Risk):
Signs of Respiratory Failure

supraclavicular retractions
intercostal retractions
subcostal retractions
head bobbing
cyanosis
grunting
apnea

51

PCAP D (High Risk):
Sensorium

lethargic
stuporous
comatose

52

PCAP D (High Risk):
Complications

present

53

PCAP D (High Risk):
Management

ICU
refer to specialist

54

_____ on admission was the best predictor of death.

Retractions (23x ↑)

55

The risk of death in children was highest among those with _____.

intercostal and subcostal retractions

56

Cyanosis and head bobbing correlates well with _____.

hypoxemia

57

Best Predictors of Hypoxemia

inability to cry
head bobbing/nodding
RR > 60 bpm

58

Diagnostic Aids for PCAP A and B

none

59

Diagnostic Aids for PCAP C and D

CXR PAL
WBC Count
Blood CS (PCAP D)
Pleural Fluid CS
Tracheal Aspirate CS
ABG
Pulse Oximetry
Sputum CS (older children)

60

_____ on CXR is sensitive for bacterial pneumonia.

Alveolar Consolidation

61

CXR serves 2 functions in PCAP:

1. stronger basis for stratification of risk
2. therapeutic intervention

62

Children who are _____ of age with a fever _____ of unknown origin may need a CXR.

< 5 years, > 39°C

63

CXR as a baseline study for PCAP is _____.

not warranted

64

PCAP is more likely when WBC count is _____.

> 15,000

65

Acute phase reactants _____ and _____ cannot differentiate between viral and bacterial PCAP.

ESR, CRP

66

Culture Studies for PCAP

Blood CS x 2 sites
Pleural Fluid CS
Tracheal Aspirate CS (1st intubation)
Sputum CS

67

ABG and pulse oximetry must be done for _____.

all patients being considered for admission

68

When is antibiotic therapy recommended in PCAP A or B?

> 2 y.o.
high grade fever without wheeze

69

When is antibiotic therapy recommended in PCAP C?

> 2 y.o.
high grade fever without wheeze
alveolar consolidation
WBC > 15,000

70

When is antibiotic therapy recommended in PCAP D?

always

71

_____ is the best predictor of the underlying etiology of PCAP.

Age

72

During the first 2 years of life, pneumonia is usually _____ in etiology.

viral

73

As age increases, bacterial pathogens such as _____ become more prevalent.

Streptococcus pneumoniae - most common
Haemophilus influenzae Type B
Mycoplasma sp.
Chlamydia sp.

74

Features of Bacterial PCAP

fever > 38.5° C
(-) wheeze

75

Features of Viral PCAP

fever < 38.5° C
(+) wheeze

76

What should be given for bacterial PCAP A or B?

Amoxicillin 40-50 mkday TID x 7 days

77

What should be given for bacterial PCAP C?

Pen G 100K ukday QID (complete HiB immunization)
Ampicillin 100 mkday QID

*given for 7 days

78

What should be given for bacterial PCAP D?

consult a specialist

79

Oral Antibiotics for PCAP

Amoxicillin
Cotrimoxazole
Chloramphenicol

80

IV Antibiotics for PCAP

Pen G
Ampicillin
Chloramphenicol
Cefuroxime
Ampicillin-Sulbactam

81

What should be given for laboratory confirmed viral PCAP?

Oseltamivir 2 mkdose BID x 5 days
Amantidine 4.4-8.8 mkday x 3-5 days

82

Neuraminidase inhibitors, Zanamivir and Oseltamivir, have been shown to reduce the duration of illness by _____.

1-1.5 days

83

Anntivirals for PCAP should be given within _____.

48 hours

84

Propylaxis of household contacts with antivirals for children _____ of age.

≥ 12 years

85

When can a patient be considered responding to the current antibiotic?

decrease in respiratory signs (tachypnea) and defervescence within 72 hours

86

If PCAP A or B does not improve within 72 hours, an _____ may be started.

oral macrolide

87

If PCAP C does not improve within 72 hours, _____ should be suspected.

Penicillin Resistant Streptococcus Pneumoniae
complications

88

2nd-line Antibiotics for PCAP A or B
Penicillin Resistant Streptococcus Pneumoniae

Cefuroxime Axetil
Co-Amoxiclav
Sultamicillin
Cepfodoxime

89

2nd-line Antibiotics for PCAP A or B
Mycoplasma sp or Chlamydia sp

Erythromycin (oral macrolide)

90

When can IV antibiotics be shifted to oral?

after 2-3 days

91

Criteria for Step-Down Therapy

responding to initial treatment
able to feed
intact GI absorption
(-) complications

92

How long should step-down oral therapy be given?

4-8 days

93

Ancillary Treatment

oxygen (O2Sat ≥ 95% or pO2 ≥ 80 mmHg)
hydration
bronchodilator (wheezing)

94

How can PCAP be prevented?

vaccines
zinc

95

Zinc Dose for PCAP

infants - 10mg
> 2 y.o. - 20mg

*given for 4-6 mos.

96

The 7-valent pneumococcal vaccine CRM 197 PCV contains S. pneumoniae serotypes _____.

4, 6B, 9V, 14, 18C, 19F, 23F

97

_____ immunity is most affeced in protein-calorie malnutrition.

Cell-Mediated

98

Complement levels are _____ in malnourished children.

low

99

In malnourished children, immunoglobulin responses that are important for _____ of invading organisms are impaired.

opsonization

100

Opportunistic pathogens such as _____ are found in malnourished children.

Acinetobacter
Corynebacterium sp
Streptococcus faecalis

101

_____ causes viral pneumonia in well-nourished children.

Respiratory Syncytial Virus (RSV)

102

_____ causes viral pneumonia in malnourished children.

Herpes Simplex Virus (HSV)

103

A child with tuberculosis can be malnourished and may thus be presumed to be _____.

immunocompromised

104

In the presence of _____ secondary to tuberculosis, patients may be predisposed to infection.

extensive pulmonary parenchymal damage

105

CHD with _____ increases the risk of developing PCAP.

large volume L→R shunt
chamber enlargement that causes extrinsic airway obstruction

106

_____ and _____ are the most common pathogens causing pneumonia in patients with CHD.

RSV, Influenza

107

_____ has been associated with persistent type of asthma but not with acute exacerbation.

Chlamydia pneumoniae

108

Use of antibiotics in early childhood is associated with an increased risk of developing _____.

asthma
allergic disorders

109

A simple _____ with concomitant _____ secondary to _____ because of asthma is often misdiagnosed as pneumonia.

Viral URTI, atelectasis, mucus plug

110

_____ is the most common cause of recurrent or persistent infiltrates on CXR.

Asthma

111

Treatment of PCAP:
Amoxicillin

40-50 mkday TID x 7 days
adult dose: 750-1500 mg

112

Treatment of PCAP:
Azithromycin

10 mkday OD x 3 days
adult dose: 600 mg

113

Treatment of PCAP:
Cefpodoxime Proxetil

20 mkday BID x 7 days
adult dose: 800 mg

114

Treatment of PCAP:
Cefuroxime Axetil

20-30 mkday BID x 7 days
adult dose: 1-2 g

115

Treatment of PCAP:
Chloramphenicol Palmitate

50-100 mkday QID x 7 days
adult dose: 2 g

116

Treatment of PCAP:
Clarithromycin

15 mkday BID x 7 days
adult dose: 1 g

117

Treatment of PCAP:
Co-Amoxiclav

40-50 mkday of Amoxicillin BID x 7 days

118

Treatment of PCAP:
Cotrimoxazole

8-10 mkday of TMP BID x 7 days
adult dose: 320 mg

40-60 mkday of SMX BID x 7 days
adult dose: 1.6 g

119

Treatment of PCAP:
Erthromycin

30-50 mkday TID or QID x 7 days
adult dose: 1-2 g

120

Treatment of PCAP:
Sultamicillin

25-50 mkday BID x 7 days
adult dose: 750-1500 mg

121

Treatment of PCAP:
Ampicillin

100-200 mkday q6 x 7 days
adult dose: 2-4 g

122

Treatment of PCAP:
Ampicillin Sulbactam

150-300 mkday q6 x 7 days
(100-200 mkday of Ampicillin)

123

Treatment of PCAP:
Ceftriaxone

50-100 mkday OD or q12 x 7 day
adult dose: 2 g

124

Treatment of PCAP:
Cefuroxime

75-100 mkday q8 x 7 days
adult dose: 2-4 g

125

Treatment of PCAP:
Penicillin G

100K-200K ukday q6 x 7 days
adult dose: 8-12M units (max 24M units/day)

126

Treatment of PCAP:
Amantidine

4.4-8.8 mkday BID x 3-5 days
max: 150 mg

127

Treatment of PCAP:
Oseltamivir

4 mkday BID x 5 days

128

Antitussive Side Effects:
somnolence, ataxia, miosis, nausea, vomiting, rash, facial swelling, pruritus, addiction, respiratory depression, obtundation

Codeine

129

Antitussive Side Effects:
confusion, excitation, nervousness, irritability, addiction, respiratory depression, behavioral disturbances

Dextromethorphan

130

Expectorant Side Effects:
GI disturbance, nausea, vomiting, dizziness, headache, rash, diarrhea, drowsiness, abdominal pain

Guaifenesin

131

Mucolytic Side Effects:
GI discomfort, increased transaminases

Bromhexine

132

Mucolytic Side Effects:
nausea, headache, GI discomfort and bleeding, diarrhea, rash

Carbocisteine

133

Antihistamine Side Effects:
loss of appetite, nausea, vomiting, epigastric pain, constipation, diarrhea, hallucinations, excitement, insomnia, drowsiness, incoordination, dizziness, tinnitus, blurred vision, diplopia, athetosis, fixed dilated pupil, sinus tachycardia, urinary retention

Diphenhydramine

134

Decongestant Side Effects:
headache, hypertensive crisis, seizures, arrhythmias, psychosis, insomnia, psychiatric disorders, hemorrhagic stroke

Phenylpropanolamine

135

Decongestant Side Effects:
hypertension, pulmonary edema

Phenylephrine