Paediatrics Flashcards
1
Q
Signs of an unwell child
A
Lethargic, poor interaction, inconsolability, tachycardia, tachypnoea, cyanosis, poor peripheral perfusion
Localising signs: ENT exam, neck stiffness, increased WOB, abdo signs, skin rash, joint swelling
2
Q
Febrile child workup <1month corrected
A
Call for help
Full sepsis workup - FBC + film, blood culture, urine culture, LP +/- CXR (if respiratory sx and signs)
Admit for empirical ABs
3
Q
Febrile child workup 1-3 months
A
Call for help Full sepsis workup - FBC + film, blood culture, urine culture, +/- LP +/- CXR (if respiratory sx and signs) D/C home with review in 12hrs if: -previously healthy -Looks well - WCC 5-15 - Urine MCS clear - CXR and CSF (if taken) are clear
If child is unwell or above criteria are not satisfied admit for obs +/- ABs
4
Q
Febrile child workup >3months with fever of clear focus
A
Child looks well - treat as clinically indicated
Child look unwell - discuss with reg/consultant, Ix as appropriate, admit for rx
5
Q
Febrile child workup >3months and no clear focus of infection
A
Child looks well - Urine MCS (SPA if <12months), DC home on treatment with review in 24hrs
Child looks unwell
- FUll sepsis workup –> FBC, blood culture, urine MCS, +/- CXR, LP
- ADmit for obs +/- ABs
6
Q
History and examination features of meningococcal disease.
A
Rapid onset of sx
- Fever, malaise, lethargy, vomiting, vomiting, headache, myalgia, arthralgia, ALOC
- May have schock
7
Q
Management of meningitis
A
- IV access within 15 mins
- Take culture and administer ceftriaxone
- Fluids
- Steroids- consider dexamethasone in undifferentiated meningitis
- Contact chemoprophylaxis in anyone who has had contact in last 7 days with rifampicin
8
Q
Common causes of otitis media
A
Viral (25%)
Streptococcus pneumoniae (35%)
Non-typable strains of HIB (25%)
Moraxella catarrhalis (15%)
9
Q
Management of acute otitis media
A
> 12mo, mildly unwell, immunocompetent –> give analgesia with no abs for first 48hrs –> if sx not resolving give amoxycillin TDS for 5 days
Advise parents to seek medical review if ear sx, hearing difficulty or persitent irritability after 2-3 months
10
Q
CSF findings in meningits
A
Bacterial: +++ neutrophils, + lymphocytes, protein ++, glucose -
Viral: Neutrophils +, lymphocytes +++, protein -, glucose N
11
Q
Criteria for Kawasaki’s disease
A
Fever for >5 days + 4 out of 5
- Polymorphous rash
- Bilateral non-purulent conjunctivitis
- Mucous membrane changes - red lips, strawberry tongue, red pharynx/oral mucosa
- Peripheral changes - palmar erythema, sole erythema, oedema of hand/feet, convalescence desquamation
- Cervical lymphadenopathy
Exclusion of diseases with similar presentation - Scalded skin syndrome, toxic shock syndrome, scarlet fever, measles, other viral exanthems, drug reaction, juvenile RA
Other common features - arthritis, d+v, coryza, cough, uveitis, gallbladder hydrops
12
Q
Ix for a child with suspected Kawasaki’s disease
A
- ASOT, anti-DNase B
- Echo (at least twice, 1 at initial presentation, if -ve then again at 6-8 wks)
- PLatelet count (thrombocytosis common in 2nd week of illness)
13
Q
Management of Kawasaki’s disease
A
- Admit
- IV immunoglobulin within first 10 days, but also to pts after 10 days if evidence of ongoing inflammation
- Aspirin 3-5mg/kg for 6-8 wks
14
Q
Common causes of osteomyelitis/septic arthritis
A
- Most commonly caused staph aureus
- GAS
- HIB
15
Q
Features of osteomyelitis
A
-Subacute onset of limp/refusal to use limb/not weight bearing
- Localised pain
- Pain on movement
- Soft tissue swelling/redness may not be present
+/- fever
16
Q
Features of septic arthritis in paeds
A
- Acute onset of refusal to use limb/limp
- Pain on movement and at rest
- Loss of movement/limited range
- SOft tissue redness and swelling often present
- Fever
17
Q
Ix for osteomyelitis and septic arthritis
A
FBC ESR - monitoring progress Blood culture Xray Bone scan Joint aspirate in septic arthritis
18
Q
Management of septic arthritis and osteomyelitis
A
- Refer to orthopaedics
- Septic arthritis requires urgent aspiration +/- arthrotomy and washout
- ABs –> flucloxacillin
- Elevate and immobilise the limb
19
Q
Management of orbital cellulitis
A
Surgical emergency - consult ENT surgeons and ophthalmologist.
Urgent CT - differentiate those with abscess to those without
Surgical drainage of abscess = decompression of orbit + material for gram-stain and culture
Abs - ceftriaxone, flucloxacillin
20
Q
Features of orbital cellulitis
A
Proptosis
Ophthalmoplegia
Poor acuity
Severe or persistent headache
21
Q
Organisms that cause orbital and periorbital cellulitis
A
<5yo - strep. pneumoniae, strep. pyogenes
>5 - staph. aureus
Hib can also cause, but not common anymore
22
Q
Features of peri-orbital cellulitis
A
Eyelid erythema and oedema without signs of orbital cellulitis
23
Q
Common presentation of Henloch Schonlein Purpura
A
Autoimmune vasculitis presenting at 2-8yo. 50% are post URTI. Palpable purpura in all patients Other features - Arthritis/arthralgia - Abdo pain - Renal involvement --> haematuria, proteinuria, HTN - Pulmonary and neuro involvement rare
24
Q
Management of HSP
A
Analgesia - paracetamol, NSAIDs
Steroids - prednisolone
Follow up for complications - renal f/u very important
About 1/3 of pts will have recurrence within 4 months
25
Children with fever and petechiae can be d/c under what circumstances
- Well (normal vitals, no ALOC, good peripheral perfusion)
- WCC 5-15
- CRP <8
- No deterioration in clinical state or rash progression in 4 hrs of obs
26
Management of pneumonia outpatient
>1 month old, previously well, does not meet criteria for admission.
- lobar consolidation (CXR or clinical) = possible bacterial cause, treat with oral amoxycillin 7 - 10 days
- subacute onset + prominant cough +/- headache/sorethroat = mycoplasma pneumoniae, treat with roxithromycin 10 days
- not unwell, coryzal prodrome, diffuse crackles, CXR minimal patchy bilateral changes, immunised = probably viral, withhold ABs
27
WHen to admit a child with pneumonia?
When to admit?
- age <3 months
- Extensive consolidation
- pleural effusion
- very unwell: drowsy/lethargic, lower chest indrawing, nasal flare
28
Management of pneumonia as an inpatient
- poor perfusion or ALOC --> resus
- O2 sats <92% --> give oxygen
- Pleural effusion --> manage
- CXR suggest Staph Aureus (lobar consolidation) --> FLucloxacillin + Gentamicin
- Clinical picture suggest Mycoplasma (subacute onset + prominant cough) --> Roxithromycin 10 days
- Not Staph or Mycoplasma --> give BenPen + Gent if under 3/12 old
29
Management of UTI
- < 6/12 old or any child who is unwell --> IV ABs --> Gent + BenPen
- suitable for oral mx --> Trimethoprim
30
Indications for Renal USS for UTIs
- atypical UTI, not responding to treatment within 48hrs, boys <3/12 old --> Renal USS during illness
- <6/12 old --> Renal USS within 6 weeks
- >6/12 old --> Renal USS only if recurrent UTIs
31
Management of the septic child
1. Call for help
2. ABCD
3. Apply oxygen if <92%
4. Continuous cardiorespiratory monitoring
5. Within 15mins of arrival: IV access (if can't get IV go IO) --> take blood cultures, venous gas(Lactate >4 = severe), blood glucose +/- FBC, UEC, Coags
6. Within 30 mins --> IV fluid + Abs
IV Fluid 20ml/kg Bolus of N saline push
7. Monitor for improvement, if no improvement give another fluid bolus
8. Within 60 mins if no improvement- ionotropes
9. If no improvement --> ventilatory support
32
Empirical ABs for child presenting with sepsis
<1month - cefotaxine + benpen
| > 1 month - ceftriaxone + flucloxacillin
33
Treatment of bacterial sinusitis with persistent nasal discharge.
1. Amoxicillin
2. Amoxicillin + clavulanic acid (if pt has had amoxicillin in last month)
3. If any orbital or intracranial signs --> IV flucloxacillin and ceftriaxone
4. Refer
34
Features of bronchiolitis
```
Increased WOB
Widespread wheezes and crepitations
+/- fever
Reduced O2 Sats
<12 months of age
Peak severity day 2-3, resolution in 7-10 days, cough can persist for weeks.
```
35
Signs of mild, moderate and severe bronchiolitis.
Mild - Normal behaviour, normal RR, minimal accessory muscle use, normal feeding, O2 sats >93%, no apnoeic episodes
Moderate - some irritability, RR increased, tracheal tug, nasal flaring, moderate chest wall retraction, reduced feeding, mild hypoxaemia (spO2 90-93%, correctible with O2), may have brief apnoeas
Severe Irritable, lethargy, fatigue. RR marked increase/decrease, tracheal tug, nasal flaring, marked chest wall retraction, reluctant/unable to feed, hypoxaemia may not be corrected by o2 (spo2 <90%), apnoea +++
36
Management of mild, moderate and severe bronchiolitis
Mild - don't need to admit, if day 1-2 of illness advise parents they may need to return if sx worsening.
Moderate and severe - admit and discuss with team
Maintain O2 sats > 92%
Consider limiting fluids to 2/3rds maintenance
1-2 hourly obs
Severe - cardiorespiratory monitoring with close nurse supervision, consider referral to ICU as may need CPAP
If d/c before day 3 must have follow up as illness will worsen.
37
Signs of upper airway obstruction
Stridor, drooling, increased WOB.
| Signs of deterioration and urgent investigation - fatigue, decreased conscious stage, hypoxia.
38
DDx of upper airway obstruction
Croup --> harsh, barking cough, febrile, miserable, but otherwise well child.
Epiglottitis --> no cough, low pitch expiratory stridor, drooling, dysphagia, high fever, unimmunised
Foreign Body - sudden onset, otherwise well child, episode of coughing, choking, aphonia, can have drooling
Anaphylaxis - swelling of face and tongue, wheeze, urticarial rash
Bacterial tracheitis - markedly tender trachea
Retropharyngeal or peritonsillar abscess
Congenital abnormalities - floppy larynx
39
Management of foreign body
Total obstruction - get out ASAP
Partial obstruction - place in upright position that they feel most comfortable, arrange for urgent removal of FB in OT
Lower than main bronchus - persistent wheeze cough, fever, dyspnoea thats unexplained, recurrent pneumonia, O/E - asymmetrical chest signs. Rx same as partial
40
Management of upper airway obstruction
Allow child to sit comfortably, minimal handling, treat specific cause
Oxygen if sats low
Call PICU if worsening or severe obstruction
Don't do IV access - upsetting child can increase obstruction
41
Management of anaphylaxis
```
Posture supine
IM Adrenaline
<6yrs - .15mls
6-12 - .3 ml
>12 .5ml
Repeat dose after 5 mins if no improvement
Fluid resus 20ml/kg bolus N saline
Can use nebulised adrenaline if not responsive to IM adrenaline
Nebulised salbutamol if respiratory distress with wheezing
Antihistamines for symptomatic relief of urticaria
All children should be observed for 4hrs
Admit if:
- Need >1 dose of adrenaline
- Need a fluid bolus
- Inadequate response to rx
- Distance from healthcare
```
42
Discharge advice post anaphylaxis
- Write anaphylaxis action plan
- EpiPen with dose based on age
- Consider medical alert bracelet
- Refer to paediatric allergy specialist
- Control asthma
43
Features of mild, moderate and severe asthma
Mild- normal mental state, minimal or no increased WOB, can talk in full sentences
Moderate - normal mental state, some increased WOB, tachycardia, some limitation in ability to talk
Severe - agitated/distressed, moderate-marked increased WOB, tachycardia, marked limitation in ability to talk
Critical - confused, drowsy, maximal WOB, exhaustion, marked tachy, unable to talk, silent chest
44
Acute management of asthma
1. Salbutamol via MDI/spacer 6 puffs if <6 and 12 puffs if >6
R/V and repeat after 20mins
2. O2 if sats < 92%
3. Oral prednisolone 1-2mg/kg/day
SEVERE - Call for help
4. Ipratropium bromide via MDI/spacer 4 puffs , 6, 8 puffs >6
5.IV Aminophylline if deteriorating
6.IV Mag Sulphate
7.IV Methylpred if vomiting or very severe
8. ICU for ventilator support - CPAP, BiPAP
45
Risk factors for neonatal jaundice
- Cephalohematoma
- Mother with +ve antibody screen
- ABO incompatibility, Rh incompatibility
- G6PD deficiency
- Hereditary spherocytosis
- Delayed passage of meconium
- Prematurity
- Dehydration
- Inadequate breastfeeding
- Previously affected sibling
- Macroscomic infant
46
Neonatal jaundice causes and investigations<24 hrs
always pathological, usually haemolysis. Other causes -- sepsis, consider hepatitis, haemolytic disease of the newborn
Ix - bilirubin (total and unconjugated), mother and baby ABO and rhesus, direct coomb's
47
Neonatal jaundice causes day 2-10
Usually physiological jaundice. Term babies resolves by 2wks, premature by 3wks.
For physiological jaundice baby needs to be otherwise well and normal. It is an unconjugated hyperbilrubinaemia
Breast milk jaundice (approx. day 3) - unconjugated, common, don't stop breastfeeding, cause unknown, jaundice may continue for many wks
Breastfeeding jaundice - insufficient milk supply
Haemolysis
Polycythaemia
Sepsis
Non-haemolytic red cell destruction (cephalohematoma)
48
Neonatal jaundice >10 days (prolonged)
Hypothyroidism (make sure you check TFTs - can cause cretinism if not corrected)
Infection/sepsis
Haemolysis - likely to be hereditary haemolysis (G6PD, spherocytosis)
Poor milk intake and breast milk jaundice can persist (dx of exclusion)
Biliary atresia - prolonged conjugated hyperbilirubinaemia (presents with pale stools and dark urine, needs op before 6wks)
49
What is kernicterus?
| How does it present?
Unconjugated, unbound bilirubin crosses the blood-brain barrier causing neurologic dysfunction +/- death (biliary encephalopathy)
Normally presents first few wks of life.
First few days - decreased alertness, hypotonia, poor feeding.
Later signs - hypertonia, arching of the back and neck
50
Presentation of febrile convulsions.
```
age 6m-6y
Must be febrile
No previous afebrile convulsions
Normal development
Without significant prior neurological abnormalities
Without CNS infection
Usually occur with simple viral illnesses.
In 3% of children
```
51
Simple vs complex febrile convulsion.
Simple - generalised tonic-clonic <15 mins long and does not recur within the same illness
Complex - focal onset , duration >15 minutes, recurrence within same illness, incomplete recovery within 1 hr
Febrile status epilepticus is >30mins
52
Characteristics of colic (paeds)
Crying in early weeks of life - peaks wk 6-8 and settled by 3-4 months
Excessive crying is >3hrs/day more than 3 days/wk
Usually worst in late afternoon/evening
Infant may draw up legs as if in pain
Well and thriving
No identifiable medical problem
53
Causes of colic (paeds)
- Excessive tiredness - >hour less than average for their age (birth 16hrs, 2-3m 15hrs) A 6 wk old baby becomes tired after 1.5hrs, 3m 2hrs.
- Hunger - more likely if mother reports baby has frequent feeds (<3hrly), poor wt gain, inadequate milk supply
54
DDx for colic (paeds)
- Cow milk/soy protein allergy --> vomiting, blood or mucous in diarrhoea, FTT, fhx of atopy, feeding problems worsening over time. Clinical dx, trial of eliminating cow's milk (modify mums diet or hydrolysed formula for 2wks)
- Gastro-oesophagel reflux -->Frequent vomiting (>4/day), crying, feeding difficulties, can be 2ndry to cow's milk protein intolerance
- Lactose overload/malabsorption --> Frothy water diarrhoea, with perianal excoriation
-
55
Management of colic (paeds)
- Exclude medical cause
- Explain and reassure --> explain normal crying and sleep patterns (sleep cry diary)
- Establish pattern to feeding/settling/sleep
- Avoid excessive stimulation --> darken bedroom for daytime sleeps
- Carry in a papoose
- Baby massage, rocking, patting
- Gentle music
- Make sure parents don't want to kill the baby - have a break
- Provide printed info
56
Features of innocent murmurs.
```
Systolic (except diastolic component of venous hum) and musical
No radiation
Soft (< grade 3/6)
Vary with position
Normal CVS exam otherwise
```
57
Types of innocent murmurs
Venous hum- blowing, continuous, heard below clavicles, disappears when lying down
Pulmonary flow murmur- brief-high pitched murmur at 2nd intercostal space, best heard lying down
Systolic ejection murmur- short systolic murmur at left sternal edge, musical sound, changes with position, intensified by fever, exercise, emotion
58
What is the Jones Criteria?
1 required, and 2 major or 1 required 1 major and 2 minor
Required- evidence of strep infection (ASO and antiDNAse B titre
Joints - migratory polyarthritis
O - Carditis
Nodules - subcutaneous nodules
Erythema marginatium
Sydenham's chorea
Minor
- Fever
- Arthralgia
- Previous RF, RHD
- Acute phase reactants - ESR, CRP, WCC
- ECG - prolonged PR interval
59
Management of ARF
Give IM Bicillin
Arthritis and fever- analgesia
Chorea - no treatment, carbamazepine or valproic acid
Carditis/heart failure - bed rest with mobilisation as able, urgent echo, diuretics, fluid restriction, ACEI in severe failure and digoxin if AF present
2ndry prophylaxis with 28 daily bicillin for 10yrs or until age 21
Echo 2yrly
Dental review yearly
