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Flashcards in Paeds Deck (98):
1

Dose of ondansetron

0.15 mg/kg PO/IV

2

Peds GCS

E: 4= Spontaneous, 3 = voice = 2 pain 1 = none

V: 5 = smiles, orients to sounds, interacts, 4 = cries, consolable, inappropriate interactions, 3 = inconsistently inconsolable, moaning, 2 = inconsolable, agitated, 1 = none

M: 6 = moves purposefully, 5 = withdraws touch, 4 = withdraws pain, 3 = flexes (decorticate), 2 = extends (decerebrate), 1 = none

3

What to send stool for in ED

- Stool for fecal leukocytes (>5/hpf), blood or both, identifies 90% of invasive disease; if neg, may not need to send for culture.

- C&S, esp. E.coli 0157:H7

- C.diff

- O&P

4

Paeds Dehydration Assessment

5

ORT for Kids

1. Zofran 0.15 mg/kg ODT

Pedialyte (not Gatorade): for mild-moderate dehydration. Calculate desired volume based on dehydration chart, give 25%/h over 4h.
Vx: add 2 mL/kg for each episode during ORT, start again 10 min after vx
Dx: add 10 mL/kg for each episode during ORT
After 4h, if not better, restart for another 4h
After 8h, if not better, admit + IVF

6

Paeds IV Fluids

Shock
20 mL/kg NS over 5-15 minutes, repeat until improvement

CBG, if <2.8 mmol/L:

0-1 month = D10 4 mL/kg
1 month - 8 years/25 kg = D25 2 mL/kg
>8 years = D50 1 mL/kg
CBG Q 30-60 minutes

 

After initial resuscitation/Rehydration Phase

Total Deficit = %dehydration X kg X 1000 mL
First 9 hours: 1/2 deficit and 1/3 maintenance
9-24h: 1/2 deficit and 2/3 maintenance


Isonatremic/Hypernatremic: D5W 0.45% NS with 20 mmol/L KCl (KCl once voided)
Hyponatremic (<130 mmol/L): D5W 0.9% NS with 20 mmol/L KCl


 

7

Dose of PRBC for transfusion in trauma in Kids

10 mL/kg

8

Urine output goals in trauma

Infants

Children

Adults

Infants: 2 mL/kg/h

Children: 1 mL/kg/h

Adults: 0.5 mL/kg/h

9

Hypertonic Saline Dose for IICP in Children

3-5 mL/kg 3% Saline

10

Asthma ICS Dosing

11

Yellow Zone Asthma Therapy

12

Asthma PFT Diagnostic Criteria

13

Asthma Therapy Continuum

14

Asthma Criteria for Good Control

15

Flovent Preparations

50 mcgs, 125 mcgs, 250 mcgs

16

Abnormal Values on WBC for infants

WBC <5 or >15

Band/neutrophil > 0.2

Bandemia >1, 500 mm3

ANC > 10, 000

17

Abnormal UA for infants

> 10 WBC or +ve Gram Stain

18

FWS Algorithm 

0-28 days

29 days - 2 months

19

FWS Algorithm

2-3 months

20

FWS Algorithm

3-6 months

21

Accepted Sources of Fever for peds (>3 months)

HSV/Gingivostomatitis

Herpangina/Ulcerative stomatitis

RSV

Croup

Flu

Varicella

Viral Exanthem (Rash)

Enterovirus, coxsackie, HFM, echo, rhino, entero

22

Abx doses for Peds FWS

< 28d old: amp + gent or cefotaxime (if >8 days old), vanco (for pneumo resistance), acyclovir (if pleocytosis)

>28d old: cetriaxone +- vanco (for MRSA skin infections/severe infection), +- acyclovir

Amp: 50 mg/kg

Cefotaxime: 50 mg/kg

Vanco: 15-20 mg/kg

Ceftriaxone: 100 mg/kg (meningitis dose), 50 mg/kg (reg dose)

Acyclovir: 60 mg/kg/day divided q8h

 

23

FWS Algorithm

6 months - 3 years

UA + culture for circumsized boys up to 6 months, uncircumsized boys up to 12 months, and girls up to 24 months. Offer UA to all children up to 24 month with T >39 deg C

>3 y, no routine workup necessary for well-appearing

24

Prevalence of SBI in peds FWS (for a well-appearing child)

0-14 days: 1/10

14-28d: 1/20

28-60 d (pre-vaccine): 1/100

28-60 d (post vaccine): 1/1000

60-90d: 1/1000 - 10, 000

>90 d: > 1/10, 000

25

Criteria for simple febrile seizure

  • age 6 months - 5 years
  • generalized
  • <15 min
  • 1 time/24h

26

Pertinent Asthma Hx

  • past ED visits/admissions/intubations
  • home meds
  • fam hx asthma/eczema
  • environmental factors

27

Asthma Exam

  1. WOB
  2. SpO2
    1. >94% awake
    2. >89% asleep
  3. PO intake
    1. diapers
    2. IVC
    3. US bladder (if full, don't need to wait for pee)

28

At what age can you give a provisional diagnosis of asthma based on presentation and response to bronchodilators?

3 years

29

At what age would you get a peak flow?

6 years

30

Ventolin Dosing

Ventolin (MDI with spacer preferred over nebulizer)

     - 0.15 mg/kg (min 2.5 mg) Q 20 min x 3 then 15-40 mg/h continuous as needed

     - 4-8 puffs q 20 min then Q1-4h PRN

31

Atrovent Dosing

Atrovent has shown to work within 1st hour of tx in children but not beyond

     - 250-500 mcg nebs Q20 min X 3

     - 4-8 puffs Q20 min PRN

32

Steroid Dosing Asthma

  • Dex 0.6 mg/kg (max 16 mg) daily x 2 days (peds only)
  • Prednisolone 2 mg/kg day 1, 1 mg/kg days 2-5 (max 50 mg)
  • Prednisone 1 mg/kg daily x 5 days (max 50 mg)

33

IV MgSO4 dose for Asthma

If no response in first 1-2h of therapy, 75 mg/kg, max 2.5 g IV. Monitor for bradycardia and hypotension. In adults, use liberally, 2 g IV NNT 2-3 in mod-severe asthma to prevent admission.

34

Andy Sloas' Four Groups of Asthmatics

Group 1: ran out of meds/mild cold - home with Rx or 1 treatment with ventolin, steroids, and home.

Group 2: Mild (CRS <3), RR increased to 50, SpO2 92% or one thing off. 6 puffs ventolin + atrovent, steroids. If needs 1-2 sets of this, watch for 1 hour, send home.

Group 3: if needed 3 back to back nebs or sets of puffs, that is equal to 1h continuous nebulized ventolin ---> 3:2:1 rule

     - if needing treatments Q3h, home

     - if needing treatments Q2h, admit to general peds ward

     - if needing treatments Q1h, admit to step-down

     - if needing continuous, PICU

Group 4: de-sat, tripoding, CRS >6

     - continuous nebs, IVSCS, IV MgSO4

     - if needed 2h continuous neb --> IV epi or terbuteline

35

Bronchiolitis Pertinent History

Infants - 2 years

RSV

Lasts 7-14 days, peaks on days 3-5

Ask about apneic episodes --> admit

36

Bronchiolitis Treatment

Hydration

Nasal suctioning with saline nasal drops QID

May try ventolin/racemic/hypertonic saline PRN

37

Amoxil Dosing & Amox/Clav Dosing for kids

  • max Amoxil 3-4 g/day
  • Amox/Clav only available in 7:1 ratio in Canada (14:1) in states
  • to reduce diarrhea, rx (for AOM)
    • 45 mg/kg Amox/Clav (7:1)
    • 45 mg/kg Amox
    • for total 90 mg/kg Amoxil with 14:1 clavulin ratio

38

Perforated TM with AOM or TM tube with purulent otorrhea

  • ciprodex better than PO Abx
  • swab & send for C&S

39

Definition of peds UTI

100, 000 CFU's per mL for clean catch or 50, 000 CFU per mL for catheterized sample of single organism + 10 WBC/mL from unspun or 5 WBC/mL from centrifuged specimen or culture or leuks/nitrites in a symptomatic child

40

Additional investigations for peds UTI

  • 1st febrile UTI 2-24 months --> KUB U/S
    • peds if +ve (for VCUG)
    • peds if second febrile UTI (even if US -ve) for VCUG
  • VUR Grades 1-3 no change in treatment, no prophylaxis, Grades 4, 5, refer to peds urology, consider sx

41

1st line Abx for febrile peds UTI

  • cefixime (Suprax) 8 mg/kg PO daily x 7-14 d

42

Measles

  • Rubeola
  • incubation: 10 days
  • infectivity: 2 days before rash until 5 days after onset of rash
  • symptoms: cough, coryza, conjunctivitis, high fever, Koplik spots, rash starting from ears, spreading all over
  • diagnosis: measles IgM
  • complications: AOM, pneumonitis, encephalitis (0.1%)

43

Mumps

  • Paramyxovirus
  • incubation: 6 days
  • infectivity: 1 day before swelling until 5 days after onset of swelling
  • symptoms: myalgias, fever, headache, swelling of parotid/submandibular glands
  • complications: orchitis (30%, usually does not lead to infertility), meningoencephalitis (10%)
  • droplet precautions

  • testing:

    • throat swab

    • buccal swab (massage parotid gland x 30 s first)

    • urine

    • IgG/IgM (serology)

  • most can manage as outpatient (avoid school/work for 2-5 days, live in separate room)

44

Rubella

  • incubation: 14-21 days
  • infectivity: 2 days before onset of rash until 7 days after onset of rash
  • symptoms: URI, posterior auricular, posterior cervical, occipital LAN, MP rash starts on face, spreads over body for 3 days
  • complications: congenital rubella syndrome (infection in first 4 months of pregnancy --> cataracts, glaucoma, CHD, dev delay, etc.)
    • pregnancy
      • IgG + IgM
        • if IgG +ve at time of exposure, reassure
        • if IgM +ve, IgG -ve, counsel for termination if in 1st trimester

45

Fifth Disease/Erythema Infectiosum/Slapped Cheek

  • Parvovirus B19
  • incubation: 5-10 days
  • infectivity: prior to onset of rash
  • symptoms: URI, waxing/waning rash (red cheeks, eyelid + circumoral sparing first then 4d later reticular rash), arthralgias (Ag/Ab deposition), transient aplastic anemia (infects erythroid progenitor cells)
  • complications:
    • 15% risk hydrops and fetal death if infected before 20 wks GA, <3% after 20 weeks.
    • pregnancy
      • risk of fetal death after household exposure <2.5%, workplace <1.5%
        • draw IgG
          • detectable by 7th day, persists lifelong
        • draw IgM
          • detectable by 3rd day, persist 30-60 days
      • if susceptible or +ve IgM, weekly US x 4-8 weeks after exposure to r/o hydrops

46

Chicken Pox

  • Varicella Zoster
  • incubation: 10-20 days
  • infectivity: 2 days before rash until all lesions crusted over
  • symptoms: fever, HA, malaise, then itchy painful rash, lasts 7-10 days
  • complications: sepsis, cerebellar ataxia, encephalitis, pneumonia, nec fasc
    • pregnancy
      • 30% varicella pneumonia, mortality 40%
      • maternal HZV not harmful but exposure to HZV without varicella immunity is
      • congenital varicella syndrome
        • usually in first 20 weeks of pregnancy
        • <2% risk at < 20 weeks, lower after
      • diagnosis
        • clinical
        • 4x rise in varicella-specific IgG Ab over 14-21d period
      • management
        • if history of chickenpox --> reassure
        • if unknown, and able to get results within 96h, draw VZV IgG Ab
        • if unable to get labs within 96h or if no immunity
        • give VZIG 625 units IM
        • if develops severe disease
          • acyclovir 10 mg/kg IV Q8h or 800 mg PO QID x 5 d

47

Hand-Foot-Mouth Disease

  • coxsackie virus
  • complications:
    • myocarditis
    • diarrhea 10 d after onset

48

Formula to estimate normal lower limit BP in children > 1 year

SBP = 70 + [2X(age in years)]

49

NRP: The three questions to ask to decide whether to give baby to mom or to resuscitate.

1. Is it term?

2. Is it crying & breathing?

3. Does it have good tone?

50

Rule of three's for Colic

3 weeks to 3 months

At least 3 h of crying at least 3d/wk

Usually after 3 PM

51

Age of incidence: Croup

3 months - 6 years

52

Dose of Dex: Croup

Dose of Racemic Epi neb: Croup

Dose of IM Epi: Croup

Dex: 0.6 mg/kg (max: 10 mg) PO X 1

Racemic epi: 0.25 mL mixed with 3-5 mL saline, watch for 2h

IM Epi: 0.01 mL/kg of 1:1000 (max: 0.3 mL)

53

Peds Vitals

Review Evernote

Correct HR by 10 and RR for 5 per 1 deg C increase

54

AAP Guidelines for UTI testing in 2 mo. - 2 yrs age

  • girls, test if 2 or more of:
    • nonblack
    • < 12 mo.
    • T >= 39
    • fx >= 2 d
    • no other source
  • uncircumcised boys
    • test if no apparent focus of infection present
    • circumcised boys, test if 2 or more of:
    • nonblack
    • T >= 39
    • fx >= 24h
    • no other source
  • circumcised boys, test if 2 or more of:
    • nonblack
    • T >= 39
    • fx >= 24h
    • no other source

55

Necrotizing Enterocolitis

Age, pathophys, clinical features, dx, tx.

  • neonatal disease
  • immune overreaction, coagulation necrosis
  • mean age 2-9 days of life, but think up to 3 months
  • poor feeding, abdo distension, bilious vomiting, fever +- BRBPR/melena
  • labs
    • 3V Abdo
    • pneumatosis intestinalis
    • portal venous gas
  • tx
    • NPO, g-tube, abx, IVF

56

Hirschprung's Disease

History, clinical features, age of onset

  • Hx Delayed first stool passage (>24-48h)
  • Needs suppository for every stool.
  • 1-2 months old.
  • On rectal exam, stool and gas is explosive.

57

Volvulus (peds)

age of onset

clinical features

dx

  • Malrotation is abnormal position, volvulus is twisting/ischemia of bowel.
  • 80% presents in 1st month of life, 90% within 1st year
  • abrupt onset bilious vx, abdo distention
    • may be intermittent
  • lab
    • upper GI series
    • sx consult without waiting for result

58

Intususseption

Age of onset

causes

clinical features

dx

 

  • 3 months - 3 years
  • causes
    • Peyer's patches, Meckel's, HSP
  • lethargy, intermittent pain
    • legs drawn to chest
  • normal exam in-between
    • sausage mass RUQ
    • occult blood (70%), gross blood (50%)
  • US ~100% sensitive
  • If high suspicion, direct to air-contrast enema
    • not if FA on xray, or in shock

59

Peds Umbilical vs. inguinal hernias

  • all inguinal need urgent repair
  • umbilical may repair if symptomatic or age > 3

60

How much weight loss is acceptable for a neonate, and when must they regain their birth weight?

  • normal to lose up to 10% birth weight during first 3-7 days, but should regain by 10-14 d
  • average gain of 20-30 g/day for first 3 months then 15-20 g for next several months

61

Normal Periodic Breathing vs. Apnea in neonates

  • normal periodic breathing: normal/fast alternating with slow + pauses 3-10 seconds
  • apnea: pause in breathing > 20 seconds or with bradycardia/cyanosis/change in muscle tone is abnormal

62

By what age do most infants sleep through the night?

  • 6 months

63

TSB levels for severe and critical hyperbilirubinemia in neonates

  • Severe hyperbilirubinemia – a total serum bilirubin (TSB) concentration greater than 340 µmol/L at any time during the first 28 days of life
  • Critical hyperbilirubinemia – a TSB concentration greater than 425 µmol/L during the first 28 days of life

64

Neonatal Jaundice

Readthrough, Evernote

65

Mastoiditis

  • almost always from AOM
  • highest age 1-3
  • CT mastoid
  • PipTazo + Vanco

66

  • Geographic tongue
  • childhood lesions
  • migratory
  • recurrent
  • asymptomatic
  • no treatment necessary, benign

67

Pediatric ABRS

  • usually ethmoid & maxillary (frontal don't develop until late adolescence)
  • don't do imaging
  • check for FB --> do consider xray if unilateral purulent discharge
  • more or less same criteria as adult, mostly gestalt (unilateral tenderness, prolonged nasal discharge)
  • clavulin/cefuroxime + nasonex, f/u GP

68

Pediatric Assessment Triangle

  1. Appearance
  2. Work of Breathing
  3. Circulation

69

NRP Algorithm

  • 0-30 Seconds
    • dry, stimulate
    • if no response, suction nose and throat with 8F catheter
  • 30s-60s
    • if HR > 100 but cyanosis/laboured breathing
    • open airway, suction
    • SpO2 from R hand
    • no naloxone
    • if HR <100/apnea
    • BMV PPV @ 40-60 BPM, Pmax ~20-30
      • start with room air
      • Mask seal
      • Reposition
      • Suction
      • Open mouth (jaw thrust)
      • Pressure (increase to max 40)
      • Airway control --> (ETT)
  • 60s-90s
    • if HR < 60, start CPR
    • 3:1 compression:breath ratio
    • if no response give Epi (0.01-0.03 mg/kg IV or 0.05-0.1 mg/kg intratracheal)
    • 10 mL/kg NS bolus over 3-5 min if blood loss suspected
    • 2 mL/kg bolus D10W for glu < 1.38 in first hours of life

70

Dose of e- in Peds Arrest

2 J/kg initially --> 4 J/kg all subsequent shocks, may go up to 10 J/kg

71

Dose of e- in Peds Cardioversion

0.5 J/kg ---> 1 J/kg, up to 2 J/kg

72

SVT vs. ST in Peds

  • >220 in infant, >180 in child more likely to be SVT

73

Treatment of Tet Spell

  • calm child
  • 100% NRB O2
  • flex knees to chest (to increase preload + SVR)
  • morphine
  • IV NS bolus

74

Approach to Suspected CHD in Sick Neonate

  • CXR, ECG
  • R vs. L SpO2
  • UE vs. LE BP's
  • R brach-femoral pulse delay
  • O2 is pulmonary vasodilator and decreases R-->L flow through PDA + vasoconstricts PDA so be careful
  • IV Prostaglandin E1 0.1 mcg/kg/min
    • titrate to lowest effective dose (typically 0.05 mcg/kg/min)
  • 10 mL/kg NS bolus (may not tolerate if CHF)
  • IV Abx as cannot r/o sepsis
  • +- Lasix 1-2 mg/kg IV
  • +- dopamine, dobutamine

75

Kawasaki's Disease

  • late fall through early spring
  • phase 1 (acute): 1-2 weeks
  • phase 2 (subacute): 2-4 weeks
  • phase 3 (convalescent): 4-6 weeks
  • Criteria
  • Classic (Complete)
    • Fever >=5d and at least 4 of:
    • bilateral, nonpurulent, bulbar (not palpebral) conjunctivitis
    • oropharyngeal erythema (any of strawberry tongue, nonexudative erythematous oropharynx, fissured, cracked, erythematous lips)
    • polymorphous rash (diffuse, non-specific, not bullous/vesicular)
    • peripheral extremity changes (any of: erythema of palms/soles, edema of palms/soles, periungal desquamation
    • cervical lymphadenopathy (>1.5 cm, usually unilateral)
  • Incomplete
    • Fever >=5d with only two of above clinical criteria
    • CRP >= 3 or ESR >= 40
    • >= 3 of the following lab findings
      • WBC >= 15
      • Anemia
      • Plt >= 450 (if >=7d fever at presentation)
      • Albumin <= 30
      • high ALT
      • Urine WBC > 10/hpf
  • Atypical
    • meets all clinical criteria for complete but also features not typical of Kawasaki's (e.g. nephrotic syndrome)
  • infants < 6 mo with 7 d fever without explanation should get lab testing +- 2D echo even if no other criteria met

76

AVPU Score

Alert

Verbal (responds to verbal)

Pain

Unresponsive

77

HUS

Review on Evernote

78

HSP

Review Evernote

79

HUS Triad

  • Microangiopathic hemolytic anemia
  • Thrombocytopenia
  • AKI

80

HSP Tetrad

  • Palpable purpura in patients with neither thrombocytopenia nor coagulopathy - everyone, although not on presentation in 25%
  • Arthritis/arthralgia ~75%
  • Abdominal pain 50%, GI bleeding in 25%
  • Renal disease ~30%

81

Peds limp

Review Evernote

82

Acute Rheumatic Fever

  • usually begins 2-6 weeks after GABS strep throat 
  • mild migratory polyarthritis
  • contrast with post-strep reactive arthritis
    • ~10 d after strep, more severe mono-oligoarthritis without any Jones features

83

Bullous Impetigo/Staph Scalded Skin Syndrome

  • spectrum of disease from staph toxin
  • +ve Nikolsky
  • usually <6 years old
  • often MRSA
  • IV abx + admission if extensive
  • pan-culture

84

Roseola

  • high fevers x 3-5 days --> defervescence --> rash

 

85

HSV Skin Infections Peds

  • stain eyes
  • eczema herpeticum
    • HSV over eczema
    • Keflex + acyclovir (80 mg/kg/d divided Q 6h x 10d)
  • herpes gingivostomatitis
    • symptomatic tx
    • PO acyclovir may shorten if given within 48h
  • consult peds if < 2 y for dose

 

86

Scarlet Fever

  • GABS

 

87

Erythema Toxicum Neonatorum

  • benign, self-limited, 1st-2nd week of life
  • 2-3 cm erythematous macules, sometimes with central pustules

88

Transient Neonatal Pustular Melanosis

  • usually black infants
  • small pustules, red macules with surrounding scale, or brown macules
  • also self-limited

89

Cradle Cap (Seborrheic Dermatitis)

  • usually starts weeks 2-6, improves by 6 mo.
  • consider atopy if starts at 2-3 months and strong fam hx
  • ddx tinea
  • try Sebulex shampoo or mineral/olive oil followed by washing + removal of scales with comb

90

Diaper Dermatitis

  • clotrimazole 1%/hydrocortisone 1% BID then cover with zinc ointment
  • check for oral thrush --> nystatin 100, 000 units/mL 2 mL QID for infants, 4-6 mL QID for children for up to 48h after resolution of lesions

91

Erythema Multiforme

  • usually viral from HSV, can be caused by drugs
  • minor if limited and no mucosal, major if mucosal
  • supportive tx for both

92

Croup

Review Evernote

93

PALS

Review Evernote + Card

94

Mastoiditis

  • postauricular erythema, swelling, tenderness
  • protrusion of auricle and obliteration of postauricular crease
  • Contrast CT Scan
  • admission IV Cetriaxone

95

Normal neonatal feeding/voiding

2-3 oz every 2-3 h

6 diapers/24h

96

Difference between caput succedaneum and subgaleal hemorrhage

See Peds Newborn Exam

97

Measles

see Evernote Measles

98

Ultimate BVM

See Evernote BVM